Assessment of integration of tuberculosis and diabetes mellitus in health services in Addis Ababa, Ethiopia

Abstract

The Co-morbidity of tuberculosis (TB) and diabetes mellitus (DM) is a major global public health challenge. Both diseases disproportionately affect low - and middle-income countries. While integrated care approaches offer synergistic benefits, TB and DM services often remain fragmented in many health systems. The purpose of this study was to assess the factors affecting the integration of health services for patients with TB and DM, and to develop an integration framework to improve the management of TB in patients with DM, and DM in TB patients. The study population was adult patients with pulmonary TB who tested positive for type 2 diabetes (T2DM) and were attending DOTS clinics in the 52 selected public health facilities in Addis Ababa. Cluster sampling with stratified simple random sampling was used to select hospitals and health centres. Simple random sampling technique was used to select patients with comorbid TB and diabetes for the quantitative study. Purposive sampling was used to select key informants for in-depth interviews. The study began with an explanatory quantitative phase, which included a survey of 357 patients with comorbid TB and diabetes and 23 key informant interviews with experts and practitioners working in clinical facilities and TB and diabetes programmes in public health facilities and the health bureau in Addis Ababa. Quantitative data were collected using structured questionnaires developed from the Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, Financing and performancE (SELFIE) multi-morbidity framework. Both quantitative and qualitative data were collected between March 2021 and June 2022. Quantitative data were analysed using SPSS version 28, while thematic analyses of qualitative data were conducted using Atlas.ti8 software. The study involved 357 respondents, a response rate of 96.5%, and in-depth interviews with 23 key informants. The results of the study found that integration of TB-DM services in health facilities is minimal, with only a quarter of facilities providing integrated care. Several factors contribute to this, including inadequate counselling on medication use, limited awareness of TB risks among DM patients, and the lack of organised TB-DM services and integration strategies. Screening practices and training of health workers are also inadequate. Leadership and governance play a crucial role in promoting integration, with supportive leadership and the availability of guidelines being key factors. In addition, the lack of a reimbursement mechanism and equitable cost of services are barriers to comprehensive care. Limited access to technology and medical products, such as electronic health record systems and diagnostic tools, affects the integration of services. Furthermore, the lack of personalised patient data and tailored registration and reporting tools hampers the provision of integaeted care and the collection of data on TB-DM co-morbidity. These findings emphasised the need for interventions to address these factors and improve the integration of TB-DM services, ultimately improving patient outcomes. The results of this study emphases the urgent need to address the limited integration of TB-DM services in health facilities. This gap has significant implications, as it hinders the provision of integrated care to a significant number of TB-DM patients. Inadequate integration puts patients at risk of suboptimal treatment outcomes, increased disease burden and higher long-term health care costs. To effectively address these challenges, it is essential to prioritise and improve the integration of TB and diabetes services. This can be achieved by improving continuity of care, establishing multidisciplinary teams, implementing clear guidelines, involving patients in decision-making, improving access to technology and adopting innovative health care approaches. Further research is needed to refine these recommendations and assess their impact on population health.