Identifying barriers to and facilitators of tuberculosis contact investigation in Kampala, Uganda: a behavioral approach
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Date
2017
Journal Title
Journal ISSN
Volume Title
Publisher
Implementation science
Abstract
The 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.
Methods: We 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.
Results: We 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 healthcenter
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.
Conclusions: The 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.
Description
Keywords
Tuberculosis, Household contact investigation, Lay health workers, COM-B model, Behavior Change Wheel framework
Citation
Ayakaka, I., Ackerman, S., Ggita, J. M., Kajubi, P., Dowdy, D., Haberer, J. E., ... & Davis, J. L. (2017). Identifying barriers to and facilitators of tuberculosis contact investigation in Kampala, Uganda: a behavioral approach. Implementation science, 12(1), 1-13. DOI 10.1186/s13012-017-0561-4