Bridging the knowledge-practice gap in tuberculosis contact management in a high-burden setting: a mixed-methods protocol for a multicenter health system strengthening study

Abstract

BackgroundPeople in close contact with tuberculosis should have screening and appropriate management, as an opportunity for active case detection and prevention. However, implementation of tuberculosis contact screening and management is limited in high-burden settings. Behaviour change is needed across three levels of the healthcare system—policymakers, healthcare providers, and patients. To bridge the wide policy-practice gap, this study draws on the Consolidated Framework for Implementation Research, the Behaviour Change Wheel, and the RE-AIM model (Reach, Effectiveness, Adoption, Implementation, Maintenance) to respectively understand barriers, implement change, and evaluate process and outcome.MethodsThis methods paper describes a mixed-methods intervention study in Eastern Indonesia. Quantitative data will be collected during baseline, intervention, and sustainability periods and analyzed using time series analysis. The primary outcome is the number of individuals completing tuberculosis preventive therapy by the end of the two-year intervention phase. Of an estimated 10,000 contacts during this period, we anticipate that a minimum of 416 will be found to have active TB or will complete preventive therapy. Qualitative data (semi-structured interviews, focus group discussions, and observations) will be collected from consenting healthcare providers, patients, and contacts. Activities to promote policy implementation include healthcare provider training, quarterly continuous quality improvement workshops, a social media discussion forum, and promotional materials. The Consolidated Framework for Implementation Research will be used to identify reasons for limited policy implementation at baseline. The Behaviour Change Wheel will be used to ensure that a suitable range of activities are implemented to facilitate change. The RE-AIM model will be used as the evaluation framework.DiscussionUse of theoretical frameworks in combination can ensure a comprehensive understanding of, and robust response to, health policy underimplementation. The selected frameworks are highly applicable to this pragmatic intervention study, in a setting where End TB Strategy targets will not be met without substantial behavior change within health systems. Continuous quality improvement cycles will provide a way to engage staff and stakeholders in understanding local data to motivate behavior change. If successful, up to 500 people could be prevented from developing complications of tuberculosis through early case-finding or receiving preventive therapy over a two-year period.Study registrationAustralian New Zealand Clinical Trials Register 375803.

Tuberculosis: yesterday, today and tomorrow

“…In the United States, it has been estimated that strategic investment in TB control in other countries could lead to a reduction in TB morbidity and mortality and overall cost savings in the United States 23 . Australian researchers and TB experts are making significant contributions to regional TB control through collaborative efforts with countries in the region [24][25][26] .…”

Training for Tuberculosis Elimination in Indonesia: Achievements, Reflections, and Potential for Impact

“…In particular, eastern Indonesia (Papua province) is recognized as being an especially high-burden region, with low socioeconomic status and geographical and language barriers to health care. Specific deficits in TB control are inadequate case-finding, and poor participation in recommended diagnostic, notification, and management guidelines by private practitioners [7,9].…”

Implementation, interrupted: Identifying and leveraging factors that sustain after a program interruption

“…Implementation science and theories of improvement have been used to inform and assess interventions across many contexts (1). The Consolidated Framework for Implementation Research (CFIR) is among the most influential of these frameworks, and has been applied to understand implementation of programs ranging from evidence-based tuberculosis (TB) practices in Indonesia to child and maternal health outcomes in Kenyan hospitals (2)(3)(4). The CFIR was created by the Veteran Affairs (VA) Healthcare System to identify constructs that impact the successful implementation of an intervention within a series of key domains, including the outer setting, inner setting, characteristics of individuals involved, intervention characteristics, and process (5).…”