A structured community engagement strategy to support uptake of TB active case-finding

Abstract

BACKGROUND:

In Lima, Peru, a mobile TB screening program (“TB Móvil”) was implemented in high TB prevalence districts to increase TB screening. Community engagement activities to promote TB Móvil were simultaneously conducted.

OBJECTIVE:

To describe a structured, theory-driven community engagement strategy to support the uptake of TB Móvil.

METHODS:

We adapted Popular Opinion Leader (POL), an evidence-based social networking intervention previously used in Peru to promote HIV testing, for TB Móvil. Community health workers, women who run soup kitchens, and motorcycle taxi drivers served as “popular opinion leaders” who disseminated information about TB Móvil in everyday conversations, aided by a multi-media campaign. Performance indicators of POL included the number/characteristics of persons screened; number of multimedia elements; and proportion of persons with abnormal radiographs hearing about TB Móvil before attending.

RESULTS:

Between February 2019 and January 2020, 63,899 people attended the TB Móvil program at 210 sites; 60.1% were female. The multimedia campaign included 36 videos, 16 audio vignettes, flyers, posters, community murals and “jingles.” Among attendees receiving an abnormal chest X-ray suggestive of TB, 48% (6,935/14,563) reported hearing about TB Móvil before attending.

CONCLUSIONS:

POL promotes the uptake of TB Móvil and should be considered as a strategy for increasing TB screening uptake.

Despite revolutionizing community-based directly observed therapy (DOT) for multidrug-resistant TB treatment in the early 2000s,¹ Peru remains an epicenter of both drug- and multidrug-resistant TB in the Americas, with an annual incidence rate of 119 per 100,000 population.² As in many high-burden settings, access to screening and care is an important barrier to TB service uptake in Peru,^3–5 which is exacerbated by lack of education, fear, and the stigma associated with TB treatment and prevention.^6,7

In this context, a TB elimination program in Lima, Peru, was launched as part of the global “Zero TB Initiative”⁸ to dramatically increase TB testing and treatment through multiple, targeted, community-engaged interventions. Because active case-finding is not conducted in Peru, a key component of the TB elimination program was “TB Móvil”⁹ (or “mobile TB” in English), a mass screening intervention using vans with digital radiograph (X-ray) machines and Cad4TB computer-aided detection software.^9,10 TB Móvil offers free TB screening and diagnostic services using chest radiography, and clinical evaluation and sputum analysis using Xpert® MTB/RIF (Cepheid, Sunnyvale, CA, USA) in people with abnormal chest radiographs.

From the start, our team recognised the critical nature of a parallel set of activities aimed at educating, engaging, and stimulating uptake of TB Móvil. Furthermore, the team envisioned a person-centered approach, in which community members felt empowered to achieve improved health. Thus, we aimed not to “recruit” people for TB Móvil, but to create desire among community members to attend TB Móvil. This report aims to describe a structured, theory-driven community engagement strategy to support the up-take of TB Móvil.

METHODS

Setting and population

Details of the TB Móvil program, including the logistical procedures for the mobile X-ray units, the diagnostic algorithm used, and outcomes of the screening intervention are described elsewhere.⁹ Briefly, TB Móvil was implemented by the Peruvian branch of the international non-governmental organization, Partners In Health (locally, Socios En Salud Sucursal Perú), in collaboration with the Ministry of Health and municipal governments of Carabayllo, Comas, and Independencia districts in northern Lima, Peru. Together, these districts cover 410 km², are home to approximately 1.1 million residents,¹¹ and are among the most impoverished areas of urban Lima, with high rates of multidrug-resistant TB.¹² Many residents of these districts live in nonpermanent dwellings on hillsides that lack paved roads, water, and sanitation.¹¹ Although a network of 51 public health clinics serves these districts, diagnostic capability for TB remains limited, as only larger clinics have X-ray machines, and routine laboratory diagnostic capacity is limited to sputum smear microscopy.

Identification and selection of effective community engagement strategies

The TB Móvil community engagement strategy is an adaptation derived from two evidence-based sources. The first was the “Advocacy, Communication and Social Mobilization for Tuberculosis Control Handbook” (ACSM), which aims to “support the design and implementation of effective advocacy, communication, and social mobilization activities in tuberculosis control at country level.”¹³ The ACSM emphasizes the importance of developing public and private partnerships, performing situational and needs assessments, crafting specific interventions, messages, concepts, and materials, and conducting ongoing monitoring and evaluation. Although the ACSM provides best practices to include in TB prevention and treatment, it is not an intervention protocol and does not explain how to implement these practices. We expanded our search for existing, evidence-based approaches that were compatible with the ACSM and found that the social networking “Popular Opinion Leader” (POL) intervention—well-known in the HIV prevention field^14,15—was an excellent fit, as it embodied and operationalized the ACSM’s best practises and could be easily adapted for TB Móvil.

