Identifying barriers and facilitators to implementation of community-based tuberculosis active case finding with mobile X-ray units in Lima, Peru: a RE-AIM evaluation

Abstract

ObjectivesIdentify barriers and facilitators to integrating community tuberculosis screening with mobile X-ray units into a health system.MethodsReach, effectiveness, adoption, implementation and maintenance evaluation.Setting3-district region of Lima, Peru.Participants63 899 people attended the mobile units from 7 February 2019 to 6 February 2020.InterventionsParticipants were screened by chest radiography, which was scored for abnormality by computer-aided detection. People with abnormal X-rays were evaluated clinically and by GeneXpert MTB/RIF (Xpert) sputum testing. People diagnosed with tuberculosis at the mobile unit were accompanied to health facilities for treatment initiation.Primary and secondary outcome measuresReach was defined as the percentage of the population of the three-district region that attended the mobile units. Effectiveness was defined as the change in tuberculosis case notifications over a historical baseline. Key implementation fidelity indicators were the percentages of people who had chest radiography performed, were evaluated clinically, had sputum samples collected, had valid Xpert results and initiated treatment.ResultsThe intervention reached 6% of the target population and was associated with an 11% (95% CI 6 to 16) increase in quarterly case notifications, adjusting for the increasing trend in notifications over the previous 3 years. Implementation indicators for screening, sputum collection and Xpert testing procedures all exceeded 85%. Only 82% of people diagnosed with tuberculosis at the mobile units received treatment; people with negative or trace Xpert results were less likely to receive treatment. Suboptimal treatment initiation was driven by health facility doctors’ lack of familiarity with Xpert and lack of confidence in diagnoses made at the mobile unit.ConclusionMobile X-ray units were a feasible and effective strategy to extend tuberculosis diagnostic services into communities and improve early case detection. Effective deployment however requires advance coordination among stakeholders and targeted provider training to ensure that people diagnosed with tuberculosis by new modalities receive prompt treatment.

Geographic accessibility to health facilities predicts uptake of community-based tuberculosis screening in an urban setting

“…TB screening and treatment are free but diagnostic delays are nonetheless common partly because of the inconvenience of accessing health facilities ( Bonadonna et al, 2017 ). To improve TB diagnosis, a mobile screening program was implemented in 2019, bringing free TB screening and evaluation services into community settings ( Yuen et al, 2021 ). Mobile screening units were stationed in residential areas, markets, transport terminals, educational institutions, and companies, as well as outside health facilities (primary-level health facilities and regional referral facilities).…”

“…This promotes earlier diagnosis and improves patient outcomes ( Golub et al, 2005 ). Mobile TB screening units have been used in diverse settings to provide a convenient location for screening (by symptom questionnaires or x-ray) and providing a sputum sample for bacteriologic testing ( Madhani et al, 2020 , Morishita et al, 2017 , Okelloh et al, 2019 , Yuen et al, 2021 ). In rural areas, mobile units decrease long travel distances to health facilities, which is often a dominant barrier to accessing TB care ( Marahatta et al, 2020 , Tulloch et al, 2015 ).…”

Understanding reasons for suboptimal tuberculosis screening in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho

“…Chest radiography offers high sensitivity and specificity as a screening tool, and computer-aided detection software can help to make mass radiographic screening feasible [26]. In settings with high TB burdens, community-based mobile radiography units have been used to reach populations that face barriers to accessing health facilities [27] and have been shown to increase population-level case notifications [28].…”

Observatorios sociales nacionales y regional de tuberculosis en ocho países de Latinoamérica y el Caribe

“…Tras la pandemia del COVID-19, la situación de la TB en el mundo y en la Región de las Américas ha retrocedido ( 1 , 32 ), y necesitamos seguir vigilantes y co-participes de las respuestas nacionales contra la tuberculosis. Por ello, contribuir directamente desde la sociedad civil en la identificación y detección de casos ( 33 ), así como en el abordaje integral de las personas afectadas por la TB, es una oportunidad única para frenar el impacto de la pandemia ( 22 ).…”