Building on facilitators and overcoming barriers to implement active tuberculosis case-finding in Nepal, experiences of community health workers and people with tuberculosis

Abstract

Background Nepal has a high burden of undetected tuberculosis (TB). In line with the World Health Organization’s End TB Strategy, the National TB Programme promotes active case-finding (ACF) as one strategy to find people with TB who are unreached by existing health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented in four districts in Nepal, generating a substantial yield of previously undetected TB. We aimed to identify the facilitators and barriers linked to the implementation of ACF within IMPACT TB, as well as how those facilitators and barriers have been or could be addressed. Methods This was an exploratory qualitative study based on 17 semi-structured key-informant interviews with people with TB who were identified through ACF, and community health workers who had implemented ACF. Thematic analysis was applied in NVivo 11, using an implementation science framework developed by Grol and Wensing to classify the data. Results We generated five main themes from the data: (1) ACF addressed the social determinants of TB by providing timely access to free healthcare, (2) knowledge and awareness about TB among people with TB, communities and community health workers were the ‘oil’ in the ACF ‘machine’, (3) trust in community health workers was fundamental for implementing ACF, (4) community engagement and support had a powerful influence on ACF implementation and (5) improved working conditions and enhanced collaboration with key stakeholders could further facilitate ACF. These themes covered a variety of facilitators and barriers, which we divided into 22 categories cutting across five framework levels: innovation, individual professional, patient, social context and organizational context. Conclusions This study provides new insights into facilitators and barriers for the implementation of ACF in Nepal and emphasizes the importance of addressing the social determinants of TB. The main themes reflect key ingredients which are required for successful ACF implementation, while the absence of these factors may convert them from facilitators into barriers for ACF. As this study outlined “how-to” strategies for ACF implementation, the findings can furthermore inform the planning and implementation of ACF in Nepal and similar contexts in low- and middle-income countries.

What makes community health worker models for tuberculosis active case finding work? A cross-sectional study of TB REACH projects to identify success factors for increasing case notifications

“…The effective integration of CHWs into the existing health systems is a well-documented enabler of project success [ 5 , 6 ] as it enhances sustainability and fosters collaboration between lay and formal healthcare providers. CHWs have also vociferously noted an enhanced credibility and clarity of their own roles with a greater level of integration [ 5 , 29 ]. Our study results were concordant with these findings.…”

Framework for planning and monitoring active TB case finding interventions to meet the global targets in the COVID-19 era and beyond: South-East Asia perspective

“…Major challenges for the community that decreased their participation in ACF activities were stigma, a lack of awareness about TB, lack of family support, fear of a loss of wages, PLOS GLOBAL PUBLIC HEALTH transportation costs, and a preference for private health care because of overcrowded public hospitals [14,[17][18][19][20]. Challenges from the health providers' perspective were a lack of motivation due to a target-oriented approach, insufficient incentives, inappropriate timing of ACF, a lack of cooperation from other health staff, and diversion from their usual work to do home visits, community screening or other activities outside health facilities [21,22].…”

“…in decreased yield and cost-effectiveness [14,20]. Additionally, with the recent COVID-19 pandemic, restrictions on movement and social gatherings have limited the implementation of community outreach activities which are integral to many ACF efforts.…”

“…Support measure such as sputum transportation, on-site testing [29,30] travel with a volunteer, and travel compensation decreased the drop-out for testing [30]. Engagement of community volunteers [14,20] and the use of mobile health technology to track screening decreased the drop-out from initiation of treatment [14,16]. Quality of diagnosis was maintained by use of rapid molecular testing, quality assurance of sputum microscopy, and use of artificial intelligence software to quickly and efficiently read high volumes of CXR [31,32].…”

“…To monitor the impact that ACF has on reducing the treatment coverage gap (i.e. identifying people with TB who would not have been diagnosed without the intervention) overall TB notifications should be collected for a baseline period, as well as prospectively in a larger evaluation area [20]. The yield/additionality ratio (how many TB cases the ACF produced over the absolute change in notifications) can also provide insight into how successful the ACF intervention is in reaching people who would otherwise not have been detected.…”