Evaluation of the implementation of the directly observed treatment strategy for tuberculosis in a large city

Lavôr, Débora Cristina Brasil da Silva; Pinheiro, Jair dos Santos; Gonçalves, Maria Jacirema Ferreira

doi:10.1590/S0080-623420160000200010

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ORIGINAL ARTICLE • REEUSPRev. esc. enferm. USP 50 (02) • Mar-Apr 2016 • https://doi.org/10.1590/S0080-623420160000200010 copy

Evaluation of the implementation of the directly observed treatment strategy for tuberculosis in a large city

Evaluación de la implantación de la estrategia de tratamiento directamente observado para tuberculosis en un municipio de gran porte

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

OBJECTIVE

To assess the degree of implementation of the Directly Observed Treatment, Short-course - DOTS for tuberculosis (TB) in a large city.

METHOD

Assessment of the implementation of the logic model, whose new cases of infectious pulmonary TB were recruited from specialized clinics and followed-up in basic health units. The judgment matrix covering the five components of the DOTS strategy were used.

RESULTS

The result of the logic model indicates DOTS was partially implemented. In external, organizational and implementation contexts, the DOTS strategy was partially implemented; and, the effectiveness was not implemented.

CONCLUSION:

The partial implementation of the DOTS strategy in the city of Manaus did not reflect in TB control compliance, leading to low effectiveness of the program.

Descriptors
Tuberculosis; Directly Observed Therapy; Health Evaluation; Program Evaluation; Public Health Nursing

Components (sub-dimensions)	Indicators (maximum score)	Score (mean)	Dimensions score (%) Min; Med; Max	Implementation degree
Institutional vulnerability (3 points)	Existence of institutions like day care centers, nursing homes, hostels, and/or prisons in the territory of the basic health unit (1)	0.0	0.0; 48.7; 100.0	Partially implemented
	Existence of partnership with community associations and civil society organizations (1)	0.8
	Representation in the Local Health Council (1)	0.5
Political commitment (10 points)	Participation in the meetings of Local Health Council (2)	0.3	0.0; 39.6; 100.0	Not implemented
	Participates in the programming consumables for operationalization of DOTS in basic health unit (water, glass, DOTS form) (2)	1.2
	Rearranges the service for location and observe the medication usage by the patient (3)	1.0
	Sets rules and routines for the operationalization of DOTS (3)	1.3
Social and individual vulnerability (7 points)	Proportion of patients with social register performed (2)	2.0	^ No data available in the data collection sites. Held only to identify which were contained in the proposed matrix. In their score, total points were considered.
	Proportion of patients with social register performed that presents social determinant of risk for treatment default (2)	2.0
	Proportion of patients with received care of social risk determinant for treatment default (3)	3.0

Components (sub-dimensions)	Indicators (maximum score)	Score (mean)	Dimensions score (%) Min; Med; Max	Implementation degree
Technical, political and financial autonomy (6 points)	Participation in the control of complementary incentives to DOTS (food aid/ transport) (2)	0.3	33.3; 65.3; 100.0	Partially implemented
	Performs planning of TB control actions (assistance parameters) (2)	1.6
	Performs adjustment in programmed actions (2)	1.9
Inter-programmatic actions (8 points)	Promotes the integration of PTC with the laboratory sector (2)	1.6	0.0; 63.9; 100.0	Partially implemented
	Promotes the integration of PTC with the STD/AIDS program (2)	1.6
	Promotes the integration of PTC with the Social Services sector (number of consultations) (4)	1.8
Management of the PTC (15 points)	Nursing work time in the PTC (5)	3.3	13.3; 49.2; 80.0	Partially implemented
	Time of the last training/ update on DOTS (2)	1.8
	Promotes integration of PTC with FHS teams in the scope of BHU (3)	1.8
	Monitors/evaluates the major TB indicators in the BHU (pact, PHSA, SR identified and examined, identification BK+ cases, HIV testing, TB treatment cohort - all forms) (5)	0.3
Information system (16 points)	Properly record information on SR Registry Book (2)	0.9	56.2; 79.8; 100.0	Implemented
	Properly register information on Case Registration Book (2)	1.5
	Properly register information on Case Monitoring Bulletin (2)	1.5
	The closure of the new TB cases - all reported forms (6)	5.5
	Send regular Monthly Report of Activities/ Case Monitoring Bulletin (4)	3.1

Components (sub-dimensions)	Indicators (maximum score)	Score (mean)	Dimensions score (%) Min; Med; Max	Implementation degree
Operation and Coverage of DOTS (30 points)	Performs and records the direct observation of medication use in the 1^st phase of the treatment (10)	3.5	26.7; 26.7; 70.0	Not implemented
	Performs and records the direct observation of medication use in the 2^nd phase of treatment (8)	3.2
	Proportion of new smear positive cases in DOTS (7)	2.8
	Implements search for absentees, including FSH support (5)	0.0
Bacteriological diagnosis (15 points)	Performs case finding (3)	1.2	33.3; 73.3; 100.0	Partially implemented
	Register and examines contacts (3)	2.2
	Performs smear for follow-up treatment (3)	3.0
	Performs HIV serology test (3)	2.0
	Performs sputum culture for cases of TB retreatment (3)	2.4
Supply of drugs/consumables (10 points)	Inventory existence of medicine that meets the cases under treatment (3)	2.0	30.0; 70.0; 100.0	Partially implemented
	Container available for sputum collection (4)	3.8
	Offers laboratory supplies (staining, slides, masks, etc.) that meets the needs of BHU (3)	1.1
Integrality (10 points)	Implement the reference cases with diseases and/or complications associated or not with TB (2)	0.4	0.0; 65.0; 90.0	Partially implemented
	Medical consultation for patients with TB (4)	2.5
	Nursing consultation for patients with TB (4)	3.1

Components (sub-dimensions)	Indicators (maximum score)	Score (mean)	Dimensions score (%) Min; Med; Max	Implementation degree
Treatment Outcome (70 points)	Cure rate of new smear positive cases in DOTS (10)	6.6	14.2; 39.0; 77.1	Not implemented
	Treatment default rate of new smear positive cases in DOTS (10)	3.2
	Cure rate of new smear positive cases in self-administered treatment (6)	0.3
	Treatment default rate of new smear positive cases in self-administered treatment (6)	3.6
	Proven cure rate of new smear positive cases (6)	1.5
	Cure rate of new smear positive cases (10)	1.3
	Treatment default rate of new smear positive cases (10)	5.5
	Cure rate of new TB cases - all forms (6)	0.7
	Treatment default rate of new TB cases - all forms (6)	4.2

Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br

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[1] Corresponding author: Maria Jacirema Ferreira Gonçalves. Rua Teresina, 475 - Adrianópolis. CEP 69057-070 - Manaus, Amazonas, Brazil. jaciremagoncalves@gmail.com