Conducting research in the “real” world: the challenge of implementation science

Camilla Burkot – MPH ‘14, Mailman School of Public Health

Quality research relies on quality data.  And collecting quality data requires, among other things, an environment that is stable, supportive, and well-resourced.  So how do you go about doing research on critical health problems in a context that lacks these precise characteristics? 

In the landlocked southern African nation of Lesotho, researchers from ICAP working on the START Study have been grappling with these questions on a daily basis.  With funds from a USAID Implementation Science grant, the purpose of START – which stands for ‘Start TB (patients) on Antiretroviral Therapy and Retain on Treatment’ – is to develop ways to improve initiation of antiretroviral therapy (ART), adherence to HIV and TB medications, and retention in care among people with HIV/TB co-infection.  Studies have shown that starting ART early after diagnosis of TB is associated with a decrease in mortality of up to 50%.  START is currently four months into enrolling patients and collecting data from 12 primary healthcare clinics and hospitals in Berea District, just north of the capital of Maseru. 

As a student at the Mailman School of Public Health, I expected to learn a lot about data collection and management when I joined the START team in Lesotho for my MPH practicum with ICAP, but I did not expect to see the extent to which research is dependent on having a stable health system, well-organized clinics, and motivated healthcare workers already in place. 

One challenge that I observed, for example, is inconsistency in the recording and reporting of routine clinical information.  When each TB/HIV patient at START’s study sites completes treatment, dies, or is lost to follow-up, START field staff collect a variety of key information about the patient and his/her course of treatment from clinic documents – a task that has turned out to be much simpler in theory than in practice.  Because many clinics in Lesotho remain without electricity, recording patient information necessarily remains largely in paper form; as such, medical information for a single TB/HIV patient may be distributed across as many as six different registers, logs, and files.  In the face of high patient volume and the absence of a system for checking the accuracy of these documents, records are often incomplete or contain contradictory information. This results in a high volume of data that must be regarded as “missing” for the purposes of research. 

Moreover, to access these records in the first place requires good partnerships with nurses and other clinic staff such as counselors and Village Health Workers.  While there are many passionate and skilled health professionals in Lesotho’s clinics striving to provide the best care possible for the Basotho people, there are others who are not as motivated and clinics suffer from high staff turnover.  At one START study site, for example, the two nurses managing the clinic both resigned in June and have yet to be replaced, which has resulted in chaotic effects on the management of that clinic and patient care. 

These are the kinds of challenges that warrant implementation science research in global health – and at the same time the ones which make that research exceptionally challenging to execute on the ground.  Despite the initial challenges in rolling out START, innovative thinking and persistence on the part of a dedicated local field staff have demonstrated that these complications are not insurmountable; they are speed bumps, not roadblocks.  But above all the process of working through them represents, in my opinion, a powerful argument in favor of a health systems strengthening orientation in global health.  From upgrading the physical infrastructure and instituting e-health and supply chain management systems, to introducing updated training programs for healthcare workers and developing mechanisms for supervising and supporting those workers even in the most remote areas. A continued focus on health systems strengthening has the potential to radically change the face of both healthcare provision and health research.   Where health systems are strengthened, not only will the possibilities for carrying out research like the START Study be enhanced, but the health challenges which motivate that research in the first place may be significantly reduced. 

The challenges of controlling TB in a mobile population

Reporting from a practicum in southern Africa.

Miriam E. Reda, MD, MPH 2013'

Tuberculosis (TB) disease is as old as history. Throughout time, the disease went from death sentence to, with the discovery of the causing organism by Robert Koch and extensive experiments, vaccinations theories and cures, that by the 20^th century it was considered a curable disease en route to elimination. However, the age of optimism was short lived as the HIV epidemic emerged in the late 20^th century and TB resurged in more extensive, aggressive and resistant forms. The concomitant burden of TB and HIV has since been top on the health agenda of international organization, medical conferences, donor societies, philanthropists, affected countries and the civil society.

  

Lesotho is one of the countries with very high burden of co-infection currently being supported by ICAP at Columbia University. A small country in southern Africa with the world’s third highest HIV prevalence at 23% and the fifth highest incidence of TB in the world,  Lesotho bears this double challenge.