The Popular Opinion Leader (POL) intervention adapted for TB Móvil

POL is a community-based strategy for fostering behavioural change by message dissemination via social networks. POL consists of nine core elements (see Table 1 for POL’s Core Elements and the adaptions made for TB Móvil).¹⁵ POL relies on identifying and training trusted individuals (popular opinion leaders or “POLs”) from a well-defined target population (POL Core Element #1) to deliver critical information via casual conversation. Although POL can be used to support the uptake of various health behaviors, it was notably tested empirically in the United States for HIV prevention in the 1990s,¹⁶ and later in Peru, India, Russia, China, and Zimbabwe.¹⁴ In a large study in Peru, POL reduced HIV stigma and increased condom use and HIV testing in communities similar to where TB Móvil was implemented.¹⁷

TABLE 1.

Core elements of the POL intervention and TB Móvil modifications ^*

	POL core element	Adapted intervention for TB Móvil
1	POL is directed to an identifiable target population in well-defined community venues where the population size can be estimated	The target population for TB screening were all residents of the three intervention districts. Within these districts, CHWs mapped popular venues, including service organizations, soup kitchens, taxi stands, municipal buildings, police stations, schools, churches, markets, factories, and businesses
2	Ethnographic techniques are systematically used to identify segments of the target population and to identify those persons who are the most popular, well-liked, and trusted by others in each segment	Based on information collected through systematic mapping and community visits, we identified two subpopulations to prioritize for recruiting POLs: women who ran comedores populares (soup kitchens) and mototaxistas (predominantly male motorcycle taxi drivers), although leaders of other community organizations and institutions were also included
3	Over the life of the program, 15% of the target population sizes found in the intervention venues are trained as POLs	We did not measure the fraction of the target population that participated as POLs
4	The program teaches POLs skills for initiating risk reduction messages to friends and acquaintances during everyday conversations	CHWs provided POLs with information about TB, the benefits of preventative screening, and the campaign itself to share with friends and acquaintances during everyday conversations
5	The training program teaches POLs characteristics of effective behavior change communication messages targeting risk-related attitudes, norms, intentions, and self-efficacy. In conversations, POLs personally endorse the benefits of safer behavior and recommend practical steps needed to implement change	Formal training about TB prevention and effective communication was only conducted with the CHWs. POLs, however, participated in the campaign and were also able to personally endorse its benefits and explain the screening process in their conversations
6	Groups of POLs meet together weekly in sessions that use instruction, facilitation modeling, and extensive role exercises to help POLs refine their skills and gain confidence in delivering effective prevention messages to others	CHWs met frequently to share their experiences. Communication with the broader POL network was maintained via WhatsApp groups to provide campaign updates and facilitate communication with the TB Móvil team
7	POLs set goals to engage in risk reduction conversations with friends and acquaintances in the target population between weekly sessions	Goals for daily campaign attendance were established, but specific numbers of conversations between POLs and other community members were not tracked
8	POLs conversational outcomes are reviewed, discussed, and reinforced at subsequent training sessions	CHWs met frequently to reflect on successes and challenges in recruiting participants. Although POL conversational outcomes were not formally reviewed, CHWs received informal feedback from POLs about their experiences in promoting the campaign
9	Logos, symbols, or other devices are used as “conversation starters” between POLs and others	Both CHWs and POLs were provided with multimedia tools (signs, posters, and flyers) to support their interactions with the community

^*Adapted from the U.S. Centers for Disease Control’s (CDC) Popular Opinion Leader Evaluation Field Guide—September 2008; https://www.cdc.gov/hiv/effective-interventions/prevent/popular-opinion-leader/index.html

POL = popular opinion leader; CHW = community healthcare worker.

To adapt POL as a community engagement strategy to support the uptake of TB Móvil, we recruited eight community health workers (CHWs)—individuals who were respected and well-connected to social organizations—to serve as POLs and who moved from community to community with the screening units throughout the intervention. In each neighborhood, CHWs conducted a systematic reconnaissance¹⁸ to verify and extend previously compiled mapping data of popular venues (POL Core Element #2), including service organizations, soup kitchens, taxi stands, municipal buildings, police stations, schools, churches, markets, and businesses. At these sites, the CHWs identified and enlisted similarly well-respected and socially connected individuals as a second layer of POLs to share information about TB Móvil and to keep residents informed about when the mobile units would be in their neighbourhood. We prioritized two subpopulations to recruit as POLs—women who ran comedores populares (soup kitchens) and mototaxistas (predominantly male motorcycle taxi drivers)—as both groups were widely dispersed throughout the intervention communities and had frequent contact with residents of all ages.

