Conceptual framework

The CFIR consists of five domains: (a) Innovation (the “thing” being implemented); (b) Inner setting (the setting in which the intervention is implemented); (c) Outer setting (the setting in which the Inner Setting exists); (d) Individuals (roles and characteristics of individuals); and (e) Implementation process (activities and strategies used to implement the interventions). An established determinants framework, the CFIR constructs and sub-constructs under these five domains reflect the evidence base of factors most likely to affect the implementation of interventions [6,7]. CFIR is therefore appropriate for assessing the factors that facilitate and impede decentralization of DR-TB services, enabling researchers to evaluate these factors and their interrelationships.

Description of the interventions

This study was conducted retrospectively to evaluate the implementation of the TB REACH Wave 9 project grant titled, “Catalyzing improvements in DR-TB care in Nigeria: A Sustainable Patient-centered approach”. The project aimed to decentralize DR-TB services through multi-component interventions. The interventions implemented were: Devolving DR-TB diagnosis notification to include the local government TB supervisors (TBLS) using WhatsApp; Tracking of patients by supporting the Global Fund-funded community-based organizations (CBOs) through output-based financial incentives; Counselling of patients with the introduction of a structured pre-treatment counselling checklist and team counselling with DR-TB survivors; Decentralization of baseline investigations to (pre-qualified) peripheral laboratories; Provision of transport support to patients for baseline investigations (this was not directly implemented by the project as the Global Fund started funding this activity nationwide through the CBOs); Deploying a mobile connectivity solution using Unstructured Supplementary Service Data (USSD) to reduce turnaround time for baseline investigations results; Verification of reported pre-treatment deaths using verbal autopsy; Decentralization of treatment initiation to the local government levels; and employing a (volunteer) liaison officer (VLO) for state-wide coordination of activities. Series of trainings for capacity building was conducted for all cadres of frontline health workers who implemented the interventions. This was followed by close, supportive supervision and mentoring throughout the implementation process.

Participants recruitment

One-on-one interviews were conducted with diverse stakeholders who were directly involved in implementing the project interventions in both states. These stakeholders were purposively selected as key informants between July 10, 2023 and August 11, 2023, allowing variability among all relevant stakeholders considering age, sex, years of experience and different cadres. We included only health workers who had worked within at least 1-year of the project intervention implementation. The participants were selected from both state and LGA level program staff which included the following personnel; two state program managers, two state DR-TB focal persons, two state (lab) quality assurance officers, two state logistics officers, two officers from community-based organizations, two clinicians, four DR-TB survivors, sixteen TBLSs, four DOTS providers and four managers of private laboratories. In all, a total of 40 key informant interviews (KIIs) were conducted.

Interviewers’ characteristics

The authors ENO and CA conducted the interviews. Both are fellows of the West African College of Physicians (WACP), ENO is a Senior Lecturer at Ebonyi State University Abakaliki, Nigeria while CA is a Consultant Public Health Physician at Alex-Ekwueme Federal University Hospital, Abakaliki, Nigeria. Both are males and have some experience in qualitative studies [13–16].

Participants’ profile

The age of the respondents ranged from 23 to 59 years. Most of the participants, 65% were females. Half of the respondents have attained tertiary education. For those in the services of the National TB Control Program, more than half have served for 5 years and above. About one fifth of the participants have been in the services of the National TB Control Program for more than 10 years.

Identified implementation barriers and enablers by CFIR domains.

Fig 1 shows the coding tree for this qualitative study with constructs that were identified from the data analysis in colored boxes.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Coding tree highlighting implementation enablers and barriers adapted from the Consolidated Framework of Implementation Research (CFIR).

https://doi.org/10.1371/journal.pone.0318274.g001

Thirty-eight themes emerged from the interviews, which were categorized into 15 CFIR constructs under the five domains (Fig 1). Majority of the emergent themes were grouped under the Innovation Characteristics (17 of 38 themes) and Inner Setting (11 of 38 themes) domains respectively. Results are presented below, organized by CFIR domains and constructs, and by identified enablers and barriers. These are summarized alongside with participants’ quotes in the supporting file, S1 Table.

Contextual factors influencing decentralization of DR-TB services by CFIR domains

Overall, participants’ impression about the impact of the entire decentralization initiative was positive. We identified 30 enablers and 8 barriers under 15 constructs of the five CFIR domains. Most of the identified constructs were within the Innovation (Relative Advantage, Innovation Complexity, Innovation Design, Innovation Cost) and Inner Setting (Structural characteristics, Culture, Tension for Change, Compatibility, Available Resources, and Access to Knowledge & Information) domains. Critical incidents and Planning were the only Outer Setting and Implementation Process dynamics identified within the respective domains; while the notable behavioural constructs describing characteristics of Individuals identified were Capability, Opportunity, and Motivation.

