{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T05:28:48Z","timestamp":1787030928231,"version":"build-2736575974"},"reference-count":54,"publisher":"AOSIS","issue":"1","license":[{"start":{"date-parts":[[2025,5,29]],"date-time":"2025-05-29T00:00:00Z","timestamp":1748476800000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:p>Background: South Africa is a high tuberculosis (TB)-burden country with the worst multidrug-resistant TB (MDRTB) epidemic in Sub-Saharan Africa. The recommendations of the World Health Organization (WHO) in high TB-burden settings are to institute processes for identifying patients with active TB and to improve social support. The community-oriented primary care (COPC) model relies on the community health workers\u2019 (CHW) every encounter in the community as an opportunity to screen for TB symptoms. This study aimed to evaluate the implementation of active surveillance for TB in a CHW team.\n\nMethods: This was a quality improvement project (QIP) focused on the implementation of TB screening in the community-based services at a primary care facility in the Nelson Mandela Bay Health District (NMBHD).\n\nResults: The baseline audit revealed one team was available in the facility even though it serviced two and a half municipal wards. The team comprised an outreach team leader and three CHWs. There were no records of community-based TB screenings done. The midway audit showed a remarkable rise in clients screened in the community. There was a failed attempt to introduce the use of mHealth technology to the team. The audit at the end of the QIP showed a continuing lack of adequate records of activities in the community.\n\nConclusion: The CHWs in this study, although capable and motivated, lacked opportunity to perform adequate community-based TB screening because of the lack of supportive supervision, inadequate recordkeeping, and a district managerial team that focused on the practice population rather than the population at risk.\n\nContribution: We recommend a continuing QIP and a re-education of health care providers about community-based health services.<\/jats:p>","DOI":"10.4102\/safp.v67i1.6106","type":"journal-article","created":{"date-parts":[[2025,6,4]],"date-time":"2025-06-04T09:16:18Z","timestamp":1749028578000},"update-policy":"https:\/\/doi.org\/10.4102\/crossmark-policy","source":"Crossref","is-referenced-by-count":2,"title":["Implementing active surveillance for tuberculosis: A quality improvement project"],"prefix":"10.4102","volume":"67","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3419-9092","authenticated-orcid":false,"given":"Febisola I.","family":"Ajudua","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/05bk57929","id-type":"ROR","asserted-by":"publisher"}],"name":"Stellenbosch University"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7373-0774","authenticated-orcid":false,"given":"Robert","family":"Mash","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/05bk57929","id-type":"ROR","asserted-by":"publisher"}],"name":"Stellenbosch University"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2580","published-online":{"date-parts":[[2025,5,29]]},"reference":[{"key":"ref0","unstructured":"World Health Organization. Global tuberculosis report 2021. Geneva: World Health Organization; 2021."},{"key":"ref1","unstructured":"World Health Organization. Statistica [homepage on the Internet]. 2020 [cited 2022 Dec 16]. Available from: https:\/\/Statistic__top-ten-causes-of-death-in-africa-in-2019.pdf"},{"key":"ref2","unstructured":"World Health Organization. Global tuberculosis report \u2013 Tuberculosis profile: South Africa [homepage on the Internet]. World Health Organization. 