Suchergebnisse

Background: Tuberculosis (TB) is one of the world's leading infectious killers. Every year, an estimated 10 million people fall ill with the disease, of whom 2.9 million people are never diagnosed and treated. Thirty low- and middle-income countries account for almost 90% of the global TB burden. The World Health Organization's (WHO) End TB Strategy highlights active case-finding (ACF) as one approach to finding people with TB who are currently being missed by health services. ACF has been shown to find more people with TB at an earlier stage of the disease compared to passive case-finding. Passive case-finding is the standard approach to TB screening, relying on people seeking care when they have TB symptoms. Given the relatively limited evidence on both the epidemiological impact of ACF and optimal implementation strategies, questions remain about what influences ACF policy development and implementation and how these processes can be improved. This thesis aims to contribute to the knowledge base on ACF policy development and implementation in high TB burden countries. Objectives: To review antecedents, components and influencing factors for ACF policy development and implementation based on the literature. To explore how international experts and National TB Programme (NTP) managers from high TB burden countries perceive ACF policy development and implementation, and to identify facilitators, barriers and "how-to" strategies for ACF implementation in Nepal and Vietnam, which serve as example countries. Methods: A scoping review of the literature (n=73) was performed, and a frequency and thematic analysis applied. Qualitative semi-structured interviews were conducted with 39 experts from a variety of institutions worldwide. The experts' perceptions were analysed using framework analysis. A mixed methods survey with NTP managers (n=23) was implemented, yielding both quantitative and qualitative data. The data were analysed in parallel and merged in the interpretation of the findings. The survey results were further complemented by a narrative review of national TB strategic plans (n=22). Qualitative semi-structured interviews were conducted with 17 key-informants in Nepal and 39 key-informants in Vietnam. Participants comprised implementers of ACF and people with TB identified through ACF. Thematic analysis was applied, using an implementation science framework. Results: The results presented in this thesis provide insights into experiences with ACF, from global policies to local implementation. Study I: The evidence base for ACF has been growing, especially since 2010. Although much is known about factors influencing ACF implementation (e.g., resources), evidence on what influences ACF policy development (e.g., politics) remains scarce. Articles described the WHO's recent emphasis on ACF as a crucial antecedent of the increasing interest in ACF, especially in high TB burden countries. Study II: Experts had a wide range of views on ACF, from ACF being a "waste basket" for resources to it being "common sense" and something that should be done. They described the influence of and "power plays" between donors, governments and non-governmental organisations on ACF policy development and highlighted the need for different types of evidence to inform ACF policy development and implementation. Experts also stressed the importance of existing systems, processes and experience in influencing ACF implementation, e.g., ACF could build on experience from other screening programmes. Study III: Perceived benefits of ACF were linked to its objective of finding people with TB early, while ACF was also perceived as a "doubleedged sword" that could cause harm, if inappropriately designed and implemented. Study IV: NTP managers unanimously agreed on the need for ACF scale-up in high TB burden countries. This was also reflected in the national TB strategic plans, even though not all documents included explicit aims and targets related to ACF. At the same time, 90% of the NTP managers also described a lack of financial and human resources for ACF. Strategies to increase resources included generating local evidence for advocacy. Managers in districts or regions were the only ones among a list of stakeholders that NTP managers considered crucial for both ACF policy development and implementation. Studies V and VI: In Nepal and Vietnam, the main themes revolved around how people (the implementers and people with TB) could "make or break" TB screening, but also how projects could provide a context that is conducive to ACF implementation (e.g., through human resources, equipment and training). Many similar facilitators and barriers for ACF implementation were identified in Nepal and Vietnam, such as the implementers' dedication, motivation, skills and network. Barriers and facilitators at the societal and organisational levels were more context specific. For instance, in Nepal, poverty and community support were mentioned as critical. In Vietnam, participants elaborated on the importance of commitment and support from various stakeholders for ACF implementation. In both countries, the implementers requested increased incentives and training. Conclusions: Based on these results, evidence remains limited with regards to factors influencing ACF policy development. Experts have opposing views on ACF policy development and implementation, while NTP managers unanimously agree on the need for ACF scale-up, which is also reflected in the national TB strategic plans. Yet, 90% of the NTP managers state that human and financial resources are currently insufficient, and funds for ACF might have to be sought from alternative domestic and external sources. Benefits and harms of ACF must be considered throughout the screening and diagnostic pathway to avoid possible negative effects for people screened, as well as communities and health systems. Furthermore, the use of different types of evidence and the engagement of stakeholders (e.g., managers in districts and regions) are necessary to mitigate "power plays" that might otherwise mislead ACF policy development and implementation. Most facilitators, barriers and "how-to" strategies for ACF implementation identified in Nepal and Vietnam are similar across contexts, but there are also nuances, e.g., based on the predominant social determinants of TB. ACF projects can provide a context that is conducive to ACF implementation, but implementation success still depends on individuals. Ultimately, if done well, ACF can be an important, complementary tool to contribute towards ending TB, while more resources and evidence are needed to improve ACF policy development and implementation.

