title: Community referral for presumptive TB in Nigeria: a comparison of four models of active case finding.
abstract: BACKGROUND
  Engagement of communities and civil society organizations is a critical part of the Post-2015 End TB Strategy. Since 2007, many models of community referral have been implemented to boost TB case detection in Nigeria. Yet clear insights into the comparative TB yield from particular approaches have been limited.
  
  
  METHODS
  We compared four models of active case finding in three Nigerian states. Data on presumptive TB case referral by community workers (CWs), TB diagnoses among referred clients, active case finding model characteristics, and CWs compensation details for 2012 were obtained from implementers and CWs via interviews and log book review. Self-reported performance data were triangulated against routine surveillance data to assess concordance. Analysis focused on assessing the predictors of presumptive TB referral.
  
  
  RESULTS
  CWs referred 4-22% of presumptive TB clients tested, and 4-24% of the total TB cases detected. The annual median referral per CW ranged widely among the models from 1 to 48 clients, with an overall average of 13.4 referrals per CW. The highest median referrals (48 per CW/yr) and mean TB diagnoses (7.1/yr) per CW (H =70.850, p < 0.001) was obtained by the model with training supervision, and $80/quarterly payments (Comprehensive Quotas-Oriented model). The model with irregularly supervised, trained, and compensated CWs contributed the least to TB case detection with a median of 13 referrals per CW/yr and mean of 0.53 TB diagnoses per CW/yr. Hours spent weekly on presumptive TB referral made the strongest unique contribution (Beta = 0.514, p < 0.001) to explaining presumptive TB referral after controlling for other variables.
  
  
  CONCLUSIONS
  All community based TB case-finding projects studied referred a relative low number of symptomatic individuals. The study shows that incentivized referral, appropriate selection of CWs, supportive supervision, leveraged treatment support roles, and a responsive TB program to receive clients for testing were the key drivers of community TB case finding.
authors.affiliation: Department of Community Health and Primary Health Care, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria. drolus_adejumo@yahoo.com.
authors.forename: A O
authors.initials: AO
authors.lastname: Adejumo
authors.affiliation: Department of Community Medicine, Ebonyi State University, Abakaliki, Nigeria.
authors.forename: B
authors.initials: B
authors.lastname: Azuogu
authors.affiliation: Abia State TB and Leprosy Control Programme, Umuahia, Abia, Nigeria.
authors.forename: O
authors.initials: O
authors.lastname: Okorie
authors.affiliation: Oyo State TB and Leprosy Control programme, Ibadan, Oyo, Nigeria.
authors.forename: O M
authors.initials: OM
authors.lastname: Lawal
authors.affiliation: KNCV/ TB CARE I, Abuja, Nigeria.
authors.forename: O J
authors.initials: OJ
authors.lastname: Onazi
authors.affiliation: KNCV/ TB CARE I, Abuja, Nigeria.
authors.forename: M
authors.initials: M
authors.lastname: Gidado
authors.affiliation: Department of Community Medicine and Primary Care, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun, Nigeria.
authors.forename: O J
authors.initials: OJ
authors.lastname: Daniel
authors.affiliation: Department of Sociology/Anthropology, University of Nigeria, Nsukka, Enugu, Nigeria.
authors.forename: J C
authors.initials: JC
authors.lastname: Okeibunor
authors.affiliation: KNCV Tuberculosis Foundation, the Hague, The Netherlands.|Department of Global Health, Academic Medical Center, Amsterdam Institute of Global Health and Development, Amsterdam, The Netherlands.
authors.forename: E
authors.initials: E
authors.lastname: Klinkenberg
authors.affiliation: KNCV Tuberculosis Foundation, the Hague, The Netherlands.|Department of Global Health, Academic Medical Center, Amsterdam Institute of Global Health and Development, Amsterdam, The Netherlands.
authors.forename: E M H
authors.initials: EMH
authors.lastname: Mitchell
mesh_terms: D000328:Adult; D003150:Community Health Workers / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007318:Inservice Training; D008297:Male; D008875:Middle Aged; D009042:Motivation; D009549:Nigeria / Q000453:epidemiology; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D014376:Tuberculosis / Q000175:diagnosis* / Q000453:epidemiology*