2021 [cited 2022 Oct 28]. Available from: http:\/\/apps.who.int\/iris"},{"key":"ref3","doi-asserted-by":"crossref","unstructured":"Wood R, Lawn S, Johnstone-Robertson S, Bekker LG. Tuberculosis control has failed in South Africa: Time to reappraise strategy. S Afr Med J. 2011;101(2):111\u2013114. https:\/\/doi.org\/10.7196\/SAMJ.4587","DOI":"10.7196\/SAMJ.4587"},{"key":"ref4","doi-asserted-by":"crossref","unstructured":"Churchyard GJ, Mametja LD, Mvusi L, et al. Tuberculosis control in South Africa: Successes, challenges and recommendations. S Afr Med J. 2014;104(3):244\u2013248. https:\/\/doi.org\/10.7196\/SAMJ.7689","DOI":"10.7196\/SAMJ.7689"},{"key":"ref5","doi-asserted-by":"crossref","unstructured":"Berkowitz N, Okorie A, Goliath R, Levitt N, Wilkinson RJ, Oni T. The prevalence and determinants of active tuberculosis among diabetes patients in Cape Town, South Africa, a high HIV\/TB burden setting. Diabetes Res Clin Pract. 2018;138:16\u201325. https:\/\/doi.org\/10.1016\/j.diabres.2018.01.018","DOI":"10.1016\/j.diabres.2018.01.018"},{"key":"ref6","doi-asserted-by":"crossref","unstructured":"Osman M, Karat AS, Khan M, et al. Health system determinants of tuberculosis mortality in South Africa: A causal loop model. BMC Health Serv Res. 2021;21(1):388. https:\/\/doi.org\/10.1186\/s12913-021-06398-0","DOI":"10.1186\/s12913-021-06398-0"},{"key":"ref7","doi-asserted-by":"crossref","unstructured":"Abubakar A, Van Baar A, Fischer R, Bomu G, Gona JK, Newton CR. Socio-cultural determinants of health-seeking behaviour on the Kenyan Coast: A qualitative study. PLoS One. 2013;8(11):0071998. https:\/\/doi.org\/10.1371\/journal.pone.0071998","DOI":"10.1371\/journal.pone.0071998"},{"key":"ref8","doi-asserted-by":"crossref","unstructured":"Makgopa S, Cele LP, Mokgatle MM. Pre-diagnosis health seeking behaviors and experiences post-diagnosis, among men diagnosed with tuberculosis in a District of Gauteng Metropolitan City, South Africa: In-depth interviews. Int J Environ Res Public Health. 2022;19(20):13635. https:\/\/doi.org\/10.3390\/ijerph192013635","DOI":"10.3390\/ijerph192013635"},{"key":"ref9","unstructured":"World Health Organization. Optimizing active case-finding for tuberculosis: Implementation lessons from South-East Asia. New Delhi: World Health Organization, Regional Office for South-East Asia; 2021."},{"key":"ref10","doi-asserted-by":"crossref","unstructured":"Skiles MP, Curtis SL, Angeles G, Mullen S, Senik T. Evaluating the impact of social support services on tuberculosis treatment default in Ukraine. PLoS One. 2018;13(8):0199513. https:\/\/doi.org\/10.1371\/journal.pone.0199513","DOI":"10.1371\/journal.pone.0199513"},{"key":"ref11","doi-asserted-by":"crossref","unstructured":"Lutge E, Lewin S, Volmink J, Friedman I, Lombard C. Economic support to improve tuberculosis treatment outcomes in South Africa: A pragmatic cluster-randomized controlled trial. BMC Trials. 2013;14(1):154. https:\/\/doi.org\/10.1186\/1745-6215-14-154","DOI":"10.1186\/1745-6215-14-154"},{"key":"ref12","unstructured":"SANAC. South African national strategic plan for HIV, TB and STIs 2017\u20132022 [homepage on the Internet]. 2017 [cited 2022 Oct 13]; p. 132. Available from: http:\/\/sanac.org.za"},{"key":"ref13","doi-asserted-by":"crossref","unstructured":"Uplekar M, Creswell J, Ottmani S-E, Weil D, Sahu S, L\u00f6nnroth K. Programmatic approaches to screening for active tuberculosis. Int J Tuberc Lung Dis. 2013;17(10):1248\u20131256. https:\/\/doi.org\/10.5588\/ijtld.13.0199","DOI":"10.5588\/ijtld.13.0199"},{"key":"ref14","doi-asserted-by":"crossref","unstructured":"Shete PB, Reid M, Goosby E. Message to world leaders: We cannot end tuberculosis without addressing the social and economic burden of the disease. Lancet Glob Health. 