A research report submitted to the Faculty of Health Sciences, University of The
Witwatersrand, in partial fulfilment of the requirements for the degree of Master of
Science Epidemiology in the Field of Implementation Sciences.
May 2018
Johannesburg, South Africa.Background: Surveillance structures for tuberculosis (TB) contact tracing are not well
integrated into routine national reporting structures. The implementation of reingineering
of primary health care through ward based outreach teams (WBOTs) is a step towards
equitable primary health care. Data and information collected by WBOTs for household
TB contact tracing is an integral part of the implementation model of primary health care
reengineering. The quality of patient record documentation becomes even more vital in
light of the increased focus on process and outcome measures in health programmes and as
a result, careful consideration be given to the WBOT data collection system used by
community health workers (CHWs). In order to contribute to efforts of developing an
optimised model for household contact tracing, the acceptability of the current paper-based
data collection system needs to be assessed in order to develop a comprehensive monitoring
& evaluaiton (M&E) framework for an optimsed model for household tuberculosis contact
tracing.
Methods: The current cross sectional research project is nested within a project that aims
to develop an optimised model for household TB contact tracing. In this nested mixed
methods study; the exploratory sequential design was used to explore the facilitators and
barriers to completing the current data collection tools used by CHWs. The study had two
components, firstly three focus group discussions (FGDs) were conducted in the three
Ekurhuleni health sub-districts (Northern, Eastern and Southern) in three purposively
selected primary health clinics and secondary data analysis of the main study`s FGDs was
also conducted. Manual coding and QDA Miner software was used for coding and all
qualitative analysis. Emerging themes were identified through inductive thematic analysis
using the constant comparison analysis framework. The results informed the quantitative
data collection and analysis. Following qualitative analysis; a close ended questionnaire
was refined and informed by the results of the qualitative inquiry. CHWs were recruited
using targetted sampling techniques from 6 primary health care facilities located in the
different sub-districts in order to administer the questionnaire. The four point Likert Scale
questionnaire was developed using theoritical framework for acceptability (TFA)
constructs to asses the level of acceptability of the current data collection tools used to
document tuberculosis contact tracing activities. Univariate and multivariate linear
regression models were fitted to examine significant relationships between the composite
acceptability scores and several predictors. All quantitative analysis was perforned on
STATA version 14 (StataCorp College Station, Texas 77845 USA).
Results: A total of five FGDs were conducted; two that were conducted as part of the main
study supplemented the data from the three that were conducted (one in each Ekurhuleni
health Sub-district). The total of 54 CHWs participated in all the five FGDs with 89% being
female. Average age of all CHWs was 34.41 years [mean (sd): 34.41(8.16)]. Five broad
themes emerged including inadequate CHW training, WBOT programme integration with
other health and social care service providers, challenges with the WBOT data collection
system, community access issues and preference for a digital based data collection system.
Data related barriers identified included limitations with the current paper based data
collection system such as insufficient competency assessments about the different data
collection tools, lack of a specific tool to capture TB contact tracing activities, incomplete
referral forms due to clinic staff not completing them, patients providing wrong
information, too many papers to complete. Those that were related to the WBOT actvities
included lack of community acceptance, resource constraints, violent patients and
community members, community members that are not welcoming . Facilitators included
motivated CHWs. 94 CHWs were enrolled for the quantitative survey with 90 (95.74%)
females. From the total, 35% of the CHWs were from the Ekurhuleni health southern subdistrict,
34% and 31% were from the eastern and northern sub-districts respectively. The
overall median (IQR) composite acceptability scores from all sub-districts was 48 (45
51), with the highest scores observed in the Eastern sub-district 49 (45 46) . In the overall
study population, the acceptability of the current WBOT data collection tools was low.
Conclusions: Main findings pertaining to CHW training indicate that the different phases
of the Primary Health Care (PHC) reingeering WBOT trainings were inconsistent. There is
also a lack of acknowledgement of attendance as CHW expressed their dissatisfaction in
not receiving certifications which resulted in low morale for conducting outreach activities.
The sub-optimal integration of the WBOT programme into the primary health care system
results in a patchy referral system characterised by incomplete back referrals resulted as
referral forms remain incomplete. Communication between the primary health care facility
staff and WBOT CHWs needs to be strengthened in order to strengthen the referral linkages
with other health and social care service providers. Funding models for WBOT programme
need to be reviewed to ensure that resources needed for optimal WBOT functioning are
secured. Restricted access to some communities, patients providing wrong addresses,
violent and unwelcoming household members and lack of WBOT safety were barriers to
accessing TB patients during outreach activities; thus leading to incomplete and innacurate
data. The limitations posed by the current paper-based data collection system have been
acknowledged and the CHWs preference for a digital based system highlights the need for
the evaluation of the current mobile data collection technologies in other regions in order
to inform nationwide scale-up.
Recommendations:
The implementation of the WBOT programme is still in its infancy and in order to improve
the data collection processes of the programme, more research on CHW post-training
competence is needed to determine the effectiveness of the wide array of training programs.
Moreover, the implementation of CHW program should be coordinated among the different
training providers including government, civil society organizations and NGOs. To
improve the quality of the CHW training delivery and content, CHW feedback should be
sought through pre-and post-assessments. There is a need to focus efforts on coordinating
and strengthening the different PHC reengineering streams and integrate them into the
primary health care system. This will likely strengthen the referral system between the
WBOT programme and PHC facilities. The current M&E policy needs to be reviewed and
special consideration should be given to TB contact tracing related indicators. This should
also be accompanied by an adjustment of the current WBOT data collection tools to better
reflect the agreed upon TB contact tracing indicators. The study further recommends further
research in the form of economic evaluations to determine the cost effectiveness of scaling
up current digital based data collection methods to inform nationwide scale up.
Key words: Ward Based Outreach Teams, data collection system, data collection tools,
community health workers, TB contact tracing, Community Based Information System,
acceptabiltity, mHealthLG201
