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

PMCID: PMC10013287

PMID: 36918800

Abstract

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. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-023-08069-3.

Full Text

The persistent burden of Tuberculosis (TB) in sub-Saharan Africa (SSA) is linked to missed diagnoses, delayed diagnoses, and challenges with access to high-quality care, which all continue to contribute to a higher risk of death, suffering, and catastrophic financial consequences [1]. While it is well recognized that early TB diagnosis and prompt treatment are cornerstones to TB control, early case detection, and timely treatment also reduce morbidity and mortality associated with TB [2]. TB is a health priority in SSA where lack of modern facilities for proper diagnosis and management has left majority of patients undiagnosed, and these continue to spread the disease. In most SSA countries, TB case finding is through passive case finding and where possible, provider-initiated active case finding of symptomatic people in a predetermined target group such as HIV-infected individuals [1–3]. Under passive case finding, an individual is required to report to a health facility for care. In Tanzania, Kenya, Uganda, and Ethiopia, for an individual to be recognized as a presumptive TB patient, they need to report to a health facility with a cough of two or more weeks with or without accompanying symptoms [4–6], limiting the opportunity to capture those who report less duration cough, women and children attending Reproductive and Child Health (RCH) clinics and diabetic patients. To a large extent, passive case finding depends on individuals’ self-initiative to visit a healthcare facility and report a cough with proper duration, socio-economic status, and knowledge, and on the degree of alertness of health workers to suspect a patient [7].
In the East African (EA) region, TB case detection is below what is required to achieve the World Health Organization (WHO) END TB strategic target of reducing TB incidence by 50% by 2025 [4–6] and is even lower among women and children. The 2021 National TB control (NTP) reports show that TB case notifications per 100,000 population were 134 in Tanzania, 135 in Kenya, 155 in Uganda, and 84 in Ethiopia, and in most countries only 40% were females [2–6]. These values appear to be less than the estimated incidences for 2021 of 208 in Tanzania, 252 in Kenya, 199 in Uganda and 119 in Ethiopia per 100,000 population [2–6]. Moreover, TB case detection at Care and Treatment Centres (CTC) is based on the screening of symptomatic patients and none is done at diabetic clinics. Furthermore, although TB contact tracing is one of the core NTP activities in all four countries [2–6], it is not sufficiently done even among contact children due to financial constraints. It is known that women are good attendants of RCH clinics either for their reproductive health services or the health of their children, therefore, the current practice limits the opportunity of capturing TB cases among women and their children, and hence limits the efforts of NTP’s of putting more infectious TB cases into care. In addition, although chest X-ray (CXR) has been recently promoted and recommended by WHO as a useful tool for TB screening and triaging algorithms [8], none of the NTPs in the region has adopted it into policy. CXR has been reported to be the most sensitive TB screening tool (with very low specificity though) since a significant proportion of TB patients are asymptomatic [9]. CXR when used to triage who should be tested with GeneXpert has been reported to reduce the number of individuals to be tested with the assay, and thus, reduces high costs associated with GeneXpert and thus improve the efficiency of GeneXpert [10].
The parent study was a multi-country cluster randomized controlled trial where the unit of randomization was the facility [11]. The EXIT-TB package was implemented in a total of 4 urban and 3 rural facilities in each participating country. Twenty-eight facilities (7 in each country) were randomized to either early intervention or deferred arm. The intervention was done in the first 12 months in 16 facilities and deferred in 12 facilities (control sites). Implementing the intervention in all 28 clinics simultaneously was a major challenge—hence we opted for this approach to scale up sequentially. While the EXIT-TB package was implemented, a qualitative descriptive approach was envisaged in gathering insights from the participants on EXIT-TB package implementation. This approach was deemed appropriate to answer three key questions to this inquiry: (i) What is the contribution of the EXIT-TB package on TB case detection in the study settings? (ii) what are the challenges encountered and possible solutions that were taken during the implementation of the EXIT-TB package? and, (iii) What are the key considerations for scaling up the EXIT-TB package? A qualitative descriptive approach is appropriate for this inquiry as it aims to develop an understanding and describe the contribution of the EXIT-TB package on TB case detection without testing an existing theory [12]. This approach offered an effective way of gaining a deep and rich understanding of HCWs, CHWs, and stakeholders’ perceptions and experiences in the chosen context, as this may differ from other contexts in terms of culture, expectations, and resources within health care settings.
In each country, regions/districts/counties and facilities were selected for the EXIT-TB implementation. Dar es Salaam in Tanzania, Nakaseke and Kiboga in Uganda, Siaya in Kanya Dire Dawa, and Addis Ababa in Ethiopia were selected because they have the highest TB rates and human immunodeficiency virus (HIV) co-infection in the region [3, 13–15]. Furthermore, the EXIT-TB package was implemented in seven healthcare facilities in each country with four facilities commencing implementation early (early implementation sites) as compared to the rest. Therefore, qualitative data were collected in these 4 early implementation facilities in each country because participants had much longer exposure to the intervention.
