Implementation of Portable Digital Chest X-ray Machine for Tuberculosis Contact Tracing in Oyo and Osun States, Nigeria: A Formative Assessment

Abstract

This paper presents a formative assessment for the implementation of mobile portable chest X-ray (PDX) machines for tuberculosis (TB) contact tracing in the Oyo and Osun states, Nigeria. This descriptive qualitative study was carried out in eight local government areas, and 24 focus group discussions and 30 key informant interviews were conducted using a four-stage sampling technique to select participants. Validated transcribed notes were entered and analyzed using Nvivo. The respondents’ ages ranged from 17 to 85 years, with a mean age of 42.08 ± 14.9 years, and 4.0% had a postgraduate degree. The majority of government officials stated that deploying the PDX machine for screening at the community level is the best means for implementation because it will offer a level of proximity convenience to the TB contacts and assuage concerns about the cost of transportation to the health facility. In addition, it was suggested that TB community screening should be carried out with screening for other health conditions such as high blood pressure and diabetes. This portable X-ray machine intervention, therefore, should be implemented at the community level for contact tracing to allow more TB contacts living with the index patient to be screened without proximity and transportation constraints.

1. Introduction

Nigeria is one of the nations with a high burden of tuberculosis, TB/HIV, and drug-resistant tuberculosis [1,2]. Nigeria is one of the eight countries that bear two-thirds of the world’s TB burden [2,3]. The risk of the disease spreading to other community members is considerably high because about 40% of the estimated 2.46 million cases in Africa go undetected [3]. The data that are currently available show that more than 80% of TB patients are still undiagnosed and untreated [4,5,6].

As part of her National Strategy Roadmap for locating unidentified TB patients, Nigeria has accepted the End TB Strategy, one of the Sustainable Development Goals (SDGs), and, more recently, the resolutions of the United Nations High-Level Meeting (UNHLM) on Tuberculosis [7,8]. Throughout the last 20 years, the WHO has categorized Nigeria as having a high burden of TB and aims to promote targeted interventions and push for resources and legislation to improve TB control. Enhancing the yearly reduction in TB incidence rates from 2% in 2015 to 10% in 2025 is the End TB Strategy’s ultimate target [9].

To ensure early TB diagnosis and close case detection gaps through regular contact screening and high-risk population screening, the first pillar of the End TB Strategy emphasizes the need for patient-centered, integrated care and prevention [10]. To end the tuberculosis epidemic in a generation, the countries with a high tuberculosis burden should give priority investments to populations at the highest risk of tuberculosis, including households and close contacts. Economic evaluations have demonstrated the cost-effectiveness of contact investigation for preventing tuberculosis and its economic benefits to society [11,12,13]. Contact persons should have access to quality and rapid tuberculosis diagnosis, treatment, and prevention services [14]. Hence, contact investigation is imperative to facilitate the global End TB Strategy. Previous studies found that the proportion of positive cases among household contacts was 20% to 40% [15]. Contact investigation also potentially contributes to finding TB cases among children [16]. However, a previous study in Indonesia revealed that only 20% of household contacts were being screened, and this low participation rate can lead to a loss of opportunity for case findings [15].

Chest X-rays were seen as a breakthrough for the quick identification of contacts for follow-up, TB active case finding, and, ultimately, TB eradication because of high sensitivity, better portability, and usability [17]. However, there were drawbacks to its use due to its immobility and high operating costs and a shortage of radiologists. Hence, because smear microscopy was affordable and easy to use, it became the alternative for diagnosing TB patients. However, the WHO formed the DOTS strategy for active case finding in hard-to-reach communities. Yet, there were still limitations to the DOTS strategy in screening children, people living with HIV, and people with smear-negative results, which led to missed cases for screening and TB treatment [18,19].

To achieve the goal of Nigeria’s National Tuberculosis, Leprosy, and Buruli Ulcer Control Programme, the use of portable chest X-ray (PDX) machines to conduct TB screening became an effective tool, and the United States Agency for International Development (USAID) assisted by funding TB-LON region projects targeted toward high-burden areas [20]. The PDX allows many people to be screened daily and determines who should be further evaluated using Xpert MTB/RIF during community-based active case finding [21]. Also, there could be an increase in the diagnosis capacities of the PDX machine when combined with a compatible artificial intelligence-powered computer-aided detection (CAD) software solution. This could lead to higher efficiency and efficacy [22]. The use of PDX machines supports the plan of the WHO to end the TB epidemic globally by 2035 by assisting in finding millions of missing people with TB, even among those living in remote areas [23]. Also, according to [24], this will decrease the number of missed cases and the number of people who need to be screened. Therefore, the paper presents the formative assessment for the implementation of mobile PDX machines for contact tracing in the Oyo and Osun states, Nigeria.