Our findings showed that most of the contextual factors perceived to influence the implementation of decentralized DR-TB services were within the Innovation and Inner Setting domains of the CFIR. Participants’ feedback on perceived advantages of the decentralization intervention correlate with findings from a systematic review of factors influencing MDR-TB diagnosis and treatment initiation which highlighted decentralization of services among others as a facilitator, and hence recommended decentralization [17]. Furthermore, within the inner setting domain, identified sub-constructs are inclusive of both those that exists regardless of implementing any interventions (e.g., structural characteristics like existing physical infrastructure and/or the health workforce culture), as well as factors that are specific to the interventions’ implementation, e.g., tension for change, compatibility, available resources, and access to knowledge & information. The abundance of these contextual factors suggests flexible opportunities that could be targeted by implementation strategies for interventions scale up.

Enablers to decentralization implementation

Many of the identified themes classified as enablers are within the innovation domain, and the relative advantages of the decentralized approach as indicated by stakeholders are: faster notification of newly diagnosed DR-TB patients, empowered healthcare workers, enhanced patient tracking, improved ease of conducting baseline investigations, brought treatment closer to the people, reduced transportation barrier thus improving access to DR-TB treatment services, and improved counseling using DR-TB survivors. These findings are consistent with similar evidence of improved DR-TB services and is also in keeping with the calls for more decentralization of TB services globally [5,18,19].

Participants also emphasized its simplicity, and the well-packaged design of the interventions. Despite being a multilevel mix of interventions, some implementation strategies may have had more impact on implementing the decentralized approach. Those highlighted by stakeholders are the: i). Use of WhatsApp platform for result notification; ii). Coordinating role of the VLO; iii). Use of DR-TB survivors as peer counselors; iv). Engagement of the private sector (for laboratory services); v). Improved patient tracking by CBOs. While some of these identified themes were novel, most of them corroborated findings in the literature as previous studies have reported implementation success by applying similar strategies. For instance, inclusion of DR-TB survivors (dubbed a ‘game changer’ by a respondent) for team counselling to reduce treatment refusal and aid prompt treatment initiation and adherence, as well as stigma reduction was well received. This was the experience of other studies that included survivors of other diseases as counselors resulting in reduced loss to follow-up [20,21].

Decentralizing laboratory services for the conduct of baseline investigations through private sector engagement improved person-centered service delivery by significantly reducing travel distance, time and cost as well as effectively bringing DR-TB services closer to the communities. Multi-country experiences have generated abundant evidence that private sector engagement is invaluable for effective TB control through for-profit involvement across the spectrum of TB programming, including laboratory services [22–24].

The use of digital tools such as the state-wide WhatsApp group for prompt DR-TB result notification enabled frontline health workers to obtain patients’ results earlier than the hardcopy. This triggered necessary action for relevant activities for treatment initiation thereby, aiding accountability for every patient. Thus, the use of the WhatsApp group positively changed the attitude of the healthcare workers by stimulating a shorter response time for treatment initiation. This is not surprising as in a similar setting in Tanzania, WhatsApp was used as a revised communication strategy to reduce lab turnaround time and resulted in 22% and 36% reduction in the times for specimen transportation from health facilities to the lab, and median time for the district to receive results respectively [25]. Use of ubiquitous WhatsApp was an appropriately fit technology for the study setting, and unlike the DR-TB IMS platform/USSD, there was no learning curve associated with use of WhatsApp groups.

Key enablers identified within the inner setting included the ability to leverage the existing health system infrastructure such as the functional DOTS centres and staff. Implementing interventions under routine programmatic conditions coupled with the adaptability of the interventions to align with the usual workflow was instrumental for compatibility, and invariably eased implementation. There is evidence that if a program does not fit with the norms and practices already existing in the health facility, the implementation process may be hampered [26]. Tension for change which reflected as readily identifiable gaps within the default DR-TB component of the program by participants highlighting challenges with patient tracking, travel time to conduct baseline investigations, treatment refusals, and overall poorer outcomes was already indicative of, and could have contributed to a readiness for implementation as has been seen in other conditions implementing evidence-based practices (EBP) [27]. Trainings and capacity building with access to knowledge & information, as well as available resources were noted to aid implementation. Identifying these inner setting dynamics is important to understand the local implementation experience, and they may be modifiable drivers of implementing evidence-based practices [28]. Furthermore, themes identified are indicative of health systems strengthening at sub-national levels as several building blocks were impacted by the multilevel interventions, and this is commendable for sustainability as multiple country experiences have shown advances in TB control and system strengthening are complementary [29].

The role of broader systems and spaces including but not limited to fiscal policy and geopolitical factors in influencing implementation, scalability, and sustainability of EBP is well established and are arguably more critical in resource-limited settings such as Nigeria [7,30]. In this study, most of the outer setting factors identified were barriers, however, a paradoxical implementation enabler was the policy move that mandated the sudden removal of subsidy on petroleum products by the Federal Government of Nigeria in May 2023 which brought economic hardship from the attendant hike in transportation prices and cost of living. Suffice it to say that the impact of fuel subsidy removal in Nigeria has made it imperative, if not mandatory to further decentralize DR-TB services in-country. TB is associated with poverty and transportation cost is implicated in contributing to catastrophic costs for households affected by TB. Interventions and policies to reduce indirect TB costs such as decentralized services (especially laboratory and treatment initiation at communities) must then be actively encouraged in line with the global End TB targets to alleviate suffering for those affected by the disease.