The EXIT-TB package involving integrated TB case-finding activities was implemented from April 2019 to January 2022. The package was implemented at the reproductive and child health clinics (RCH), diabetics and HIV clinics in addition to the outpatients’ departments (OPD) using systematic TB symptom screening at these service delivery points [11]. We introduced a stamp of TB symptoms in all patient forms to aid in TB symptom screening. This was followed by further clinical evaluation by the clinicians at the OPD, RCH, and diabetic and HIV clinics. Healthcare workers and/or CHWs at the entry point of the OPD, RCH, diabetic and HIV clinics were trained on how to screen for TB symptoms. Following clinician evaluation, all symptomatic patients defined as patients who either reported a cough and/or haemoptysis of any duration or excessing weight loss, or excessive night sweats or fever were further screened using CXR (with exception of pregnant women, diabetic patients, and HIV infected individuals who were directly subjected to TB diagnostic test). Contact tracing among children with a household member with TB and CXR of all symptomatic children were also performed. Following CXR findings, patients were triaged accordingly, and presumptive TB patients were either tested using smear microscopy or GeneXpert (depending on availability). Presumptive TB patients were grouped as follows (i) Those with CXR suggestive of TB regardless of the presence of other TB cardinal symptoms, (ii) Patients with a short duration cough with CXR suggestive of TB regardless of other TB cardinal symptoms, (iii) Patients with a long duration cough defined as cough of two or more weeks regardless of the CXR findings, (iv) Diabetic patients with cough and/or haemoptysis of any duration, (v) HIV infected individuals (stage 1 and 2) with any of the TB symptoms regardless of the duration of the TB symptoms, (vi) HIV infected individuals with advanced diseases (stage 3 and 4) regardless of the presence of cough, and (vii) Pregnant women with a cough with or without any other TB cardinal symptoms or haemoptysis regardless of duration. To minimize the cost of CXR, the project facilitated the procurement of an X-ray machine in one of the facilities in Kenya and met the cost for presumptive patients in other facilities (in all countries) for patients from low-income families. Only two facilities (one in Kenya and one in Tanzania) had no CXR services. In Kenya, the project paid for CXR services for presumptive patients from low-income families in a facility located about 2 kms from the project site however they were required to meet the transport costs. In Tanzania, the project facilitated the payment of the cost of CXR for presumptive patients from low-income families in a nearby private facility that was within walking distance of the project site. All diagnosed TB patients were treated according to the National TB treatment guidelines.
A total of 73 in-depth interviews (IDI) were conducted with purposefully selected service providers, patients, policymakers, and stakeholders as we wanted to gather perspectives on EXIT-TB from different healthcare facilities and countries. While equal representation is not a primary focus in qualitative studies [11], the level and ownership of facility (public, private & FBO and dispensary, health centre, and hospital) and country were considered during participants’ enrolment. No age preference was made for this qualitative inquiry other than being a service provider who participated in EXIT-TB implementation, a policy marker who is aware of the EXIT-TB package; a patient who received EXIT-TB intervention; OR a stakeholder working on TB control issues in respective countries.
IDI data transcription and translation was done simultaneously by research assistants, and transcripts were verified by the research team in respective countries. Interview transcripts were deidentified, pseudonyms were generated for each participant, and the data was uploaded into the NVivo 12 software (QSR International) for management and deductive thematic coding. A stepwise approach was used for the thematic analysis of the interview transcripts [16]. First, the research team examined the research questions and generated several themes based on consensus. This resulted in an analytical matrix of the main themes and subthemes. Individual transcripts and phrases (codes) representing participants’ responses to investigators’ questions were exported to relevant themes and related sub-themes within NVivo. A consensus-based approach was then used by the research team to decide on including codes that do not fit within the pre-developed sub-themes and themes; the codes were excluded when they did not provide critical value to the study, as confirmed by subjective and objective evaluations. The coded data within NVivo were then exported to Microsoft Word (Microsoft Corporation) for interpretative analysis and report generation.
The demographic characteristics of participants are represented in and Table 1. In total, 73 participants aged 22–70 years were included in this qualitative audit, with most participants aged between 41 and 50 years. Most participants 43 (58.9%) were male. Participants included clinicians 24 (32.9%), TB coordinators and stakeholders 17 (23.3%), community health workers 14 (19.1%), medical In-charges 10 (13.7%) and nurses 8 (11.0%).