As the vans progressed through the intervention communities, the POL network evolved to incorporate new members from each community. Due to its expansive nature and the different period of each POL’s involvement, formal and continuous training sessions on effective communication were conducted only with the core CHW team; however, all POLs received basic information about TB Móvil, as well as multimedia resources (posters and flyers) to aid in their community interactions (POL Core Elements #4 and #5). To reinforce key messages about TB prevention with a broader audience, educational discussions were conducted throughout the campaign for all POLs, with emphasis on the most effective ways to communicate the benefits of TB screening and address common questions and concerns (POL Core Elements #6 and #7). After the campaign, CHWs continued to serve as intermediaries between the intervention and network of POLs by sharing updates via WhatsApp groups and, in some cases, coordinating future campaigns in their community (POL Core Element #8).

Community engagement strategy implementation

Before launching TB Móvil in each district and neighborhood, project coordinators met district leaders to introduce the initiative and request their support in providing security at the vans. Coordinators also visited government health centers to explain the automated X-ray screening technology used by TB Móvil and establish a treatment referral process for residents diagnosed with TB. The team obtained maps of each health center’s jurisdiction, which were subdivided into smaller residential zones for data collection, allowing the team to monitor the number of participants from each zone and adjust outreach accordingly. Contact information was collected from municipality and healthcare personnel to create TB Móvil WhatsApp groups to share van locations and facilitate communication with the team. Specific implementation activities were performed over five phases: 1) 1 month before the campaign; 2) 1 week before the campaign; 3) 1–2 days before the campaign; 4) during the campaign; 5) the days following the campaign (Figure 1). The community engagement activities alone (not including the workers who managed the mobile units) necessitated four CHWs per van throughout the vans’ operational hours (usually 8 am–5 pm, Monday–Sunday).

FIGURE 1.

Timeline for implementation of TB Móvil community engagement strategies. CHW = community health worker.

One month before: potential campaign sites were identified based on recommendations from health centers and community contacts. CHWs visited each site to evaluate road access, zone safety, and proximity to community centers to attract more participants. Once a site was selected, CHWs visited nearby social venues and identified POLs to help disseminate information.

One week before: CHWs placed posters and large banners (POL Core Element #9) at highly visible points near the venue (e.g., stores, street corners, parks) to publicize campaign dates and locations. They provided flyers to previously identified POLs for distribution within their social networks and at their social venues.

1–2 days before: CHWs used megaphones to advertise the campaign in the surrounding area, prioritizing hard-to-reach zones and vulnerable populations. To advertise van locations, virtual posters with digital map links were published on the TB Móvil Facebook page and distributed to healthcare personnel, municipality employees, and representatives from local organisations via TB Móvil WhatsApp groups.

During the campaign: CHWs advertised TB Móvil to passersby with large, brightly colored signs and answered questions about the screening process. They visited nearby schools, markets, and health centers and accompanied interested persons to the campaign. At the vans, loudspeakers played music and audio clips to attract attention and provide entertainment for attendees. The audio playlist included jingles, scripted “conversations” about TB prevention, information about the screening process, and promotional messages from local artists and public figures. Some clips targeted specific age or gender demographics, and new recordings were added throughout the year in response to common questions or misconceptions.

Ongoing activities: Promotional videos were published on the TB Móvil Facebook page and disseminated through WhatsApp groups to provide updates on the intervention. Some videos featured participant testimonials or local influencers inviting the community to participate; community members could post questions and provide feedback via comments and private messages. Additionally, a telephone hotline was established to provide information about the campaign, van locations, and test results. We also commissioned local artists to paint murals at bus stops, schools, and parks to raise awareness about the initiative and promote positive messages about health and community empowerment. The initiative was also covered by local television, radio, and print news outlets.

Continual assessment of the POL community engagement strategy

POL performance indicators included the number and characteristics of persons screened at TB Móvil; number of multimedia elements produced for the POL strategy; and proportion of persons with abnormal radiographs hearing about TB Móvil before attending. The TB Móvil screening program (as well as the data for the aforementioned linked indicators) was authorized by the Universidad Peruana Cayetano Heredia’s Ethics Committee, Lima, Peru (protocol 18004). For TB Móvil, the need for informed consent was waived, as the activities offered little risk to participants; also, getting informed agreement would have been impractical in the setting of a high-volume community screening programme.⁹

RESULTS

Persons attending TB Móvil vans

Between February 2019 and January 2020, 62,964 people attended/registered for TB Móvil at 210 distinct screening sites (Figure 2), 92% of whom were residents of the three intervention districts; 61.3% were female (38,569 persons) and 38.8% (24,395 persons) were male (Table 2).

FIGURE 2.

Location of TB Móvil screening locations (n = 210) in Carabayllo (n = 105), Comas (n = 84), and Independencia (n = 21) districts of Lima, Peru; February 2019–January 2020.

