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

描述（由申请人提供）：接触者调查是一项广泛提倡的战略，旨在通过筛查新发结核病患者的家庭接触者和转诊高危患者接受基于临床的确认性检测和治疗，将结核病病例发现从诊所扩展到社区。不幸的是，高危人群的临床随访率低是在高负担国家实施接触者调查的主要障碍。在基于世卫组织认可的获得结核病评估服务障碍概念模型的形成性评估中，我们确定患者缺乏对结核病和结核病评估的知识，以及经济和地理障碍是造成这一质量差距的主要决定因素。本提案的目的是确定在有针对性的移动电话健康（mHealth）信息和激励措施的支持下，家庭痰收集是否是克服实施接触调查的这些障碍的有效和可扩展的解决方案。科学的方法是在乌干达五个农村社区开展一项家庭随机对照试验，比较两种评估高危接触者的方法：转诊到诊所进行结核病检测（标准方法）与由移动健康干预支持的家庭痰收集。我们将使用RE-AIM框架进行干预评估，评估这些干预措施对患者和公众健康的影响，使用预先规定的措施来衡量其覆盖范围、有效性、采用、实施和维持。具体而言，我们将首先确定与标准接触者调查相比，移动医疗便利的家庭痰收集是否增加了结核病和艾滋病毒的诊断和临床随访（覆盖面）、结核病治疗的开始（有效性）和完成（维持）率。其次，我们将使用定量和定性方法来评估不同地点的组成干预措施的内部有效性和保真度（采用）。第三，我们将采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。拟议的研究将为低收入国家接触调查提供全面的、基于实践的证据，包括是否可以通过减少不必要的诊所转诊和增加传染性结核病患者的早期识别和治疗来更广泛和有效地实施接触调查，从而对患者护理和卫生政策作出重大贡献。我们已经组建了一个完善的调查小组，他们将利用乌干达结核病监测项目的良好环境进行卫生服务研究。他们将把他们在临床研究、行为科学和应用数学方面的创新多学科方法方面的专业知识与他们在结核病诊断和接触者调查等核心内容领域的丰富经验结合起来；移动健康;行为改变理论与实施框架；生物统计学;用健康经济学来评估一种尖端的，以病人为中心的技术干预。

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.