There was a consensus among most participants that the implementation of the EXIT-TB project has increased TB case detection. The descriptions during qualitative interviews strongly reflected project monitoring and evaluation data in the 16 selected facilities that indicated an increase in TB case detection from 320 in Tanzania, 253 in Kenya, 169 in Uganda and 39 in Ethiopia per 100,000 population during the 2017 baseline survey to 505 in Tanzania, 334 in Kenya, 208 in Uganda and 78 in Ethiopia per 100,000 population at the end of the EXIT-TB project in 2022.The contributors of the EXIT-TB package to increased TB case detection described by participants were six-fold (Table 2). The first contributor was the use of CXR services to screen for TB after symptom screening. In some countries, CXR services were made free, especially for those who couldn’t afford them. Free CXR especially among those who couldn’t afford the cost recurrently emerged as a key driver of increased uptake of TB screening. One participant in Uganda mentioned free CXR services worked better because most people could not afford the cost of X-ray services before the project. Free CXR were described as facilitating access of poor people to this essential service in the TB diagnosis process. Relatedly, there were affirmations in Tanzania and Ethiopia that the project improved access to TB services among the poor and low-income population. In Tanzania, some participants described a tendency of peer referral for free CXR services, particularly in areas with low-income populations. In Ethiopia, the project was cited to have facilitated the treatment of poor communities who could otherwise fail to meet the cost of diagnosis and medical care.
Although few participants affirmed encountering no challenges, most participants mentioned several challenges and barriers. The challenges and barriers encountered during the implementation of EXIT-TB can be heuristically categorised into two groups: supply-side challenges and demand-side challenges (Table 3). These barriers appeared common in all implementation countries. However, the supply-side challenges dominated compared to the demand-side challenges.
Service delivery barriers included disorganised patient flow across points of care which resulted in unnecessary delays in screening; delays in medical consultation and short consultation time for TB presumptive patients because of high clinicians’ workload; clinicians not performing screening when not done at the entry points, clinicians not performing thorough investigations for TB presumptive patients, poor integration of TB screening in routine clinical investigations and limited space for offering EXIT-TB services within HIV clinics. A key service delivery concern was the COVID-19 pandemic. The challenges introduced by the COVID-19 pandemic were the closure of some facilities particularly those identified as COVID-19 centres, increased demand for personal protective equipment (PPEs) including facemasks which created deficits, fear of some clients attending facilities because of fear of COVID-19 infection (see below) and fear among providers to offer care to patients presenting with cough as they may be dealing with COVID-19 which increased chances of infection. Another challenge was the need to perform TB screening alongside COVID-19 screening which added more documentation responsibilities on the part of the provider. Some of these issues are highlighted in Table 3 below.
This paper examined the contribution of EXIT-TB, challenges encountered during implementation and suggestions for scaling up the EXIT-TB package in Tanzania, Kenya, Uganda, and Ethiopia. The implementation of the EXIT-TB package was done in recognition of low TB case detection in EA despite a decline in prevalence, incidence, and death rates globally [1, 17–22]. IDIs were conducted with service providers, policymakers, and other implementing partners with a focus on their experiences with EXIT-TB implementation, changes noticed and their insights on important considerations for scaling up the package in a similar or another setting.
The findings indicate a broad consensus that EXIT-TB has contributed to an increase in TB screening and diagnosis in the study settings. The findings further indicated an improvement in TB service delivery by reducing waiting time for screening and diagnosis. Healthcare providers appear to have benefited from EXIT-TB implementation by gaining more competence in conducting TB screening and diagnosis and improving their decision-making capacity. The provision of chest X-rays as screening and diagnostic tools and free X-ray services for those who could not afford them facilitated more TB case finding. Likewise, TB case finding integration to other clinics, community sensitization and cooperation between providers at the facility and community as well as better linkage of clients from communities to facilities emerged as major contributors to the success noted. One of the important practices emerging in our study was the engagement of CHWs in community sensitization and screening at the facility as a driver of increased screening. Another important finding was the use of new simple screening criteria as the key drivers of TB screening uptake. During EXIT-TB implementation, anyone presenting with a cough of any duration was screened contrary to the guideline in implementation countries where a cough of more than two weeks is often considered. Our findings strongly mirror the findings of most of the previous studies. Evidence continues to indicate that integrated TB screening packages have significantly increased TB diagnosis in many countries. For instance, a recent study in Ghana suggests that an integrated TB screening package with a simplified process for TB screening, linkage, integration of screening services across service delivery points and referral and engagement of community health care providers are the major drivers of increased TB screening [11, 23]. Another study in Eswatini indicated an increase in TB screening among pregnant women because of the integration of TB/HIV services in Reproductive Maternal Neonatal and Child Health settings despite some concerns with symptom screening [24]. Furthermore, it is important to note that the contribution of CHWs in driving the success of TB screening interventions has been widely documented [25-27]. In India for instance, CHW has been documented to be critical in the success of active TB case findings [25]. In Mozambique, CHWs have been the driving force behind the success of facility-based TB screening [26]. This indicates that the value of employing CHWs in integrated TB screening activities is indispensable. This explains why Sinha, Shenoi & Friedland [27], have illustrated the effectiveness of CHWs across the entire cascade of TB care and outlined additional opportunities for CHWs to address challenges particular to the TB pandemic. Taken together, these findings indicate that integration of TB screening into routine care, affordability of screening tests, use of CHWs for community sensitization and screening and use of simplified screening criteria are critical in increasing TB screening and diagnosis.
