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PROCESS EVALUATION OF QUALITY IN THE DIAGNOSIS AND

TREATMENT OF TUBERCULOSIS AT KERSA DISTRICT, JIMMA

ZONE

BY

DESALEGN DABARO

THESIS SUBMITTED TO DEPARTMENT OF HEALTH PLANNING AND

HEALTH SERVICES MANAGEMENT, MONITORING AND EVALUATION

UNIT, AS PARTIAL FULFILLMENT OF MASTERS DEGREE IN HEALTH

MONITORING AND EVALUATION.

JIMMA UNIVERSITY

OCTOBER, 2012

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PROCESS EVALUATION OF QUALITY OF CARE IN DIAGNOSIS

AND TREATMENT OF TUBERCULOSIS AT KERSA DISTRICT,

JIMMA ZONE

THESIS SUBMITTED TO DEPARTMENT OF HEALTH

PLANNING AND HEALTH SERVICES MANAGEMENT,

MONITORING AND EVALUATION UNIT, AS PARTIAL

FULFILLMENT OF MASTERS DEGREE IN HEALTH

MONITORING AND EVALUATION.

BY

DESALEGN DABARO (BSC)

ADVISORS

1. MR. YOHANNES EJIGU (MSC in HME)

2. MR. WAJU BEYENE (MPH)

JIMMA UNIVERSITY

OCTOBER, 2012

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Abstract

Background: Even though Ethiopia has implemented the DOTS service for long time, the

national targets of TB control were not achieved yet. Like the country wide, the kersa

district shares the same problem, and also TB control program has never been evaluated in

this district. Hence, the aim of this evaluation is to assess the quality of service provided in

the diagnosis and treatment of TB at Kersa district from June 25 to July 19, 2012

Method: Facility based case study design involving both qualitative and a quantitative

method was used. Reviewing the records of TB patients registered for one year

(october1/2010 to september30/2011), consecutive reviewing of individual patient folders

of 384 patients aged 15 years or more, exit interview of 61 patients aged 15 or more, and

interviewing 14 experts, resource inventory and observation of laboratory practice and

patient-provider interaction were the methods of data collection. Quantitative data was

analyzed using SPSS 16.0 software and the findings were presented in figures, mean,

proportion and frequency table. Expert interview result was summarized and analyzed in

major thematic areas and supplemented the quantitative finding.

Results: The availability dimension was judged as fair based on preset judgment criteria.

There were no pediatric dose of TB drug and revised TB register in all HCs and no

separate TB treatment unit in two of HCs. The compliance of HCWs with the guideline of

the program was judged as poor. From 384 TB suspects 249 (64.8%) were requested for

AFB examination, 4.4% of them were smear positive. Diagnosis of all smears positive PTB

patients was correct. While cure rate of smear positive PTB was 64.6%, treatment success

rate of all forms TB was 98%. All patients were satisfied with the majority of satisfaction

items, but relatively high (29.5%) patients were dissatisfied with the convenience of HCs to

their home and 31.1% were dissatisfied with the daily visiting of HCs for TB treatment.

Conclusion and recommendation: The overall quality of the service was fair. The absence

of pediatric dose of anti-TB drugs, absence of separate TB units in two of HCs, absence of

TB register, weak supervision mechanisms, poor screening of TB suspects and poor

recording mechanisms were main constraints of service. It is recommended that there

should be adequate and continuous supply of TB drugs, all HCWs should screen TB

suspects based on the NTP guideline, planed and regular supervision mechanisms of the

service should be strengthened and there should be new (revised) TB register.

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Acknowledgement

I would like to express my deep appreciation and sincerely thanks to my advisor Mr.

Yohannes Ejigu and Mr. Waju Beyene for their constructive comments from the beginning

of this study.

It is also my pleasure to extend my deep gratitude to all of monitoring and evaluation

department instructors for their great roles of teaching to shape me as an evaluator.

I am also grateful to health office managers, tuberculosis prevention and control program

expert and health care providers in Kersa district for their kindly support throughout this

study.

I am also grateful to Jimma University for provision of financial support to conduct this

study.

Glory to my God for He has made everything beautiful in its time.

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Table of Contents

Abstract ........................................................................................................................................ iii

Acknowledgement ........................................................................................................................ iv

Chapter 1: Introduction .................................................................................................................. 1

1.1: Background ............................................................................................................. 1

1.2: Statement of the problem ......................................................................................... 2

1.3: Purpose of the evaluation ......................................................................................... 3

Chapter 2: Program description ...................................................................................................... 4

2.1: Stakeholder identification ........................................................................................ 4

2.2: Objective of the TB program ................................................................................... 6

2.3: Major strategies ....................................................................................................... 6

2.4: Resources and activities of the program ................................................................... 6

2.5: Stage of program development................................................................................. 9

Chapter 3: Literature review ..........................................................................................................11

3.1: Quality of care in TB program ............................................................................... 11

Chapter 4: Questions and objectives of evaluation .........................................................................14

4.1: Evaluation questions .............................................................................................. 14

4.2: Objective of evaluation .......................................................................................... 14

Chapter 5: Methods of evaluation ..................................................................................................15

5.1: Study area and period ............................................................................................ 15

5.2: Theoretical framework of the evaluation ................................................................ 15

5.3: Focus and approach of evaluation .......................................................................... 17

5.4: Evaluation design .................................................................................................. 17

5.5: Dimensions of evaluation....................................................................................... 17

5.6: Population and sampling ........................................................................................ 19

5.7: Sample size and Sampling technique ..................................................................... 19

5.8: Inclusion and exclusion criteria .............................................................................. 21

5.9: Data collection ....................................................................................................... 21

5.9.1: Development of tools ...................................................................................... 21

5.9.2: Data collectors ................................................................................................ 22

5.9.3: Data quality management ................................................................................ 22

5.10: Data analysis........................................................................................................ 22

5.11: Matrix of analysis and judgment .......................................................................... 23

5.12: Ethical consideration ............................................................................................ 23

5.13: Dissemination plan .............................................................................................. 24

Chapter 6: RESULT ......................................................................................................................25

6.1: Availability dimension ........................................................................................... 25

6.2: Compliance dimension........................................................................................... 28

6.2.1: Diagnosis of tuberculosis ................................................................................ 28

6.2.2: Treatment of tuberculosis ................................................................................ 30

6.2.3: Treatment monitoring ..................................................................................... 31

6.3: Patient satisfaction survey ...................................................................................... 35

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6.4: Summary of dimension .......................................................................................... 40

Chapter 7: Discussion ...................................................................................................................41

Chapter 8: Conclusion and recommendation ..................................................................................45

8.1: Conclusion............................................................................................................. 45

8.2: Recommendation ................................................................................................... 45

Chapter 9: Meta evaluation ...........................................................................................................46

9.1: Accuracy standard ................................................................................................. 46

9.2: Utility standard ...................................................................................................... 46

9.3: Feasibility standard ................................................................................................ 46

9.4: Propriety standard .................................................................................................. 47

Chapter 10: References .................................................................................................................47

Chapter 11: Annex ........................................................................................................................51

11.1: Consent forms ...................................................................................................... 51

11.2: Tools of data collection ........................................................................................ 53

List of tables and figure

Table 1: Stakeholder analysis and description ................................................................................. 5

Table 2: Summary of sample size, data source and sampling technique .........................................21

Table 3: Judgment analysis matrix of diagnosis and treatment of TB at Kersa district, 2012...........23

Table 4: Judgment matrix of availability dimension of diagnosis and treatment of TB at Kersa

district, 2012 .................................................................................................................................27

Table 5: Number of smear positive PTB patients received sputum follow up test at Kersa district,

2012..............................................................................................................................................31

Table 6: Compliance dimension of diagnosis and treatment of tuberculosis at Kersa district, 2012 .34

Table 7: Socio-demographic characteristics of TB patients at Kersa district, 2012. ........................35

Table 8: The satisfaction level of patients with the DOTS service at Kersa district, 2012 (N=61) ...38

Table 9: Summary indicators of client satisfaction level at Kersa district .......................................39

Table 10: Summary dimensions of quality in the diagnosis and measurement of tuberculosis at

Kersa district, 2012 .......................................................................................................................40

Figure 1: Logic model of diagnosis and treatment of tuberculosis at kersa district, 2012 ................. 8

Figure 2: Conceptual framework of diagnosis and treatment of tuberculosis at Kersa District, 2012

.....................................................................................................................................................16

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Abbreviations

AFB Acid-Fast Bacilli

CDR Case Detection Rate

DOTS Directly Observed Treatment Strategy

EPTB Extra pulmonary Tuberculosis

HC Health Center

HBCs High Burden Countries

HIV Human Immunodeficiency Virus

HCWs Health Care Workers

NTP National Tuberculosis Control Programme

PTB Positive Pulmonary Tuberculosis

TB Tuberculosis

WHO World Health Organization

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Chapter 1: Introduction

1.1: Background

Tuberculosis (TB) is an infectious disease caused by the bacillus Mycobacterium

tuberculosis. It is a major global health problem. Each year, there are around 9 million

new cases of TB, and close to 2 million people die from the disease. All countries are

affected, but most cases occur in Africa and Asia. Globally there are 22 high-burden

countries (HBCs) that account for about 80% of the world‟s TB cases (1, 2).

According to latest estimates, Ethiopia stands 7th in the list of HBCs for TB. According

to ministry of health hospital statistics data, tuberculosis is the leading cause of

morbidity, the third cause of hospital admission next to deliveries and malaria, and the

second cause of death next to malaria (3).

In Ethiopia the incidence of TB of all forms and smear positive TB stand at 341 and 152

per 100,000 populations, respectively. The prevalence and mortality of Tuberculosis of

all forms is estimated to be 546 and 73 per 100,000 populations respectively. In the year

2006/7 Ethiopia registered 129,743 cases of TB (3).

Global efforts to control TB were strengthened in 1991, when a World Health Assembly

resolution recognized TB as a major global public health problem. Two targets for TB

control such as 70% of case detection rate and 85% of cure rate were established as the

part of this resolution. Eventually these two targets were embedded within the DOTS

strategy launched by WHO in 1994, and subsequently endorsed by the WHO STOP TB

Strategy in 2006 (3).

The effort of TB control began in Ethiopia in the early 1960s with the establishment of

TB centers and sanatoriums in three major urban areas in the country. Now a day

Ethiopia has adopted the global targets for TB control by implementing both DOTS and

STOP TB Strategy (3).

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1.2: Statement of the problem

Without treatment, individuals with active TB will infect an average of 10-15 people

each year and can ultimately die from the disease. The increasing burden of TB is due to

many factors, including; poor management of programs; the spread of HIV; poverty;

population growth; and rapid, uncontrolled urbanization (4).

Despite widespread acceptance of the principles of DOTS, most developing countries

have been unable to expand DOTS as rapidly as needed and have failed to achieve the

global targets. The quality and population coverage of DOTS are still low in most

countries. The TB laboratory service network is poor and also there were insufficient

resources and shortage of trained staff to provide essential service (5, 6).

In 1992 a standardized TB prevention and control programme, incorporating DOTS, was

started as a pilot in Arsi and Bale zone, Oromia Region of Ethiopia. The current DOTS

geographic coverage reaches 90%, whereas the Health Facility coverage is 75% (3).

Though the country has implemented the DOTS service for long time, the national

targets of TB control were not achieved yet. Currently case notification and treatment

success rate were 46% and 84%, respectively (1, 6).

Jimma zone in general and kersa district particularly share the same problems of

achievement. According to zonal health department report the case detection rate of

Jimma zone was 24.4% and 31.7% for smear positive and all form of TB respectively

(7). In the same year the kersa district and Jimma zone health department annual

performance report shows that the case detection rate of kersa district is low and even

far below from national and zonal report too, and it was 15.4% and 26.4% for smear

positive and all form of TB respectively (7, 8).

