Enablers and Challenges in the Implementation of Active Case Findings in a Selected District of Karnataka, South India: A Qualitative Study

Abstract

Background. Active case finding (ACF) for tuberculosis (TB) is a promising tool to enhance early case detection among marginalized populations. As opposed to passive case finding, it involves systematically searching for TB in individuals who would not spontaneously present for care. The National TB Program (NTP) of India has initiated ACF for TB through the existing general health system since the end of 2017. However, prior to scale-up, there is need for exploring the implementation challenges and solutions to improve the efficiency of this program. Objectives. (1) To explore the enablers and challenges in the implementation of ACF for TB by NTP in the Bengaluru rural district of Karnataka, South India, and (2) to explore the perceived solutions to improve the efficiency of ACF activity. Methods. A qualitative descriptive study was conducted in the Bengaluru rural district during July 2018. In-depth interviews using purposively selected health care providers involved in active case finding (n = 9) and presumptive TB patients (n = 8) were conducted. Manual content analysis was conducted by two independent researchers to generate categories and themes. Results. The challenges in conduct of ACF were as follows: inadequate training of health care workers, shortage of staff, indifferent attitude of community due to stigma, lack of awareness about TB, illiteracy, inability to convince patients for sputum test, and delay in getting CBNAAT results. The field staff recommended the installation of mobile CBNAAT machine, involvement of general health staff in activity, training of health workers on counseling of patients, and issue of identity cards for community health workers/volunteers so that people recognize them. Conclusion. The health system challenges in conduct of ACF need to be addressed by training the health staff involved in activity and also improving the access to TB diagnostics.

Active case-finding policy development, implementation and scale-up in high-burden countries: A mixed-methods survey with National Tuberculosis Programme managers and document review

“…Many of the described factors influencing ACF policy implementation align with the available evidence in the field. Firstly, ACF policy implementation has been widely studied, as documented by a scoping review [ 17 ] and more recent studies [ 24 , 25 ]. In line with our study, a major barrier for ACF implementation is the lack of human and financial resources [ 26 – 30 ].…”

Treatment outcomes of tuberculosis patients detected by active case finding under the Revised National Tuberculosis Control Programme during 2018 in Haridwar district of Uttarakhand

“…[ 6 8 ] In addition, testing for sputum examination and other investigation is perceived as a difficult task by the programmatic staff. [ 9 ] Evidences from literature suggest that multiple factors play a key role in prediagnostic LTFU. These factors range from issues related to logistics, family, health system, and health providers and patients' issues.…”

Tuberculosis related stigma in India: roadblocks and the way forward

“…While the TB control programme may be encouraged with the increase in case notification, there have been many concerns that are ignored with little attention to the stigma that this strategy perpetuates. This activity has been reported to be disturbing as health care workers visit the homes of the individuals for eliciting symptoms and collection of sputum which makes them uncomfortable, as this is done with little or no privacy leading to embarrassing questions from neighbors [27]. We see people in the community shying away from revealing their symptoms for fear of a TB diagnosis and still others who refuse to give sputum for TB testing once found to have symptoms of TB [27].…”

“…This activity has been reported to be disturbing as health care workers visit the homes of the individuals for eliciting symptoms and collection of sputum which makes them uncomfortable, as this is done with little or no privacy leading to embarrassing questions from neighbors [27]. We see people in the community shying away from revealing their symptoms for fear of a TB diagnosis and still others who refuse to give sputum for TB testing once found to have symptoms of TB [27]. These reactions could be linked to the reports of stigma as a result of fear of discrimination, fear of losing their rented homes, prospects of their daughter's marriage or fear of losing jobs [6, 24,28].…”