The study unmasked a range of supply and demand-side challenges related to the implementation of the EXIT-TB package and the entire TB program in the countries. On the one hand, key supply-side challenges included practice-and resource challenges. Important practice challenges included the concerns of disorganised care in some facilities and negative attitudes towards the project and TB-Diagnostic procedure among some HCWs. Relatedly, important resource challenges included infrastructure barriers and human resources for health issues in terms of expertise and quantity as well as an inadequate stock of essential materials. Dysfunctional or absence of X-Ray and GeneXpert services in some healthcare facilities emerged as a recurrent challenge. Looking across the literature, similar practice and resource challenges have been widely documented on the supply side as facing not only TB screening but also healthcare service provision as a whole. Specifically, to the implementation of integrated TB packages, practice challenges such as the negativity of HCWs and resource challenges such as infrastructure, equipment, essential materials, and human resource gaps have been documented to Impact TB screening in some African countries [2, 4, 5, 11, 14, 23, 28, 29]. For instance, a recent qualitative study examining factors that influence the implementation of TB screening among PLHIV in selected HIV clinics in Ghana [23] reported negative attitudes and low commitment of HCWs to TB screening and limited facility infrastructure as the main barriers. Consequently, the need to increase HCWs’ commitment towards TB screening interventions was recommended by the authors. Within East Africa, concerns of understaffing, inadequate diagnostic materials, service disorganization and malpractice have been recently identified by our team as impacting TB Diagnosis in Kenya, Uganda, and Tanzania [11]. This indicates that the success of TB Screening interventions requires addressing both practice and resource challenges in healthcare facilities.
On the other hand, the key demand side challenges emerging from our study included delayed care seeking, immature discontinuation of the screening process because of failure to return to the facility, negative beliefs, fears of stigma towards screening and financial challenges. Similar to supply-side challenges, demand-side challenges have been widely discussed in the literature. A common approach in most literature is to document both supply and demand sides concurrently. For example, studies in Uganda have documented concerns of infrastructure, understaffing and expertise concerns on the supply side and stigma and financial challenges on the demand side as the barriers to TB screening [28, 29]. However, a few works of literature have specifically highlighted the demand side barriers to TB screening. For example, a qualitative study of TB patients in Mozambique identified concerns of stigma related to diagnosis and treatment, inadequate knowledge, and negative beliefs as among the barriers to TB diagnosis and treatment [30]. The existence of these challenges may explain why participants suggested improvement of service delivery, access to diagnostic equipment and supplies, physical infrastructure, and financing, addressing client fears and stigma, and improving the linkage of clients from communities to facilities for scaling up of EXIT-TB packages. This indicates that the success of the integrated TB screening package largely depends on the efforts to address both the supply and demand side challenges more broadly.
While the implementation of the EXIT-TB package in multiple countries is a major strength, this may also be a limitation. The implementation of the EXIT-TB package across many countries with many healthcare facilities covering rural and urban settings. While a focus on fewer countries could have resulted in richer data, we believe that multi-country studies are important in generating evidence that can be easily adopted globally. Some researchers have provided evidence to support this notion [31].

