Community views on active case finding for tuberculosis in low- and middle-income countries: a qualitative evidence synthesis

What do people think of strategies to identify cases of tuberculosis in low‐ and middle‐income countries?

What is active case finding?

Active case finding (ACF) involves health workers going out into communities to identify people with tuberculosis who otherwise might not have sought help in clinics (e.g. because they live too far from health facilities or cannot afford to get there). The aim of ACF is to find people who have tuberculosis and provide them with treatment, in order to reduce the spread of disease and improve the health of infected people.

What did we want to find out?

We aimed to understand the experiences and perspectives of people who had been involved in ACF, including people with tuberculosis, community members, and health workers.

What did we find?

We included 45 studies and sampled from 20 across a broad range of World Health Organization (WHO) regions (Africa, South‐East Asia, Eastern Mediterranean, and the Americas). From these data, we drew the following five main conclusions.

• ACF improves access to diagnosis for many, but does little to help the poorest people.
ACF improves access to health services for people with worse health and fewer resources. However, programmes are not always sensitive to the challenges people have in their daily lives. Those who migrate for work or who live in remote areas also have little access to ACF.

• People are afraid of diagnosis and its impact.
Being targeted for screening is frightening. It exposes people to discrimination due to stigma, and people may also assume they have HIV. For this reason, some people may refuse to participate in diagnosis and treatment. In addition, people report feeling overwhelmed and afraid upon diagnosis, as they anticipate medicine side effects and the prospect of living with a serious illness.

• Screening is undermined by weak health infrastructure.
In many settings, lack of investment has resulted in poor services. As a result, people face repeated tests and clinic visits, wasted time, and difficult interactions with health workers. People with tuberculosis or other conditions who attend screening expect follow‐up care, which they may or may not receive. Finally, community members, parents, and health workers often receive inadequate information, which can lead to harm for children.

• Health workers are an under‐valued but important part of ACF.
ACF can feel difficult for health workers due to lack of support. They are also poorly protected against tuberculosis and fear that they or their families might become infected. Despite these obstacles, the care and support provided by health workers helps people feel able to manage their condition.

• Local leadership is necessary but not sufficient for ensuring appropriate programmes.
When people from the local community promote or conduct ACF, it increases support for the service. However, health workers need to balance professional authority with local knowledge and rapport.

How up to date is this evidence?

We searched for studies published before 22 June 2023.