title: Improving case detection of tuberculosis among children in Bangladesh: lessons learned through an implementation research.
abstract: According to the Bangladesh National Tuberculosis Control Program (NTP), the proportion of childhood tuberculosis (TB) among all reported cases is only 3%. This is considerably lower compared to other high-burden countries. One of our previous studies identified substantial gaps at the primary care level related to capacity of service providers, supply of required logistics and community awareness about childhood TB. Therefore, we conducted an implementation study with the objectives to address those gaps.
  
  
  
  This implementation research was designed with pre and post-test evaluation at selected primary care facilities in urban and rural areas. Three interventions were implemented: (1) Training on childhood TB management for all categories of service providers (2) mass awareness campaign among primary and secondary school students and their teachers, mothers of <5y children, religious and community leaders and (3) facilitation of logistics supply at the study facilities. Training was conducted following the national guideline. We developed posters, leaflets, flipcharts and organized folksongs and street dramas as awareness campaign strategy. Quarterly follow up meetings were held with the facility managers of the study clinics. Cross-sectional surveys were conducted at the baseline and end line alongside review of service statistics to compare the change in community awareness and case detection of childhood TB.
  
  
  
  Awareness regarding childhood TB among all target audience increased significantly showing better understanding of child TB symptoms, transmission, duration and treatment option. Overall proportion of TB case detection among children increased in all three sites compared to baseline as well as NTP estimate with relatively higher proportion in urban site. Majority of the children were suffering from extra-pulmonary TB and there were more female TB cases than male. However, supply and maintenance of necessary diagnostics and child friendly TB drugs remained suboptimal.
  
  
  
  Through implementation research, detection of childhood TB cases increased in all study facilities exceeding the NTP's estimate. Community awareness on childhood TB improved significantly across all study sites as well. The NTP should implement strategies to raise community awareness alongside increasing the capacity of service providers and ensuring availability of diagnostics and pediatric TB drugs at the primary care level.
authors.affiliation: Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212, Bangladesh.
authors.forename: Ziaul
authors.initials: Z
authors.lastname: Islam
authors.affiliation: Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212, Bangladesh. sanin@icddrb.org.
authors.forename: Kazi Istiaque
authors.initials: KI
authors.lastname: Sanin
authors.affiliation: Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, 1212, Bangladesh.
authors.forename: Tahmeed
authors.initials: T
authors.lastname: Ahmed
mesh_terms: D001291:Attitude of Health Personnel; D001459:Bangladesh / Q000453:epidemiology; D002648:Child; D000067576:Child Health / Q000706:statistics & numerical data*; D002669:Child Welfare / Q000706:statistics & numerical data*; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods; D014376:Tuberculosis / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology* / Q000517:prevention & control*
keywords: Bangladesh; Child TB; Child TB awareness; Implementation research; Tuberculosis