Sections

"[{\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR1\", \"CR2\", \"CR1\", \"CR3\", \"CR4\", \"CR6\", \"CR7\"], \"section\": \"Introduction\", \"text\": \"The persistent burden of Tuberculosis (TB) in sub-Saharan Africa (SSA) is linked to missed diagnoses, delayed diagnoses, and challenges with access to high-quality care, which all continue to contribute to a higher risk of death, suffering, and catastrophic financial consequences [1].\\u00a0While it is well recognized that early TB diagnosis and prompt treatment are cornerstones to TB control, early case detection, and timely treatment also reduce morbidity and mortality associated with TB [2]. TB is a health priority in SSA where lack of modern facilities for proper diagnosis and management has left majority of patients undiagnosed, and these continue to spread the disease. In most SSA countries, TB case finding is through passive case finding and where possible, provider-initiated active case finding of symptomatic people in a predetermined target group such as HIV-infected individuals [1\\u20133]. Under passive case finding, an individual is required to report to a health facility for care. In Tanzania, Kenya, Uganda, and Ethiopia, for an individual to be recognized as a presumptive TB patient, they need to report to a health facility with a cough of two or more weeks with or without accompanying symptoms [4\\u20136], limiting the opportunity to capture those who report less duration cough, women and children attending Reproductive and Child Health (RCH) clinics and diabetic patients. To a large extent, passive case finding depends on individuals\\u2019 self-initiative to visit a healthcare facility and report a cough with proper duration, socio-economic status, and knowledge, and on the degree of alertness of health workers to suspect a patient [7].\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR4\", \"CR6\", \"CR2\", \"CR6\", \"CR2\", \"CR6\", \"CR2\", \"CR6\", \"CR8\", \"CR9\", \"CR10\"], \"section\": \"Introduction\", \"text\": \"In the East African (EA) region, TB case detection is below what is required to achieve the World Health Organization (WHO) END TB strategic target of reducing TB incidence by 50% by 2025 [4\\u20136] and is even lower among women and children. The 2021 National TB control (NTP) reports show that TB case notifications per 100,000 population were 134 in Tanzania, 135 in Kenya, 155 in Uganda, and 84 in Ethiopia, and in most countries only 40% were females [2\\u20136]. These values appear to be less than the estimated incidences for 2021 of 208 in Tanzania, 252 in Kenya, 199 in Uganda and 119 in Ethiopia per 100,000 population [2\\u20136]. Moreover, TB case detection at Care and Treatment Centres (CTC) is based on the screening of symptomatic patients and none is done at diabetic clinics. Furthermore, although TB contact tracing is one of the core NTP activities in all four countries [2\\u20136], it is not sufficiently done even among contact children due to financial constraints. It is known that women are good attendants of RCH clinics either for their reproductive health services or the health of their children, therefore, the current practice limits the opportunity of capturing TB cases among women and their children, and hence limits the efforts of NTP\\u2019s of putting more infectious TB cases into care. In addition, although chest X-ray (CXR) has been recently promoted and recommended by WHO as a useful tool for TB screening and triaging algorithms [8], none of the NTPs in the region has adopted it into policy. CXR has been reported to be the most sensitive TB screening tool (with very low specificity though) since a significant proportion of TB patients are asymptomatic [9]. CXR when used to triage who should be tested with GeneXpert has been reported to reduce the number of individuals to be tested with the assay, and thus, reduces high costs associated with GeneXpert and thus improve the efficiency of GeneXpert [10].\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR11\", \"CR12\"], \"section\": \"Design\", \"text\": \"The parent study was a multi-country cluster randomized controlled trial where the unit of randomization was the facility [11]. The EXIT-TB package was implemented in a total of 4 urban and 3 rural facilities in each participating country. Twenty-eight facilities (7 in each country) were randomized to either early intervention or deferred arm. The intervention was done in the first 12\\u00a0months in 16 facilities and deferred in 12 facilities (control sites). Implementing the intervention in all 28 clinics simultaneously was a major challenge\\u2014hence we opted for this approach to scale up sequentially. While the EXIT-TB package was implemented, a qualitative descriptive approach was envisaged in gathering insights from the participants on EXIT-TB package implementation. This approach was deemed appropriate to answer three key questions to this inquiry: (i) What is the contribution of the EXIT-TB package on TB case detection in the study settings? (ii) what are the challenges encountered and possible solutions that were taken during the implementation of the EXIT-TB package? and, (iii) What are the key considerations for scaling up the EXIT-TB package? A qualitative descriptive approach is appropriate for this inquiry as it aims to develop an understanding and describe the contribution of the EXIT-TB package on TB case detection without testing an existing theory [12]. This approach offered an effective way of gaining a deep and rich understanding of HCWs, CHWs, and stakeholders\\u2019 perceptions and experiences in the chosen context, as this may differ from other contexts in terms of culture, expectations, and resources within health care settings.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR3\", \"CR13\", \"CR15\"], \"section\": \"Settings\", \"text\": \"In each country, regions/districts/counties and facilities were selected for the EXIT-TB implementation. Dar es Salaam in Tanzania, Nakaseke and Kiboga in Uganda, Siaya in Kanya Dire Dawa, and Addis Ababa in Ethiopia were selected because they have the highest TB rates and human immunodeficiency virus (HIV) co-infection in the region [3, 13\\u201315]. Furthermore, the EXIT-TB package was implemented in seven healthcare facilities in each country with four facilities commencing implementation early (early implementation sites) as compared to the rest. Therefore, qualitative data were collected in these 4 early implementation facilities in each country because participants had much longer exposure to the intervention.