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In addition to this poor achievement, TB program has never been evaluated before at

Kersa district. Hence the aim of this study is to evaluate the quality of diagnosis and

treatment of TB at Kersa district.

1.3: Purpose of the evaluation

The finding of this study will help programme coordinators, service providers and all

those concerned by providing information to create a better basis for health care

planning and management to improve TB program.

The study also serves as a base line for other studies and used as a bench mark for

continuous quality improvement in the district particular and in the zone, region and

country in general.

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Chapter 2: Program description

2.1: Stakeholder identification

The major stakeholders of the program included were the Jimma University, program

managers at Jimma zone health department and Kersa district health office and health

care providers. These stakeholders identified during evaluability assessment which were

conducted before evaluation.

Stakeholders provided the general information of the program performance, decided on

the readiness of TB program for evaluation, identified the areas of the program to be

evaluated and participated in evaluation question development. Likewise they have

participated on developing indicators and setting the matrix of analysis for program

judgment.

There was one day meeting with stakeholders before starting the evaluation to agree on

the evaluation parameters. During the whole process of evaluation they were kept

informed regarding progress of the evaluation. Finally there is evaluation result

dissemination plan to all stakeholders to communicate the findings and lessons learned

included in the report.

The finding of the evaluation report was provided to the program stakeholders. The

findings expected to be used for planning, capacity building program, raising awareness,

adjust plan, share experiences from lessons learnt, strengthening and developing/revising

strategies, and taking corrective measures. The following table summarizes about

stakeholders‟ engagement along with their interests and perspectives. (Table 1)

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Table 1: Stakeholder analysis and description

s/n Stakeholder Roles in the

program

Roles in the evaluation perspectives in finding

utilization

1 Jimma Zone

health

department

planning, guidance

and supervision

Provides data, reviewing

Indicator, set criteria for

judgment

Use the finding and

recommendation of the

evaluation for program

improvement

2 Kersa

District

health office

Guidance,

supervision and

keeps the TB

registers

Provides data, reviewing

Indicator, set criteria for

judgment

Use the finding and

recommendation of the

evaluation for program

improvement

3 Serbo HC

Health

workers

Service provision,

keep patient record

cards and manage

drugs stock.

Provides data, reviewing

Indicator, set criteria for

judgment

Use the finding and

recommendation of the

evaluation for program

improvement

4 Patients Service users,

defaulter tracing

Provide information

during data collection

To improve utilization and

participation in the

program

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2.2: Objective of the TB program

The general objectives of NTP are interrupting transmission of the infections; reducing

morbidity, mortality and disability; preventing emergence and spread of drug resistance;

reduce burden of TB among people living with HIV; and reducing HIV burden among TB

patients (3).

2.3: Major strategies

Major strategies in reaching the objectives include early case detection, adequate

chemotherapy, and provision of comprehensive and standard patient care, enhanced case

management, community participation, accurate monitoring and evaluation of program

performance (3).

National targets of NTP: Two national targets of NTP are achieving and maintaining the

detection of at least 70% of new sputum smear positive TB cases, and the cure rate of at

least 85% among these detected cases (3).

The objective TB program at Kersa district were to increase smear-positive TB cases

detection rate from 15 % to 40% and to increase treatment success rate from 80% to 90%

at the end of 2011/12 (8).

2.4: Resources and activities of the program

The resources and activities of the program were identified from the NTP guideline of

Ethiopia (3).

Identified resources include the presence of trained providers, separate TB unit, adequate

and uninterrupted supply of TB drugs, AFB reagents and other laboratory consumables

(slides, sputum cup, immersion oil), equipment (microscopy and weighing scales), health

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education materials, manuals and guidelines supply of registers and formats (AFB request

paper, performance report form ,referral forms and standard supervision checklist)

Patient management activities were mainly carried out by general HCWs at the health

centers include case detection, contact examination, case treatment, patient education, HIV

counseling and testing and recording and reporting.

Programme management activities which were mainly carried out by separate TB units

were planning, training, and monitoring and evaluation (supportive supervision, review

meetings) and resource mobilization

The indicators of treatment outcomes were collected from a review TB register. Treatment

adherence rate, cure rate of smear positive PTB, treatment complete rate of smear negative

PTB, EPTB and overall treatment success rate were some of the outcome indicators

reviewed. In addition to this, the perspective of patients with the DOTS service was also

surveyed.

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Inputs Activities Outputs Outcomes Impacts

Diagnosis &

treatment

Training of HCWs

Distribution of drug, reagent, guidelines, register, standard formats,

microscopes, weighing scales and other medical

supplies

Drugs, reagents, guidelines, microscopes, standard formats & other

medical supplies

# Patients

diagnosed & treated

# HCWs trained

Improved CDR, TSR

& Health status

Increased patient

satisfaction

Reduction in

TB morbidity

& mortality

Reduced Incidence &

Prevalence of TB

Improved Rx.

adherence

Increased patient

knowledge

# Patients received HE

Provision of HE

Human a resource, Infrastructure

HE materials

Improved HCWs‟ knowledge

Supervision checklist Supervision

Recording and reporting materials

Recording & reporting

# Supervision conducted

# Reports submitted

# Drugs, Reagents, and

guidelines, registers,

standard formats

microscopes, weighing

scales and other supplies

distributed

Regular supply of resources & improved surveillance system

Figure 1: Logic model of diagnosis and treatment of tuberculosis at kersa district, 2012

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2.5: Stage of program development

History of TB control started from attempts of treating unidentified cause to treating cases

infected with the bacilli, from no remedy to effective treatment, from compulsory isolation

to chemical isolation (treating infectious cases with anti-TB drugs), and from vertical to

integrated approach where the service delivery was progressively decentralized to

peripheral health institutions in the communities (9).

After the introduction of effective treatment, TB control was organized as a vertical

program staffed with health workers particularly assigned to run the program. This reduced

the annual risk of infection by 5 -13% in developed countries due to the available resources

and improved general living conditions (9).

However, similar results were not achieved in developing countries due to the associated

high cost. Hence, TB control was integrated into general health service to ensure effective

and efficient use of resources. However, lack of technical efficiency by the general health

workers, neglect of TB control activities, health sector reform and resurgence of TB due to

human immunodeficiency syndrome epidemic weakened the TB control efforts. This was

also complicated by socioeconomic deterioration: increased poverty, malnutrition and

overcrowding (9).

The affordability of rifampicin, poor treatment adherence and high TB burden paved way to

the introduction of DOTS strategy. DOTS strategy aims to detect 70% of new smear-

positive cases and to cure 85% of them. However, its effectiveness was limited in settings

with low health service coverage. To improve TB control efforts, the Stop TB partnership

further envisioned eliminating TB as a public health problem and, ultimately, to achieve a

world free of TB (9).

In Ethiopia the TB program becomes the today‟s situation through the different

developmental hierarchy like, in 1960s TB sanatoria established, , in 1976 NTP established,

in 1992 TB DOTS first piloted, in 1994 central office of NTP combined the tuberculosis

and leprosy program and tuberculosis and tuberculosis team established, In 1995 Planning

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and programming department for 1996-2000 designed, in 1996 tripartite- tripartite

agreement signed: FMHO, WHO, KNCV to implement DOTS strategy all over the country,

in 1997 Planning and Programming Department implemented, in 1997 TB and Leprosy

program is integrated in to the general health services, in 2001 TBL control program fully

integrated and in 2004 TB/HIV collaborative activities were initially rolled out. In the study

area, kersa district, TB Control program implementation has started since 1996. Four HCs

and 8 health posts provide the DOTS service and only three HCs provide AFB examination

service (3, 9)

Government is the main source of the fund. However, there was one nongovernmental

organization called „heal TB‟, that work with the government on TB control program. The

main contribution of this organization was provision of in-service training to HCWs and

supervision of the service at both health facility and community level (8).

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Chapter 3: Literature review

3.1: Quality of care in TB program

One component of the DOTS strategy is regular, uninterrupted supply of all essential anti-

tuberculosis drugs and laboratory supplies, in line with this NTP guideline of Ethiopia

recommended that every health unit involved in the prevention, diagnosis and treatment of

Tuberculosis should have an adequate and uninterrupted supply of drugs, laboratory

reagents and equipment in order to achieve sustainable program implementation. But

different study findings showed that not all health facilities have adequate resource as

recommended by NTP as well as WHO, this could be one of the important factors which

made the program not to met the intended target; 70% of case detection rate and 85% of

cure rate by DOTS (3).

Study in southern nation and nationalities region of Ethiopia revealed that only 9 of 13

diagnostic centers have reagents for Acid-fast stain, this indicates as there was scarcity of

reagents for AFB staining (10). Similarly, study in Jimma zone showed that only 60.0% of

the study health facilities had sufficient laboratory reagents and slides for sputum smear

microscopy. The same study showed that TB drugs were available on weekends in only

10% of the study health facilities, and only 50% of the study health facilities had a copy of

NTP manual and teaching material (flip charts) on TB (11).

Developing human resource is one of the integral components of the Stop TB Strategy,

because expanding access to TB care relies heavily on the availability of well-trained health

workers within the primary health care system( 2). But different studies showed the scarcity

and inadequate training of HCWs in DOTS service. Qualitative study of barriers to

tuberculosis care among Somali pastoralists in Ethiopia showed that there were lack of

access to formal health services and high staff turnover (12). In addition to this, study done

in Tigray region showed that TB care providers were not trained in 44% of study facilities

(13).

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As Donabedian described, the quality of care is the product of applying science and

technology in actual practice and this becomes true when the application is based on preset

recommended standards of program (14). However, studies in different settings showed that

due to different reasons, some providers do not use standards of operation, and this has a

negative impact in the program achievement.

According to the study finding in Tigray region, TB diagnosis was considered as incorrect

in 9 of 42 smear positive PTB (13). In public-private mix Hospitals of Indonesia 4-18% of

sputum smear positive Tuberculosis cases were not managed with standardized diagnosis

and treatment (15); and study in Gambia showed that the proper implementation of

fundamental DOTS-elements, particularly follow up and sputum review were undermined

due high workload (16).

Study findings in Jimma zone showed that address of patients and name of contact person

were not registered in 23% and 18% of cases, respectively, and also the proper number of

smear was performed for only 38.3% cases. (11) Study in Tigray region showed that only

39% TB focal persons were able to manage adverse effects (13).

According to study finding in southern region of Ethiopia, from 2209 slides collected from

peripheral laboratories for external quality assurance overall, false reading was 3.2% (17).

Study in Jimma zone showed, the proportion of smear positive patients successfully

completing the minimum of 8 months of treatment was 69.2%. The treatment defaulters

rate was 10% and above in 3(30%) of the health facilities. The overall treatment completion

rate was 74%, while default and death rates were 22% and 3.8%, respectively (13)

Regarding the knowledge of patients about the tuberculosis, the same study revealed that

only 29 (12%) of the 237 patients mentioned bacteria as a cause of TB. Exposure to cold

was mentioned by 92 (39%) respondents. Even though 186 (79%) stated that they could

potentially transmit TB to others, only 39% knew the correct means of transmission. Over

half knew neither the side effects nor the indications for stopping their medication. Of the

237 patients, 34% encountered problems during the continuation phase, and 30% were

worried that someone might know about their illness (13).