Objective To explore antecedents, components and influencing factors on active case-finding (ACF) policy development and implementation. Design Scoping review, searching MEDLINE, Web of Science, the Cochrane Database of Systematic Reviews and the World Health Organization (WHO) Library from January 1968 to January 2018. We excluded studies focusing on latent tuberculosis (TB) infection, passive case-finding, childhood TB and studies about effectiveness, yield, accuracy and impact without descriptions of how this evidence has/could influence ACF policy or implementation. We included any type of study written in English, and conducted frequency and thematic analyses. Results Seventy-three articles fulfilled our eligibility criteria. Most (67%) were published after 2010. The studies were conducted in all WHO regions, but primarily in Africa (22%), Europe (23%) and the Western-Pacific region (12%). Forty-one percent of the studies were classified as quantitative, followed by reviews (22%) and qualitative studies (12%). Most articles focused on ACF for tuberculosis contacts (25%) or migrants (32%). Fourteen percent of the articles described community-based screening of high-risk populations. Fifty-nine percent of studies reported influencing factors for ACF implementation; mostly linked to the health system (eg, resources) and the community/individual (eg, social determinants of health). Only two articles highlighted factors influencing ACF policy development (eg, politics). Six articles described WHO's ACF-related recommendations as important antecedent for ACF. Key components of successful ACF implementation include health system capacity, mechanisms for integration, education and collaboration for ACF. Conclusion We identified some main themes regarding the antecedents, components and influencing factors for ACF policy development and implementation. While we know much about facilitators and barriers for ACF policy implementation, we know less about how to strengthen those facilitators and how to overcome those ...

ABSTRACT Objective To explore antecedents, components and influencing factors on active case- finding (ACF) policy development and implementation. Design Scoping review, searching MEDLINE, Web of Science, the Cochrane Database of Systematic Reviews and the World Health Organization (WHO) Library from January 1968 to January 2018. We excluded studies focusing on latent tuberculosis (TB) infection, passive case- finding, childhood TB and studies about effectiveness, yield, accuracy and impact without descriptions of how this evidence has/could influence ACF policy or implementation. We included any type of study written in English, and conducted frequency and thematic analyses. Results Seventy- three articles fulfilled our eligibility criteria. Most (67%) were published after 2010. The studies were conducted in all WHO regions, but primarily in Africa (22%), Europe (23%) and the Western- Pacific region (12%). Forty- one percent of the studies were classified as quantitative, followed by reviews (22%) and qualitative studies (12%). Most articles focused on ACF for tuberculosis contacts (25%) or migrants (32%). Fourteen percent of the articles described community- based screening of high- risk populations. Fifty- nine percent of studies reported influencing factors for ACF implementation; mostly linked to the health system (eg, resources) and the community/individual (eg, social determinants of health). Only two articles highlighted factors influencing ACF policy development (eg, politics). Six articles described WHO's ACF- related recommendations as important antecedent for ACF. Key components of successful ACF implementation include health system capacity, mechanisms for integration, education and collaboration for ACF. Conclusion We identified some main themes regarding the antecedents, components and influencing factors for ACF policy development and implementation. While we know much about facilitators and barriers for ACF policy implementation, we know less about how to strengthen those facilitators and how to overcome those barriers. A major knowledge gap remains when it comes to understanding which contextual factors influence ACF policy development. Research is required to understand, inform and improve ACF policy development and implementation.