2018;6(12):e1272\u2013e1273. https:\/\/doi.org\/10.1016\/S2214-109X(18)30378-4","DOI":"10.1016\/S2214-109X(18)30378-4"},{"key":"ref15","doi-asserted-by":"crossref","unstructured":"Fusheini A, Eyles J. Achieving universal health coverage in South Africa through a district health system approach: Conflicting ideologies of health care provision. BMC Health Serv Res. 2016;16(1):1\u201311. https:\/\/doi.org\/10.1186\/s12913-016-1797-4","DOI":"10.1186\/s12913-016-1797-4"},{"key":"ref16","unstructured":"South African National Department of Health. Policy framework and strategy for ward-based primary healthcare outreach teams 2018\/19\u20132023\/24 [homepage on the Internet]. 2018 [cited 2019 Dec 28]; p. 16\u201320. Available from: https:\/\/rhap.org.za\/wp-content\/uploads\/2018\/04\/Policy-WBPHCOT-4-April-2018-1.pdf"},{"key":"ref17","unstructured":"World Health Organization. Estimates of TB burden. 2020 [cited 2022 Jul 06]. Tuberculosis profile: South Africa. Available from: worldhealthorg.shinyapp.io"},{"key":"ref18","doi-asserted-by":"crossref","unstructured":"Roomaney RA, Van Wyk B, Cois A, Pillay-Van Wyk V. Multimorbidity patterns in a national HIV survey of South African youth and adults. Front Public Health. 2022;10:862993. https:\/\/doi.org\/10.3389\/fpubh.2022.862993","DOI":"10.3389\/fpubh.2022.862993"},{"key":"ref19","doi-asserted-by":"crossref","unstructured":"Ortiz-Brizuela E, Menzies D. Tuberculosis active case-finding: Looking for cases in all the right places?. Lancet Public Health. 2021;6(5):e261\u2013e262. https:\/\/doi.org\/10.1016\/S2468-2667(21)00048-7","DOI":"10.1016\/S2468-2667(21)00048-7"},{"key":"ref20","doi-asserted-by":"crossref","unstructured":"Gomes I, Dong C, Vandewalle P, et al. Comparative assessment of the cost-effectiveness of Tuberculosis (TB) active case-finding interventions: A systematic analysis of TB REACH wave 5 projects. PLoS One. 2022;17(9):e0270816. https:\/\/doi.org\/10.1371\/journal.pone.0270816","DOI":"10.1371\/journal.pone.0270816"},{"key":"ref21","doi-asserted-by":"crossref","unstructured":"Shah L, Rojas M, Mori O, et al. Cost-effectiveness of active case-finding of household contacts of pulmonary tuberculosis patients in a low HIV, tuberculosis-endemic urban area of Lima, Peru. Epidemiol Infect. 2017;145(6):1107\u20131117. https:\/\/doi.org\/10.1017\/S0950268816003186","DOI":"10.1017\/S0950268816003186"},{"key":"ref22","unstructured":"WHO. The end TB strategy. Geneva: World Health Organisation; 2015."},{"key":"ref23","doi-asserted-by":"crossref","unstructured":"Knut L\u00f6nnroth K, Raviglione M. The WHO\u2019s new end TB strategy in the post-2015 era of the Sustainable Development Goals. Trans R Soc Trop Med Hyg. 2016;110(3):148\u2013150. https:\/\/doi.org\/10.1093\/trstmh\/trv108","DOI":"10.1093\/trstmh\/trv108"},{"key":"ref24","unstructured":"Marcus T, editor. A practical guide to doing community oriented primary care. 2nd ed. Pretoria: Minuteman Press Lynnwood, 2016; p. 212."},{"key":"ref25","doi-asserted-by":"crossref","unstructured":"Wingfield T, Verguet S. Active case finding in tuberculosis-affected households: Time to scale up. Lancet Glob Health. 2019;7(3):e296\u2013e298. https:\/\/doi.org\/10.1016\/S2214-109X(19)30015-4","DOI":"10.1016\/S2214-109X(19)30015-4"},{"key":"ref26","doi-asserted-by":"crossref","unstructured":"Wingfield T, Boccia D, Tovar MA, et al. Designing and implementing a socioeconomic intervention to enhance TB control: Operational evidence from the CRESIPT project in Peru. BMC Public Health. 