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Similar to this, study conducted in Gilgile gibe field research area of west Ethiopia showed

that among 476 TB suspects 395 (83%) ever heard of TB( have awareness ), and regarding

the perception about the TB 50.4%, 33.7% and 15.9% perceived as evil eye, germs and

Satan and witchcraft respectively (18). Study conducted in Sudan showed that only 36.2%

of respondents had satisfactory knowledge about tuberculosis and its treatment (19). study

on Women‟s Perspectives on Pathway to Diagnosis of Pulmonary Tuberculosis identified

many barriers that could prevent women from getting a proper diagnosis, including lack of

knowledge, lack of financial resources, lack of power, male supremacy in decision-making,

perceived corruption in healthcare facilities, fear of stigma and this fear heavily boosted by

the idea that PTB equates HIV/AIDS (20).

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Chapter 4: Questions and objectives of evaluation

4.1: Evaluation questions

1. Are the required resources available for diagnosis and treatment of TB? If not, why?

2. Is the diagnosis and treatment of TB being implemented according to the NTP guideline?

If not, why?

3. Are the TB patients satisfied by the services provided? If not, why?

4.2: Objective of evaluation

General objective

To evaluate the quality of care provided in the diagnosis and treatment of Tuberculosis in

Kersa district from June 25-July19/2012

Specific objective

1. To assess the availability of resources for the diagnosis and treatment of TB.

2. To assess the compliance of Tuberculosis diagnosis and treatment with the NTP

guideline.

3. To assess the satisfaction level of TB patients with service received.

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Chapter 5: Methods of evaluation

5.1: Study area and period

Kersa is one of the 17districts in the Jimma zone. It is located at 22km to the North Eastern

part of Jimma town. Its total area is 978.6km2. It is bounded by Limu Kossa and Tiro Afeta

districts in the north, Ommo Nada districts in the East , Manna district and Jimma town in

the South, Dedo district in the West. The altitude ranges from 1600-2400 above sea levels.

Temperature rang is 240c-28oc. Annual average rainfall is 1586.6mm. There are 35 Kebele

in the district, and the total population of the district is 188268.

Health facilities of the district include five HCs, 35 health posts, one drug store and 12 drug

vendors, and total human resource workings under health office are 76 technical staff, 70

HEWs, and 30administrative/ supportive staff (8).

This study was conducted from June 25 to July 19, 2012

5.2: Theoretical framework of the evaluation

The Donabedian model of health care quality assessment was used. This model consists of

three approaches of health care quality measurement, such as structure, process and

outcome. (14)

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Compliance

Clinicians screen TB suspects

and order AFB test

AFB test performed by

laboratory technicians

Clinicians interpreted the

laboratory result and enrolled

to TB treatment

Figure 2: Conceptual framework of diagnosis and treatment of tuberculosis at Kersa District,

2012

(Adapted from Avedis Donabedian, 2003 edition with few modification)

* Laboratory consumables: slides, sputum cup, immersion oil,

*standard formats: AFB request form, referral form, report form

Sat

isfi

ed

pat

ients

Structure Process Outcome

Availability of:

Infrastructure, Qualified

health care providers,

Medical equipments, TB

drugs, AFB reagents and

laboratory consumables

*, guidelines, register

books Standard formats

and guideline

Improved

health status

Amenities of care: a

properly functioning

appointment system,

pleasant and

comfortable

surroundings, privacy

etc Increased treatment

adherence

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5.3: Focus and approach of evaluation

Both formative and participatory approaches of program evaluation were used. Formative

approach was used because it provides information for the program improvement, and this

was also the main purpose of this evaluation. This means that the evaluation information

would indicate how things are going by highlighting problems related to program activities

and would also indicate whether the activities being conducted in a proper manner or not.

(21). Participatory approach was used to engage and enable stakeholders to take role from

the beginning of evaluation as described in chapter 2, section 2.1.

The focus of this evaluation was the process of the service, and some outcome indicators,

such as case detection rate, treatment success rate, and patient satisfaction were also

assessed.

5.4: Evaluation design

Facility based case study design involving both quantitative and qualitative methods were

used. This design was used because it investigates a contemporary phenomenon in depth

and within its real-life context; relies on multiple sources of evidence, with data needing to

converge in a triangulating fashion and benefits from the prior development of theoretical

propositions to guide data collection and analysis (22).

5.5: Dimensions of evaluation

Availability of infrastructure and resources for diagnosis, compliance of HCWs to NTP

guideline and client satisfaction were the main dimensions of this evaluation.

This study assessed the availability and adequacy of infrastructure, trained health workers,

medical equipments, anti-TB drugs, AFB staining reagents and consumables (slides,

immersion oil, sputum cup etc), standard formats (AFB request paper, referral forms, and

report forms), TB register and laboratory register.

Client satisfaction was assessed with four component dimensions of access, such as

availability, accommodation, accessibility and acceptability (23).

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Operational definition of terms:

Quality: - means the provision of health care service that is known to be safe, effective and

satisfy the needs of clients.

Availability: Is the presence of required resources for diagnosis and treatment of TB as per

guideline.

Adequacy: Is the degree of fit between the volume and type of existing services and

resources to the client volume and types of needs.

Compliance: is the occurrence of diagnosis and treatment activities based on national

guideline recommendations.

Client satisfaction: is the measure of clients‟ perceived quality of care in the services

provided.

Accessibility: Is the relationship between the location of supply and the location of clients,

taking account of client transportation resources and travel time and distance.

Accommodation: Is the relationships between the manners in which the supply resources

are organized

Acceptability: Is the relationship of clients' attitudes about personal and practice of

providers to the actual characteristics of existing providers.

Structure: Refers the conditions under which care is provided.

Process: Is the activities that constitute health care including diagnosis, treatment and

patient education which usually carried out by professional personnel, but also including

other contributions to care, particularly by patients and their families.

Outcome: Is the changes (desirable or undesirable) in individuals and populations that can

be attributed to health care.

19 | P a g e

5.6: Population and sampling

All adult patients diagnosed at outpatient department, all TB patients and all HCWs involved in

DOTS service at Kersa district were target population for this study. All individual patient

folders with cough of two or more weeks, TB unit register, all TB patients who have been

following TB treatment and all HCWs who involved in DOTs service were source population.

5.7: Sample size and Sampling technique

For health facilities: To maximize the source of information all functional HCs (4HCs) were

included.

Record review: At TB diagnosis unit level

The sample size for chart (individual patient folder) audit was determined using single

population proportion formula. The assumptions: Level of confidence 95%, 5% margin of error,

and P is the proportion of compliance of HWs to national TB guideline to diagnose TB, but since

there is no study done on compliance of HCWs on national TB guideline on study area, p =50%

was taken to have maximum sample size. Based on these assumptions the actual sample size for

the study was computed using the formula for single population proportion

n = (Z α/2)2 P (1-p)

d2

Where, n= sample size, Z α/2= Critical value=1.96, P= compliance of HCWs to national

guideline, d= precision (marginal error) =0.05,

Then n = (1.96)2 (0.5*0.5) =384

(0.05)2

TB register review: All one year records of new TB patients registered for treatment from

october1/2010 to september30/2011, which were 154 were reviewed.

20 | P a g e

Sample size for observation:

The sample size for observation of laboratory practice and patient-providers interaction was

determined based on the saturation of information. The sample size for laboratory practice was

12 and for providers-patient interaction was 20.

Sampling techniques:

The sample size (N=384) of individual patient folders proportionally allocated to three HCs,

which provide the AFB examination service. Proportional allocation was based on the average

number of adult patients (>15years old) visiting the HCs. From OPD abstract register, in average

230 adult patients visit Serbo HC, 130 visits Bala Wajo and 125 visit Bulbul HC per week.

Hence, 182 patient folders selected from Serbo HC, 103 from Bala Wajo and 99 from Bulbul

HC. Then, consecutive patient folders selected retrospectively from study period backward until

the required sample size was obtained.

TB register: All one year records of new TB patients registered from October1/2010 to

september30/2011, which were 154, were reviewed to have adequate sample size.

Expert interview: Fourteen experts was interviewed purposely: Three clinicians who work at

adult OPD, three laboratory technicians, three TB service providers, and four heads of health

centers. In addition to this the expert of the program at the district was interviewed to have more

details of the program. Consecutive patients who full fill the inclusion criterion (age 15 years or

older) were included in patient exit interview.

Observation: Both laboratory practice and provider-patient interaction was conducted with

consecutive patients.

21 | P a g e

Table 2: Summary of sample size, data source and sampling technique

Study unit Sample size Sampling technique

HCs 4 Purposive

Individual patient folder 384 Consecutive

TB unit register 154 Census

Expert interview 14 Purposive

TB patients 61 All TB patients

Laboratory practice observation 12 Consecutive

Provider – patient interaction observation 20 Consecutive

5.8: Inclusion and exclusion criteria

Inclusion criteria:

HCs which provide both diagnosis and treatment service were included. Individual patient folder

of adult patients aged 15 or more years and experiencing persistent cough for two or more weeks

were eligible. Cough was accompanied by one or more of TB symptoms were Weight loss, Chest

pain, Shortness of breath, intermittent fever, and Night sweats, loss of appetite, fatigue and malaise.

The records of all new patients registered for one year was eligible for TB unit register review.

Clinicians, health officers in this case, laboratory technicians, TB unit focal person, and heads of

HCs and TB program expert of the district health office were participants of this study. In

addition to this, all TB patients who were following their treatment at study HCs during the study

period were eligible. All patients were 15 or more years of old. All study subjects who did not

met the above criteria and also TB patients who were critically ill to respond were ineligible.

5.9: Data collection

5.9.1: Development of tools

The tools were developed after reviewing NTP guideline and WHO standards. Checklists for TB

resource inventory and health center, laboratory practice and provider-patient interaction

observation were prepared with the consideration NTP guideline and WHO standards.

22 | P a g e

Semi-structured questioner was developed after preliminary analysis of both quantitative and

qualitative data for expert interview. Questioner for client interview adapted with little

modification from standard client satisfaction questionnaire (23)

5.9.2: Data collectors

Individual patient folders and TB registers were reviewed by three nurses; resource inventory

was done by one nurse, three nurses conducted provider-patient observation and patient exit

interview and one laboratory technician observed laboratory practice. Expert interview was

conducted by principal investigator. Data collectors have been supervised by one health officer.

Therefore, the evaluation team consisted of nine data collectors, including principal investigator

and one supervisor. All the data collectors and supervisor were trained about the data collection

for two days. However, orientation was given to the supervisor separately on how to supervise

the data collectors.

5.9.3: Data quality management

Client interview questionnaire was translated into Afan Oromo and back translated into English

to check its consistency. Tools used in the study were pre-tested in one HC with population

having similar socio- demographic status which was not included in the study and correction was

done accordingly. Data collectors and supervisor were trained on how to collect data and how to

supervise data collectors, respectively. During data collection, regular supervision was conducted

daily. Field notes changed in to fair notes on daily basis.

5.10: Data analysis

Quantitative data was checked for completeness, edited, coded, entered and analyzed using SPSS

version 16.0. Descriptive summery was done using tables, proportion and figures. Qualitative

data was categorized thematically and supplemented the quantitative findings. Finally the

dimensions of quality in the diagnosis and treatment of TB was judged based on the pre- set

judgment matrix.

