Abstract
BackgroundThe World Health Organization recommends routine household tuberculosis contact investigation in high-burden countries but adoption has been limited. We sought to identify barriers to and facilitators of TB contact investigation during its introduction in Kampala, Uganda.MethodsWe collected cross-sectional qualitative data through focus group discussions and interviews with stakeholders, addressing three core activities of contact investigation: arranging household screening visits through index TB patients, visiting households to screen contacts and refer them to clinics, and evaluating at-risk contacts coming to clinics. We analyzed the data using a validated theory of behavior change, the Capability, Opportunity, and Motivation determine Behavior (COM-B) model, and sought to identify targeted interventions using the related Behavior Change Wheel implementation framework.ResultsWe led seven focus-group discussions with 61 health-care workers, two with 21 lay health workers (LHWs), and one with four household contacts of newly diagnosed TB patients. We, in addition, performed 32 interviews with household contacts from 14 households of newly diagnosed TB patients. Commonly noted barriers included stigma, limited knowledge about TB among contacts, insufficient time and space in clinics for counselling, mistrust of health-center staff among index patients and contacts, and high travel costs for LHWs and contacts. The most important facilitators identified were the personalized and enabling services provided by LHWs. We identified education, persuasion, enablement, modeling of health-positive behaviors, incentivization, and restructuring of the service environment as relevant intervention functions with potential to alleviate barriers to and enhance facilitators of TB contact investigation.ConclusionsThe use of a behavioral theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers to and facilitators of TB contact investigation. The behavioral determinants identified here may be useful in tailoring interventions to improve implementation of contact investigation in Kampala and other similar urban settings.
Highlights
The World Health Organization recommends routine household tuberculosis contact investigation in high-burden countries but adoption has been limited
To support the efforts of the Uganda National TB and Leprosy Programme (NTLP) to improve TB diagnostic evaluation and case detection, we established a community-based network for implementation research at seven public health facilities in Kampala; six out-patient facilities affiliated to the Kampala Capital City Authority (KCCA) and one local general hospital
These facilities provide free primary health care, as well as TB and HIV evaluation and treatment through specialized nursing units with on-site, quality-assured laboratories. They are staffed by medical doctors, clinical officers, nurses, laboratory technicians, and other trained health assistants; there are positions, usually unpaid, for lay health workers (LHWs)
Summary
The World Health Organization recommends routine household tuberculosis contact investigation in high-burden countries but adoption has been limited. The traditional, “passive” TB case-finding strategy depends on widespread awareness of TB symptoms and early clinic attendance by affected individuals. These features are rarely observed in high TB-burden communities, with the result that infectious patients remain in the community longer, thereby worsening individual outcomes and perpetuating the cycle of airborne, person-to-person transmission of TB [5,6,7]. The prototypical community-based active case-finding strategy is household contact investigation, in which health workers visit homes of patients with newly identified TB to screen co-habitants or close contacts for TB and refer atrisk individuals to clinics for evaluation and treatment [8]. Expert guidelines on how to implement household contact investigation in these settings have recently been published [11], but there is an ongoing need for research into barriers to and facilitators of contact investigation to better inform uptake
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