Biermann Olivia, Dixit Kritika, Rai Bhola, Caws Maxine, Lönnroth Knut, Viney Kerri
Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Tomtebodavägen 18a, 17177, Stockholm, Sweden.
Birat Nepal Medical Trust, Lazimpat, Kathmandu, Nepal.
BMC Health Serv Res. 2021 Apr 1;21(1):295. doi: 10.1186/s12913-021-06290-x.
Nepal has a high burden of undetected tuberculosis (TB). In line with the World Health Organization's End TB Strategy, the National TB Programme promotes active case-finding (ACF) as one strategy to find people with TB who are unreached by existing health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented in four districts in Nepal, generating a substantial yield of previously undetected TB. We aimed to identify the facilitators and barriers linked to the implementation of ACF within IMPACT TB, as well as how those facilitators and barriers have been or could be addressed.
This was an exploratory qualitative study based on 17 semi-structured key-informant interviews with people with TB who were identified through ACF, and community health workers who had implemented ACF. Thematic analysis was applied in NVivo 11, using an implementation science framework developed by Grol and Wensing to classify the data.
We generated five main themes from the data: (1) ACF addressed the social determinants of TB by providing timely access to free healthcare, (2) knowledge and awareness about TB among people with TB, communities and community health workers were the 'oil' in the ACF 'machine', (3) trust in community health workers was fundamental for implementing ACF, (4) community engagement and support had a powerful influence on ACF implementation and (5) improved working conditions and enhanced collaboration with key stakeholders could further facilitate ACF. These themes covered a variety of facilitators and barriers, which we divided into 22 categories cutting across five framework levels: innovation, individual professional, patient, social context and organizational context.
This study provides new insights into facilitators and barriers for the implementation of ACF in Nepal and emphasizes the importance of addressing the social determinants of TB. The main themes reflect key ingredients which are required for successful ACF implementation, while the absence of these factors may convert them from facilitators into barriers for ACF. As this study outlined "how-to" strategies for ACF implementation, the findings can furthermore inform the planning and implementation of ACF in Nepal and similar contexts in low- and middle-income countries.
尼泊尔未被发现的结核病负担沉重。根据世界卫生组织的《终止结核病战略》，国家结核病规划将主动病例发现（ACF）作为一种策略，以找到现有卫生服务未覆盖的结核病患者。“影响结核病（实施经过验证的基于社区的主动结核病病例发现干预措施）”项目在尼泊尔的四个地区实施，发现了大量此前未被发现的结核病病例。我们旨在确定与“影响结核病”项目中ACF实施相关的促进因素和障碍，以及这些促进因素和障碍是如何得到解决或可以如何得到解决的。
这是一项探索性定性研究，基于对通过ACF确定的结核病患者和实施ACF的社区卫生工作者进行的17次半结构化关键知情人访谈。使用Grol和Wensing开发的实施科学框架，在NVivo 11中进行主题分析，对数据进行分类。
我们从数据中得出了五个主要主题：（1）ACF通过提供及时获得免费医疗服务的机会，解决了结核病的社会决定因素；（2）结核病患者、社区和社区卫生工作者对结核病的知识和认识是ACF“机器”中的“润滑油”；（3）对社区卫生工作者的信任是实施ACF的基础；（4）社区参与和支持对ACF实施有强大影响；（5）改善工作条件以及加强与关键利益相关者的合作可以进一步促进ACF。这些主题涵盖了各种促进因素和障碍，我们将其分为22类，跨越五个框架层面：创新、个体专业人员、患者、社会背景和组织背景。
本研究为尼泊尔ACF实施的促进因素和障碍提供了新的见解，并强调了解决结核病社会决定因素的重要性。主要主题反映了成功实施ACF所需的关键要素，而这些因素的缺失可能会将它们从促进因素转变为ACF的障碍。由于本研究概述了ACF实施的“如何做”策略，研究结果还可为尼泊尔以及低收入和中等收入国家类似背景下ACF的规划和实施提供参考。