23 | P a g e

5.11: Matrix of analysis and judgment

The weight of dimensions and the respective indicators was given depending on their level of

relevance to the program. In each evaluation dimension detailed indicators that used to decide

the performance of the diagnosis and treatment of TB were listed. The indicators were given

weight and the value of dimensions was the sum of respective indicators, then the sum of all

dimension attributed to the quality of the service. The judgment criteria and standards of each

dimension and respective indicators were summarized in the following table; and more

description was presented in result section. (See chapter 6)

Table 3: Judgment analysis matrix of diagnosis and treatment of TB at Kersa district, 2012

Dimension

Rec

om

men

ded

(%)

Obse

rved

(%

)

Indic

ators

Wei

ght

(%)

Res

ult

(%

)

Judgment criteria of each dimension and their

respective indicators (%)

Availability 100 10 40 >90 v. good, 81-90 good, 70-80 fair, < 70 poor

Compliance 100 10 40 >90 v. good, 81-90 good, 70-80 fair, < 70 poor

satisfaction 100 13 20 >90 v. good, 81 -90 good, 70-80 fair, < 70 poor

Overall quality of the service 33 100 >90 v. good, 81 -90 good, 70-80 fair, < 70 poor

5.12: Ethical consideration

Ethical clearance was obtained from the ethical committee of public health and medical science

college of Jimma University. Permission was obtained from Kersa district health office.

For all participants‟ information sheet and consent form which can introduce about the study,

respondents right, autonomy and willingness to participate in the study was prepared and given

or read to participants and willingness was obtained from the study participants prior to each

interview. Names and other personal information which can violate the confidentiality of the

respondents was not taken or recorded. Any information was kept confidential and only used for

evaluation purpose. During data collection privacy of respondents was kept, free to withdrawal

from the interview at any time.

24 | P a g e

5.13: Dissemination plan

The finding was presented to the Jimma University scientific community and submitted to the

department of health service management, unit of monitoring and evaluation of College of Public

health and Medical sciences. It was also communicated to concerned stakeholders of Kersa

district health office to enable them to make informed decision in their managerial activities.

25 | P a g e

Chapter 6: RESULT

6.1: Availability of resources

This evaluation was conducted in four HCs which provide the general medical service including

DOTS service. All HCs provide DOTS service, but there was no AFB examination service in

one of HCs (Kusay Beru). Treatment provided throughout the week and also AFB examination

service provided throughout the week except weekends.

In all HCs there was adequate amount of adult dose of TB drugs and AFB staining reagents,

however there was no pediatric dose of drug in all HCs. In each HC there were one functional

microscopy and weighing scale. One of HCs (Kusay Beru) was equipped with solar microscopy,

because there was no electricity.

According to the HCWs response the reason for the absence of pediatric dose TB drug in all HCs

was the absence of it at district health office, Jimma zone health department and even at Oromia

region health bureau. Even though the HC which did not have electricity was equipped with solar

microscopy, there was no AFB examination service. According to HCWs opinion solar

microscopy is not appropriate for AFB examination and the result is not reliable.

There were two providers in one of HCs (Serbo) and the rest three each has one provider who

have received in service training about TB care. However, in one of HCs (Kusay Beru) TB

treatment has been provided by not trained provider. The reason for this was the provider of TB

care was at the same time the head of the HC; thus overburdened by HC administrative work and

can‟t provide TB treatment for full time. One of HCs (Serbo) has two health officers and the rest

each three HC has one. Similar to this there were two laboratory technicians in Serbo HC and the

rest three each has one. Except in Kusay Beru HC, where AFB examination service was not

provided, all laboratory technicians in the rest HCs have received in service training on AFB

microscopic examination.

The reason for successful provision of in service training was the presence of partner called „heal

TB‟ who provide in service training and supervision of health facilities. Experts expressed the

necessity of having additional provider in TB treatment because when one is out off work due to

26 | P a g e

illness or annual leave the additional health worker will be replaced so the work will not be

interrupted.

There was no separate TB treatment unit two of HCs (Bala Wajo and Kusay Beru). According to

the experts‟ response there were no free rooms to separate for TB treatment. However, all

participants agreed on the necessity of having the separate TB clinics and explained that it will

be established for the future. Similarly, there was no separate room for AFB examination, thus

the AFB was integrated with other routine laboratory services. There were also no separate

sputum specimen collection areas in all HCs.

In all HCs there were IEC materials in different language (Afan Oromo, Amharic and English)

posted in waiting areas and different units of services. TB suspects screening procedures was

posited in OPD room in all HCs, but there was no NTP guideline at OPD room in all HCs. The

guideline of the program was available in two of HCs (Serbo and Bulbul) which also have

separate TB treatment unit. Guideline was available only in TB units. There was TB treatment

algorism in all HCs, whether it was separate TB clinic or not. In all HCs there were standard

formats (AFB request paper, referral and report forms) and laboratory AFB register, but there

was no standard TB register in all HCs.

27 | P a g e

Table 4: Judgment matrix of availability dimension of diagnosis and treatment of TB at Kersa district, 2012

Indicators

Nu

mb

er

Obse

rved

Wei

ght

Res

ult

Res

ult

in %

Judgm

ent

Number of HCs where full time DOTS providers were available 4 3 10 7.5 75 Fair

Number of HCs where separate TB clinics were available 4 2 5 2.5 50 Poor

Number of HCs where adequate amount of adult dose of TB drugs were available 4 4 20 20 100 v. good

Number of HCs where adequate amount of pediatric dose of TB drugs were available 4 0 10 0 0 Poor

Number of HCs where adequate amount of AFB reagents were available 4 4 10 10 100 v. good

Number of HCs where functional weighing scales for DOTS service was available 4 4 15 15 100 v. good

Number of laboratory units where functional microscopy available 4 4 15 15 100 v. good

Number of laboratory units where laboratory AFB registration book were available 4 4 5 5 100 v. good

Number of TB unit /TB treatment providing unit/ where standard TB unit register were available 4 0 5 0 0 Poor

Number of TB unit /TB treatment providing unit/ where program guideline was available 4 2 5 2.5 50 Poor

Overall availability dimension 100 77.5 77.5 Fair

28 | P a g e

6.2: Compliance dimension

6.2.1: Diagnosis of tuberculosis

Individual patient folder of 384 TB suspects (patients with cough of > 2weeks) diagnosed at

three HCs (Serbo, Bulbul and Bala Wajo) were reviewed to make sure that whether TB suspects

were requested for AFB examination service or not. One eighty two (47.4%) of them were

diagnosed at Serbo HC, 103 (26.8%) at Bulbul HC and 99 (25.8%) at Bala Wajo HC. The age of

all patients was 15 year and above, the mean age was 36.80 (SD +/- 16.14). One hundred eighty

three (47.7%) of patients were males and 201(52.3%) were females.

AFB examination was ordered for only 249 (64.8%) of 384 patients. Experts mentioned that the

reason for not ordering all the TB suspects for AFB examination could be the negligence of

HCWs. One of heads of HCs said, “if the clinicians are alert to screen TB suspects accordingly,

the procedure is very easy to do so and nothing makes them to miss the case.”

The test result of 21(8.4%) patients was not recorded in both individual patient folders and in the

laboratory AFB register, so they were assumed not had received AFB examination service.

Therefore AFB performed only for 228 (59.4%) of TB suspects. Ten (4.4%) of which were

smear positive, and thus diagnosed as smear positive PTB. This diagnosis was considered as

correct because the laboratory register review showed that all patients had three initial smears

positive for AFB.

Regarding low case detection, experts suggested that requesting all TB suspects for AFB test and also

strengthening referral linkage of TB suspects from community could increase smear positive case

detection.

29 | P a g e

The finding of laboratory practice observation

Twelve laboratory practice observation was conducted. Each patient submitted 3 specimens,

therefore the total number of sputum specimen submitted were (12X3=36). Observation

conducted from collection of sputum up to recording and dispatching of the result.

All of the patients observed were new for AFB examination. In all HCs the laboratory

technicians were responsible for specimen collection. Clinicians sent the TB suspects with the

AFB request paper to the laboratory unit. The common information filled in the request paper

was the name, age, sex, the purpose of the AFB request (whether for diagnosis or follow up).

Only for two patients did HCWs wrote the name of the health center where diagnosis performed.

Laboratory technicians instructed all patients to produce the suitable sputum specimen. For all

specimens (specimen number=36) new sputum container and new frosted slides were used. In all

laboratories the applicator stick was used for smearing and Bunsen burner for fixing the smear.

All laboratories did not filter both carbon fuchsin and methyline blue. In all cases the staining

procedures was undertaken in the recommended AFB staining procedures (five minutes for

carbon fuchsin, three minutes for acid alcohol and one minute for methyline blue).

Time spent to examine each slide was observed. It takes 1-5minutes to examine each slide with

the mean time of 3.2 minutes. All technicians stored AFB slides accordingly for external quality

control; all negative and positive slides in separate boxes.

Laboratory technicians described that though they stored AFB slides for rechecking, they have

never sent to regional laboratory. TB focal person at the district is responsible to collect and take

AFB slides from the diagnostic units to regional laboratory. But the district TB focal person was

even did not supervisees each HC in the last six months prior to the study period.

Diagnoses from TB register review

Forty nine of 154 TB patients were smear positive, 14 of which were diagnosed at study HCs.

Laboratory register review showed that, 12 of those 14 smears positive PTB patients diagnosed

at study HCs had three, and the rest two patients had two initial smears positive for AFB. Therefore,

diagnosis was considered as correct for all smear positive PTB patients diagnosed at study HCs.

30 | P a g e

Experts described that smear negative PTB and EPTB were diagnosed at Jimma specialized

Hospital. Therefore, the compliance of diagnosis for smear negative and EPTB were not

assessed.

6.2.2: Treatment of tuberculosis

Records of 154 all forms of new TB patients registered in four HCs for one year october1/2010

to september30/2011, was reviewed. One hundred twelve (72.7%) were registered at Serbo HC,

19 (12.3%) at Bulbul HC, 23 (14.9%) at Bala Wajo HC. Forty nine (31.8%) of patients were

smear positive PTB, 36 (23.4%) smear negative PTB and 69 (44.8%) were EPTB. one hundred

one (66%) of patients were treated by RH and 52 (34%) were by EH. Seventy three (47.4%)

were males and 81 (52.6%) were females. Twenty one of patients aged below five year, and

majority of patients, 133 were in age category of 15-45 years.

Except one all patients finished intensive phase of treatment. While 31 (64.6%) of 48 smears

positive PTB patients claimed as cured, 120 of all forms of cases completed the treatment. One

patient died at the midst of intensive phase, one has default the treatment and the result of one

was not recorded. Therefore, in general the treatment success rate including cured and treatment

completed was 98%.

According to HCWs response the reasons for such high success rate were: treatment service has

never been interrupted in any particular time, the number of patients was small to follow up and

patients have good awareness regarding the consequence of treatment interruption. In addition

to these there was good provider- patient interaction, which could strengthen the treatment

compliance. The reason for relatively low cure rate was some patients could not produce

appropriate sputum for follow up AFB test, therefore follow 5th

/7th

month sputum were not

performed.

31 | P a g e

6.2.3: Treatment monitoring

The weight of the patients was used to determine the dose of the drug. There was no pediatric

dose of the drug, so the dose and regimen of the drug that such patients had received was not

assessed.

The weight of all patients under intensive phase of treatment was recorded at the beginning of

treatment. One hundred twenty one (91%) of 133 patients received the right dose of drug under

intensive phase. Eight patients received under the recommended doses and four patients received

above the recommended dose.

The weight of 110 patients was measured at the beginning of continuation phase (end of

intensive phase), and the rest 23 patients were not. From those 110 patient, 58 (52.7%) received

the right dose, 47 (42.7%) received below and five (4.5%) patients received above the

recommended dose. All patients received the right regimen under both phases of treatment.

From TB register, 106 (62.3%) of 153 intensive phase patients received the observed treatment

for the recommended 56 days while the rest treated for less than 56 days (mean=43 days).

