Developing a Patient-Centered Community-Based Model for Management of Multi-Drug Resistant Tuberculosis in Uganda: A Mixed Methods Study

Abstract Background: The advent of all-oral regimens for the management of multi-drug resistant tuberculosis (MDR-TB) makes the implementation of community-based directly observed therapy (CB-DOT) a possibility for this group of patients. We set out to determine patient preferences for different attributes of a community-based model for the management of MDR-TB in Uganda. Methods: The study was conducted at five tertiary referral hospitals. We used a parallel convergent mixed methods study design. To collect quantitative data, we conducted a discrete choice experiment (DCE) with three different attributes of community-based care (provider type, location of care, and type of support) combined into eight choice sets, each with two options and an opt-out. We collected additional qualitative data by eliciting patient reasons for selection of each choice set. We fitted a mixed logit choice model to determine patient preferences for different attributes of community-based care. Thematic analysis using NVivo12 was done to understand the reasons for the choices made. Results: From December 2019 to January 2020, we interviewed 103 patients with MDR-TB. Majority (58.3%) were male; 61.2% were HIV negative; and the median age was 37 (IQR 30-47) years. Two thirds (65.1%) earned less than $1 per day. Study participants preferred at least one of the CB-DOT models of care to none (current standard of care). The most preferred model consisted of a community health worker (CHW) giving DOT at home and travel vouchers to enable attendance at monthly clinic follow-up visits. Qualitative interviews revealed that patients perceived CHWs as knowledgeable and able to offer psychosocial support. Patients also indicated a preference for taking medication at home because it saves both time and money and presents a lower risk of being stigmatized. Conclusion: People with MDR-TB prefer to be supported to take their medicine at home by a member of their community. The effectiveness of this model of care will be further evaluated.