Role of community health workers in improving cost efficiency in an active case finding tuberculosis programme: an operational research study from rural Bihar, India

Factors associated with Community Health Agents' knowledge about tuberculosis

OBJECTIVE

To analyze the factors associated with the knowledge of Community Health Agents (ACS) about tuberculosis.

METHODS

A cross-sectional study was conducted with 110 ACS. A questionnaire was used to assess knowledge about pulmonary tuberculosis (component 1) and the work functions of ACS in the National Tuberculosis Control Program (component 2). The level of knowledge, according to the scores converted into a scale of 0 to 100, was classified as: 0-50% (low), 51-75% (medium), and over 75% (high). Multiple regression was used in the analysis of associated factors.

RESULTS

The global score (average of the scores of components 1 and 2) median knowledge was 68.6%. Overall knowledge about tuberculosis was positively associated with the length of professional experience, having received training on tuberculosis, and access to the tuberculosis guide/handbook.

CONCLUSIONS

Investments in training and capacity-building strategies for ACS will contribute to increasing these professionals' knowledge, resulting in greater success in tuberculosis control.

Implementation of evidence-based multiple focus integrated intensified TB screening to end TB (EXIT-TB) package in East Africa: a qualitative study

INTRODUCTION

Tuberculosis (TB) remains a major cause of morbidity and mortality, especially in sub-Saharan Africa. We qualitatively evaluated the implementation of an Evidence-Based Multiple Focus Integrated Intensified TB Screening package (EXIT-TB) in the East African region, aimed at increasing TB case detection and number of patients receiving care.

OBJECTIVE

We present the accounts of participants from Tanzania, Kenya, Uganda, and Ethiopia regarding the implementation of EXIT-TB, and suggestions for scaling up.

METHODS

A qualitative descriptive design was used to gather insights from purposefully selected healthcare workers, community health workers, and other stakeholders. A total of 27, 13, 14, and 19 in-depth interviews were conducted in Tanzania, Kenya, Uganda, and Ethiopia respectively. Data were transcribed and translated simultaneously and then thematically analysed.

RESULTS

The EXIT-TB project was described to contribute to increased TB case detection, improved detection of Multidrug-resistant TB patients, reduced delays and waiting time for diagnosis, raised the index of TB suspicion, and improved decision-making among HCWs. The attributes of TB case detection were: (i) free X-ray screening services; (ii) integrating TB case-finding activities in other clinics such as Reproductive and Child Health clinics (RCH), and diabetic clinics; (iii), engagement of CHWs, policymakers, and ministry level program managers; (iv) enhanced community awareness and linkage of clients; (v) cooperation between HCWs and CHWs, (vi) improved screening infrastructure, (vii) the adoption of the new simplified screening criteria and (viii) training of implementers. The supply-side challenges encountered ranged from disorganized care, limited space, the COVID-19 pandemic, inadequate human resources, inadequate knowledge and expertise, stock out of supplies, delayed maintenance of equipment, to absence of X-ray and GeneXpert machines in some facilities. The demand side challenges ranged from delayed care seeking, inadequate awareness, negative beliefs, fears towards screening, to financial challenges. Suggestions for scaling up ranged from improving service delivery, access to diagnostic equipment and supplies, and infrastructure, to addressing client fears and stigma.

CONCLUSION

The EXIT-TB package appears to have contributed towards increasing TB case detection and reducing delays in TB treatment in the study settings. Addressing the challenges identified is needed to maximize the impact of the EXIT-TB intervention.

Routine childhood vaccination in India from 2005-2006 to 2015-2016: Temporal trends and geographic variation

OBJECTIVE

India has experienced a substantial increase in the coverage of routine childhood vaccines in recent years. However, a large fraction of these vaccines is not delivered in a timely manner, i.e., at the recommended age. Further, substantial disparities exist in both coverage and timeliness across states. We aim to quantify the changes in coverage and timeliness of routine childhood vaccination in India over time, their variation across states, and changes in these variations over time.

METHODS

We used data from two rounds of India's National Family Health Surveys, NFHS-3 (2005-06) and NFHS-4 (2015-16) on bacille Calmette-Guerin vaccine (BCG), three doses of diphtheria, pertussis, and tetanus vaccine (DPT1, DPT2, DPT3), and measles-containing vaccine (MCV). We used the Turnbull estimator to estimate the cumulative distribution function (CDF) of administering each vaccine by a certain age while accounting for two-sided censoring in the survey data. We then used these estimated CDFs to calculate coverage and timeliness at the national and state levels.

FINDINGS

At the national level, both vaccination coverage and timeliness estimates increased from NFHS-3 to NFHS-4 for all vaccines. The increase in timeliness ranging from 27.3% for DPT3 to 74.0% for MCV continued to be lower than coverage, ranging from 75.3% (95% CI 57.7-87.2) for DPT3 to 74.0% (95% CI 42.2-33.0) for MCV, for all vaccines. Cross-state variation in timeliness was greater than the variation in coverage. Variation in both timeliness and coverage reduced from NFHS-3 to NFHS-4. However, this reduction was greater for timeliness than for coverage.