Seventeen (32.7%) of 52 continuation phase patients treated by EH visited HCs in regular interval

of one month to receive TB drugs and the remaining 35 patients missed at least one monthly

appointment (mean=2.48). The adherence rate of patients treated with RH was not assessed, because

there was no revised TB register in all HCs.

The application of recommended sputum examination of smear positive PTB patients at the end

of 2nd

, 5th, 6th/7

th months of treatment was checked from TB unit register review. Forty eight

smear positive PTB patients finished both intensive and continuation phase of treatment and their

sputum follow up test presented in the following table. (Table 5)

Table 5: Number of smear positive PTB patients received sputum follow up test at Kersa district,

2012.

AFB test Performed Not performed Number

Frequency Percent Frequency Percent

32 | P a g e

End of 2nd month 42 87.5 6 12.5 48

End of 5th month 27 56.2 21 43.8 48

End of 6th month 10 38.5 16 61.5 26

End of 7th month 8 36.4 14 63.6 22

For patients received EH the last sputum conversion test performed at the end of 7th

month, for these received RH the last follow up sputum performed at the end of 6th

month.

The finding of provider - patient interaction

Twenty patients were observed during the study period while taking the TB drug in front of

providers. There was no barrier of communication concerning the language, all of patients and

providers were using Afan Oromo.

After greeting their clients, providers took the patient cards and tick on the TB unit register; then

gave them the drug. Patients swallow drug in front of the providers. Eight out of 20 (40%)

observed patients were treated by the providers not assigned for TB treatment, and treatment

monitoring chart of 5 (25%) patients was not filled in TB register during treatment.

Providers knew and call each of their clients in their name. They asked their clients about their

health status on daily basis. The communication between patients and providers looks like the

communication between two friends. This means, providers start communication like: good

morning Mr. /s X? How are you? Are you ok? Are you feeling good? Do you have any

difference of feeling from yesterday? ...... Therefore their communication was not stepwise as

expected, but very good relationship did they have.

Reporting and Supervision

Regarding the submission performance report, all HCs submitted complete and timely (quarterly)

report to the district health office in 2010/11, from July 1/2010 to June 30/2011.

Regarding HCs supervision, all HCs have never been supervised by either district TB program

expert or heads of HCs with in the six months, prior to this study. Before four months of this

33 | P a g e

study, all HCs were supervised by Jimma zone health department TB program expert, but did not

provided the written feedback. As the providers mentioned, the experts of the program have

provided only the oral feedback of the supervision.

However, all HCs have been supervised by heal TB staffs (NGO) at least once within the six

months; and one of the HCs (Bulbul) received the written feed back of the supervision during

study period. They have supervised not only TB unit but also the laboratory unit and OPD

(clinicians‟ practice).

34 | P a g e

Table 6: Compliance dimension of diagnosis and treatment of tuberculosis at Kersa district, 2012

Indicators Number Observed weight Result Result

in %

Judgment

Proportion of patients with > 2 weeks of cough for who smear test ordered. 384 249 15 9.7 64.6 Poor

Treatment adherence rate under intensive phase 153 106 15 10.4 69.3 Poor

Proportion of patients under intensive phase of treatment who enrolled in correct dose of treatment 133 121 15 13.6 90.6 Good

Proportion of patients under continuation phase who enrolled in correct dose of treatment 109 64 10 2.9 29 Poor

Proportion of SM + ve PTB for who sputum follow up performed at the end of 2nd month of Rx 48 42 10 8.7 87 Good

Proportion of SM + ve PTB for who sputum follow up performed at the end of 5th month of Rx 48 27 5 2.8 28 Poor

Proportion of SM + ve PTB for who sputum follow up performed at the end of 6/7th month of Rx 48 18 5 1.8 18 Poor

Treatment success rate 153 150 15 14.7 98 v. good

Number of complete reports submitted timely to district health office in 2011/12 4 4 5 5 100 v. good

Number of supervision conducted by district TB program expert in the last six months. 16 0 5 0 0 Poor

Over all compliance dimension 100 69.6 69.6 Poor

35 | P a g e

6.3: Patient satisfaction survey

From total 72 TB patients at Kersa district during data collection period, 12 were not participated

in this study, because 4 were below 15 years old and 7 were referred to health posts. Therefore

exit interview was conducted with only 61 TB patients, of which 16 (26.2%) were under

intensive phase and 45 (73.8%) were under continuation phase of treatment. Thirty nine (63.9%)

patients were following their treatment at Serbo HC, 8 (13.15) at Bulbul HC, 9 (14.8%) at Bala

Wajo HC and 5 (8.2%) at Kusay Beru HC.

Table 7: Socio-demographic characteristics of TB patients at Kersa district, 2012.

Sex Number Percent

male 29 47.5

female 32 52.5

Age Number Percent

15-24 30 49.2

25-44 31 50.8

Ethnicity Number Percent

Oromo 52 85.2

Amhara 3 4.9

Kefa 3 4.9

Silte 2 3.3

Yem 1 1.6

Religion Number Percent

Muslim 51 83.6

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orthodox 10 16.4

Marital status Number Percent

married 42 68.9

not married 19 31.1

Occupation Number Percent

farmer 26 42.6

house wife 18 29.5

student 8 13.1

merchant 6 9.8

government employees 3 4.9

Educational status Number Percent

illiterate 27 44.3

1-4 20 32.8

5-8 10 16.4

>9 4 6.5

Residence Number Percent

rural 51 83.6

urban 10 16.4

Only two patients use public transport, car, and one patient uses horse as means of transportation,

and the rest 58 (95.1%) patients visit HCs on foot. The distance of their home to HCs was

assessed in terms of the time that they spend for one trip to HC. The mean time it takes is

37 | P a g e

83.46minutes with the SD of 59.3. The walk time of 12 patients was less than 30 minutes; it

takes 30-60 minutes for 17 patients, 61-120 minutes for 25 patients and the rest spent above 120

minutes to reach HCs.

Among the total interviewed, 12 of the patients claimed the presence of other family members

suffering from cough for two and more than two weeks. Out of those 10 (83.3%) visited HCs for

AFB examination, and the rest were not. Similarly 32 participants claimed for the presence of

children below five years of age in their house, out of which 24 (75%) brought to HCs and got

diagnosis for TB.

Patient satisfaction level

Client satisfaction was assessed using 13 likert scale items. The responses of client were

dichotomized in to satisfied and dissatisfied; those who were very satisfied and satisfied were

categorized as „satisfied‟ and very dissatisfied and dissatisfied were categorized as „dissatisfied‟.

In general, the majority of patients were satisfied with all items. All participants were satisfied

with items which indicate the availability of providers, availability of TB treatment and

laboratory service, convenience of TB clinic to get easy. More than 90% of patients were

satisfied with convenience of TB clinic working hour, waiting time, attention and respect of

providers, friendless with the providers and overall service quality.

However, 29.5 % of patients were dissatisfied with the convenience of HC to their home; and

31.1% were dissatisfied with the daily visiting of HC for TB treatment. In addition to this, 21.3%

were neither satisfied nor dissatisfied with the competency of providers and adequacy of

explanation about the treatment. (Table 8)

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Table 8: The satisfaction level of patients with the DOTS service at Kersa district, 2012 (N=61)

Satisfaction questions

v.

sati

sfie

d

Sat

isfi

ed

Neu

tral

Dis

sati

sfie

d

v. d

issa

tisf

ied

How satisfied are you with the availability of laboratory service when you needed? 86.9 13.1 0 0 0

How satisfied are you with availability of TB drugs when you needed? 93.4 6.6 0 0 0

How satisfied are you with presence of TB treatment service providers at work time? 95.1 4.9 0 0 0

How satisfied are you with convenience of HC to your home? 32.8 37.7 0 24.6 4.9

How satisfied are you with easy in getting to TB clinic? 90.2 9.8 0 0 0

How satisfied are you with the daily visiting of health center for TB treatment? 36.1 29.5 3.3 29.5 1.6

How satisfied are you with convenience of TB unit work hours? 75.4 23.0 1.6 0 0

How satisfied are you with time spent in waiting room? 78.7 19.7 1.6 0 0

How satisfied are you with the friendliness/courtesy of the providers? 93.4 4.9 1.6 0 0

How satisfied are you with the attention and respect of providers to your privacy? 96.7 3.3 0 0 0

How satisfied are you with the competence/knowledge of the providers? 78.7 0 21.3 0 0

How satisfied are you with the adequacy of explanation about treatment? 78.7 0 21.3 0 0

How satisfied are you with the overall quality of the service? 50.8 39.3 9.8 0 0

39 | P a g e

Table 9: Summary indicators of client satisfaction level at Kersa district

s/n Indicators % Observed Weight Result

Result

in %

Judgment

1 Proportion of patients satisfied with the availability of laboratory services when needed 100 100 5 5 100 v. good

2 Proportion of patients satisfied with the availability of drugs when needed 100 100 10 10 100 v. good

3 Proportion of patients satisfied with the availability of providers in TB clinic 100 100 10 10 100 v. good

4 Proportion of patients satisfied with the convenience of HC to their home 100 70.5 5 3.5 70.5 Poor

5 Proportion of patients satisfied with the simplicity/convenience to get TB clinic at HC 100 100 5 5 100 v. good

6 Proportion of patients satisfied with the daily visiting of HC for TB treatment? 100 65.6 10 6.6 65.6 Poor

7 Proportion of patients satisfied with the convenience of TB unit work hours 100 100 5 5 100 v. good

8 Proportion of patients satisfied with the time spent while waiting for providers. 100 98.4 10 9.8 98.4 v. good

9 Proportion of patients satisfied with the attention and respect of providers to their

privacy.

100 100 10 10 100 v. good

10 Proportion of patients satisfied with the competence/knowledge of the providers 100 78.8 5 3.9 78.8 Poor

11 Proportion of patients satisfied with the adequacy of explanation about the treatment 100 78.8 5 3.9 78.7 Poor

12 Proportion of patents satisfied with the overall quality of the service 100 90.2 20 18 90 v. good

40 | P a g e

6.4: Summary of dimension

The quality of the service was measured through 33 indicators of the different respective

dimension as presented in the following table. (Table 10)

Table 10: Summary dimensions of quality in the diagnosis and measurement of tuberculosis

at Kersa district, 2012

s/n Dimension Expected Observed # Indicators Weigh Result Judgment

1 Availability 100% 77.5% 10 40% 31% Fair

2 Compliance 100% 69.6% 10 40% 27.8% Poor

3 satisfaction 100% 90% 13 20% 18% Good

Overall quality of the service 33 100% 77% Fair

41 | P a g e

Chapter 7: Discussion

All HCs have been providing TB treatment, but one of which did not have AFB

examination service due to the absence electricity. This mean there were only three

diagnostic units for 188,268 population of the district. From this account the diagnostic unit

(microscopic unit) to population ratio is 1:62,756, this is lower than the WHO

recommendation for developing countries, which is 1:50,000 (24).

All HCs have at least one nurse who has received in service training on TB care, however

in one of HCs there was no full time assigned TB treatment provider. Therefore, in three of

four HCs (75%) TB care was provided by trained TB focal persons, which is better when

compared with the study finding at Tigray where only in 57% of TB clinics TB care run by

trained TB focal person. Based on the study finding of health workforce crisis in TB control

of 22 HBCs, there was the shortage of staffs at district health facility level in two countries

and 14 at central level. However the same the same study revealed that there was no

apparent association between reported staff numbers and the country's TB burden or current

case detection rates (25).

From TB register review the cure rate of smear positive PTB was 64.6% and treatment

success rate was 98%. When compared with the study finding at south India, the present

study revealed relatively low cure rate and high treatment success rate, which were 84.2%

and 83.4% respectively (26). The treatment success rate is also far better than the national

target (85%) for treatment success (3).