Individual actions and behaviour influence effective project implementation which reflects the extent of achieving the patient’s needs [6]. In describing the individual characteristics domain, only the concept of ‘need’ was not identified as a relevant factor. Participants felt that they were physically and psychologically capable of implementing the intervention, had the opportunities to do so, and were motivated to implement the interventions. Self-efficacy of the participants was linked to the frequent training and re-training of the health workers. This observation highlights the importance of regular training of health care workers and supportive supervision as they perform their duties to improve their knowledge and confidence for successful implementation of an initiative [31–33]. Participants were highly motivated to see their patients recover from ill health and prevent the spread of the disease in the interest of protecting public health. This is commendable and could be the effect of a sustained drive and commitment to find the missing millions through consistent active case-finding initiatives that has been the hallmark of the NTBLCP strategic plans since the past decade [34].

Effective planning was the only facilitator at the process level and themes identified were assignment of roles and responsibilities, as well as outlining intervention-specific steps and workspace in advance. Certain tasks were done with structured checklists as job aids, and there were project-defined goals with specific indicators monitored.

Barriers to decentralization implementation

Overall participants’ feedback specific to the multicomponent intervention revealed that verbal autopsy and USSD interventions were the least implemented and some outrightly opined the interventions should either be modified or dropped entirely. Fear of stigmatization by the dead patients’ relatives was a major barrier that limited the use of verbal autopsy as planned and while this may be unconnected to cultural sensitivity to discussing the dead in Africa, it certainly underscores the reality of TB-related stigma in the communities [35–37]. Overall, the uptake and use of USSD by end-users (TBLS and Lab FP) was slow. While this may be partly explained by diverse reasons for late adoption of digital interventions among frontline healthcare workers [38,39], this technological intervention was considered unimportant by the participants. Also, within the innovation domain, low pricing of baseline tests below the market price was a huge barrier identified given that expansion of laboratory services mainly entailed engaging the private sector. This finding is unsurprising as evidence for sustained program partnership with the private sector requires substantial and continuous support, including financial support [40].

Poor power supply and inadequacy of laboratory facilities in rural areas are the core identified barriers external to the TB program implementation setting. While the use of alternative power supply significantly raises operational costs, decentralization efforts were increasingly hindered by unavailability of suitably qualified lab facilities towards more rural settings, and potentially limits further decentralization of services. Understandably, DR-TB expertise diminishes away from the city-centre with less competent hands in rural areas necessitating the need for more capacity building.

Fear of being infected with TB among health workers has been reported severally and directly linked to their service delivery [41,42], thus, an important barrier to be addressed to optimize decentralization of DR-TB services.

Decentralization of DR-TB services is notably cost-effective especially in low-resource settings; however, it could be very challenging and requires varying mix of interventions to address local operational challenges [5]. In this study, we identified more facilitators, and the key enablers centered around the intervention characteristics, individual characteristics, and features of the inner setting within the TB program implementation space. Conversely, majority of the identified barriers were from two intervention strategies that seemed ill-suited, and from outer setting dynamics of fiscal policy and geographic access barriers that were external to the program. While the global push towards more person-centered TB services makes decentralization more imperative, implementation strategies must be adaptable to the local context. In addition to documenting intervention successes, reporting implementation experiences and outcomes with the use of a standardized framework like the CFIR is helpful for reporting lessons learnt to glean pragmatic insights and evidence to guide policy and practice.

Strengths and limitations

This project piloted the decentralization of DR-TB treatment enrollment services in Nigeria with a systematic evaluation of its implementation within routine national TB programming. Being a multilevel complex health intervention, using a determinant’s framework as the CFIR contextualizes study findings, facilitates comparison, and contributes to global implementation science research. Our study has some limitations. The use of digital health interventions has potential pitfalls such as confidentiality issues as WhatsApp does not have mandatory password protection, and images maybe locally saved onto the user’s photo library on their phone. However, in this study, the free tool was primarily used to enhance communication by reducing the turnaround time for retrieving lab result diagnosis of DR-TB, and we relied on WhatsApp’s end-to-end encryption feature for data protection.

Selection bias was caused by using a purposive sample from the top 10 states with the highest burden of PTLTFU thus, results could differ in some states. The two study states are in the southern part of the country, and being in different geo-political zones, notwithstanding, they have comparable data with many other states in the country and share similar problems with regards to DR-TB service delivery. Consequently, the findings from this study though not generalizable, will be useful for scaling up and sustaining decentralization of DR-TB services in Nigeria.