2. Materials and Methods

2.1. Study Design

This descriptive qualitative study was used to identify strategies to implement PDX machine intervention for contact tracing in Oyo and Osun states, Nigeria.

2.2. Study Area

This project was carried out in 8 (Osun = 4 and Oyo = 4) local government areas (LGAs) in hard-to-reach communities and Nigeria’s high-burden TB states of Oyo and Osun. In Oyo state, the study LGAs were Ibadan North, Oyo East, Ogbomoso South, and Iseyin, while in Osun state, Iwo, Oshogbo, Ife Central, and Ede South were used for the study.

2.3. Target Population

The target population for this study was bacteriologically diagnosed pulmonary TB patients (TBPs), household TB contacts (HTBCs), and community volunteers (CVs). Others were the ward development committee (WDC) chair, government-employed TB personnel (directly observed treatment, short-course (DOTS) officers, tuberculosis and leprosy supervisor (TBLS) officers, state tuberculosis and leprosy managers (STBLMs)), and TB LON 3 project staff.

2.4. Sample Size

The saturation technique was used to drive this study. However, we conducted 24 (12/state) focus group discussions (FGDs) and 30 (15/state) key informant interviews (KIIs). The participants for the FGDs were TBPs, HTBCs, and CVs. Each FGD group is made up of 6–10 participants. Also, KIIs were conducted among DOTS officers, TBLS officers, STBLMs, WDC chair, and TB-LON 3 staff. (

Table 1. Sample size.

S/N	LGA	Facility	FGD (TBPs; HTBCs, CVs)	KII (DOTS Officers, TBLSs, STBLMs, WDC)
	Osun State
1	Iwo	Fees PHC	3	3
2	Ede South	State Hospital Ede	3	3
3	Ife Central	Enunwa PHC	3	3
4	Osogbo	State Hospital, Subiaco	3	3
		TB LON 3 project staff		2
		Total	12	14 + 1 (STBLPMs)
Oyo State
1	Ibadan North	PHC Sabo	3	3
2	Oyo East	State Hospital, Oyo	3	3
3	Ogbomosho South	PHC Igboyi	3	3
4	Iseyin	General Hospital Iseyin	3	3
		TB LON 3 project staff		2
		Total	12	14 + 1 (STBLPMs)
		Grand Total	24 FGDs	30 KIIs

).

2.5. Sampling Techniques

The participants for this research were chosen using a 4-stage sampling method.

Stage 1: Using the IHVN (Institute of Human Virology Nigeria) program sites, a purposeful sampling method was used to select two states (Oyo and Osun) in the southwest of Nigeria.

Stage 2: Four LGAs were randomly selected from Oyo and Osun states.

Stage 3: One facility was chosen from each LGA using random numbers generated from www.randomizer.org (accessed on 21 September 2022) from the IHVN-supported DOTS facilities list.

Stage 4: In the catchment areas of the chosen DOTS facilities, a purposeful sampling method was used to select all the stakeholders required for the study.

2.6. Methods of Data Collection

A qualitative method of data collection was adopted for this study.

2.7. Instruments for Data Collection

Validated instruments (key informant interview (KII) and focus group discussion (FGD) guides) were developed and used for this study. The FGD guide was used among TBPs, HTBCs, and CVs. On the other hand, the KII was used among DOTS officers, TBLS officers, STBLMs, WDC chair, and TB-LON 3 project staff. The tools were used to identify procedures for reaching and recruiting TB contacts, challenges involved in the recruitment of TB contacts for investigation, perceived approach for PDX implementation for contact tracing, and foreseen challenges and prevention/mitigation of the challenges. The instruments were developed by the research team based on the literature review and inputs of the TB and public health specialists.