2015;15(1):810. https:\/\/doi.org\/10.1186\/s12889-015-2128-0","DOI":"10.1186\/s12889-015-2128-0"},{"key":"ref27","doi-asserted-by":"crossref","unstructured":"Begun M, Newall AT, Marks GB, Wood JG. Contact tracing of tuberculosis: A systematic review of transmission modelling studies. PLoS One. 2013;8(9):e72470. https:\/\/doi.org\/10.1371\/journal.pone.0072470","DOI":"10.1371\/journal.pone.0072470"},{"key":"ref28","doi-asserted-by":"crossref","unstructured":"Little KM, Msandiwa R, Martinson N, Golub J, Chaisson R, Dowdy D. Yield of household contact tracing for tuberculosis in rural South Africa. BMC Infect Dis. 2018;18(1):1\u20138. https:\/\/doi.org\/10.1186\/s12879-018-3193-7","DOI":"10.1186\/s12879-018-3193-7"},{"key":"ref29","doi-asserted-by":"crossref","unstructured":"Morishita F, Eang MT, Nishikiori N, Yadav RP. Increased case notification through active case finding of tuberculosis among household and neighbourhood contacts in Cambodia. PLoS One. 2016;11(3):e0150405. https:\/\/doi.org\/10.1371\/journal.pone.0150405","DOI":"10.1371\/journal.pone.0150405"},{"key":"ref30","doi-asserted-by":"crossref","unstructured":"Podewils LJ, Bronner Murrison L, Bristow C, Bantubani N, Mametja LD. The other side of surveillance: Monitoring, application, and integration of tuberculosis data to guide and evaluate programme activities in South Africa. S Afr Med J. 2016;106(4):55. https:\/\/doi.org\/10.7196\/SAMJ.2016.v106i4.10207","DOI":"10.7196\/SAMJ.2016.v106i4.10207"},{"key":"ref31","doi-asserted-by":"crossref","unstructured":"Moosa S, Derese A, Peersman W. Insights of health district managers on the implementation of primary health care outreach teams in Johannesburg, South Africa: A descriptive study with focus group discussions. Hum Resour Health. 2017;15(1):7. https:\/\/doi.org\/10.1186\/s12960-017-0183-6","DOI":"10.1186\/s12960-017-0183-6"},{"key":"ref32","doi-asserted-by":"crossref","unstructured":"Naidoo N, Railton J, Jobson G, et al. Making ward-based outreach teams an effective component of human immunodeficiency virus programmes in South Africa. S Afr J HIV Med. 2018;19(1):a778. https:\/\/doi.org\/10.4102\/sajhivmed.v19i1.778","DOI":"10.4102\/sajhivmed.v19i1.778"},{"key":"ref33","unstructured":"tbfacts.org. TB Statistics South Africa \u2013 National, incidence, provincial National TB statistics for South Africa. Pretoria: Statistics South Africa; 2018."},{"key":"ref34","unstructured":"National Department of Health. Ideal clinic TM manual [homepage on the Internet]. 2021 [cited 2022 Dec 15]. Available from: https:\/\/www.idealhealthfacility.org.za\/App\/Document\/Download\/266"},{"key":"ref35","doi-asserted-by":"crossref","unstructured":"Mash R, Ray S, Essuman A, Burgue\u00f1o E. Community orientated primary care in the sub-Saharan Africa context: A scoping review of different models, their effectiveness and feasibility. BMJ Glob Health. 2019;4(suppl 8):e001489. https:\/\/doi.org\/10.1136\/bmjgh-2019-001489","DOI":"10.1136\/bmjgh-2019-001489"},{"key":"ref36","unstructured":"Pillay Y, Barron P. The implementation of PHC re-engineering in South Africa [homepage on the Internet]. PHASA. 2012 [cited 2018 July 23]. Available from: https:\/\/www.phasa.org.za%3Ethe-implementation-of-phc-reengineering-in-South-Africa"},{"key":"ref37","doi-asserted-by":"crossref","unstructured":"Bennett R, Marcus TS, Abbott G, et al. Modelling cost benefit of community-oriented primary care in rural South Africa. Afr J Prim Health Care Fam Med. 2020;12(1):1\u20138. https:\/\/doi.org\/10.4102\/phcfm.v12i1.2225","DOI":"10.4102\/phcfm.v12i1.2225"},{"key":"ref38","doi-asserted-by":"crossref","unstructured":"Austin-Evelyn K, Rabkin M, MacHeka T, et al. Community health worker perspectives on a new primary health care initiative in the Eastern Cape of South Africa. PLoS One. 2017;12(3):e0173863. https:\/\/doi.org\/10.1371\/journal.pone.0173863","DOI":"10.1371\/journal.pone.0173863"},{"key":"ref39","doi-asserted-by":"crossref","unstructured":"Nelson C, Madiba S. Barriers to the Implementation of the ward-based outreach team program in Mpumalanga Province: Results from process evaluation. J Prim Care Community Health. 