OBJECTIVE: To explore antecedents, components and influencing factors on active case-finding (ACF) policy development and implementation. DESIGN: Scoping review, searching MEDLINE, Web of Science, the Cochrane Database of Systematic Reviews and the World Health Organization (WHO) Library from January 1968 to January 2018. We excluded studies focusing on latent tuberculosis (TB) infection, passive case-finding, childhood TB and studies about effectiveness, yield, accuracy and impact without descriptions of how this evidence has/could influence ACF policy or implementation. We included any type of study written in English, and conducted frequency and thematic analyses. RESULTS: Seventy-three articles fulfilled our eligibility criteria. Most (67%) were published after 2010. The studies were conducted in all WHO regions, but primarily in Africa (22%), Europe (23%) and the Western-Pacific region (12%). Forty-one percent of the studies were classified as quantitative, followed by reviews (22%) and qualitative studies (12%). Most articles focused on ACF for tuberculosis contacts (25%) or migrants (32%). Fourteen percent of the articles described community-based screening of high-risk populations. Fifty-nine percent of studies reported influencing factors for ACF implementation; mostly linked to the health system (eg, resources) and the community/individual (eg, social determinants of health). Only two articles highlighted factors influencing ACF policy development (eg, politics). Six articles described WHO's ACF-related recommendations as important antecedent for ACF. Key components of successful ACF implementation include health system capacity, mechanisms for integration, education and collaboration for ACF. CONCLUSION: We identified some main themes regarding the antecedents, components and influencing factors for ACF policy development and implementation. While we know much about facilitators and barriers for ACF policy implementation, we know less about how to strengthen those facilitators and how to overcome ...

Objective: To explore experts' views on factors influencing national and global active case-finding (ACF) policy development and implementation, and the use of evidence in these processes. Design: This is an exploratory study based on semistructured expert interviews. Framework analysis was applied. Participants: The study involved a purposive sample of 39 experts from international, non-governmental and non-profit organisations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. Results: This study highlighted the perceived need among experts for different types of evidence for ACF policy development and implementation, and for stakeholder engagement including researchers and policymakers to foster evidence use. Interviewees stressed the influence of government, donor and non-governmental stakeholders in ACF policy development. Such key stakeholders also influence ACF policy implementation, in addition to available systems and processes in a given health system, and implementers' motivation and incentives. According to the interviewees, the World Health Organization (WHO) guidelines for systematic screening face the innate challenge of providing guidance to countries across the broad area of ACF in terms of target groups, settings and screening algorithms. The guidelines could be improved by focusing on what should be done rather than what can be done in ACF, and by providing howto examples. Leadership, integration into health systems and long-term financing are key for ACF to be sustainable. Conclusions: We provide new insights into ACF policy processes globally, particularly regarding facilitators for and barriers to ACF policy development, evidence need and use, and donor organisations' influence. According to expert participants, national and global ACF policy development and implementation can be improved by broadening stakeholder engagement. Meanwhile, using diverse evidence to inform ACF policy development and implementation could mitigate the 'power plays plus push' that might otherwise disrupt and mislead these policy processes.

OBJECTIVE: To explore experts' views on factors influencing national and global active case-finding (ACF) policy development and implementation, and the use of evidence in these processes. DESIGN: This is an exploratory study based on semistructured expert interviews. Framework analysis was applied. PARTICIPANTS: The study involved a purposive sample of 39 experts from international, non-governmental and non-profit organisations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. RESULTS: This study highlighted the perceived need among experts for different types of evidence for ACF policy development and implementation, and for stakeholder engagement including researchers and policymakers to foster evidence use. Interviewees stressed the influence of government, donor and non-governmental stakeholders in ACF policy development. Such key stakeholders also influence ACF policy implementation, in addition to available systems and processes in a given health system, and implementers' motivation and incentives. According to the interviewees, the World Health Organization (WHO) guidelines for systematic screening face the innate challenge of providing guidance to countries across the broad area of ACF in terms of target groups, settings and screening algorithms. The guidelines could be improved by focusing on what should be done rather than what can be done in ACF, and by providing howto examples. Leadership, integration into health systems and long-term financing are key for ACF to be sustainable. CONCLUSIONS: We provide new insights into ACF policy processes globally, particularly regarding facilitators for and barriers to ACF policy development, evidence need and use, and donor organisations' influence. According to expert participants, national and global ACF policy development and implementation can be improved by broadening stakeholder engagement. Meanwhile, using diverse evidence to inform ACF policy development and implementation could ...

