title: Identifying barriers to and facilitators of tuberculosis contact investigation in Kampala, Uganda: a behavioral approach.
abstract: The World Health Organization recommends routine household tuberculosis contact investigation in high-burden countries but adoption has been limited. We sought to identify barriers to and facilitators of TB contact investigation during its introduction in Kampala, Uganda.
  
  
  
  We collected cross-sectional qualitative data through focus group discussions and interviews with stakeholders, addressing three core activities of contact investigation: arranging household screening visits through index TB patients, visiting households to screen contacts and refer them to clinics, and evaluating at-risk contacts coming to clinics. We analyzed the data using a validated theory of behavior change, the Capability, Opportunity, and Motivation determine Behavior (COM-B) model, and sought to identify targeted interventions using the related Behavior Change Wheel implementation framework.
  
  
  
  We led seven focus-group discussions with 61 health-care workers, two with 21 lay health workers (LHWs), and one with four household contacts of newly diagnosed TB patients. We, in addition, performed 32 interviews with household contacts from 14 households of newly diagnosed TB patients. Commonly noted barriers included stigma, limited knowledge about TB among contacts, insufficient time and space in clinics for counselling, mistrust of health-center staff among index patients and contacts, and high travel costs for LHWs and contacts. The most important facilitators identified were the personalized and enabling services provided by LHWs. We identified education, persuasion, enablement, modeling of health-positive behaviors, incentivization, and restructuring of the service environment as relevant intervention functions with potential to alleviate barriers to and enhance facilitators of TB contact investigation.
  
  
  
  The use of a behavioral theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers to and facilitators of TB contact investigation. The behavioral determinants identified here may be useful in tailoring interventions to improve implementation of contact investigation in Kampala and other similar urban settings.
authors.affiliation: Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: Irene
authors.initials: I
authors.lastname: Ayakaka
authors.affiliation: Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, CA, USA.
authors.forename: Sara
authors.initials: S
authors.lastname: Ackerman
authors.affiliation: Uganda Tuberculosis Implementation Research Consortium, College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Ggita
authors.affiliation: Child Health and Development Centre, School of Medicine; College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: Phoebe
authors.initials: P
authors.lastname: Kajubi
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: David
authors.initials: D
authors.lastname: Dowdy
authors.affiliation: Center for Global Health, Massachusetts General Hospital, and Harvard University Medical School, Boston, MA, USA.
authors.forename: Jessica E
authors.initials: JE
authors.lastname: Haberer
authors.affiliation: Division of Pulmonary and Critical Care Medicine, and Curry International Tuberculosis Center, San Francisco General Hospital, University of California, San Francisco, CA, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Fair
authors.affiliation: Division of Pulmonary and Critical Care Medicine, and Curry International Tuberculosis Center, San Francisco General Hospital, University of California, San Francisco, CA, USA.
authors.forename: Philip
authors.initials: P
authors.lastname: Hopewell
authors.affiliation: Department of Biostatistics and Epidemiology, School of Medicine, University of California, San Francisco, CA, USA.|Division of General Internal Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Handley
authors.affiliation: Division of Pulmonary and Critical Care Medicine, and Curry International Tuberculosis Center, San Francisco General Hospital, University of California, San Francisco, CA, USA.
authors.forename: Adithya
authors.initials: A
authors.lastname: Cattamanchi
authors.affiliation: Clinical Epidemiology Unit, Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: Achilles
authors.initials: A
authors.lastname: Katamba
authors.affiliation: Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, CT, USA. lucian.davis@yale.edu.
authors.forename: J Lucian
authors.initials: JL
authors.lastname: Davis
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006792:House Calls / Q000706:statistics & numerical data*; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D057545:Social Stigma; D014376:Tuberculosis / Q000175:diagnosis*; D014454:Uganda
keywords: Behavior Change Wheel framework; COM-B model; Household contact investigation; Implementation science; Lay health workers; Tuberculosis