From TB register review 5.8% of patients under intensive phase received below the

recommended dose and 2.9% above the recommended dose. Similarly, 40.6% patients

under continuation phase of treatment received below the recommended dose and 4.7%

above the recommended dose. In addition to this 21 children received the adult dose of drug

due to the absence of pediatric dose in all HCs. This contrasts the NTP as well as WHO

standards; and also could cause drug side effect, hepatotoxicity (27).

42 | P a g e

The adherence rate of intensive phase patients was 62.3%; and 32.7% of continuation phase

patients did not miss their monthly appointment. This is the better adherence rate when

compared with the study finding in Tigray region where only 5% of patients received

observed treatment for recommended 56 days of intensive phase and only 16% attended

health facilities on monthly basis to collect TB drug (14).

However, this finding is against the recommendation of both NTP guideline and WHO

standards of TB treatment. According to this recommendation, all intensive phase patients

must take TB treatment on daily basis, followed by 6 months of self-administered treatment

with a monthly visit to health facility to receive the drugs. (3, 6)

From total 48 smear positive PTB patients, 87.5%, 56.2% and 37.5% have got smear follow

up test at the end of 2nd

,5th and 6/7

th months of treatment, respectively. This contrasts the

NTP guideline, which recommends that all sputum-positive patients on TB treatment must

have one sputum specimen follow test at the end of 2nd, 5th and 7th „month (3). The

proportion of patients got the sputum follow- up test at the end of 2nd

month was relatively

high, 87.5%. However, this is lower than the study finding at Burkina Faso, which is

92.1%. (28)

Only 64.8% of patients with persistent cough for two or more weeks were ordered for AFB.

However the NTP and WHO standards recommended 100% of such patients should have

AFB examination (3).

The major reasons that providers mentioned regarding this poor diagnosis was negligence

of HCWs to screen TB suspects. The similar finding was obtained from the study at China,

where the failure of doctors to recognize TB symptoms and being not very alert to TB-

related symptoms were reasons that the experts described for the purpose of poor diagnosis

(29).

Smear positive case detection rate was 4.4%, this contrasts the recommended smear

positive case detection for developing countries, that is 10% (24); and also relatively lower

43 | P a g e

than the study finding at Tanzania, where it was 6.1% (30). It is also too far lower than the

study finding in India where 27 %o, (31), SNNPR where it was 25%. (32), and Rwanda,

where, 17.3% of TB suspects were smear positive (33).

Limited access or utilization of health facilities, insufficient clinical suspicion and referral

of TB suspects for diagnosis, inadequate use or functioning of smear microscopy services

were some of the reasons for low smear positive case detection (24). Similarly, low

availability of TB diagnosis units (only 3AFB examination service providing HCs), low

requesting of TB suspects for AFB examination and absence of laboratory quality control

system were the contributing factors for low smear positive case detection (4.4%).

There was poor supervision system in all HCs. All HCs have never been supervised by

district TB focal person within six months, prior to study period. However, NTP guideline

and WHO recommends planned and regular supervision of TB program. According to NTP

guideline district TB focal person should supervise health facilities once per month (3).

All patients were satisfied with the majority of satisfaction items. The overall satisfaction

level was 90%. This is higher than the study findings in Jimma specialized Hospital, which

were 57.1% and 77%, (34), and 77% (35) and Saud Arabia, which was 66.1% (36).

The difference could be due the context of service provision. This study was conducted in

HCs where patients experienced long time relationship with the providers, but the studies

presented above were conducted in Hospital level and did not have such long time

relationship with the providers.

However certain number of patients became dissatisfied with the convenience of HC to

their home and visiting the HC on daily basis for TB treatment. This might be due to the

distance of HCs to the location of patients. Because the travel time of 15 of 18 patients

dissatisfied with the HCs convenience and 10 of 19 patients dissatisfied with the daily

visiting of HCs was 1hr or more (mean time= 84.4 minutes). This is relatively similar with

the study finding (82.4 minutes) at West Shoa Zone, Central Ethiopia (37).

44 | P a g e

Major limitations considered were respondent bias for client exit interview and also during

the patient- provider observation HCWs may act as required because of the observer is

there. In addition to this, the possible limitations include the medical records which were

the source of information for this study might not be documented well.

As presented in the above table, the structural aspect (availability) of service was fair; the

process aspect (compliance) was poor and the outcome of the service (client satisfaction)

was good. This finding was against the conceptual framework of the service.

However, the structure-process-outcome model is only a servant, not a master. It should be

remembered that the relations postulated to exist between adjacent pairs in the structure-

process-outcome model are not certainties. The general assumptions behind the

Donabedians model (Structure-process-outcome) of health care quality measurement were

(14).

If appropriate resources are available, the likelihood of their appropriate use and

then achieving attainable outcomes is high.

Resources availability doesn‟t guarantee quality of service. However, processes of

care cannot be implemented in the absence of adequate resources

If healthcare is provided in compliance with standard guideline, potentially

attainable outcomes will be achieved.

If clients are satisfied with the service provided, then they tend to be loyal.

And if they‟re loyal they not only utilize the service more, but also refer other

clients. However client satisfaction doesn‟t guarantee the quality of service.

45 | P a g e

Chapter 8: Conclusion and recommendation

8.1: Conclusion

The overall quality of the service was fair. However there were certain constraints in the

provision of quality TB care. Absence of pediatric dose of TB drugs, absence of separate

TB units in two of HCs and absence of TB register were some of the constraints from

structural aspects of quality. Likewise, prescribing incorrect dose of drug, low treatment

adherence rate for both phases, not requesting all TB suspects for AFB examination and

poor supervision trends were some of the constraints from process aspects of quality.

Though all patients were satisfied with majority of satisfaction items, relatively high

proportion, 31.1% were dissatisfied with daily visiting of HCs and 29.5% were dissatisfied

with the convenience of HCs to their home.

8.2: Recommendation

There should be regular and continuous supply of TB drug (pediatric dose)

Heads of HCs should supervise the performance of the HCWs regularly (preferably

once per week).

District health office should facilitate refresher in-service training for HCWs

working at diagnosis units by using the NTP guideline.

TB focal person should carry out specific supportive supervisions visits in HCs

monthly on a regular basis.

Both internal and external laboratory quality control system should be strengthened.

All HCs should decentralize DOTS service to health posts.

46 | P a g e

Chapter 9: Meta evaluation

Meta evaluation standards such as utility, feasibility, propriety, and accuracy were used to

determine the effectiveness of evaluation. The quality of this study was evaluated based on

the Meta evaluation standards by using program evaluation models Meta evaluation

checklist set by Daniel L. Stufflebeam (38).

9.1: Accuracy standard

All the data collection, analysis, and presentation techniques were carried out based on

scientific methods. Quality control strategies were formulated well. Data was collected

from multiple sources using multiple methods and triangulation was employed to reach a

valid conclusion by program document review, and expert interview to maximize accuracy.

9.2: Utility standard

The evaluation protocol considers the information needs of major intended users by

involving them starting from the evaluability assessment to the implementation of

evaluation. The evaluation questions were the needs of the stakeholders about the program.

Thus, there was a high likelihood of addressing information needs and values of

stakeholders that ensure utilization of the evaluation findings for program improvement.

9.3: Feasibility standard

TB control program by using the DOTS and other strategy is a well-established program

with national guideline that makes certain the availability of adequate data for the

evaluation. The cost considered the presence of limited resources and the resources which

were used are justifiable for benefits of program improvement.

47 | P a g e

9.4: Propriety standard

There was no procedure that affects the privacy, dignity, confidentiality, and rights of

participants. Ethical Issues of the evaluation protocol are well respected. This ensures that

the evaluation fulfills the propriety standards.

Chapter 10: References

1. World Health Organization. WHO report 2011. Global tuberculosis control:

WHO/HTM/TB/2011.16. Geneva, Switzerland: WHO, 2011

2. World Health Organization. The Global Plan To Stop TB 2011-15: Transforming

the fight toward elimination of tuberculosis. Geneva, Switzerland: WHO, 2011

3. Federal Ministry of Health Ethiopia: Tuberculosis, Leprosy and TB/HIV Prevention

and Control Programme Manual Fourth Edition. Addis Ababa, Ethiopia: FMOH,

2008

4. Kendall, A.E. U.S. Response to the Global Threat of Tuberculosis: Basic Facts.

2012

5. Makombe, R. Special Summit of African Union on HIV/AIDS, Tuberculosis and

Malaria (ATM). SP/Ex.CL/ATM/4 (I) .Abuja, Nigeria: AU, 2–4 may, 2006

6. World Health Organization. WHO report 2010. Global tuberculosis control:

WHO/HTM/TB/2010.7. Geneva, Switzerland: WHO, 2010

7. Kersa district health office. DHO report 2010/11. District Tuberculosis control:

Serbo, Kersa: DHO, 2010/11

8. Jimma zone health department. Zonal performance report 2010/11. Jimma zone

Tuberculosis control: Jimma: Jimma, 2010/11

9. Good practice guidance on HIV/AIDS, TB and malaria final report, July 2008

10. Shargie E, & Lindtjorn, B. DOTS improves treatment outcomes and service

coverage for Tuberculosis in South Ethiopia: A retrospective trend analysis. BMC

Public Health, 2005

11. Taddese Geremew, C. J. Assessment of quality of care delivered for infectious

pulmonary tuberculosis patients. Ethiop J Health Sci. , Vol. 1, No. 1. Jimma Zone

Health Office, Ministry of Health, August,2011

48 | P a g e

12. Qian Long, Y. L. (2 October 2008). Barriers to tuberculosis care: a qualitative study

among Somali pastoralists in Ethiopia. BMC Health Services Research, 2008

13. M Mesfin, J. N. Quality of tuberculosis care and its association with patient

adherence to treatment in eight Ethiopian districts. Oxford University Press, (2009)

14. Donabedian, A. Introduction to Quality Assurance in Health Care. First edition,

Oxford University, 2003

15. Ari Probandari, L. L. –K. Missed opportunity for standardized diagnosis and

treatment among adult Tuberculosis patients in hospitals involved in Public-Private

Mix for Directly Observed Treatment Short-Course strategy in Indonesia: a cross-

sectional study: BMC health service research, 2010

16. Sanneh AFNS, P. J. Comparison of Pulmonary TB DOTS clinic medication before

and after the introduction of daily DOTS treatment and attitudes of treatment

defaulters in the Western Division of the Gambia. African Health Sciences Vol 10

No 2 ., June 2010

17. Shargie E, M. A. (2005).Quality control of sputum microscopic examinations for

acid fast bacilli in southern Ethiopia. Ethiop.J.Health Dev.2005;19(2):104-108]

18. Gemeda Abebe, A.L. Awareness, healthcare seeking behavior and perceived stigma

towards tuberculosis among tuberculosis suspects in a rural community in southwest

Ethiopia. (Unpublished) 2007

19. Mohamed A.I, M.Pharm, Y. M. (anuary 2007,). Knowledge of Tuberculosis: A

Survey among Tuberculosis Patients in Omdurman, Sudan: Khartoum, Sudan.