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR11\"], \"section\": \"EXIT-TB intervention package\", \"text\": \"The EXIT-TB package involving integrated TB case-finding activities was implemented from April 2019 to January 2022. The package was implemented at the reproductive and child health clinics (RCH), diabetics and HIV clinics in addition to the outpatients\\u2019 departments (OPD) using systematic TB symptom screening at these service delivery points [11]. We introduced a stamp of TB symptoms in all patient forms to aid in TB symptom screening. This was followed by further clinical evaluation by the clinicians at the OPD, RCH, and diabetic and HIV clinics. Healthcare workers and/or CHWs at the entry point of the OPD, RCH, diabetic and HIV clinics were trained on how to screen for TB symptoms. Following clinician evaluation, all symptomatic patients defined as patients who either reported a cough and/or haemoptysis of any duration or excessing weight loss, or excessive night sweats or fever were further screened using CXR (with exception of pregnant women, diabetic patients, and HIV infected individuals who were directly subjected to TB diagnostic test). Contact tracing among children with a household member with TB and CXR of all symptomatic children were also performed. Following CXR findings, patients were triaged accordingly, and presumptive TB patients were either tested using smear microscopy or GeneXpert (depending on availability). Presumptive TB patients were grouped as follows (i) Those with CXR suggestive of TB regardless of the presence of other TB cardinal symptoms, (ii) Patients with a short duration cough with CXR suggestive of TB regardless of other TB cardinal symptoms, (iii) Patients with a long duration cough defined as cough of two or more weeks regardless of the CXR findings, (iv) Diabetic patients with cough and/or haemoptysis of any duration, (v) HIV infected individuals (stage 1 and 2) with any of the TB symptoms regardless of the duration of the TB symptoms, (vi) HIV infected individuals with advanced diseases (stage 3 and 4) regardless of the presence of cough, and (vii) Pregnant women with a cough with or without any other TB cardinal symptoms or haemoptysis regardless of duration. To minimize the cost of CXR, the project facilitated the procurement of an X-ray machine in one of the facilities in Kenya and met the cost for presumptive patients in other facilities (in all countries) for patients from low-income families. Only two facilities (one in Kenya and one in Tanzania) had no CXR services. In Kenya, the project paid for CXR services for presumptive patients from low-income families in a facility located about 2 kms from the project site however they were required to meet the transport costs. In Tanzania, the project facilitated the payment of the cost of CXR for presumptive patients from low-income families in a nearby private facility that was within walking distance of the project site. All diagnosed TB patients were treated according to the National TB treatment guidelines.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR11\"], \"section\": \"Study population, sample size, and sampling method\", \"text\": \"A total of 73 in-depth interviews (IDI) were conducted with purposefully selected service providers, patients, policymakers, and stakeholders as we wanted to gather perspectives on EXIT-TB from different healthcare facilities and countries. While equal representation is not a primary focus in qualitative studies [11], the level and ownership of facility (public, private & FBO and dispensary, health centre, and hospital) and country were considered during participants\\u2019 enrolment. No age preference was made for this qualitative inquiry other than being a service provider who participated in EXIT-TB implementation, a policy marker who is aware of the EXIT-TB package; a patient who received EXIT-TB intervention; OR a stakeholder working on TB control issues in respective countries.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR16\"], \"section\": \"Data management and analysis\", \"text\": \"IDI data transcription and translation was done simultaneously by research assistants, and transcripts were verified by the research team in respective countries. Interview transcripts were deidentified, pseudonyms were generated for each participant, and the data was uploaded into the NVivo 12 software (QSR International) for management and deductive thematic coding. A stepwise approach was used for the thematic analysis of the interview transcripts [16]. First, the research team examined the research questions and generated several themes based on consensus. This resulted in an analytical matrix of the main themes and subthemes. Individual transcripts and phrases (codes) representing participants\\u2019 responses to investigators\\u2019 questions were exported to relevant themes and related sub-themes within NVivo. A consensus-based approach was then used by the research team to decide on including codes that do not fit within the pre-developed sub-themes and themes; the codes were excluded when they did not provide critical value to the study, as confirmed by subjective and objective evaluations. The coded data within NVivo were then exported to Microsoft Word (Microsoft Corporation) for interpretative analysis and report generation.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"Tab1\"], \"section\": \"Participants demographic characteristics\", \"text\": \"The demographic characteristics of participants are represented in and Table\\u00a01. In total, 73 participants aged 22\\u201370\\u00a0years were included in this qualitative audit, with most participants aged between 41 and 50\\u00a0years. Most participants 43 (58.9%) were male. Participants included clinicians 24 (32.9%), TB coordinators and stakeholders 17 (23.3%), community health workers 14 (19.1%), medical In-charges 10 (13.7%) and nurses 8 (11.0%).