2.8. Data Collection Procedures

Digital recorders and field notes were utilized for the KIIs and FGDs to enable the interviewers to capture all the information during the interviews for accuracy in the data analysis process. The study recruited eight data collectors, comprising three males and five females (Osun = 4 and Oyo = 4) with at least a first degree in health and/or health-related to assist with data collection for the study. One of the data collectors with more than five years of experience in data collection and a Master of Public Health degree was selected as a supervisor to coordinate the process. The project team and data collectors participated in a 2-day intensive residential training, and they were involved in the pilot testing of the instruments on the third day of their training to create an opportunity for them to acquire practical interviewing skills. The pilot of the tool took place at Oniyanrin PHC, Ibadan Northwest Local Government, and the main data collection took place in November 2022.

2.9. Data Management and Analysis

Data processing started with the verbatim transcription of tape recordings by note-takers. This was performed on the same day the data were collected to avoid losing or omitting important details. Field notes were used to beef up audio-taped recordings developed into transcribed notes. The transcribed notes were further subjected to validation, and data collectors, consultants, supervisors, and data clerks participated in the audit and validation of the translated notes. Validated transcribed notes were entered into the computer using NVIVO version 12 Pro. An inductive-dominant coding approach was used to drive the coding process [25]. Thematic content analysis procedures guided the data analysis.

3. Results

3.1. Participants’ Socio-Demographic Characteristics

The respondents’ ages ranged from 17 to 85 years, with a mean age of 42.08 ± 14.9 years; among these, 46.7% were between 35 and 54 years. A few (4.0%) had a postgraduate degree, were married (65.3%), and were TB patients (31.3%) (

Table 2. Socio-demographic characteristics (N = 150).

Socio-Demographic Variables	No.	%
Age *
15–34	49	32.7
35–54	70	46.7
55–74	27	18.0
75 and above	4	2.7
Sex
Male	86	57.3
Female	64	42.7
Marital status
Single	43	28.7
Married	98	65.3
Separated	3	2.0
Divorced	2	1.3
Widow/widower	4	2.7
Religion
Islam	85	56.7
Christianity	62	41.3
Traditional	3	2.0
Ethnicity
Yoruba	145	96.7
Igbo	3	2.0
Others	2	1.3
Level of education
None	12	8.0
Primary	34	22.7
Secondary	59	39.3
OND/NCE	13	8.7
HND/First degree	26	17.3
Postgraduate degree	6	4.0
Occupation
Civil or public servant	29	19.3
Trader	37	24.7
Farmer or fisherman	8	5.3
Artisan	26	17.3
Unemployed	12	8.0
Others	38	25.3
Respondent classification
TB patients	47	31.3
Government staff	18	12.0
TB contacts Community leaders	39 6	26.0 6.0
Community volunteers	34	22.7
TB LON 3 staff	3	2.0

* Mean age = 42.08 ± 14.9 years.

).

Table 3. Socio-demographic characteristics (disaggregated).

State	Mean Age	Marital Status	Religion	Ethnicity	Highest Educational Level	Occupation
Osun (N = 76)	46.07 ± 15.8 years	Single	Islam	Yoruba	None	Civil/public servant
		22 (28.9%)	50 (65.8%)	73 (96.1%)	11 (14.5%)	21 (27.6%)
		Married	Christianity	Igbo	Primary	Trader
		49 (64.5%)	23 (30.3%)	1 (1.3%)	20 (26.3%)	18 (23.7%)
		Separated	Traditional	Others	Secondary	Farmer/Fisherman
		2 (2.6%)	3 (3.9%)	2 (2.6%)	25 (32.9%)	5 (6.6%)
		Divorced			OND/NCE	Artisan
		1 (1.3%)			7 (9.2%)	14 (18.4%)
		Widow/Widower			HND/First degree	Unemployed
		2 (2.6%)			12 (15.8%)	5 (6.6%)
					Postgraduate degree	Other
					1 (1.3%)	13 (17.1%)
Oyo (N = 74)	38.15 ± 12.8 years	Single	Islam	Yoruba	None	Civil/public servant
		21 (28.4%)	35 (47.3%)	72 (97.3%)	1 (1.4%)	8 (10.8%)
		Married	Christianity	Igbo	Primary	Trader
		49 (66.2%)	39 (52.7%)	2 (2.7%)	14 (18.9%)	19 (25.7%)
		Separated			Secondary	Farmer/fisherman
		1 (1.4%)			34 (45.9%)	3 (4.1%)
		Divorced			OND/NCE	Artisan
		1 (1.4%)			6 (8.1%)	12 (16.2%)
		Widow/Widower			HND/First degree	Unemployed
		2 (2.7%)			14 (18.9%)	7 (9.5%)
					Postgraduate	Other
					5 (6.8%)	25 (33.8%)

shows the disaggregated socio-demographic characteristics of the respondents from Osun and Oyo states. The mean age of the respondents in Osun State was 46.07 ± 15.8 years; 57.3% were male, and 32.9% had secondary school education. In Oyo State, the mean age of the respondents was 38.15 ± 12.8 years, 45.9% had a secondary school education, and 66.2% were married.

