Abstract:
Background: Many evidence-based health interventions, particularly in low-income settings,
have failed to deliver the expected impact. We designed an Adaptive Diseases Control Expert
Programme in Tanzania (ADEPT) to address systemic challenges in health care delivery and examined
the feasibility, acceptability and effectiveness of the model using tuberculosis (TB) and diabetes
mellitus (DM) as a prototype. Methods: This was an effectiveness-implementation hybrid type-3
design that was implemented in Dar es Salaam, Iringa and Kilimanjaro regions. The strategy included
a stepwise training approach with web-based platforms adapting the Gibbs’ reflective cycle. Health
facilities with TB services were supplemented with DM diagnostics, including glycated haemoglobin
A1c (HbA1c). The clinical audit was deployed as a measure of fidelity. Retrospective and cross sectional designs were used to assess the fidelity, acceptability and feasibility of the model. Results:
From 2019–2021, the clinical audit showed that ADEPT intervention health facilities more often
identified median 8 (IQR 6–19) individuals with dual TB and DM, compared with control health
facilities, median of 1 (IQR 0–3) (p = 0.02). Likewise, the clinical utility of HbA1c on intervention
sites was 63% (IQR:35–75%) in TB/DM individuals compared to none in the control sites at all levels,
whereas other components of the standard of clinical management of patients with dual TB and DM
did not significantly differ. The health facilities showed no difference in screening for additional
comorbidities such as hypertension and malnutrition. The stepwise training enrolled a total of46 nurse officers and medical doctors/specialists for web-based training and 40 (87%) attended the
workshop. Thirty-one (67%), 18 nurse officers and 13 medical doctors/specialists, implemented the
second step of training others and yielded a total of 519 additional front-line health care workers
trained: 371 nurses and 148 clinicians. Overall, the ADEPT model was scored as feasible by metrics
applied to both front-line health care providers and health facilities. Conclusions: It was feasible to
use a stepwise training and clinical audit to support the integration of TB and DM management and
it was largely acceptable and effective in differing regions within Tanzania. When adapted in the
Tanzania health system context, the model will likely improve quality of services.
