Tanzania: Community outreach approach in Shinyanga region increases case notification

(SHDEPHA+) KAHAMA (Service, Health and Development for People living positively with HIV/AIDS) has been conducting a community outreach TB case finding approach in Shinyanga region in the north west of Tanzania, which includes 18 wards of Msalala District Council and 20 wards of Kahama Town. The target for the intervention is the general population with a special focus on children, female sex workers, small-scale miners and males who have sex with males.

This case finding intervention is supported by Community Health Workers (CHW) and Peer Educators (PE) who are a critical project resource particularly on community engagement, awareness creation and TB screening in communities, drop in centers, and in the mines within the target population. They are trained in the process of TB sensitization, screening and sputum collection.

To make sure that the target population is being reached, the CHW’s and PE’s are selected from the same wards where the target population resides. This builds trust, openness and makes for a better response from people when receiving TB services in communities. CHW’s and PE’s conduct door-to-door campaigns where they collect sputum and transport it from households to diagnose centers, which increases TB notification and has no cost for the patient.

The key activities implemented in this intervention are the following:

Individual education: Well-trained PE’s provide individual education to empower people with awareness on TB. The community members are provided with information materials including TB leaflets and posters that aim to increase TB awareness and screening.

TB Screening: CHW’s are recruited, trained and well identified to conduct screenings where they separate patients into 2 groups: people with a high likelihood of having active TB (positive screen) and those who are unlikely to have active TB (negative screen). Means of transportation like tricycles and bicycles are used to facilitate mobile screening at community level within specific hotspots.

TB linkages and referral services: People who screen positive or who display TB symptoms are referred to a nearby Basic Management Unit. Sputum samples are collected and transported to health facilities for examination. Results from TB tests are sent back to the village on a daily basis by the CHW’s. Support materials such as sputum packages, gloves, means of transportation for regular TB screening and sputum collection are also provided.

TB Treatment: Patients whose sputum smear tests positive for TB are referred to a health facility for treatment initiation. CHW’s and PE’S accompany patients to ensure that they receive the adequate treatment and that they take their medication daily.

Patient tracking and follow-up: Ongoing support is provided to patients diagnosed with TB to enhance and improve treatment adherence by the CHW’s and Field Officers. The CHW’s track patients with the help of Field Officers to follow treatment outcomes, which are categorized and documented using Monitoring & Evaluation tools.

Performance Monitoring: It is a vital activity to ensure that the PE’s and CHW’s comply with their scope of work and reach the planned daily minimum number of beneficiaries. To assess their performance, the Field Officers review the number of beneficiaries that each PE and CHW has reached on a daily, weekly and monthly basis through demand creation, individual education, TB screening services, referral and linkage to TB treatment.

The case finding intervention resulted in increased TB case notifications in the evaluation population (compared to Q2-2017). From Q3-2017 to Q2-2018, 75’585 people were screened, out of which 13’642 had presumptive TB. 2’501 people were tested and 792 had confirmed TB (656 Bac+ TB). 755 patients were started on treatment.

Understanding and addressing barriers

As part of the study, access to TB services was examined from a gender perspective. Randomly, 2’040 respondents (1’043 males and 997 females; 150 TB patients and 1’890 none TB patients) were sampled and they filled in a study questionnaire. The themes explored revolved around decision making on access to TB prevention and treatment services, stigma associated with TB and health-seeking behavior (traditional vs. modern treatment options).

Results showed that 1’536 (75%, including 504 women) considered men should make decisions for all family members when it came to seeking any type of health assistance such as TB services. 1’936 (504 males and 1’432 females) answered that they felt TB was associated with stigma. Furthermore, 1’275 (62.5%) respondents believed in traditional forms of healing for TB treatment.

With the help of these findings, communication strategies and messages aimed at behavioral change, positive gender equitable norms and positive masculinity were employed to ultimately improve access to TB preventive and curative services among women, men and children.

Not every stakeholder understands the different challenges that each individual faces when seeking health care; these barriers can be social, cultural, political, economic or based on their gender or sexual orientation. To address this issue, orientation and sensitization workshops for health service providers have been put in place.

In addition, the community activist kit called SASA! (Start, Awareness, Support, Action) is being used to inspire and enable communities to rethink and reshape social norms.

During community dialogues, well-trained Peer educators, who know the community well, encourage participation from households where women are facing barriers to accessing care. The dialogue enables SHDEPHA+ KAHAMA to address these issues proactively, rather than reacting on a case-by-case basis, which is better received by the community.

Next steps to improve and maintain impact

The project is ready to continue and expand by scaling up its successful interventions. The project has already expanded its coverage area with additional Peer Educators and Community Health Workers in 2 more district councils: Mbogwe DC and Bukombe DC. The focus is on treatment follow-up and on building lasting ties between communities and health service providers to eliminate TB.

The future interventions will employ community radio and theater groups to complement peer education and SASA! Strategies. Based on previous experiences, it has been learned that the media is an effective approach to reach large audiences in the evaluation area. Additionally, moonlight events are being planned to reach those who are hard to find during daytime due to their type of work.

Sputum fixers will be used in remote areas where sputum samples can’t easily be transported to the BMU for processing and diagnosis. Sputum examination results will be sent back to the village on regular basis. Patients found to have TB sputum smear positive will be referred to health facilities for initiation of treatment. On-going support will be provided to the patients to enhance and improve treatment adherence.