Assessing Implementation Fidelity of Directly Observed Treatment Provider at Phuentsholing General Hospital and Jigme Dorji Wangchuk National Referral Hospital in Bhutan: Mixed-method study

Kunzang Dorji, Yodi Mahendradhata; Trisasi Lestari

2018 | Tesis | S2 Ilmu Kesehatan Masyarakat

Background: DOTS strategy has been adopted in Bhutan since 1997 but treatment under DOT supervision has not well understood. On the other hand, a high rate of MDR-TB among new cases is alarming and indicates that MDR-TB is being transmitted as a primary infection in the general population. Therefore, evaluation of implementation fidelity of DOT is essential. Implementation fidelity is defined by adherence to intervention design, exposure or dose, quality of delivery, and participant responsiveness. Objective: To assess the implementation fidelity of DOT provider at Phuentsholing General Hospital and Jigme Dorji Wangchuk National Referral Hospital. Methods: The study used mixed-method explanatory sequential design. In Quantitative approach, we conducted a cross-sectional survey of 139 TB patients with structured questionnaires from September to November 2017 in PGH and JDWNRH. Descriptive analysis of the data was performed. In a qualitative approach, 13 in-depth interviews were conducted including 4 health staffs and 9 TB patients from two hospitals. Qualitative data analysis software was employed to identify the key issues from the interviews through coding, categorization and grouping into emergent themes. Results: We found hospital-based DOT offered depends on the type of TB disease category, which is statistically significant (P=<0.05); DOT was offered more to SPPT (84.72%) and MDR-TB (100%) compared to SNPT (26.67%) and EPT (20.51%). The overall DOT coverage was 61.87% of two hospitals; JDWNRH has provided only 58.86% of DOT while PGH has provided 85.71%. The major factors affecting poor adherence of DOT were patient, not willing to come on a daily basis due to the long distance of the DOT facility, lack of financial and family support. Several components from Quality of TB service delivery still needs to be improved, though patient responsiveness and satisfaction level was good. Conclusion: DOT is partially implemented and its fidelity is moderate, due to several challenges associated with hospital-based daily DOT as a method of TB treatment supervision.

Background: DOTS strategy has been adopted in Bhutan since 1997 but treatment under DOT supervision has not well understood. On the other hand, a high rate of MDR-TB among new cases is alarming and indicates that MDR-TB is being transmitted as a primary infection in the general population. Therefore, evaluation of implementation fidelity of DOT is essential. Implementation fidelity is defined by adherence to intervention design, exposure or dose, quality of delivery, and participant responsiveness. Objective: To assess the implementation fidelity of DOT provider at Phuentsholing General Hospital and Jigme Dorji Wangchuk National Referral Hospital. Methods: The study used mixed-method explanatory sequential design. In Quantitative approach, we conducted a cross-sectional survey of 139 TB patients with structured questionnaires from September to November 2017 in PGH and JDWNRH. Descriptive analysis of the data was performed. In a qualitative approach, 13 in-depth interviews were conducted including 4 health staffs and 9 TB patients from two hospitals. Qualitative data analysis software was employed to identify the key issues from the interviews through coding, categorization and grouping into emergent themes. Results: We found hospital-based DOT offered depends on the type of TB disease category, which is statistically significant (P=<0.05); DOT was offered more to SPPT (84.72%) and MDR-TB (100%) compared to SNPT (26.67%) and EPT (20.51%). The overall DOT coverage was 61.87% of two hospitals; JDWNRH has provided only 58.86% of DOT while PGH has provided 85.71%. The major factors affecting poor adherence of DOT were patient, not willing to come on a daily basis due to the long distance of the DOT facility, lack of financial and family support. Several components from Quality of TB service delivery still needs to be improved, though patient responsiveness and satisfaction level was good. Conclusion: DOT is partially implemented and its fidelity is moderate, due to several challenges associated with hospital-based daily DOT as a method of TB treatment supervision.

Kata Kunci : Tuberculosis Bhutan, Implementation fidelity, DOT provider