2020;11:2150132720975552. https:\/\/doi.org\/10.1177\/2150132720975552","DOI":"10.1177\/2150132720975552"},{"key":"ref40","doi-asserted-by":"crossref","unstructured":"Marcus TS, Hugo J, Jinabhai CC. Which primary care model? A qualitative analysis of ward-based outreach teams in South Africa. Afr J Prim Health Care Fam Med. 2017;9(1):a1252. https:\/\/doi.org\/10.4102\/phcfm.v9i1.1252","DOI":"10.4102\/phcfm.v9i1.1252"},{"key":"ref41","doi-asserted-by":"crossref","unstructured":"Mash R, Goliath C, Mahomed H, Reid S, Hellenberg D, Perez G. A framework for implementation of community-orientated primary care in the metro health services, Cape Town, South Africa. Afr J Prim Health Care Fam Med. 2020;12(1):1\u20135. https:\/\/doi.org\/10.4102\/phcfm.v12i1.2632","DOI":"10.4102\/phcfm.v12i1.2632"},{"key":"ref42","doi-asserted-by":"crossref","unstructured":"Schneider H, Nxumalo N. Leadership and governance of community health worker programmes at scale: A cross case analysis of provincial implementation in South Africa. Int J Equity Health. 2017;16(1):72. https:\/\/doi.org\/10.1186\/s12939-017-0565-3","DOI":"10.1186\/s12939-017-0565-3"},{"key":"ref43","doi-asserted-by":"crossref","unstructured":"Kok MC, Dieleman M, Taegtmeyer M, et al. Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review. Health Policy Plann. 2015;30(9):1207\u20131227. https:\/\/doi.org\/10.1093\/heapol\/czu126","DOI":"10.1093\/heapol\/czu126"},{"key":"ref44","unstructured":"World Health Organization, United Nations Children\u2019s Fund. Operational framework for primary health care: Transforming vision into action [homepage on the Internet]. 2020; p. 1\u2013106. Available from: https:\/\/apps.who.int\/iris\/handle\/10665\/337641"},{"key":"ref45","doi-asserted-by":"crossref","unstructured":"Greenhalgh T, Abimbola S. The NASSS framework a synthesis of multiple theories of technology implementation. Stud Health Technol Inform. 2019;263:193\u2013204. https:\/\/doi.org\/10.3233\/SHTI190123","DOI":"10.3233\/SHTI190123"},{"key":"ref46","doi-asserted-by":"crossref","unstructured":"Sheikh A, Anderson M, Albala S, et al. Health information technology and digital innovation for national learning health and care systems. Lancet Digital Health. 2021;3(6):e383\u2013e396. https:\/\/doi.org\/10.1016\/S2589-7500(21)00005-4","DOI":"10.1016\/S2589-7500(21)00005-4"},{"key":"ref47","unstructured":"World Health Organization. Classification of digital health interventions v 1.0 [homepage on the Internet]. 2018 [cited 2022 Nov 28]. Available from: http:\/\/who.int\/reproductivehealth\/topics\/mhealth\/en\/"},{"key":"ref48","doi-asserted-by":"crossref","unstructured":"Cline GB, Luiz JM. Information technology systems in public sector health facilities in developing countries: The case of South Africa. BMC Med Inform Decis Mak. 2013;13(1):13. https:\/\/doi.org\/10.1186\/1472-6947-13-13","DOI":"10.1186\/1472-6947-13-13"},{"key":"ref49","doi-asserted-by":"crossref","unstructured":"Simen-Kapeu A, Reserva ME, Ekpini RE. Galvanizing action on primary health care: Analyzing bottlenecks and strategies to strengthen community health systems inwest and central Africa. Glob Health Sci Pract. 2021;16(suppl 1):S47\u2013S64. https:\/\/doi.org\/10.9745\/GHSP-D-20-00377","DOI":"10.9745\/GHSP-D-20-00377"},{"key":"ref50","doi-asserted-by":"crossref","unstructured":"Buehler B, Ruggiero R, Mehta K. Empowering community health workers with technology solutions. 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