Private sector tuberculosis care quality during the COVID-19 pandemic: A repeated cross-sectional standardized patients study of adherence to national TB guidelines in urban Nigeria

Abstract Only a third of TB cases in Nigeria in 2020 were diagnosed and notified, in part due to low detection and underreporting from the private health sector. Using a standardized patient (SP) survey approach, we assessed how management of presumptive TB in the private sector aligns with national guidelines and whether this differed from a study conducted before the start of the COVID-19 pandemic. Thirteen standardized patients presented a presumptive TB case to 511 private providers in urban areas of Lagos and Kano states in May and June 2021. Private provider case management was compared with national guidelines divided into three main steps: SP questioned about cough duration; sputum collection attempted for TB testing; and non-prescription of anti-TB medications, antibiotics, and steroids. SP visits conducted in May-June 2021 were directly compared to SP visits conducted in the same areas in June-July 2019. Overall, only 145 of 511 (28%, 95% CI: 24.5–32.5%) interactions were correctly managed according to Nigerian guidelines, as few providers completed all three necessary steps. Providers in 71% of visits asked about cough duration (362 of 511, 95% CI: 66.7–74.7%), 35% tested or recommended a sputum test (181 of 511, 95% CI: 31.3–39.8%), and 79% avoided prescribing or dispensing unnecessary medications (406 of 511, 95% CI: 75.6–82.8%). COVID-19 related questions were asked in only 2.4% (12 of 511, 95% CI: 1.3–4.2%) of visits. During the COVID-19 pandemic, few providers completed all steps of the national guidelines. Providers performed better on individual steps, particularly asking about symptoms and avoiding prescription of harmful medications. Comparing visits conducted before and during the COVID-19 pandemic showed that COVID-19 did not significantly change the quality of TB care. Key Messages What is already known on this topic: Less than half of new TB cases in Nigeria are diagnosed and notified. As most initial health care seeking for TB in Nigeria occurs in the private sector, increasing the quality of TB care in the private sector is of great importance. COVID-19 may have put further stressors on TB care quality due to changes in care seeking behavior, stigma against COVID-19, and disproportionate attention at the health system level on pandemic control. This study explored whether private providers’ practices are in alignment with national standards for TB screening in Nigeria, how these practices have changed following the onset of the COVID-19 pandemic, and what factors are associated with providers that deliver clinically correct TB screening services. What this study adds: Fewer than one-third of the SP visits conducted in this study were correctly managed according to the Nigerian National TB and Leprosy Control Program guidelines. Clinical correctness of TB care in the private sector of urban Nigeria has not been majorly affected by COVID-19 according to our study results. Our results indicate that very little observed attention was paid to COVID-19 in this sample of private facilities. How this study might affect research, practice or policy: Increased efforts to engage and support private providers, and implementing solutions such as working with drug shop proprietors to make referring for testing a standard part of their practice may help reduce the testing bottleneck at drug shops. Although Nigeria has maintained pre-pandemic levels of TB notification, it is important to establish high-quality screening by all providers to find the missing patients with TB and close the gap in TB notification.

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