CONCLUSIONS

A large fraction of the children in India receive vaccines later than the recommended age thereby keeping them exposed to vaccine-preventable diseases. Interventions that specifically focus on improving the timely delivery of vaccines are needed to improve the overall effectiveness of the routine immunization program.

Gaps and Interventions across the Diagnostic Care Cascade of TB Patients at the Level of Patient, Community and Health System: A Qualitative Review of the Literature

Tuberculosis (TB) continues to be one of the important public health concerns globally, and India is among the seven countries with the largest burden of TB. There has been a consistent increase in the notifications of TB cases across the globe. However, the 2018 estimates envisage a gap of about 30% between the incident and notified cases of TB, indicating a significant number of patients who remain undiagnosed or ‘missed’. It is important to understand who is ‘missed’, find this population, and provide quality care. Given these complexities, we reviewed the diagnostic gaps in the care cascade for TB. We searched Medline via PubMed and CENTRAL databases via the Cochrane Library. The search strategy for PubMed was tailored to individual databases and was as: ((((((tuberculosis[Title/Abstract]) OR (TB[Title/Abstract])) OR (koch *[Title/Abstract])) OR (“tuberculosis”[MeSH Terms]))) AND (((diagnos *) AND (“diagnosis”[MeSH Terms])))). Furthermore, we screened the references list of the potentially relevant studies to seek additional studies. Studies retrieved from these electronic searches and relevant references included in the bibliography of those studies were reviewed. Original studies in English that assessed the causes of diagnostic gaps and interventions used to address them were included. Delays in diagnosis were found to be attributable to both the individuals’ and the health system’s capacity to diagnose and promptly commence treatment. This review provides insights into the diagnostic gaps in a cascade of care for TB and different interventions adopted in studies to close this gap. The major diagnostic gaps identified in this review are as follows: people may not have access to TB diagnostic tests, individuals are at a higher risk of missed diagnosis, services are available but people may not seek care with a diagnostic facility, and patients are not diagnosed despite reaching health facilities. Therefore, reaching the goal to End TB requires putting in place models and methods to provide prompt and quality assured diagnosis to populations at par.

Feasibility of a randomized clinical trial evaluating a community intervention for household tuberculosis child contact management in Cameroon and Uganda

Background

One of the main barriers of the management of household tuberculosis child contacts is the necessity for parents to bring healthy children to the facility. We assessed the feasibility of a community intervention for tuberculosis (TB) household child contact management and the conditions for its evaluation in a cluster randomized controlled trial in Cameroon and Uganda.

Methods

We assessed three dimensions of feasibility using a mixed method approach: (1) recruitment capability using retrospective aggregated data from facility registers; (2) acceptability of the intervention using focus group discussions with TB patients and in-depth interviews with healthcare providers and community leaders; and (3) adaptation, integration, and resources of the intervention in existing TB services using a survey and discussions with stakeholders.

Results

Reaching the sample size is feasible in all clusters in 15 months with the condition of regrouping 2 facilities in the same cluster in Uganda due to decentralization of TB services. Community health worker (CHW) selection and training and simplified tools for contact screening, tolerability, and adherence of preventive therapy were key elements for the implementation of the community intervention. Healthcare providers and patients found the intervention of child contact investigations and TB preventive treatment management in the household acceptable in both countries due to its benefits (competing priorities, transport cost) as compared to facility-based management. TB stigma was present, but not a barrier for the community intervention. Visit schedule and team conduct were identified as key facilitators for the intervention.

Conclusions

This study shows that evaluating a community intervention for TB child contact management in a cluster randomized trial is feasible in Cameroon and Uganda.

Trial registration

Clini calTr ials. gov NCT03832023. Registered on February 6^th 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-00996-3.

Can Patient Navigators Help Potential TB Patients Navigate the Diagnostic and Treatment Pathways? An Implementation Research from India

Navigating the Indian health system is a challenge for people with tuberculosis (TB) symptoms. The onus of organizing care is on the patient and their families alone. Factors like gender discrimination and opportunity costs further aggravate this. As a result, people may not complete the diagnostic and treatment pathway even though they experience poor health. Navigators can aid in the pathway’s completion. We implemented two projects in India—a public sector intervention in Bihar, with a population of 1.02 million, and a private sector intervention in Andhra Pradesh (AP), with a population of 8.45 million. Accredited Social Health Activists (ASHAs) of the public health system in Bihar and local field officers in AP facilitated the patients’ navigation through the health system. In Bihar, ASHAs accompanied community-identified presumptive TB patients to the nearest primary health center, assisted them through the diagnostic process, and supported the patients throughout the TB treatment. In AP, the field officers liaised with the private physicians, accompanied presumptive patients through the diagnosis, counseled and started treatment, and followed-up with the patients during the treatment. Both projects recorded case-based data for all of the patients, and used the yield and historical TB notifications to evaluate the intervention’s effect. Between July 2017 and December 2018, Bihar confirmed 1650 patients, which represented an increase of 94% in public notifications compared to the baseline. About 97% of them started treatment. During the same period in AP, private notifications increased by 147% compared to the baseline, and all 5765 patients started treatment. Patient navigators support the patients in the diagnostic and treatment pathways, and improve their health system experience. This novel approach of involving navigators in TB projects can improve the completion of the care cascade and reduce the loss to follow-up at various stages.