Increasing Case Detection of Tuberculosis in Nigeria: Design and Test Phase Report - Breakthrough ACTION Nigeria

"Less than 24% of projected incident cases of TB were notified in 2017."
This report, published by Breakthrough ACTION, provides an overview of the human-centred design (HCD) process used to design and test prototypes to improve tuberculosis (TB) case finding in Nigeria. The report covers the first three weeks of the third phase of work, the Design and Test Phase, which focused on the "Desirability" of five solutions that were selected to move forward. The process and its results are shared in this report together with recommendations and next steps.
As explained in the report, "Tuberculosis is in the top causes of mortality for men and women in Nigeria. Despite this, Nigeria has one of the lowest rates of TB case detection in the world, with about 24 percent of cases being notified to the National Tuberculosis and Leprosy Control Programme (NTBLCP)." Breakthrough ACTION, in collaboration with the NTBLCP and with the support of the United States Agency for International Development (USAID), initiated an HCD process in 2018 in order to find a solution.
In general, the HCD process focuses on the human experiences of the users or key participants of the system as a starting point and works from there. In this case, the process involved working with patients, healthcare workers, and community members to build insights about what is happening on the ground. This process could include, for example, patient stories of their journey with TB, provider experiences of treating patients and working within the system, or community anecdotes of how TB is perceived and managed in the public sphere.
This report outlines the specific HCD methodology followed by Breakthrough ACTION when developing social and behaviour change (SBC) initiatives, which is described with the help of the SBC Flow Chart (see Related Summaries, below). The chart includes a first phase, "Define," which focuses on clarifying the purpose of the exercise and building understanding using context, data, and experience. The output is an overarching intent statement and key insights from qualitative research into the situation. The Define phase of this project was completed in May and June of 2018. During the "Design and Test" stage, the insights from the Define phase are used as springboards for generating ideas, and promising concepts are selected, developed, and improved through iterative cycles of prototyping, testing, and refinement. The objective of the Design and Test phase is to generate many ideas and get early feedback, identifying which ones are worth further investment and which ones should not be pursued. These activities are designed to focus the design efforts and reduce the risks of designing and scaling undesirable ideas.
The report details the five candidate interventions that were iterated and refined through rapid prototyping and testing for two weeks with members of the public. These five interventions had emerged from 760 initial ideas, which were narrowed down to 12 before reaching the final five. As explained in the report, the design team exposed their concepts to over 750 people in the "Design and Test" process, both in digital environments and in real life. These interactions were focused on learning how the interventions can be improved and strengthened.
The discussion of each of the five interventions includes information about their heritage from the previous "Discovery" phase and their evolution through the idea generation and field-testing process. In particular, it looks at the goals of each intervention, how it is implemented, and the lessons learned during the testing process.
The five interventions are:
- A simplified "cough testing" referral method aimed at patent and proprietary medicine vendors that builds on existing programmes by increasing usability and reducing effort required, resulting in more referrals of presumptive cases.
- A process and co-design approach to activate local religious institutions and leaders to deliver TB education and testimonials in religious settings, as well as to provide on-site testing and results delivery, thereby decreasing public stigma and increasing referrals from the community.
- A cough companion service operating from directly observed treatment, short-course clinics that engages former TB patients to accompany new patients to their homes the day they are diagnosed with TB, allowing for: immediate contact tracing, TB screening, and sputum sample collection; systematic capture of precise patient address; infection prevention and control measures; and individualised counselling.
- An intervention aimed initially at hospitals using a recognition and reward system to raise the motivation of other healthcare professionals to refer TB-presumptive cases to improve referral rates for TB testing within the hospital.
- A "Brother's Keeper" integrated SBC campaign that draws on people's desire to help others get tested for TB.
As stated in the report, each intervention seeks to address different barriers to improving case detection of TB. They can, therefore, be implemented individually or collectively as complementary interventions.
The report also outlines recommendations and the next steps in the HCD cycle. It recommends, for example, moving onto a 12-week "Feasibility Stage", which should occur as soon as possible to capitalise on the momentum and partnerships created through the process to date. The Feasibility Stage seeks to round out key points in the ideas to reduce the risk of failure and increase effectiveness.
Breakthrough ACTION also recommends breaking up the five interventions into smaller steps, assessing which parts of the ideas should form the scope of the next stage and removing or pausing other parts until a later stage. In addition, it recommends moving the portfolio of interventions forward as a single set of complementary parts rather than continuing to design and assess them as five separate interventions. The Feasibility Stage will provide data that can be used to assess impact. Following this stage, more clarity is expected on the most successful parts of the portfolio, including those that are ready to move forward at scale.
Editor's Note: This HCD process led to the implementation of the Check Am O! Campaign. See Related Summaries, below, for more information about this SBC initiative.
Breakthrough ACTION website on May 2 2024. Image credit: Breakthrough ACTION
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