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Table 1 Description of the Solutions Implemented at the Ghana Study Site

From: Solutions to improve the latent tuberculosis Cascade of Care in Ghana: a longitudinal impact assessment

 DescriptionCascade Step affecteda
Program Strengtheningb
 Initial and in-service health care worker training• Initial training-LTBI management training sessions for HCW (cascade of care steps, TST administration and reading, INH administration). These sessions also included a review of data entry/management using the LTBI contact registry. Two full days sessions were held. Approximately 20 people present.All steps
• Initial training-Implementation of local solutions. One full day session. ~ 40 people present.
• In-service training (full day)- Weekly for the first 2 months; bi-weekly × 2 sessions; then monthly for remainder of Phase 2. These sessions included a review of data collection and entry into the registry, LTBI management, and an assessment of how the solutions were functioning.
Solutions
 Educational materials• Information posters about LTBI diagnosis and treatment in HHCs were created.All steps
• Posters were put up through the clinic waiting room and doctor’s offices.
 Phone reminders• HCW were provided with phone vouchers to cover the cost of calling patients for visit reminders and follow-ups. A call was made to every contact before their visit and a follow-up call was made to all HHCs after they initiated treatment.Step 1
Step 2
Step 3
 Community Education• Series of group education sessions conducted by the community health team from the Offinso clinic (2 members/session) at local schools, churches, and mosques.Step 1
• Sessions focused on LTBI, contact investigation, and stigma reduction.Step 2
• A total of six sessions were conducted.
 Community leader education/de-stigmatization (Durbar)• A large meeting with local chiefs and sub-chiefs, as well as community opinion leaders was held.Step 1
• TB and LTBI education was provided. The aim was to gain the support and trust from the attendees so that they would encourage local people to participate in LTBI screening, diagnosis, and treatment.Step 2
 Home visits• Routine home visits to all newly diagnosed index patients were implemented. Two HCW would visit the index patient’s home within the first 2 weeks of diagnosis.Step 1
• At the visit, HHCs were identified and a symptom screen and TST (for those eligible) was performed.Step 2
• A home visit was also performed for all HHCs started on LTBI treatment (HCW would drop off LTBI medications and perform a monitoring visit).
 Patient transport reimbursement• Patients were reimbursed for their transportation costs to the clinic. All types of visits were covered (initial assessment, treatment follow up, etc.)Step 2
• Patients were also given a per diem cost to cover the cost of lunch on the day of their medical evaluation clinic visit.Step 3
 Chest x-ray (CXR) reimbursement• The cost of obtaining a CXR was covered for all contacts over 5 years old who had a positive TST. If a contact had medical insurance, the remaining cost not covered by insurance was covered (a minority of patients had insurance coverage). Insurance would cover 25 GHC (total cost of CXR is 40 GHC).Step 3
 WhatsApp group for physicians• After the implementation of digital CXR in the region, a WhatsApp group for doctors was initiated to enable faster interpretation and feedback.Step 4
• Call vouchers were provided to doctors taking care of HHCs during the study to allow them to pay for data for this service.
  1. aStep 1-Identification of contacts; Step 2-Initial assessment; Step 3-Medical Evaluation; Step 4-Treatment Initiation. See Fig. 1 for detailed description of cascade steps for those < 5 years of age and ≥ 5 years of age
  2. bProgram strengthening activities were done in all study sites. Each site determined the LTBI educational content that was included in their healthcare worker training sessions. At the study site in Ghana, healthcare workers were educated about LTBI management for household contacts. Explicit training for how they should educate patients was not provided