title: Challenges from Tuberculosis Diagnosis to Care in Community-Based Active Case Finding among the Urban Poor in Cambodia: A Mixed-Methods Study.
abstract: BACKGROUND
  While community-based active case finding (ACF) for tuberculosis (TB) holds promise for increasing early case detection among hard-to-reach populations, limited data exist on the acceptability of active screening. We aimed to identify barriers and explore facilitators on the pathway from diagnosis to care among TB patients and health providers.
  
  
  METHODS
  Mixed-methods study. We administered a survey questionnaire to, and performed in-depth interviews with, TB patients identified through ACF from poor urban settlements in Phnom Penh, Cambodia. Additionally, we conducted focus group discussions and in-depth interviews with community and public health providers involved in ACF, respectively.
  
  
  RESULTS
  Acceptance of home TB screening was strong among key stakeholders due to perceived reductions in access barriers and in direct and indirect patient costs. Privacy and stigma were not an issue. To build trust and facilitate communication, the participation of community representatives alongside health workers was preferred. Most health providers saw ACF as complementary to existing TB services; however, additional workload as a result of ACF was perceived as straining operating capacity at public sector sites. Proximity to a health facility and disease severity were the strongest determinants of prompt care-seeking. The main reasons reported for delays in treatment-seeking were non-acceptance of diagnosis, high indirect costs related to lost income/productivity and transportation expenses, and anticipated side-effects from TB drugs.
  
  
  CONCLUSIONS
  TB patients and health providers considered home-based ACF complementary to facility-based TB screening. Strong engagement with community representatives was believed critical in gaining access to high risk communities. The main barriers to prompt treatment uptake in ACF were refusal of diagnosis, high indirect costs, and anticipated treatment side-effects. A patient-centred approach and community involvement were essential in mitigating barriers to care in marginalised communities.
authors.affiliation: Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia; Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Natalie
authors.initials: N
authors.lastname: Lorent
authors.affiliation: Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia.
authors.forename: Kimcheng
authors.initials: K
authors.lastname: Choun
authors.affiliation: Global Alliance for TB Drug Development, New York, New York, United States of America.
authors.forename: Shelly
authors.initials: S
authors.lastname: Malhotra
authors.affiliation: CENAT, National Tuberculosis and Leprosy Control Programme, Phnom Penh, Cambodia.
authors.forename: Pichenda
authors.initials: P
authors.lastname: Koeut
authors.affiliation: Infectious Diseases Department, Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia.
authors.forename: Sopheak
authors.initials: S
authors.lastname: Thai
authors.affiliation: CENAT, National Tuberculosis and Leprosy Control Programme, Phnom Penh, Cambodia.
authors.forename: Kim Eam
authors.initials: KE
authors.lastname: Khun
authors.affiliation: Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Epidemiology and Social Medicine Department, University of Antwerp, Antwerp, Belgium.
authors.forename: Robert
authors.initials: R
authors.lastname: Colebunders
authors.affiliation: Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
authors.forename: Lut
authors.initials: L
authors.lastname: Lynen
mesh_terms: D000328:Adult; D000368:Aged; D002160:Cambodia; D019058:Community Networks; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D012959:Socioeconomic Factors; D014376:Tuberculosis / Q000175:diagnosis* / Q000188:drug therapy* / Q000191:economics; D014505:Urban Population