TABLE 2.

Age and sex of TB Móvil attendees who registered for TB screening during February 2019–January 2020

Characteristics	n	%
Female
0–3 years	137	0.2
4–14 years	5,881	9.3
15–34 years	9,878	15.7
35–54 years	13,089	20.8
⩾55 years	9,584	15.2
Male
0–3 years	157	0.3
4–14 years	5,642	9.0
15–34 years	6,073	9.7
35–54 years	6,044	9.6
⩾55 years	6,479	10.3
All participants, all ages	62,964	100

Multimedia and communication materials created

Eleven promotional videos and 26 “influencer” videos featuring local artists and public figures were produced to explain the benefits of TB Móvil’s fast and safe technology for the community (Figure 3). Sixteen audio recordings were created to depict the screening procedure, with mini-vignettes illustrating how to overcome participation barriers, and two TB Móvil jingles were created to provide a mental “hook” for the intervention. Flyers (200 per week) and posters (60 per week) supported CHW and POL activities, and murals (12 total) were painted in highly trafficked areas to reinforce key messages. TB Móvil’s social media presence included a Facebook page (>2,400 followers), WhatsApp groups for POL communication, and a project hotline (receiving 20–25 calls per day). The Supplement Data (see Figshare: https://doi.org/10.6084/m9.figshare.17076461.v1) contains the entire library of audiovisual materials produced for the structured community engagement strategy.

FIGURE 3.

Type and quantity of community engagement activities implemented as part of the TB Móvil community engagement plan.

Recognition of TB Móvil by persons with radiographic abnormalities

Among attendees receiving an abnormal chest X-ray suggestive of TB, 48% (6,935/14,563) reported having heard about TB Móvil before attending.

DISCUSSION

Our structured community engagement strategy using POL appeared to support the uptake of the TB Móvil program, evidenced by the overall number of attendees and, more importantly, the near 50% recognition rate of the program by persons with an abnormal TB chest X-ray. Although this report focused on our strategy to promote the uptake of TB Móvil (and not the TB Móvil program itself), it is worth noting that a recent analysis of the impact of TB Móvil reported an 11% (95% confidence interval [CI] 6–16) increase in quarterly case notifications,⁹ which supports the use of POL as community engagement strategy to increase TB screening uptake. Informed by the ACSM handbook for national TB programs and operationalized by adapting the POL HIV intervention, our approach included multiple outreach strategies, prolonged presence in the intervention districts, and consistent branding across physical and online platforms, that likely synergized to increase the target community’s awareness and desire to participate in TB Móvil. Moreover, the POL model’s emphasis on targeted word-of-mouth diffusion appeared to align well with preferences for personalized, interactive, and engaged messaging. We take as a further indicator of its success the strong endorsement by the Peruvian Ministry of Health and National TB Program and their willingness to continue the program beyond the demonstration project.

An important strength of our strategy was the continual use of demographic data to inform real-time adjustments in outreach and messaging. For example, the demographic data led to an early observation that participation rates among working-age men were lower than the rate of female participation in the same age group. Of note, although men are disproportionately affected by TB in low- and middle-income countries (including Peru), they are typically underrepresented by standard screening efforts.¹⁹ To promote equitable participation, we increased out-reach to predominantly male businesses, like transportation companies, and stationed the vans near those venues to ensure that all employees could participate. We also recorded audio vignettes specifically for men (see Supplementary Data 1 in Figshare: https://doi.org/10.6084/m9.figshare.17076461.v1). For example, to appeal to men working day shifts, we created a scripted conversation to emphasize TB Móvil’s weekend hours. We believe that our engagement strategy’s close coordination and involvement with community leaders (e.g., CHWs, other POLs) to disseminate information and attention to prioritizing outreach/tailoring messaging toward subpopulations that might otherwise be underrepresented through traditional screening programs as a means of promoting equity merits greater consideration in TB programs.

We acknowledge both drawbacks to our strategy and limitations to our evaluation process. While POL was highly adaptable to promoting TB Móvil adoption, as a social networking intervention, its strength—high community participation—also presents challenges and necessitates constant engagement with and within communities, in comparison to more traditional, albeit passive, message diffusion methods (e.g., billboards and other media). Because our objective with the community engagement strategy was pragmatic, and we did not conduct a formal implementation study, we did not collect and cannot report indicators of its formal assessment. Therefore, we cannot ascertain the extent to which any single activity in our strategy contributed to the uptake of TB Móvil nor how our strategy compares to other approaches. However, in the absence of other structured community engagement strategies to support TB screening uptake, we believe that our POL-based strategy holds promise as a replicable approach to increase the uptake of TB screening.

CONCLUSION

The adapted POL community engagement strategy appeared to support the uptake of TB Móvil and warrants consideration to increase TB screening uptake.