3.2. Procedures for Reaching and Recruiting TB Contacts

Respondents were asked about the identification of index TB cases for contact tracing, and half of the government officials said that index TB cases could be identified via their phone numbers and house addresses previously documented in the treatment card or on the recording and reporting (R&R) tools, which are in the purview of the DOTS officers.

When asked about the approach being used for contact investigation, most government officials mentioned the “snowballing” approach, which involves asking confirmed TB cases to list the number of persons living with them and make arrangements for home visits to them for TB screening. One of the STBLM officials specifically said,

“Once you identified somebody who is a TB case, that is somebody who has been diagnosed to have TB, and you have placed the person on treatment. So, you will now ask the person about the people living with them in the house and how many they are. Then, you follow the person to the house to go and screen those people. That is how we go about contact investigation.”

A few government officials reported that TB contacts are mainly recruited and screened by community volunteers.

When the TB patients were asked how their contacts can be recruited for contact investigation, the majority said that recruiting the contacts should be through the TB patients and that it is the TB patients’ responsibility to bring their contacts to the facility for screening. Many of the TB patients also mentioned that TB patients can provide the phone numbers of their contacts to the DOTS officer so that they can be contacted and invited over to the facility. However, they should not be informed that they are coming for TB screening. A few of the TB patients mentioned that the TB contacts should be screened within the community and not necessarily need to visit the health facility to be screened for TB.

When the TB contacts were asked about the perceived strategies that can be used for the recruitment of contacts of TB patients for screening, most of the respondents mentioned the adoption of a house-to-house screening approach and the engagement of various mass media sources to promote TB screening. However, there should be an emphasis on the fact that the screening is free. Some of the TB contacts also recommend that once index cases are identified, they should be counselled on the need to screen their relatives for TB. A few of the participants also suggested obtaining the phone number of the contacts from the TB patients and inviting them for screening. A few TB contacts further mentioned that it was the responsibility of the health workers to visit the communities and screen people for TB. The majority of the community volunteers, on the other hand, said that the TB contacts are mostly reached through their phone number, which the TB patients usually provide to invite them to the health facility for TB screening.

3.3. Challenges Involved in the Recruitment of TB Contacts for Investigation

The majority of the government officials mentioned resistance to providing sputum samples by the TB contacts for bacteriological diagnosis after been screened due to some cultural beliefs, such as ritual use. They also mentioned the provision of a wrong phone number and their home address as part of the challenges faced.

Furthermore, some of the government officials mentioned limited logistics support in carrying out the contact investigation from the National Tuberculosis, Leprosy and Buruli Ulcer Control Programme of the Federal Ministry of Health, the refusal of TB contacts to enroll in TB Preventive Therapy (TPT), as well as contract tracers not receiving adequate remuneration for their services as part of the challenges encountered in contact investigation.

The majority of the TB contacts mentioned financial constraints to visit the health facility to be screened for TB and the distance to the health facility. A few of the TB contacts were also of the opinion that the TB contacts can be in a state of denial and refuse to visit the health facility even when invited for TB screening.

More than half of the community volunteers mentioned that the TB contacts often give the wrong home address and phone number so that they will not be contacted, making contact tracing complex for them. They also mentioned that some of the TB contacts refused outright to be screened for TB because of fear of being positive and the display of a hostile attitude toward the community volunteers by the TB contacts during household TB screening. A community volunteer from Oyo State said,

“They would insult you while asking them questions like Ma; you have been coughing for the past two weeks; do you think you can have tuberculosis? They will be like, “Are you okay? I am coughing. Does that mean I have tuberculosis?” So, they will insult you. If I go for community mobilisation and someone insults me, and if I have low self-esteem or I am not brilliant, I will not be able to go to another person and talk to the person. So with the insults, it will be difficult for me to go to another person.”