Background: Non-governmental organizations (NGOs) have a key role in improving health in low-and middle-income countries. Their work needs to be synergistic, complementary to public services, and rooted in community mobilization and collective action. The study explores how an NGO and its health services are perceived by the population that it serves, and how it can contribute to reducing barriers to care. Design: A qualitative exploratory study was conducted in remote Ecuador, characterized by its widespread poverty and lack of official governance. An international NGO collaborated closely with the public services to deliver preventative and curative health services. Data were collected using focus group discussions and semistructured interviews with purposively sampled community members, healthcare personnel, and community health workers based on their links to the health services. Conventional qualitative content analysis was used, focusing on manifest content. Results: Emerging themes relate to the public private partnership (PPP), the NGO and its services, and community participation. The population perceives the NGO positively, linking it to healthcare improvements. Their priority is to get services, irrespective of the providers structure. The presence of an NGO in the operation may contribute to unrealistic expectations of health services, affecting perceptions of the latter negatively. Conclusions: To avoid unrealistic expectations and dissatisfaction, and to increase and sustain the populations trust in the organization, an NGO should operate in a manner that is as integrated as possible within the existing structure. The NGO should work close to the population it serves, with services anchored in the community. PPP parties should develop a common platform with joint messages to the target population on the providers structure, and regarding partners roles and responsibilities. Interaction between the population and the providers on service content and their expectations is key to positive outcomes of PPP operations. ; Funding Agencies|Karolinska Institutet; Linkoping University; Ecuador

Background Active case-finding (ACF), also referred to as community-based tuberculosis screening, is a component of the World Health Organization's End TB Strategy. ACF has potential benefits but also harms, which need to be carefully assessed when developing and implementing ACF policies. While empirical evidence on the benefits of ACF is still weak, evidence on the harms is even weaker. This study aimed to explore experts' views on the benefits and harms of ACF for people with presumptive TB and communities. Methods This was an exploratory study. Semi-structured interviews were conducted with a purposive sample of 39 experts from international, non-governmental/non-profit organizations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. Framework analysis was applied. Results Findings elaborated perceived benefits of ACF, including reaching vulnerable populations, reducing patient costs, helping raise awareness for tuberculosis among individuals and engaging communities, and reducing tuberculosis transmission. Perceived harms included increasing stigma and discrimination, causing false-positive diagnoses, as well as triggering other unintended consequences related to screening for tuberculosis patients, such as deportation of migrants once confirmed to have tuberculosis. Most of the perceived benefits of ACF could be linked to its objective of finding and treating persons with tuberculosis early (theme 1), while ACF was also perceived as a "double-edged sword" and could cause harms, if inappropriately designed and implemented (theme 2). The analysis underlined the importance of considering the benefits and harms of ACF throughout the screening pathway. The study provides new insights into the perceived benefits and harms of ACF from the perspectives of experts in the field. Conclusion This study highlights gaps in the evidence base surrounding ACF and can stimulate further research, debate and analysis regarding the benefits and harms of ACF to inform contextual optimization of design and implementation of ACF strategies. ; publishedVersion ; Peer reviewed

