Potential facilitators and inhibitors to the implementation and sustainability of the community-based tuberculosis care interventions. A case study from Moshupa, Botswana

PLOS ONE RESEARCH ARTICLE Potential facilitators and inhibitors to the implementation and sustainability of the community-based tuberculosis care interventions. A case study from Moshupa, Botswana Gabalape Arnold Sejie ID1,2*, Ozayr H. Mahomed1,3 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Discipline of Public Health Medicine, University of KwaZulu, Natal, Durban, South Africa, 2 Department of Health Promotion and Education, Boitekanelo College, Gaborone, Botswana, 3 Dasman Diabetes Institute, Kuwait City, Kuwait * Abstract OPEN ACCESS Citation: Sejie GA, Mahomed OH (2023) Potential facilitators and inhibitors to the implementation and sustainability of the community-based tuberculosis care interventions. A case study from Moshupa, Botswana. PLoS ONE 18(8): e0290010. https://doi. org/10.1371/journal.pone.0290010 Editor: Gifty Dufie Ampofo, University of Health and Allied Sciences, GHANA Received: December 7, 2022 Accepted: July 31, 2023 Published: August 10, 2023 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0290010 Copyright: © 2023 Sejie, Mahomed. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting information files. Background Eliminating Tuberculosis is one of the targets of Sustainable Development Goal Three. Decentralizing TB care beyond health facilities by leveraging community involvement is crucial for safeguarding effective tuberculosis care. In this study, we explored potential facilitators and inhibitors of the implementation and sustainability of community-based interventions for the prevention and treatment of TB in the Moshupa district, Botswana. Methods This study adopted a qualitative approach using a collective case design. An interpretive paradigm based on relativist ontology and subjectivist epistemology along with abductive research logic was used. The study enrolled treatment supporters of tuberculosis patients diagnosed with drug-susceptible tuberculosis between January 2019 and December 2019 in Moshupa Village for semi-structured interviews, Health care professionals for in-depth interviews, and e community leaders for focus group discussions. Clinic-based observations in Mma-Seetsele clinic were also conducted to corroborate the participants’ views. The data collected was analyzed using the NVivo version 12 software package, and statements of the participants were presented as quotes to substantiate the issues discussed. Results This study highlighted effective partnerships between health services and external stakeholders, community empowerment, and the availability of policies and standard operating procedures as facilitators of community TB implementation and sustainability. However, Insufficient funding, low service provider training, policies not embracing age and educational eligibility for treatment supporters, shortage of equipment, medicines, and supplies, PLOS ONE | https://doi.org/10.1371/journal.pone.0290010 August 10, 2023 1 / 17 PLOS ONE Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Abbreviations: CHW, Community health worker; DOTS, Directly Observed Treatment Short Course; IRB, Institutional Review Board; NGO, NonGovernmental Organization; PTB, Pulmonary TB; TB, Tuberculosis; WHO, World Health Organization. Facilitators and inhibitors to the implementation and sustainability of the community-based TB care inadequate transport availability and incentives to meet clients’ basic needs, paper-based systems, inadequate supervision, incomplete data reporting, and low service quality affected the Community TB program efficacy and sustainability in Moshupa. We also found that there was low service provider motivation and retention and that clients had low trust in treatment supporters. Conclusion The findings of this study imply that the operational effectiveness of the community TB care approach to disease elimination is compromised; therefore, initiatives addressing the key components, including the availability of resources, governance arrangements and supportive systems for community health workers, are required for successful community TB implementation and sustainability. Introduction Tuberculosis [TB] remains a serious public health threat to people of all sexes and ages, particularly in Botswana. In 2022, the World Health Organization (WHO) projections indicated TB as one of the leading causes of death worldwide [1]. Globally, an estimated 10.6 million people fell ill with TB, of which 1.6 million died from the disease, including 187 000 deaths among HIV-positive people in 2021 [2]. The burden of disease varied enormously among countries, with a global average of approximately 137 cases per 100 000 population [2]. The WHO African region had the highest TB burden, with TB incidence of 237 cases per 100 000 population and accounting for 23% of the global TB burden [2]. The proportion of TB cases co-infected with HIV was highest in countries in the WHO African Region, exceeding 50% in parts of southern Africa [2]. Botswana carries a notable proportion of the global TB/HIV burden and is listed among the 30 high-burden country lists for TB/HIV [3], with an incidence rate of 235/100,000, TB-related death rate of 35/100 000 among the HIV negative and 62/100 000 among the HIV positive, and a treatment coverage of 45% in 2020 [4]. The overall treatment success rate for the new and relapse cases treated in 2019 for Botswana was 72%, with 73% and 70% among the HIV coinfected and multi drug resistant cases, respectively [4]. Moshupa, a rural village in Botswana, had the highest TB notification rate in the country with 754/100 00 cases, and a 57% treatment success rate in 2017 [5]. The WHO in its resolve to intensify the fight against TB adopted the End TB Strategy, which envisions a TB-free world by 2035 [3]. This strategy emphasizes the importance of taking into consideration the journey of a TB patient through a series of interlinked settings and facilities, one of which is to decentralize TB care beyond health facilities and harness the contribution of communities through the provision of effective community-based directly observed therapy (DOT) to TB patients at greatest socio-economic risk, thus improving and strengthening community mobilization and treatment support [5]. The Botswana National Tuberculosis and Leprosy Program (BNTP) adopted community TB care (CTBC) (...truncated)