LSTM Home > LSTM Research > LSTM Online Archive

Building on facilitators and overcoming barriers to implement active tuberculosis case-finding in Nepal, experiences of community health workers and people with tuberculosis.

Biermann, Olivia, Dixit, Kritika, Rai, Bhola, Caws, Maxine ORCID:, Lönnroth, Knut and Viney, Kerri (2021) 'Building on facilitators and overcoming barriers to implement active tuberculosis case-finding in Nepal, experiences of community health workers and people with tuberculosis.'. BMC health services research, Vol 21, Issue 1, p. 295.

[img] Text
Building on facilitators - tuberculosis MCaws.docx - Accepted Version
Available under License Creative Commons Attribution.

Download (96kB)



Nepal has a high burden of undetected tuberculosis (TB). In line with the World Health Organization's End TB Strategy, the National TB Programme promotes active case-finding (ACF) as one strategy to find people with TB who are unreached by existing health services. The IMPACT TB (Implementing proven community-based active TB case-finding intervention) project was implemented in four districts in Nepal, generating a substantial yield of previously undetected TB. We aimed to identify the facilitators and barriers linked to the implementation of ACF within IMPACT TB, as well as how those facilitators and barriers have been or could be addressed.


This was an exploratory qualitative study based on 17 semi-structured key-informant interviews with people with TB who were identified through ACF, and community health workers who had implemented ACF. Thematic analysis was applied in NVivo 11, using an implementation science framework developed by Grol and Wensing to classify the data.


We generated five main themes from the data: (1) ACF addressed the social determinants of TB by providing timely access to free healthcare, (2) knowledge and awareness about TB among people with TB, communities and community health workers were the 'oil' in the ACF 'machine', (3) trust in community health workers was fundamental for implementing ACF, (4) community engagement and support had a powerful influence on ACF implementation and (5) improved working conditions and enhanced collaboration with key stakeholders could further facilitate ACF. These themes covered a variety of facilitators and barriers, which we divided into 22 categories cutting across five framework levels: innovation, individual professional, patient, social context and organizational context.


This study provides new insights into facilitators and barriers for the implementation of ACF in Nepal and emphasizes the importance of addressing the social determinants of TB. The main themes reflect key ingredients which are required for successful ACF implementation, while the absence of these factors may convert them from facilitators into barriers for ACF. As this study outlined "how-to" strategies for ACF implementation, the findings can furthermore inform the planning and implementation of ACF in Nepal and similar contexts in low- and middle-income countries.

Item Type: Article
Subjects: WA Public Health > Health Problems of Special Population Groups > WA 395 Health in developing countries
WA Public Health > Health Administration and Organization > WA 546 Local Health Administration. Community Health Services
WF Respiratory System > Tuberculosis > WF 200 Tuberculosis (General)
WF Respiratory System > Tuberculosis > WF 205 Epidemiology
WF Respiratory System > Tuberculosis > WF 220 Diagnosis. Prognosis
Faculty: Department: Clinical Sciences & International Health > Clinical Sciences Department
Digital Object Identifer (DOI):
Depositing User: Julie Franco
Date Deposited: 27 Apr 2021 12:21
Last Modified: 27 Apr 2021 12:21


View details

Actions (login required)

Edit Item Edit Item