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

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. What is already known on this topic: What this study adds: How this study might affect research, practice or policy: ### Competing Interest Statement MP reports that he has no financial or industry conflicts. He serves as an advisor to the following non-profit global health agencies: World Health Organization, Foundation for Innovative New Diagnostics, Bill & Melinda Gates Foundation, and Stop TB Partnership. The other authors declare that they have no known conflicts of interest. ### Funding Statement This work was supported by the Bill & Melinda Gates Foundation [grant number INV-022420] and the SHOPS Plus program funded by USAID [Contract #: AID-OAA-A-15-00067]. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics committee of the McGill University Health Centre gave ethical approval for this work (COVID BMGF / 2021-7197). IRB of Georgetown University gave ethical approval for this work (Georgetown-MedStar IRB System STUDY00003422). Ethics committee of the Health Research Ethics Committee Lagos State University Teaching Hospital gave ethical approval for this work (LREC/06/10/1517). Ethics committee of the Health Research Ethics Committee Kano State Ministry of Health gave ethical approval for this work (MOH/Off797/T.I/2168). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes