Barriers and facilitators of investigation coverage among index tuberculosis case contacts in rural Mbarara district, Uganda

Tukamuhebwa, Paddy Mutungi
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Background: In 2012, the World Health Organization (WHO) recommended the investigation of contacts of index tuberculosis (TB) patients in low and middle-income countries (LMICs) as a strategy for accelerating TB case detection. Despite this WHO policy guidance, coverage of TB contact investigation in Uganda remains low nine years after adopting this recommendation. Studies identifying the barriers and facilitators to optimal TB contact investigation coverage have only been done in urban areas in Uganda and Kenya. Aim: To explore health providers perspectives of the factors that influence TB contact investigation coverage in three rural, primary health facilities (PHC) in Mbarara District, South Western Uganda. Methods: An exploratory qualitative study design was used to conduct semistructured interviews with health workers involved in the TB program at the district, health facility and community levels between February 2020 and July 2020. The sample included the district TB supervisors, health facility TB focal persons, nurses, clinical officers and Community Health Workers (CHWs). The data were taperecorded, transcribed and uploaded into MAXQDA for analysis. The analysis was done inductively using reflexive thematic analysis in six iterative steps: familiarization with the data, creating initial codes, theme search, reviewing the themes, developing theme definitions, and report writing. Five domains of the Consolidated Framework for Implementation Research; characteristics of the intervention, inner setting, outer setting, individuals involved and implementation process—were used to guide the development of semi-structured interviews and identification of barriers and facilitators of TB contact investigation. Results: Nineteen health workers, two district TB and supervisors, five clinical officers, five nurses, six community health workers and one laboratory staff participated in the research representing a 100% response rate. Intervention-related factors, healthcare system factors, and contextual factors were the three themes that emerged from this research. Health system barriers comprised inadequate or delayed funding, staff shortages, insufficient personal protective equipment and stock-out of GeneXpert cartridges. Contextual obstacles included rough terrain, poverty, and stigma associated with TB and COVID-19. Increased knowledge and understanding of the intervention, strong leadership and teamwork, and on-the-job training of health workers were all facilitators. All of the CFIR domains were important in examining the challenges and enablers of contact investigation coverage. Conclusion and recommendations: In this study, we were able to identify provider opinions on the barriers and facilitators of TB contact investigation coverage by using the Consolidated Framework for Implementation Research. The intervention-related, health system and contextual factors identified from this research may be used to guide the development of tailored interventions for rural hard to reach communities. To increase TB contact investigation coverage in rural areas, the National TB and Leprosy Program should advocate for increased funding to the TB program and address barriers in the flow of funds up the grass-root level. The government also should address the staffing gaps, strengthen the supply chain of essential suppliers and reinforce all the health system components. The Ministry of Health should also develop stigma reduction interventions and explore interventions for reaching out to hard to reach rural populations.
A research report submitted to the Faculty of Health Sciences in partial fulfilment of the requirements for the degree of MSc in Epidemiology in Implementation Science.