\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"Tab2\"], \"section\": \"Increased TB case detection\", \"text\": \"There was a consensus among most participants that the implementation of the EXIT-TB project has increased TB case detection. The descriptions during qualitative interviews strongly reflected project monitoring and evaluation data in the 16 selected facilities that indicated an increase in TB case detection from 320 in Tanzania, 253 in Kenya, 169 in Uganda and 39 in Ethiopia per 100,000 population during the 2017 baseline survey to 505 in Tanzania, 334 in Kenya, 208 in Uganda and 78 in Ethiopia per 100,000 population at the end of the EXIT-TB project in 2022.The contributors of the EXIT-TB package to increased TB case detection described by participants were six-fold (Table 2). The first contributor was the use of CXR services to screen for TB after symptom screening. In some countries, CXR services were made free, especially for those who couldn\\u2019t afford them. Free CXR especially among those who couldn\\u2019t afford the cost recurrently emerged as a key driver of increased uptake of TB screening. One participant in Uganda mentioned free CXR services worked better because most people could not afford the cost of X-ray services before the project. Free CXR were described as facilitating access of poor people to this essential service in the TB diagnosis process. Relatedly, there were affirmations in Tanzania and Ethiopia that the project improved access to TB services among the poor and low-income population. In Tanzania, some participants described a tendency of peer referral for free CXR services, particularly in areas with low-income populations. In Ethiopia, the project was cited to have facilitated the treatment of poor communities who could otherwise fail to meet the cost of diagnosis and medical care.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"Tab3\"], \"section\": \"Theme 2: Challenges faced in delivering EXIT-TB package\", \"text\": \"Although few participants affirmed encountering no challenges, most participants mentioned several challenges and barriers. The challenges and barriers encountered during the implementation of EXIT-TB can be heuristically categorised into two groups: supply-side challenges and demand-side challenges (Table 3). These barriers appeared common in all implementation countries. However, the supply-side challenges dominated compared to the demand-side challenges.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"Tab3\"], \"section\": \"Service delivery barriers\", \"text\": \"Service delivery barriers included disorganised patient flow across points of care which resulted in unnecessary delays in screening; delays in medical consultation and short consultation time for TB presumptive patients because of high clinicians\\u2019 workload; clinicians not performing screening when not done at the entry points, clinicians not performing thorough investigations for TB presumptive patients, poor integration of TB screening in routine clinical investigations and limited space for offering EXIT-TB services within HIV clinics. A key service delivery concern was the COVID-19 pandemic. The challenges introduced by the COVID-19 pandemic were the closure of some facilities particularly those identified as COVID-19 centres, increased demand for personal protective equipment (PPEs) including facemasks which created deficits, fear of some clients attending facilities because of fear of COVID-19 infection (see below) and fear among providers to offer care to patients presenting with cough as they may be dealing with COVID-19 which increased chances of infection. Another challenge was the need to perform TB screening alongside COVID-19 screening which added more documentation responsibilities on the part of the provider. Some of these issues are highlighted in Table 3 below.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR1\", \"CR17\", \"CR22\"], \"section\": \"Discussion\", \"text\": \"This paper examined the contribution of EXIT-TB, challenges encountered during implementation and suggestions for scaling up the EXIT-TB package in Tanzania, Kenya, Uganda, and Ethiopia. The implementation of the EXIT-TB package was done in recognition of low TB case detection in EA despite a decline in prevalence, incidence, and death rates globally [1, 17\\u201322]. IDIs were conducted with service providers, policymakers, and other implementing partners with a focus on their experiences with EXIT-TB implementation, changes noticed and their insights on important considerations for scaling up the package in a similar or another setting.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR11\", \"CR23\", \"CR24\", \"CR25\", \"CR26\", \"CR27\"], \"section\": \"Discussion\", \"text\": \"The findings indicate a broad consensus that EXIT-TB has contributed to an increase in TB screening and diagnosis in the study settings. The findings further indicated an improvement in TB service delivery by reducing waiting time for screening and diagnosis. Healthcare providers appear to have benefited from EXIT-TB implementation by gaining more competence in conducting TB screening and diagnosis and improving their decision-making capacity. The provision of chest X-rays as screening and diagnostic tools and free X-ray services for those who could not afford them facilitated more TB case finding. Likewise, TB case finding integration to other clinics, community sensitization and cooperation between providers at the facility and community as well as better linkage of clients from communities to facilities emerged as major contributors to the success noted. One of the important practices emerging in our study was the engagement of CHWs in community sensitization and screening at the facility as a driver of increased screening. Another important finding was the use of new simple screening criteria as the key drivers of TB screening uptake. During EXIT-TB implementation, anyone presenting with a cough of any duration was screened contrary to the guideline in implementation countries where a cough of more than two weeks is often considered. Our findings strongly mirror the findings of most of the previous studies. Evidence