Sudanese Journal of Public Health: January 2007

20. Wikström, G. Women‟s Perspectives on Pathway to Diagnosis of Pulmonary

Tuberculosis Women Voices from Community Level in Uganda. Nordic School of

Public Health, 2011

21. Alkin, Marvin C. Evaluation essentials from A to Z. New York, USA: The Guilford

Press, 2011

22. Yin, Robert K. Case study research: Design and methods. Reve Beverly Hills,

California: Sage; 2009

23. Roy P, Thomas WJ. The concept of access. Medical Care. Vol. XIX, No. 2 .J.B.

Lippincott. co.; February 1981. P. 128-131

49 | P a g e

24. World Health Organization. Compendium of Indicators for Monitoring and

Evaluating National Tuberculosis Programs. WHO/HTM/TB/2004.344.Geneva,

Switzerland: WHO, 2004

25. José Figueroa-Munoz1, Karen Palmer1, Mario R Dal Poz2, Leopold Blanc1,Karin

Bergström1 and Mario Raviglione1. 24 February 2005. The health workforce crisis

in TB control: a report from high-burden countries.: World Health Organization :

Geneva, Switzerland , 24 February 2005

26. K. Jaggarajamma, G. Sudha, V. Chandrasekaran, C. Nirupa, A. Thomas, T. Santha,

M. Muniyandi and P.R. Narayanan. reasons for non-compliance among patients

treated under revised national tuberculosis control programme (rNTP), tiruvallur

district, south INDIA. Indian J Tuberc 2007; 54:130-135

27. Jussi J. Saukkonen, David L. Cohn, etal… An Official ATS Statement:

Hepatotoxicity of Antituberculosis Therapy. American Thoracic Society

Documents. Vol 174. pp 935–952, 2006 (Internet address: www.atsjournals.org

28. S. M. Dembele, H. Z. Ouedraogo, A. Combary, N. Saleri, J. Macq, B. Dujardin.

Conversion rates at two-month follow-up of smear-positive tuberculosis patients in

Burkina Faso. The International Journal of Tuberculosis and Lung Disease .INT J

TUBERC LUNG DIS 11(12):1339–1344, 2007

29. B. Xua,b, G. Fochsen b, Y. Xiua, A. Thorson b, J.R. Kempc, Q.W. Jiang.

Perceptions and experiences of health care seeking and access to TB care.

Departments of Epidemiology, School of Public Health. Fudan University:

Shanghai, China. Health Policy 69 (2004) 139–149

30. Jeremiah S., Benson R., Emmanuel O., et al. Low sputum smear positive

tuberculosis among pulmonary tuberculosis suspects in a tertiary hospital in

Mwanza, Tanzania. Tanzania Journal of Health Research Volume 14, Number 2,

April 201

31. Mohammad Tahir, S.K. Sharma, Duncan-smith Rohrberg, Deepak Gupta, U.B.

Singh and P.K. Sinha. DOTS at a tertiary care center in northern India: Indian J

Med Res 123, May 2006, pp 702-706

50 | P a g e

32. Mohammed A. Yassin1 and Luis E. Cuevas2. How many sputum smears are

necessary for case finding in pulmonary tuberculosis? Tropical Medicine and

International Health, volume 8 no 10 pp 927–932 October 2003

33. Muvunyi et al. Prevalence and diagnostic aspects of sputum smear positive

tuberculosis cases at a tertiary care institution in Rwanda. African Journal of

Microbiology Research Vol. 4(1) pp. 088-091 January, 2010

34. Lemessa olijira, Solomon Gebreselassie. Satisfaction with outpatient health services

at Jimma Hospital, south Western Ethiopia. (Ethiop. J. Health Dev. 2001;15(3):179-

184)

35. Fekadu A. et al. Assessment of clients‟ satisfaction with health service deliveries at

Jimma University specialized hospital. Ethiop J Health Sci. Vol. 21, No. 2 July

2011

36. Alzolibani.A. Patient satisfaction and expectations of the quality of service of

University affiliated dermatology clinics. Journal of Public Health and

Epidemiology Vol. 3(2), pp. 61-67, February 2011

37. Birhanu et al. Determinants of satisfaction with health care provider interactions at

health centers in central Ethiopia: BMC Health Services Research 2010, 10:78

38. Stufflebeam LD. Evaluation models, new directions for Evaluation American

Evaluation Associations, San Francisco, Jossy-bass, November 2001

51 | P a g e

Chapter 11: Annex

11.1: Consent forms

Consent forms for all TB DOTS service providers at _______________________ HC

Dear sir/ madam

My name is ______________________________________________________ I came

from Jimma University. I am a conducting the process evaluation of quality in the diagnosis

and treatment of tuberculosis. The purpose of the study is to find ways of improving the

quality of diagnosis and treatment of tuberculosis. I am interested to know your experiences

so far in providing TB DOTS services. May I ask you some questions about this? Please be

assured that this discussion is strictly confidential and your name will not be recorded.

Also, you are not obliged to answer any question you don‟t want to, and you may withdraw

from the interview at any time.

Do I have your permission to continue? Yes ____________No________________

Name and signature of the data collector: _________________________________

Name and signature of the supervisor: ___________________________________

52 | P a g e

Consent forms for TB patients at _________________________________ HC

Dear sir/ madam

My name is _______________________________________________________ I came

from _________________________________________ I am a member of an evaluation

team of process evaluation of quality in the diagnosis and treatment of tuberculosis at kersa

district. It is believed that provision of quality tuberculosis diagnosis and treatment

increases clients' satisfaction, which contributes to increase good treatment outcome. The

purpose of this study is to evaluate the quality of diagnosis and treatment service provided

in health center and level of satisfaction of Tuberculosis patients, and finally to give

important comment that will help to strengthen and improve quality of service. To do this,

your information is very important. I would like to ask you a few questions about your visit

to the health facility to find out your experience today. I would be very grateful if you could

spend a few minutes to answer questions related to the service. I will not put your name or

registration number in the format. All the information you give will be kept strictly

confidential. Your participation is voluntary and you are not obliged to answer any

questions you don't want. But your honest participation will contribute to generate

information that can be used to improve the quality of diagnosis and treatment of

tuberculosis.

Do I have your permission to continue? Yes _____ No________________________

Name and signature of the data collector: __________________________________

Name and signature of the supervisor: _____________________________________

53 | P a g e

11.2: Tools of data collection

Checklist for OPD charts audit/ Individual patient folder review:

Name of HC ______________________________________________________________________

Name of data collector__________________________ sig. _________________________________

Name of supervisor __________________________ sig. ___________________________________

Instruction

1. Age of patient should be >15years

2. Mark () if one of the following chief complaints was recorded in patient charts, and mark (X) if not.

3. Mark () if sputum smear test was ordered, test result recorded, either negative or positive, and mark (X) if not.

4. If the test result was positive again mark () under the number of slides positive, and mark (X) if not.

S/N

Ag

e

Sex

Co

ug

h f

or

2>

wee

ks

Wei

gh

t lo

ss

Ch

est

pai

n

Sh

ort

nes

s o

f

bre

ath

Fev

er

Nig

ht

swee

t

Lo

ss o

f

app

etit

e

Fat

igu

e

Lab

tes

t fo

r

AF

B o

rder

ed?

Res

ult

reg

iste

red

AF

B N

egat

ive

AF

B p

osi

tive

Nu

mb

er

of

AF

B

po

siti

ve

slid

es

Others

1

2

3

4

5

6

7

54 | P a g e

TB unit register review checklist:

Name of HC ______________________________________________________________________

Name of data collector__________________________ sig. _________________________________

Name of supervisor __________________________ sig. _________________________________

Instruction: Mark () if the following evidences were recorded in TB patient chart, and mark (X) if not.

S/N

MR

N

Un

it T

B

Pat

ien

t n

ame

Pat

ien

t ad

dre

ss

Sex

Co

nta

ct n

ame

Co

nta

ct a

dd

ress

Ag

e

Sm

ear

resu

lt

Lab

no

.

Wei

gh

t

Cat

ego

ry

P/P

os

P/n

eg.

EP

TB

In

ten

siv

e p

has

e

DA

TE

RX

sta

rted

Mo

nth

RX

sta

rted

No

. d

ays

RX

in

terr

up

ted

HIV

tes

t o

ffer

ed

HIV

res

ult

Sputum follow up

in months

Co

nti

nu

atio

n p

has

e

No

. d

ays

RX

in

terr

up

ted

Treatment outcome

Oth

ers

Cu

red

Co

mp

lete

d

Die

d

Fai

lure

Def

ault

Tra

nsf

erre

d o

ut

Dru

g

Do

se

2nd

3rd

5th

6th

Oth

ers

Dru

g

Do

se

55 | P a g e

Record review checklist for TB patient charts

Name of HC ______________________________________________________________________

Name of data collector__________________________ sig. _________________________________

Name of supervisor __________________________ sig. _________________________________

Instruction: Mark () if the following evidences were recorded in TB patient chart, and mark (X) if not.

X-R

AY

res

ult

if p

erfo

rmed

cult

ure

res

ult

if p

erfo

rmed

His

to -

pat

ho

log

ical

evid

ence

fro

m a

bio

psy

( F

NA

tes

t) i

f C

lin

ical

evid

ence

con

sist

ent

wit

h

acti

ve

EP

TB

T

reat

men

t

wit

h b

road

-

spec

tru

m

anti

bio

tics

AF

B r

esu

lt i

f

per

form

ed

afte

r

anti

bio

tic

trea

tmen

t

Disease

Classification

Others

S/N

Ag

e

Sex

3sl

ide

2 s

lid

es

1 s

lid

e

Su

gg

esti

ve

for

TB

N

ot

Su

gg

esti

ve

for

TB

Po

siti

ve

Neg

ativ

e

Po

siti

ve

Neg

ativ

e

Yes

No

Yes

No

Po

siti

ve

Neg

ativ

e

SM

-ve

PT

B

SM

+v

e

PT

B

EP

TB

56 | P a g e

Exit Interview for TB patients

General Information

1. Name of health center_________________________________

2. Date of data collection ________ /_____/ ______

3. Name of data collector _________________ Signature______________

4. Name of Supervisor checking filled questionnaire ___________________

Sig.______

II. Socio-demographic characteristics of clients

1. Age _________________________

2. Sex 1) Male 2) Female

3. Educational status:1) Illiterate 2) 1st-4

th grade 4) 5

th-8

th grade 5) 9

th -10

thgrade 6) other

____

4. Occupation: 1) Farmer 2) merchant 3) Gov. Employ 4) Daily labourer

5. Current marital status: 1. Single/Never married 2 Married 3 Divorced 4 Widowed

6. Place of residence 1) Urban 2) Rural

7. How far your home from HC? _______________ (in minutes)

8. Means of transportation to visit HC: 1) On foot 2) car 3) horse 4) Motor bicycle

8. Phase of treatment: 1) Intensive phase 2) continuation phase

9. For how long did you take treatment? _______________________ (In days or months)

10. Is there your family member with cough of > 2weeks? Yes_______ No ____

11. If YES forQ10 were you advised to bring for examination? Y____N___

12. Is there under five in your house? Y____N___

13. If YES forQ12 were you advised to bring for examination? Y____N__

57 | P a g e

Satisfaction Questions with the services provided

The ________________________ HC is committed to quality and client satisfaction. We

would like to know your opinion of quality in the diagnosis and treatment of TB. Please

indicate your level of satisfaction with each of the following characteristics of DOTS

service. On a scale of 1 to 5, mark (X) under the appropriate number that indicates how

satisfied you are with each of the following items. A score of 1 being very dissatisfied, 2

dissatisfied, 3 neutral 4 satisfied and 5 being very satisfied.

III. Satisfaction with the services provided

The following are statements about different characteristics that client satisfies with. Please

mark

(X) according to your agreement in the statement.

Number from 1-5 represents your satisfaction level with each statement, and rate as follow

based on your agreement:

5 =Very satisfied 4 =satisfied 3= Neutral 2 =Dissatisfied 1 =Very dissatisfied

Table: Patient Satisfaction Questions

S/N client satisfaction items

v.

sati

sfie

d (

5)

Sat

isfi

ed (

4)

Neu

tral

(3)

Dis

sati

sfie

d (

2)

V.

