In Uganda, Tuberculosis Investigations Focus on Community

Tuberculosis affects millions of people every year. Unfortunately, many people with TB are undiagnosed, as stigma, misinformation, and logistical resources often stand in the way of help.

Yale School of Public Health researchers have teamed up with the Makerere University College of Health Sciences in Uganda, East Africa, to test a “human-centered” strategy to find and treat more people with TB. The study has adopted a creative approach to delivering contact investigation, the World Health Organization’s recommended technique for finding TB. By using rapid iteration and a diverse range of qualitative methods, researchers have come up with new ways to track, treat, and stop TB. They published a paper describing their trial protocol in BMC Public Health.

Instead of the standard implementation strategy, in which those diagnosed with TB and their close contacts are asked to come forward for help, the researchers are employing a handful of human-centered approaches for delivering contact tracing, including a sputum-collection instructional video, a contact identification algorithm, and a motorcycle taxi service to shuttle people and samples for free. The ongoing trial is limited to 12 rural Ugandan health care facilities. The collaborators hope that these out-of-the-box solutions will encourage more close contacts of individuals with TB to get tested and treated.

“We know that contact tracing works for finding TB,” the study’s senior author, Dr. J. Lucian (Luke) Davis, MD, associate professor of epidemiology (microbial diseases), said. “The human-centered approach tries to ensure contact tracing also works for the people affected by TB. If so, everyone will benefit.”

The Yale researchers worked with Dr. Achilles Katamba, MBChB, associate professor adjunct of epidemiology (microbial diseases) and other Ugandan colleagues to generate the new strategy over several design phases. They held adhesive-note brainstorming sessions, community focus groups, health care worker interviews, and small-group design sprints to gather as much input as they could, then prototyped their strategy in Uganda for over a year.

The team packaged their final selection of human-centered trial components under a brand that Ugandans could recognize. The health care workers and motorcycle riders wear uniforms featuring a custom graphic logo with two Marabou storks, a beloved local bird, flying in front of a sunrise. Their gear carries the brand name Tuli Wamu Nawe, a phrase in the local Luganda language which means, “We are Together with You.” The name strategy emerged from a partnership with a design team at the non-profit social enterprise IDEO.org.

“Active Case Finding (ACF) through contact investigation is a priority strategy to find missing TB cases and curb transmission. However, the best approach to maximize ACF is not known,” Katamba said. “The Human Centered Design and Community of Practice study provides an opportunity to maximize ACF while putting in consideration clients’ needs and circumstances during ACF.”

Support for Health Care Workers

Health care workers also receive help as part of the novel study approach. The organizers assemble WhatsApp groups for each participating health care facility, connecting all facets of the contact tracing effort in one place for emotional support, care coordination, and shared accountability. The chat, along with weekly improvement meetings and confidential audit and feedback reports, could add to the study’s effectiveness by establishing “communities of practice,” the researchers said.

The collaborators recently finished recruiting participants. Now, they are measuring the effectiveness of the implementation strategy by counting the proportion of symptomatic close contacts who get evaluated for TB. In late October, they will have compared the results with those from standard contact tracing methods. They plan to publish their findings in a peer-reviewed journal.