Community health care workers in pursuit of TB: Discourses and dilemmas.

Community-led tuberculosis (TB) active case finding is widely promoted, heavily funded, but many efforts fail to meet expectations. The underlying reasons why TB symptom screening programs underperform are poorly understood. This study examines Nigerian stakeholders' insights to characterize the mechanisms, enabling structures and influences that lead programs to succeed or fail. Eight focus group discussions were held with Community Health Workers (CWs) from four models of community-based TB screening and referral. In-depth interviews were conducted with 2 State TB program managers, 8 Community based organizations (CBOs), and 6 state TB and Leprosy Local Government supervisors. Transcripts were coded using Framework Analysis to assess how divergent understandings of CWs' roles, expectations, as well as design, political and structural factors contributed to the observed underperformance. Altruism, religious faith, passion, and commitment to the health and well-being of their communities were reasons CWs gave for starting TB symptom screening and referral. Yet politicized or donor-driven CWs' selection processes at times yielded implementers without a firm grounding in TB or the social, cultural, and physical terrain. CWs encountered suspicion, stigma, and hostility in both health facilities and communities. As the interface between the TB program and communities, CWs often bore the brunt of frustrations with inadequate TB services and CBO/iNGO collaboration. Some CWs expended their own social and financial capital to cover gaps in the active case finding (ACF) programs and public health services or curtailed their screening activities. Effective community-led TB active case finding is challenging to design, implement and sustain. Contrary to conventional wisdom, CWs did not experience it as inherently empowering. Sustainable, supportive models that combine meaningful engagement for communities with effective program stewardship and governance are needed. Crucially effective and successful implementation of community-based TB screening and referral requires a functional public health system to which to refer.

'Sustaining the DOTS': stakeholders' experience of a social protection intervention for TB in Nigeria.

Background: Social protection for TB patients can lower patient costs and improve adherence. The aim of this study was to explore patients' and health workers' experiences of a social protection intervention for TB in order to inform a more patient-centred approach for the Nigeria National TB Programme strategy. Methods: This was a qualitative study consisting of 103 in-depth interviews and two focus group discussions with patients who received the intervention, and 10 key informant interviews with health workers. A thematic content analysis of the interviews was performed. Results: Of those who completed the interviews, 53 (51.5%) were male, and 69 (67.0%) were below 40 years. Most of the participants received care and support from their families but delayed access to TB services due to lack of funds for transportation, nutritional supplementation and non-TB drugs. The intervention had a high level of acceptability and uptake; particularly clear benefits emerged for most patients who used the social protection funds to purchase food and supplements, other drugs, transportation and additional personal necessities. Some patients assert that the financial incentive package increased their awareness of timing of their follow-up visits. In addition, health workers observed increased enthusiasm to treatment and improvement in adherence among participants. Conclusions: Patients and health workers reported positive experiences with the financial incentives provided for TB treatment.