continues to indicate that integrated TB screening packages have significantly increased TB diagnosis in many countries. For instance, a recent study in Ghana suggests that an integrated TB screening package with a simplified process for TB screening, linkage, integration of screening services across service delivery points and referral and engagement of community health care providers are the major drivers of increased TB screening [11, 23]. Another study in Eswatini indicated an increase in TB screening among pregnant women because of the integration of TB/HIV services in Reproductive Maternal Neonatal and Child Health settings despite some concerns with symptom screening [24]. Furthermore, it is important to note that the contribution of CHWs in driving the success of TB screening interventions has been widely documented [25-27]. In India for instance, CHW has been documented to be critical in the success of active TB case findings [25]. In Mozambique, CHWs have been the driving force behind the success of facility-based TB screening [26]. This indicates that the value of employing CHWs in integrated TB screening activities is indispensable. This explains why Sinha, Shenoi & Friedland [27], have illustrated the effectiveness of CHWs across the entire cascade of TB care and outlined additional opportunities for CHWs to address challenges particular to the TB pandemic. Taken together, these findings indicate that integration of TB screening into routine care, affordability of screening tests, use of CHWs for community sensitization and screening and use of simplified screening criteria are critical in increasing TB screening and diagnosis.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR2\", \"CR4\", \"CR5\", \"CR11\", \"CR14\", \"CR23\", \"CR28\", \"CR29\", \"CR23\", \"CR11\"], \"section\": \"Discussion\", \"text\": \"The study unmasked a range of supply and demand-side challenges related to the implementation of the EXIT-TB package and the entire TB program in the countries. On the one hand, key supply-side challenges included practice-and resource challenges. Important practice challenges included the concerns of disorganised care in some facilities and negative attitudes towards the project and TB-Diagnostic procedure among some HCWs. Relatedly, important resource challenges included infrastructure barriers and human resources for health issues in terms of expertise and quantity as well as an inadequate stock of essential materials. Dysfunctional or absence of X-Ray and GeneXpert services in some healthcare facilities emerged as a recurrent challenge. Looking across the literature, similar practice and resource challenges have been widely documented on the supply side as facing not only TB screening but also healthcare service provision as a whole. Specifically, to the implementation of integrated TB packages, practice challenges such as the negativity of HCWs and resource challenges such as infrastructure, equipment, essential materials, and human resource gaps have been documented to Impact TB screening in some African countries [2, 4, 5, 11, 14, 23, 28, 29]. For instance, a recent qualitative study examining factors that influence the implementation of TB screening among PLHIV in selected HIV clinics in Ghana [23] reported negative attitudes and low commitment of HCWs to TB screening and limited facility infrastructure as the main barriers. Consequently, the need to increase HCWs\\u2019 commitment towards TB screening interventions was recommended by the authors. Within East Africa, concerns of understaffing, inadequate diagnostic materials, service disorganization and malpractice have been recently identified by our team as impacting TB Diagnosis in Kenya, Uganda, and Tanzania [11]. This indicates that the success of TB Screening interventions requires addressing both practice and resource challenges in healthcare facilities.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR28\", \"CR29\", \"CR30\"], \"section\": \"Discussion\", \"text\": \"On the other hand, the key demand side challenges emerging from our study included delayed care seeking, immature discontinuation of the screening process because of failure to return to the facility, negative beliefs, fears of stigma towards screening and financial challenges. Similar to supply-side challenges, demand-side challenges have been widely discussed in the literature. A common approach in most literature is to document both supply and demand sides concurrently. For example, studies in Uganda have documented concerns of infrastructure, understaffing and expertise concerns on the supply side and stigma and financial challenges on the demand side as the barriers to TB screening [28, 29]. However, a few works of literature have specifically highlighted the demand side barriers to TB screening. For example, a qualitative study of TB patients in Mozambique identified concerns of stigma related to diagnosis and treatment, inadequate knowledge, and negative beliefs as among the barriers to TB diagnosis and treatment [30]. The existence of these challenges may explain why participants suggested improvement of service delivery, access to diagnostic equipment and supplies, physical infrastructure, and financing, addressing client fears and stigma, and improving the linkage of clients from communities to facilities for scaling up of EXIT-TB packages. This indicates that the success of the integrated TB screening package largely depends on the efforts to address both the supply and demand side challenges more broadly.\"}, {\"pmc\": \"PMC10013287\", \"pmid\": \"36918800\", \"reference_ids\": [\"CR31\"], \"section\": \"Limitations\", \"text\": \"While the implementation of the EXIT-TB package in multiple countries is a major strength, this may also be a limitation. The implementation of the EXIT-TB package across many countries with many healthcare facilities covering rural and urban settings. While a focus on fewer countries could have resulted in richer data, we believe that multi-country studies are important in generating evidence that can be easily adopted globally. Some researchers have provided evidence to support this notion [31].\"}]"

Metadata

"{\"issue-copyright-statement\": \"\\u00a9 The Author(s) 2023\"}"