Abstract
BackgroundPeople in close contact with tuberculosis should have screening and appropriate management, as an opportunity for active case detection and prevention. However, implementation of tuberculosis contact screening and management is limited in high-burden settings. Behaviour change is needed across three levels of the healthcare system—policymakers, healthcare providers, and patients. To bridge the wide policy-practice gap, this study draws on the Consolidated Framework for Implementation Research, the Behaviour Change Wheel, and the RE-AIM model (Reach, Effectiveness, Adoption, Implementation, Maintenance) to respectively understand barriers, implement change, and evaluate process and outcome.MethodsThis methods paper describes a mixed-methods intervention study in Eastern Indonesia. Quantitative data will be collected during baseline, intervention, and sustainability periods and analyzed using time series analysis. The primary outcome is the number of individuals completing tuberculosis preventive therapy by the end of the two-year intervention phase. Of an estimated 10,000 contacts during this period, we anticipate that a minimum of 416 will be found to have active TB or will complete preventive therapy. Qualitative data (semi-structured interviews, focus group discussions, and observations) will be collected from consenting healthcare providers, patients, and contacts. Activities to promote policy implementation include healthcare provider training, quarterly continuous quality improvement workshops, a social media discussion forum, and promotional materials. The Consolidated Framework for Implementation Research will be used to identify reasons for limited policy implementation at baseline. The Behaviour Change Wheel will be used to ensure that a suitable range of activities are implemented to facilitate change. The RE-AIM model will be used as the evaluation framework.DiscussionUse of theoretical frameworks in combination can ensure a comprehensive understanding of, and robust response to, health policy underimplementation. The selected frameworks are highly applicable to this pragmatic intervention study, in a setting where End TB Strategy targets will not be met without substantial behavior change within health systems. Continuous quality improvement cycles will provide a way to engage staff and stakeholders in understanding local data to motivate behavior change. If successful, up to 500 people could be prevented from developing complications of tuberculosis through early case-finding or receiving preventive therapy over a two-year period.Study registrationAustralian New Zealand Clinical Trials Register 375803.
Highlights
People in close contact with tuberculosis should have screening and appropriate management, as an opportunity for active case detection and prevention
We describe context-specific barriers to and facilitators of TB contact management at the study site using the Consolidated Framework for Implementation Research (CFIR) and map these to the Behaviour Change Wheel
The study is led by a collaborative investigator group in Indonesia and Australia and registered with the Australian New Zealand Clinical Trials Registry [35]
Summary
People in close contact with tuberculosis should have screening and appropriate management, as an opportunity for active case detection and prevention. A key TB prevention activity comprises contact investigation and management for people living in the same household as someone with infectious TB. Contact investigation provides opportunities to detect co-prevalent TB—that is, other people with active TB (“TB disease”) who might have been the source or have acquired infection from the index case. It allows people with latent infection (“TB infection”) to be detected and commenced on treatment to prevent incident disease [4]
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