Chapter V.

CONCLUSION AND RECOMMENDATIONS

CONCLUSION
In conclusion, contact screening activities of PICTS project were being implemented
by well-experienced CHVs with a high level of implementation adherence in a resource-limited
setting. Implementation challenges encountered by CHVs include TB related stigma in the
community, incorrect contact information, reluctance for contact screening, challenges in
referral and difficulty to trace extended contacts at workplaces. Discrimination against TB in
the community still existed despite advancement in diagnosis and treatment services. Positive
perceptions towards contact screening, good organizational supports and highly motivated
CHVs were identified as facilitators for contact screening. To alleviate discrimination against
TB patients in the community, simple and sticky TB related educational messages are required
to better inform the public about TB transmission and available services for diagnosis and
treatment. Also, additional supports should be provided for CHVs to get better to access
extended contacts of TB patients and get presumptive TB cases to get further TB diagnostic
testing are recommended.
RECOMMENDATIONS
Implementing contact screening with complete adherence to standard operating
procedures is not easy. The findings from the study indicated that CHVs had to adapt to
circumstances in real world settings when implementing contact screening in the field. As
misperceptions and discrimination against TB still persist in the community, and limited
knowledge, attitudes and false beliefs regarding TB could be barriers to TB treatment, simple
and sticky health education messages are required. This could be achieved by distributing small
educational gifts such as shirts, fans and small towels that display memorable health messages
related to TB symptoms and nature of transmission during contact screening in the field. This
could not only improve CHVs’ relations with the general public but also disseminate
knowledge of TB symptoms easier than conventional pamphlets which people might or might
not keep. In Myanmar, there had been TB health education campaigns involving well-known
local celebrities to promote awareness for TB prevention. HE messages demonstrated by
celebrities were displayed on posters and T-shirts and distributed to the public. Such campaigns
could be extended to promote awareness about nature of TB transmission and services
available for diagnosis and treatment. Implementing such campaigns could educate general
public to understand more about nature of TB and become less reluctant to screen and undergo
diagnostic testing for TB.
 To address the issues of wrong addresses and phone numbers provided by TB patients,
detailed addresses that include landmarks of where patients live and their occupation should
be recorded so that it would be easier to locate former TB patients if they cannot be contacted
initially via phone. Mobile text message (SMS) system could to be useful and reliable in
reducing missed appointments for TB diagnostic testing for presumptive TB cases. Thus, once
presumptive TB cases were identified and referred for TB diagnosis, SMS system could be
used to send simple TB related health messages as well as reminder for sputum expectoration
and appointment for TB diagnostic testing. Presumptive TB cases could be provided free
transport to diagnostic centres to alleviate their financial burden for transportation costs. As
administrative support from the project supervisors has been instrumental in implementation
of contact screening, PICTS project should maintain its strong organizational support for CHVs
in terms of training and supervision. As this study assessed only adherence aspect of the project,
further implementation research should be focused on studying other implementation outcomes
such as cost-effectiveness, sustainability of contact screening and feasibility of scaling up
contact screening in larger project areas.