Strengthening health systems to improve tuberculosis contact screening and management in Timika, Indonesia

This is a mixed-methods, before-and-after, multi-site, intervention study to implement the WHO tuberculosis contact management and investigation policy. Activities fulfill the definition of a complex intervention Setting: Mimika district, Papua Province, Indonesia. Five healthcare facilities will participate in phase 1 and seven in phase 2 of the policy roll out. Physical or informational materials that will be used in the intervention: - Indonesian Policy on TB Contact management - Resources (paper, video) designed for patients Procedures, activities, and/or processes used: 1. Training Training will be provided by the doctoral research student and Indonesian medical experts in prevention and management of TB, in the form of workshops for healthcare providers from the five primary participating sites, and any additional healthcare providers from other sites who wish to attend (including the follow-up sites). Training sessions will be free of charge and during usual working hours, by arrangement with management at their respective workplaces. The elements of TB contact investigation and management policy will be taught, including practical implications and logistics of rolling this out at each clinic. Hands-on training will also be provided in the medical or nursing skills required to implement the policy, such as collection of induced sputum from contacts found to have symptoms of TB, and accurate weight-based dosing of isoniazid. Pre- and post-training tests will be conducted to understand knowledge and measure the effectiveness of the training. Continuous quality improvement 2. Continuous quality improvement (CQI) forms a cornerstone of implementation of this project at the five initial sites. CQI cycles will be implemented whereby every three months (approximately, coinciding with study staff and participant availability), a workshop will be held to allow staff at the five sites to engage pro-actively with the data they routinely collect and report (but rarely review) on TB outcomes and contact management. Plots and pictograms will be generated that are easy for healthcare providers to understand, showing progress in key performance indicators, such as the proportion of contacts who are investigated, and the proportion of eligible contacts who are commenced on IPT. Discussions to congratulate and motivate staff will be undertaken, and challenges will be workshopped. Where appropriate, recommendations arising from these CQI workshops to address challenges in policy implementation (e.g. staffing allocations, access to transport for outreach services) will be communicated by the doctoral researcher to the District Health Authority. The approach will draw on lessons learned in previous research using CQI cycles in primary care to improve adherence to guidelines. 3. Social media discussion forum Mentoring and clinical support will be provided via a ‘WhatsApp’ group. ‘WhatsApp Messenger’ is the most widely-used, freely-available communication application in Indonesia, accessible from mobile devises or desktop computers. It allows sharing of text messages, photographs, documents, voice calls and video calls. Healthcare providers participating in the study at both initial and follow-up sites will be invited to the ‘WhatsApp’ group moderated by the doctoral research student and with access to an Indonesian TB specialist. This will provide a forum for information sharing relevant to the study, and participants will be able to post questions relating to the contact management policy or other aspects of TB care. 3. Awareness-raising activities and promotional materials Posters and information brochures have been developed by the project team in the main local Papuan language and Bahasa Indonesian. These provide pictures and writing about latent TB, how it can progress to active TB, and how preventive treatment can stop it. Who will deliver the intervention: - PhD student with medical background and masters in public health working alongside District Health Authority and staff at healthcare facilities. Mode of delivery: - face to face training and CQI workshops - social media information and support group Number of times the intervention will be delivered: - CQI workshops for 2 hours every 3 months, face to face using data generated by healthcare facilities on TB key performance indicators - Training, social media support, visits to healthcare facilities to provide motivation and support - ongoing throughout the 2-year intervention period Location where the intervention occurs: - Five primary sites: 2 hospitals and 3 Puskesmas (primary healthcare facilities) - Seven secondary sites (7 Puskesmas) which will receive training and support from staff at the first 5 sites Study design: This is a mixed-methods intervention study. Interrupted time series analysis will be used to analyse longitudinal data before, during and after the intervention. Study periods comprise a 26-month retrospective baseline period from 1 January 2015 – 31 March 2017, a 5-month prospective baseline period with active data cleaning and validation, a 24-month intervention period (including activities at initial and follow-up sites) and a 12-month sustainability period. These periods were pragmatically chosen based on data and resource availability. These periods were chosen pragmatically on the basis of available data and timing of study commencement. An annotated line graph will be produced to show the primary outcome (numbers of people completing isoniazid preventive therapy) over time, with the timing of key study activities, external activities and environmental influences being indicated on the graph. A two-tiered approach to the intervention will be used to provide an additional measure of sustainability: intensive activities will take place with the five initial participating sites, then healthcare providers at these sites will then be trained (using a ‘train the trainer’ approach) to share their knowledge with the seven follow-up sites.