title: Patient and community experiences of tuberculosis diagnosis and care within a community-based intervention in Ethiopia: a qualitative study.
abstract: BACKGROUND
  The Ethiopian TB control programme relies on passive case finding of TB cases. The predominantly rural-based population in Ethiopia has limited access to health facilities creating barriers to TB services. An intervention package aimed to bring TB diagnosis and treatment services closer to communities has been implemented through partnership with health extension workers (HEWs). They undertook advocacy, communication and social mobilization (ACSM) activities, identified symptomatic individuals, collected sputum, prepared smears and fixed slides at community level. Field supervisors supported HEWs by delivering smeared slides to the laboratory, feeding back results to the HEWs and following up smear-negative cases. Patients diagnosed with TB initiated treatment in the community, they were supported by supervisors and HEWs through the local health post. Case notification increased from 64 to 127/100,000 population/year.
  
  
  METHODS
  This qualitative study assessed community members' treatment seeking behaviour and their perceptions of the intervention. In-depth interviews (n=36) were undertaken with participants in six districts. Participants were clients of the community-based intervention, currently on TB treatment or those screened negative for TB. Transcripts were translated to English and a thematic analytical framework was developed guided by the different steps symptomatic individuals take within the intervention package. Coding was done and queries run using NVivo software.
  
  
  RESULTS
  Prior to the intervention many patients with chronic cough did not access TB services. Participants described difficulties they faced in accessing district level health facilities that required travel outside their communities. Giving sputum samples and receiving results from within their home communities was appreciated by all participants. The intervention had a high level of acceptability; particularly clear benefits emerged for poor women and men and those too weak to travel. Some participants appeared to prefer a diagnosis of TB, this is likely because receiving a negative smear microscopy result brought further uncertainty and necessitated seeking further investigation.
  
  
  CONCLUSIONS
  There is evidence rural populations with high levels of poverty, and in particular women, are at high risk of unmet health needs and undiagnosed TB. Embedding TB services within communities was an acceptable approach for vulnerable groups experiencing poor access to health facilities. In the Ethiopian context this approach can facilitate early diagnosis and improve treatment outcomes.
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. Olivia.Tulloch@LSTMed.ac.uk.
authors.forename: Olivia
authors.initials: O
authors.lastname: Tulloch
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. Sally.Theobald@LSTMed.ac.uk.
authors.forename: Sally
authors.initials: S
authors.lastname: Theobald
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. morishita.fukushi@gmail.com.
authors.forename: Fukushi
authors.initials: F
authors.lastname: Morishita
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. danieljohn42@yahoo.com.|HHA/REACH ETHIOPIA, Hawassa, SNPPR, Ethiopia. danieljohn42@yahoo.com.
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Datiko
authors.affiliation: HHA/REACH ETHIOPIA, Hawassa, SNPPR, Ethiopia. girumasnake2006@yahoo.com.
authors.forename: Girum
authors.initials: G
authors.lastname: Asnake
authors.affiliation: HHA/REACH ETHIOPIA, Hawassa, SNPPR, Ethiopia. tadessmt@yahoo.com.
authors.forename: Tadesse
authors.initials: T
authors.lastname: Tesema
authors.affiliation: HHA/REACH ETHIOPIA, Hawassa, SNPPR, Ethiopia. habiba.jemal@yahoo.com.
authors.forename: Habiba
authors.initials: H
authors.lastname: Jamal
authors.affiliation: HHA/REACH ETHIOPIA, Hawassa, SNPPR, Ethiopia. paulos.markos@yahoo.com.
authors.forename: Paulos
authors.initials: P
authors.lastname: Markos
authors.affiliation: Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. lcuevas@liv.ac.uk.
authors.forename: Luis E
authors.initials: LE
authors.lastname: Cuevas
authors.affiliation: Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK. mohammed.yassin@theglobalfund.org.|Global Fund to Fight AIDS, Tuberculosis and Malaria, Chemin des Blandonnet 8, 1214, Vernier, Geneva, Switzerland. mohammed.yassin@theglobalfund.org.
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Yassin
mesh_terms: D000293:Adolescent; D000328:Adult; D003153:Community Health Services / Q000379:methods*; D005002:Ethiopia / Q000453:epidemiology; D005260:Female; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D017060:Patient Satisfaction; D012424:Rural Population; D014376:Tuberculosis / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D055815:Young Adult