Sat

isfi

ed (

1)

Availability dimension

1 How satisfied are you with the availability of laboratory service

when needed?

2 How satisfied are you with availability of treatment service when

needed?

3 How satisfied are you with presence of TB treatment service

providers at work time?

58 | P a g e

Accessibility dimension

1 How satisfied are you with convenience of HC to your home?

2 How satisfied are you with easy in getting to TB clinic?

Accommodation dimension

1 How satisfied are you with the daily visiting of health center for

TB treatment?

2 How satisfied are you with convenience of TB unit work hours?

3 How satisfied are you with time spent in waiting room?

Acceptability dimension

1 How satisfied are you with the friendliness/courtesy of the

providers?

2 How satisfied are you with the attention and respect of providers

to your privacy?

3 How satisfied are you with the competence/knowledge of the

providers?

4 How satisfied are you with the adequacy of explanation about

treatment?

5 How satisfied are you with overall quality of service?

Have you any other comments that you would like to share?

59 | P a g e

Gaaffiiwwan hammam akka tajaajila kennamutti gammadaniif qophaa’e.

Buufatni fayyaa____________________________________________ tajaajila qulqulluu fi

fayyadamtoota gammachiisuuf kan dhabbatee dha. Amma wanti nuti barbaannu yaada isin

qulqullina tajaajila fi yaalii dhukkuba daranyoo sombaaf kennamu irratti qabdan

baruudhaaf. Mee adaraa sadarkaa gammachuu isin tokko tokko tajaajila daranyoo sombaaf

kennamu irratti qabdan nuf ibsaa. Sadarkaa 1 hamma 5 jiru irratti hammam akka itti

gammadan mallattoo (X) kennuun agarsiisaa. Tokkoon tokkoon gaffiichaa madaalli 1 kan

baay‟ee itti hin gammaneef, 2 itti hin gammanneef, 3 yaada hin qabuuf, 4 itti gamadeeraaf,

5 baay‟ee itti gamadeeraaf kan qophaa‟ee dha.

Lakk. Gaaffiwwan hammam akka itti gammadani

Baa

y‟e

e gam

mad

eera

(5)

Itti

gam

mad

eera

(4)

Yaa

da

hin

qab

u(3

)

Itti

hin

gam

man

ne(

2)

Baa

y‟e

e hin

gam

man

ne(

1)

Jiraachuu tajaajilaa

1 Yeroo barbaaddanitti jiraachuu tajaajila laaboratoriitti hammam

gammadan?

2 Yeroo barbaddanitti jiraachuu yaalii daranyoo sombaa argachuutti

hammam gammadan?

3 Hojeetaan fayyaa kilinika qorichi daranyoo sombaa guyyaa

guyyaan kennamuutti argamuu isaanitti hammam gammadan?

Salphina tajaajila

1 Buufatni fayyaa fageenyi inni mana keessan irraa qabutti

hammam gammadan?

2 Akka salphaatti kilinika daranyoon sombaa itti yaalamu jiru

argachuutti hammam gammadan?

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Iddoo tajaajila

1 Qoricha daranyoo sombaa fudhachuuf buufata fayya deemutti

hammam gammadan?

2 Sa‟atii hojii kutaa daranyoo sombatti hammam gammadan?

3 Kutaa egumsaatti yeroo turtanitti (dabarsitanitti) hammam

gammadan?

Fudhatamuuma tajaajilaa

1 Walitti dhihenya ogeessa tajaajila kennuu wajjin qabdanitti

hammam gammadan?.

2 Ogeessi tajaajila kennu hammam akka isin dhageefatuu fi

hammam dhoksaa keessan dhageefatu irratti hammam

gammadan?

3 Dandeetti ogeessi tajaala kennu irratti hammam gammadan?

4 Ga‟umsa ogeessi tajajila kennu waa‟ee yaalii kennamu ibsuu

irratti qabutti hammam gammadan?

5 Tajaajila walii gala argattan irratti hammam gammaddani?

Yaada dabalataa nuf lachuu barbaddu ni jiraa?

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Interview guide to head of laboratory unit

i. Name of health center_________________________________

ii. Date of data collection ________ /_____/ ______

iii. Name of data collector _________________ Signature______________

iv. Name of Supervisor checking filled questionnaire ___________________

Sig.______

1. No of workers

Lab. Technicians_____________________

Lab. Technologist ____________________

2. Have you ever been received AFB microscopic examination training?

3. Is there quality control mechanisms (either internal or external QC mechanism)?

_________________________________________________________________________

4. Has there been interruption of lab work due to shortage of supplies and equipment or any

other reasons? __________________________________________________________

5. In your opinion what could be the factors which affect case detection?

_________________________________________________________________________

6. In your opinion how DOTS service can be improve in general?

_________________________________________________________________________

Thank you

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Interview guide to clinicians and DOTS providers

1. What are the general problems related to TB diagnosis? What are the likelihood

solutions?

_________________________________________________________________________

2. What are the general problems related to TB treatment? What are the likelihood

solutions?

_________________________________________________________________________

3. In your opinion how could case detection be improved?

________________________________________________________________________

4. In your opinion how could treatment adherence improved?

Thank you

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Interview guide to district program expert

1. Would you please describe your profession and experience in NTP in the district?

________________________________________________________________________

________________________________________________________________________

2. What are the general problems related to TB diagnosis? What are the likelihood

solutions?

_________________________________________________________________________

_________________________________________________________________________

3. What are the general problems related to TB treatment? What are the likelihood

solutions?

_________________________________________________________________________

_________________________________________________________________________

4. In your opinion how could case detection be improved?

________________________________________________________________________________

________________________________________________________________________________

5. In your opinion how DOTS service can be improve in general?

_________________________________________________________________________

_________________________________________________________________________

6. Describe the availability of health workers involved in TB diagnosis and treatment in the

district?

_________________________________________________________________

7. Describe the adequacy of drugs and reagents? Is there an occasion of interruption and

why? Which items? What measures were taken for interruption or shortage and your

suggestion to improve?

_________________________________________________________________

8. Describe if any other comments you would like to share?

____________________________________________________________

Thank you

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Data collection checklists:

This assessment should be completed by observing HC and through discussions with the

person in charge. In all cases you should verify the items exist by actually observing them

yourself. Remember that the objective is to identify equipment and facilities that currently

exist and not to evaluate the performance of staff. For each item, tick what you observed

and/or response from the person in charge, or describe, as appropriate under “remark”

column.

NOTE: check for expire date of reagents and drugs, describe appropriately

A. Check list to assess availability of infrastructure and facilities:

Health center Yes No Remark

Is there a clear sign that indicates the name of the HC?

Is there a clear sign that indicates different service unit in HC?

Does the HC opening and closing time clearly stated on the

sign?

Is there a waiting area for patients?

Is the waiting area clean?

Are there adequate seat in the waiting area?

Are the following HE materials in waiting area? …. In what

language

Poster

Radio

Television

CDs /cassettes about TB

OPD room

Is the room clean?

Is the diagnostic room ventilated? … Is it

Window/ventilator/others?

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Does HC have light?

Are the following facilities/items in the room?

HE material posted in OPD room at visible place.....In what

language?

NTP guideline

Lab. AFB request paper

Drug prescription paper

Patient referral form

Laboratory layout and equipment

Does lab. Unit clean?

Does lab unit has the following standards

NTP guideline

Quality control standards

Standard operating procedures( posted on staining area)

Health education material posted on visible place (in what

language?)

Laboratory arrangement….Does lab unit has the following

work areas?

Separate area/room for specimen reception

Separate area/room for preparing and staining smears

Separate area/room for smear examination

Separate area/room for registration

Benches or tables….does lab unit has benches or tables for

Specimen reception, slide storage and laboratory registers

Smear-preparation

Staining

Microscopic examination

List of laboratory materials……are the following materials

available?

Microscope

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Immersion oil with a dropper

Lens tissue

Glove

Slides

Wire loop / wooden applicator

Bunsen burner or spirit lamp burner

Forceps for holding slide and fixing

Sink with running water

Basin if there is no sink

Water filter can if no running water

Waste receptacle

Disinfectant ( either 5% phenol or 10% sodium hypo chloride)

Sputum cups

Slide holder

Slide rack

Alarm clock

Bucket for water

Box for keeping examined slides

List of the reagents used in Ziehl Nelson staining technique

Carbon fuchsine

Acid alcohol

Methylene blue

Is there posted AFB sops in the laboratory at visible spaces?

Is TB unit clean?

Is TB unit ventilated?

Does health education material posted in TB unit at visible

spaces?

Is there NTP manual in TB unit?

Is there TB unit register?

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Is there functional weighting scale in TB unit?

Others

TB Unit

Is the TB unit clean?

Check availability of following items in TB unit

TB unit register

NTP guideline

RH Eligibility and Dosage Flow Chart

Health education material posted on visible place (in what

language?)

RHZE

RH

Functional weighing scale

Pharmacy unit STORE…check availability of

RHZE

RH

Sputum cup

Slides

Carbol fuchsine

Methyline blue

Immersion oil

Review stock card for either

RHZE Stock out for the last three months

RH Stock out for the last three months

Sputum cup Stock out for the last three months

Slides Stock out for the last three months

Carbol fuchsine Stock out for the last three months

Methyline blue Stock out for the last three months

Immersion oil Stock out for the last three months

Check availability of buffer stock for at least one month

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RHZE

RH

Sputum cup

Slides

Carbol fuchsine

Methyline blue

Immersion oil

Laboratory activity observation checklist

This assessment should be completed by observing lab unit. In all cases you should verify

each activity by actually observing on site. Note that this is not to evaluate the performance

lab personnel; to observe the routine aspects of sputum smear examination. For each tick

Yes/No based on what you observed and/or describe, as appropriate under “remark”

column.

Pre analytic phase Yes No Remark

Equipment and materials arranged before starting smear

preparation

Ask the name of patients, match it with the name on the request

paper

Use new sputum cup to collect specimen

Write the same number on the body of container and request

paper

Demonstrating the patient to bring quality sputum specimen

Evaluating the quality and volume of specimen

Cross check the number of the request form and sputum container

Analytic phase

Use new slides

Use filtered carbol- fuchsine

Use filtered methyline blue

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Use a new applicator stick

Labelling the slides with lab S/N and number on sputum

container before preparing smear

Keep slides separated from one to an other

Prepared < 12 slides at once

Prepared slides dry in the air

Prepared slides dry in the flame

Fix the dried slide with the flame

Fix the dried slide with the Alcohol

Stain smear for 5 minutes with the first stain carbol-fuchsine

Decolourise smear for 3 minutes by Acid alcohol

Counter stain for 1 minute by methyline blue

Air dry the smear

Cross match slide numbers and request papers

Clean the objective after each examination with tissue paper

Post analytic phase

Record the result of each slide before removing from the Mic. Stage

Save slides for further re checking

Post analytic phase

Register the result…describe the means of dispatching the result

Others

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Provider-patient interaction observation checklist

S/N Provider-patient interaction Yes No

1. While discussing with the patient, did the provider use clear language

that patient understand simply…if possible local language

2. Before the treatment, did the provider measure patient weight?

3. Did the health worker provide correct drug based on the weight of patient?

4. Did the treatment provider observe the patient while swallowing the

drugs?

5. Did the provider remind the patient of the schedule of the next

sputum examination?

6. Did provider provided health education?

7. Did the provider let the patient ask any questions the patient may

have?

8. Did the provider respond to patient‟s questions?

9. Did the provider stress very well about the problem of defaulting&

explain the method they can be easily traced

10. Did the health worker record on the unit register immediately after

consultation of every patient?