Some of the community volunteers mentioned that some TB patients who are in treatment do travel and discontinue therapy at the health facility. According to the TB LON 3 staff, the challenges faced during project implementation are attrition, the resistance of patients to be screened in the community due to TB stigmatization, and a limited number of available contact tracers to optimally trace TB contacts in the community.

3.4. Perceived Approach for PDX Implementation for Contact Tracing

The majority of the government officials stated that deploying the PDX machine for screening at the community level is the best means for implementation because it will offer a level of proximity convenience to the TB contacts and assuage concerns about the cost of transportation to the health facility. Also, a few government officials said using the PDX machine for community outreach is the best approach because it provides the opportunity to screen many people quickly and eradicate the social stigma associated with TB. This is because TB contacts will be able to be screened together with other community members and will minimize the stigma that may be associated with this screening for TB contacts.

In addition, it was suggested that TB community screening should be carried out with screening for other health conditions such as high blood pressure and diabetes. They further suggested that free drugs should be provided and distributed during the outreach to encourage a high turnout among the TB contacts.

However, some government officials mentioned that deploying the PDX machine at the household level would be the best means for contact tracing because it will encourage TB contacts to have more interest in the screening. A few government officials also mentioned the sufficient availability of the PDX machines and the trained personnel who will operate the machines.

When TB patients were asked about the best approach to implement PDX machine for the screening of their contacts, some of the TB patients stated that the house-to-house approach would be the best because of its discreet nature and the fact that it also offers a level of privacy and confidentiality to the TB contacts. A TB patient from Oyo State said,

“The best method to make this work smoothly is going from house to house because many people do not want to come out; they hide at home. So, when you get to their houses and explain, they will want to use the opportunity to be screened. So, when they take it to their houses and tell them they want to be screened for free, not money involved, to be screened for the disease will not be difficult.”

Also, some of the community volunteers suggested that deploying the PDX machine intervention for contact tracing at the health facilities is the best approach. They reported that the location of the health facility would be easily accessible to them, and this approach will guarantee the safety of the machine since it is not being moved around from one place to another. A community volunteer from Osun State said specifically,

“The best is that we should use the machine in the health centre because there will be a secure place to use this machine in the facility. If we say we should be carrying it up and down, it can get damaged quickly; it might be that when we are doing it for them in the house, water or anything can pour on it. But nothing like that can happen if space is provided for the machine in the facility.”

However, many of the community volunteers believed that community screening would be the best approach to implementing the PDX machine intervention for contact tracing. This approach will allow many community members and TB contacts to be screened in their community, which will prevent a distance barrier.

3.5. Foreseen Challenges and Prevention/Mitigation of the Challenges

When asked about the likely challenges to expect during the implementation of this PDX intervention for contact tracing, a few of the government officials raised concerns that there may be negative feedback in the community and that using the PDX machine will only expose people to unnecessary radiation, especially pregnant women. The low acceptance rate of TB screening with the PDX machine at the initial stages of implementation was also mentioned.

More than half of the TB patients mentioned that the community members may be hostile to the project staff because of the belief that they do not have TB, and money for TB contacts to transport themselves to the health facility for the TB screening was also mentioned. A few TB patients mentioned issues around logistics coordination, such as creating a conducive environment for the people to sit during the screening exercise, as a challenge.

Refusal to be screened by some TB contacts, abusive responses from some community members, low turnout rates for TB screening, and denial of test results if positive were mentioned by TB contacts as likely challenges. Most community volunteers mentioned refusal to be screened by TB contacts due to the stigmatization attached to having TB in society.

Regarding the difficulties expected if the facility screening is adopted, more than half of the community volunteers said people have a negative perception of health facilities and this might scare people off and further enhance their unwillingness and refusal to utilize the health facility for TB screening. A community volunteer from Osun State specifically said,

“It would not allow people to come for the test because once they hear about the health centre, they attribute something negative to it. But if we take it to the community and explain it to them softly and with a good disposition that may draw their attention to wanting to do the test, they will want to know their health status, and maybe they will not be infected.”

With regards to implementing the PDX machine intervention at the community level through the free medical outreach approach, some community volunteers mentioned fear of the test outcome, TB contacts becoming tired because of the long waiting time before screening, security threats, and non-approval to conduct the health outreach in some communities as the likely challenges.

Some TB LON 3 staff mentioned the refusal of TB contacts to be screened for TB, irrespective of the location of the screening. Another TB LON 3 staff member mentioned that deploying the PDX machine at the community level will be challenging because of the radiation safety measures that must be put in place within the community.

