Mobile Health for Implementation of Home-based TB Contact Investigation in Uganda

描述(申请人提供)：接触调查是一项广泛倡导的战略，通过筛查新结核病患者的家庭接触者和转介高危患者进行以诊所为基础的确证测试和治疗，将结核病病例检测从诊所扩展到社区。不幸的是，高危人群的低随访率是在高负担国家实施接触者调查的主要障碍。在一项基于世卫组织认可的获得结核病评估服务障碍的概念模型的形成性评估中，我们发现患者缺乏关于结核病和结核病评估的知识，经济和地理障碍是造成这一质量差距的主要决定因素。这项提议的目的是确定在有针对性的移动电话健康(MHealth)信息和奖励的支持下，家庭痰收集是否是克服实施接触者调查的这些障碍的有效和可扩展的解决方案。科学的方法将是在乌干达的五个农村社区进行一项家庭随机对照试验，比较两种评估危险接触者的方法：转诊到诊所进行结核病检测(标准方法)与由mHealth干预措施支持的家庭痰收集。我们将使用RE-AIM干预评估框架来评估这些干预措施对患者和公共健康的影响，使用关于其覆盖范围、有效性、采用、实施和维护的预先指定的措施。具体地说，我们将首先确定，与标准接触调查相比，mHealth促进的家庭痰收集是否提高了结核病和艾滋病毒诊断和临床随访(REACH)、结核病治疗开始(有效性)和完成(维护)的比率。其次，我们将使用定量和定性的方法来评估跨不同地点(采用)的组成部分干预的内部有效性和保真度。第三，我们将使用经济和流行病模型来估计这种干预(实施)的成本和流行病学影响。拟议的研究将对患者护理和卫生政策做出重大贡献，提供关于低收入国家接触调查的全面、基于实践的证据，包括是否可以通过减少不必要的临床转诊和增加感染性结核病患者的早期识别和治疗来更广泛和更有效地实施。我们已经组建了一支久负盛名的调查小组，他们将利用乌干达结核病监测项目出色的卫生服务研究环境。他们将把他们在临床研究、行为科学和应用数学领域的创新、多学科方法方面的专业知识与他们在核心内容领域的丰富经验结合起来，包括结核病诊断和接触调查、移动健康、行为变化理论和实施框架、生物统计学和健康经济学，以评估以患者为中心的尖端技术干预。

DESCRIPTION (provided by applicant): Contact investigation is a widely advocated strategy for extending tuberculosis (TB) case detection from clinics to communities through screening of household contacts of new TB patients and referral of at-risk patients for clinic-based confirmatory testing and treatment. Unfortunately, low rates of clinic follow-up among at-risk individuals represent a major barrier to implementing contact investigation in high-burden countries. In a formative evaluation based on a WHO-endorsed conceptual model of barriers to accessing TB evaluation services, we have identified a lack of patient knowledge about TB and TB evaluation, and economic and geographic barriers as the major determinants of this quality gap. The objective of this proposal is to determine if home sputum collection, supported by targeted, mobile-phone health (mHealth) messages and incentives, is an effective and scalable solution for overcoming these barriers to implementing contact investigation. The scientific approach will be to carry-out a household-randomized, controlled trial in five rural Ugandan communities comparing two approaches to evaluation of at-risk contacts: referral to clinics for TB testing (standard approach) vs. home sputum collection supported by mHealth interventions. We will use the RE-AIM framework for intervention evaluation to assess the patient and public-health impact of these interventions, using pre-specified measures of their reach, effectiveness, adoption, implementation, and maintenance. Specifically, we will first determine if mHealth-facilitated home sputum collection increases rates of TB and HIV diagnosis and clinic follow-up (reach), TB treatment initiation (effectiveness), and completion (maintenance), as compared to standard contact investigation. Second, we will use quantitative and qualitative methods to evaluate the internal effectiveness and fidelity of the component interventions across different sites (adoption). Third, we will employ economic and epidemic modeling to estimate the costs and epidemiological impact of this intervention (implementation). The proposed research will make a significant contribution to patient care and health policy by providing comprehensive, practice-based evidence on contact investigation in a low- income country, including whether it can be implemented more widely and efficiently by decreasing unnecessary clinic referrals and increasing early identification and treatment of infectious TB patients. We have assembled a well-established team of investigators, who will take advantage of the outstanding environment for health services research with the Uganda TB Surveillance Project. Together, they will combine their expertise in innovative, multi-disciplinary methods from clinical research, behavioral science, and applied mathematics with their extensive experience in core content areas, including TB diagnosis and contact investigation; mHealth; theories of behavior change and implementation frameworks; biostatistics; and health economics to evaluate a cutting-edge, patient-centered technological intervention.