BACKGROUND Active case-finding (ACF), also referred to as community-based tuberculosis screening, is a component of the World Health Organization's End TB Strategy. ACF has potential benefits but also harms, which need to be carefully assessed when developing and implementing ACF policies. While empirical evidence on the benefits of ACF is still weak, evidence on the harms is even weaker. This study aimed to explore experts' views on the benefits and harms of ACF for people with presumptive TB and communities. METHODS This was an exploratory study. Semi-structured interviews were conducted with a purposive sample of 39 experts from international, non-governmental/non-profit organizations, funders, government institutions, international societies, think tanks, universities and research institutions worldwide. Framework analysis was applied. RESULTS Findings elaborated perceived benefits of ACF, including reaching vulnerable populations, reducing patient costs, helping raise awareness for tuberculosis among individuals and engaging communities, and reducing tuberculosis transmission. Perceived harms included increasing stigma and discrimination, causing false-positive diagnoses, as well as triggering other unintended consequences related to screening for tuberculosis patients, such as deportation of migrants once confirmed to have tuberculosis. Most of the perceived benefits of ACF could be linked to its objective of finding and treating persons with tuberculosis early (theme 1), while ACF was also perceived as a "double-edged sword" and could cause harms, if inappropriately designed and implemented (theme 2). The analysis underlined the importance of considering the benefits and harms of ACF throughout the screening pathway. The study provides new insights into the perceived benefits and harms of ACF from the perspectives of experts in the field. CONCLUSION This study highlights gaps in the evidence base surrounding ACF and can stimulate further research, debate and analysis regarding the benefits and harms of ACF to inform contextual optimization of design and implementation of ACF strategies.

BACKGROUND: Vietnam has a high burden of undetected tuberculosis (TB). The Vietnamese National TB Strategic Plan highlights active case-finding (ACF) as one strategy to find people with TB who are currently unreached by the existing government health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented across six districts of Ho Chi Minh City, 2017–2019. We aimed to explore the facilitators and barriers for ACF implementation during the IMPACT TB project to understand how and why the intervention achieved high yields. METHODS: This was an exploratory qualitative study based on 39 semi-structured key-informant interviews with TB patients who were diagnosed through ACF, employees and volunteers who implemented ACF, and leaders from district, national, or international institutions and organizations in Vietnam. Thematic analysis was applied, using an implementation science framework by Grol and Wensing. RESULTS: We generated three main themes: (1) the studied ACF model used in Vietnam provided a conducive social and organizational context for ACF implementation with areas for improvement, including communication and awareness-raising, preparation and logistics, data systems and processes, and incentives; (2) employees and volunteers capitalized on their strengths to facilitate ACF implementation, e.g., experience, skills, and communication; and (3) employees and volunteers were in a position to address patient-level barriers to ACF implementation, e.g., stigma, discrimination, and mistrust. These themes covered a variety of facilitators and barriers, which we divided into 17 categories. All categories were mentioned by employees and volunteers, except the category of having a network that facilitates ACF implementation, which was only mentioned by volunteers. This study also highlighted examples and ideas of how to address facilitators and barriers. CONCLUSIONS: IMPACT TB provided a favorable social and organizational context for ACF ...

BACKGROUND Vietnam has a high burden of undetected tuberculosis (TB). The Vietnamese National TB Strategic Plan highlights active case-finding (ACF) as one strategy to find people with TB who are currently unreached by the existing government health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented across six districts of Ho Chi Minh City, 2017-2019. We aimed to explore the facilitators and barriers for ACF implementation during the IMPACT TB project to understand how and why the intervention achieved high yields. METHODS This was an exploratory qualitative study based on 39 semi-structured key-informant interviews with TB patients who were diagnosed through ACF, employees and volunteers who implemented ACF, and leaders from district, national, or international institutions and organizations in Vietnam. Thematic analysis was applied, using an implementation science framework by Grol and Wensing. RESULTS We generated three main themes: (1) the studied ACF model used in Vietnam provided a conducive social and organizational context for ACF implementation with areas for improvement, including communication and awareness-raising, preparation and logistics, data systems and processes, and incentives; (2) employees and volunteers capitalized on their strengths to facilitate ACF implementation, e.g., experience, skills, and communication; and (3) employees and volunteers were in a position to address patient-level barriers to ACF implementation, e.g., stigma, discrimination, and mistrust. These themes covered a variety of facilitators and barriers, which we divided into 17 categories. All categories were mentioned by employees and volunteers, except the category of having a network that facilitates ACF implementation, which was only mentioned by volunteers. This study also highlighted examples and ideas of how to address facilitators and barriers. CONCLUSIONS IMPACT TB provided a favorable social and organizational context for ACF implementation. Individual employees and volunteers still determined the success of the project, as they had to be able to capitalize on their own strengths and address patient-level barriers. Volunteers especially used their networks to facilitate ACF. Knowledge of both facilitators and barriers, and how to address them can inform the planning and implementation ACF in Vietnam and similar contexts across low- and middle-income countries worldwide.