In addition, with a very limited employment opportunities for men in Lesotho, the South African mining sector represents a prospect for many Basotho men to cross the borders and work on making a better living to support their families. However, this opportunity comes with substantial occupational hazards for acquiring TB.  Miners work in closed poorly ventilated mine shafts with prolonged exposure to silica dust and are exposed to the social consequences of living away from their families for extended period of time. The combination of all these different factors leads to a disproportionately high disease burden among miners with TB incidence in gold mines in South Africa being the highest in the world and in Lesotho 10 % of TB patient and 25% of MDR-TB patients are either current miners or ex-miners.

TB REACH care supporter performing TB screening for a miner and his wife at TEBA Maseru 

This troubling situation was addressed by the South African Development Committee (SADC) in its August 2012 Declaration aiming at the elimination of TB in the Region through improving practices of environmental, health and safety standards of the mining sector in the region.

Less than a year after this declaration, ICAP, in collaboration with the Lesotho Ministry of Health (MOH) and The Employment Bureau if Africa (TEBA), worked extensively on the design and implementation of the TB REACH project which targets 26,000 miners and their families through establishing TB clinics at TEBA sites to provide TB education, counseling, on-site prompt diagnosis and same day treatment initiation with close follow up and contact tracing. The project is innovative in its nature since it is able to catch the highly mobile population of miners through establishing points of care at TEBA where miners report regularly to get their deferred payments, offering services over the weekend and making use of the latest advancement in TB diagnosis with onsite GeneXpert machines.

 

TB REACH laboratory technician running sputum samples on the GeneXpert machine at TEBA Maseru

I had the opportunity to contribute to this project in Lesotho as my practicum for completing my Masters in Public Health graduation requirements. My experience in Lesotho and with TB REACH has been highly interesting and enriching.

Despite the fact that Lesotho is a small country with various challenges, it is full of very friendly people. I was overwhelmed by the kindness I was welcomed with to the country and by the approachable and pleasant way people interacted with. Moreover, Lesotho offers breathtaking sceneries; gorgeous mountains and some parts of Lesotho are a very concrete example of rural villages with rocky roads, basic lifestyle, poor access to transportation and scarce health clinics all of which make the provision of medical services extremely challenging. I had to chance to visit some of the most remote health clinics abundantly mentioned in public health textbooks.

As for setting up the TB REACH project, my experience was vastly educational and fulfilling on various levels. Initially, I was involved in drafting, revising and finalizing the nurses’ and health care workers’ training curricula. It was a challenging task taking the WHO guidelines and trying to contextualize them to suit Lesotho’s National guidelines and regulations however through discussions with several clinical advisors I was able to further understand the process and I learned greatly on the mechanisms of integrating both the medical and public health aspects of one disease.

Then, I was heavily involved in delivering the actual training which was a very exciting experience as I was able to interact with the nurses, understand their perspective about patients’ management, explore their creativity in resource limited settings and touch the difference in their knowledge by the end of the training. After this training I realized that capacity building is a fascinating area in public health that I plan on developing further as it is a process of mutual exchange of information, knowledge and skills.

TB REACH launching with Dr. Wafaa El-Sadr and ICAP staff is Lesotho, TEBA Country Representative Mr. Kikini Kikini and WHO Country Representative Prof. Mufunda

Moreover, I was involved helping establish Monitoring and Evaluation tools and indicators, procurement of medical supplies for clinics, supervision and mentorship of clinic’s staff and creation of educational material that would convey comprehensive yet simple, understandable messages to miners. Despite learning extensively about all these aspects of a project throughout my courses at school, the actual realities of adequately implementing the theory on the ground with heavy stakeholder involvement are worth hundreds of hours of classroom experience. A few hours spent with the people and the communities addressed can prove to be the best way to learn how to design and implement a successful intervention.

The TB Reach project was launched by the Lesotho Minister of Health and Dr. Wafaa El-Sadr in late July and is currently running in three districts in Lesotho. Moreover this project represents the first step towards a more holistic approach of the TB/HIV co-infection among miners and in Lesotho in general as ICAP will continue working on expanding services to integrate the inseparable TB and HIV services in accordance with its overall goals and mission.

Top picture: Dr. Wafaa El-Sadr with the Lesotho Minister of Health Dr. Pinkie Manamolela

Bottom right: Ribbon cutting during TB REACH launching by Dr. Wafaa El-Sadr, Dr. Pinkie Manamolela (Minister of Health) and Mr. Kikini Kikini

Bottom left: ICAP Lesotho Country Director Ms. Blanche Pitt (right), ICAP global director Dr. Wafaa El-Sadr (middle) and ICAP Lesotho Technical Director Dr. Koen Frederix (left)

Mariam E. Reda, MD

MPH Candidate, Mailman School of Public Health