Respondents were also asked about the prevention or mitigation of the mentioned challenges. Some of the government officials suggested routine community awareness and health education about the benefits of the project to the community members. Furthermore, a few suggested that the project should employ trained and experienced personnel who can operate the PDX machine and interpret its results accurately and provide a radiation-free PDX machine as strategies that can help mitigate the predicted challenges during project implementation. A DOTS officer in Osun State reported that

“Any personnel who is going to handle the machine has to be well trained, then the issue of radiation prevention has to be put in place if this machine can be developed in such a way that the radiation aspect of it will not be there. That is, it will be free of radiation. Yes, it will be better. Everybody will like to take part; if it does not have any aftermath, everybody will like to do that, and I will have access to my result immediately.”

A few of the government officials also suggested that the community outreach approach should be deployed by screening other health conditions or providing other health services. They further mentioned that nothing about TB screening should be mentioned during community awareness so as not to scare people from showing up for the screening. A DOTS officer in Osun State reported that

“People must not be told that they want to be screened for tuberculosis because if you tell them, they would not respond. We will tell them this machine works for the general body, to check how the body is functioning, and they will turn up. If you tell them it is for tuberculosis diagnosis, they would not answer, be it household or community level. But for the facility, what you can use to hold such a person is that they walked to the facility by themselves; they will have no choice.”

Most of the TB patients and more than half of the TB contacts suggested the need for the project staff to have perseverance, exercise patience, and have composure during field activities because of the perceived resistance they might face from some members of the community as a strategy for them to withstand the sheer unwillingness that some TB contacts will exhibit when it comes to screening for TB.

Some of the TB contacts mentioned the recruitment of adequate staff, provision of incentives to the people, making the screening accessible, and continuous awareness creation as other means of preventing the likely challenges.

All the WDCs mentioned that proper advocacy visits must be conducted to community gatekeepers—community leaders, market leaders, and religious leaders—to elicit their buy-in into the project; in addition, they also stated that the cost of screening must be low or free to increase the turnout of the people in the utilization of the intervention. A WDC in Osun State reported that

“If we get to a mosque, we can talk to the Imam and explain our purpose so he can tell his members our reason for coming. In church, we can see the pastor in charge and explain. If it is the market, we can talk to the market leader to create awareness in the market. For those in the villages, we talk to the ‘Baale’ (village leader) to inform his co-villagers that the chest people are coming, making it easy.”

Some WDCs also mentioned the need to elicit the presence of community leaders during the implementation process to ensure a proper plan for crowd management. Increased awareness and sensitization about the intervention through mass media outlets and community sensitization to encourage positive behavior toward TB screening were also stated by some WDCs. Moreover, the project must be authenticated at the community level, which could only happen through the involvement of community leaders.

Most of the community volunteers mentioned the need to have enough machines in the community during the screening; continuous outreach activities at the community level; provision of information, education, and communication materials on behavioral change toward TB screening; and collaborating with security agents to offer protection during outreach as some of the strategies that can help prevent or mitigate the challenges. According to the TB LON 3 staff, proper counselling on the importance of TB screening for TB contacts and the need for the TB contacts to be available on the day marked for screening either at the community or facility level were mentioned as part of the strategies that can help prevent the envisioned implementation challenges.

4. Discussion

This study explored perceived strategies to implement PDX machines for contact tracing in the Oyo and Osun states, Nigeria and identifies likely challenges and possible mitigations. It was identified that TB contacts are resistant to providing their sputum samples for bacteriological diagnosis due to some cultural beliefs, such as ritual use. A similar study by [26], however, reported that TB contacts are supportive of being screened and tested for TB; however, the majority who tested negative for TB are unwilling to be placed on TB preventive therapy (TPT). This implies that TB contacts are willing to be screened but do not want to provide their sputum samples.

Regarding the approach for PDX implementation for contact tracing, this study identified that deploying the PDX machine for screening TB contacts at the community level is the best means for implementation because it will offer a level of proximity convenience and assuage concerns about the cost of transportation to the health facility. The study results confirm the importance of accessibility to healthcare facilities, as highlighted by a previous study, justifying the need for an effective community-based screening strategy in areas with high numbers of missed TB cases [27]. As pointed out by several previous studies, TB case finding will only be successful if an effective screening algorithm is implemented using sensitive diagnostic tools according to the specific needs of the population [22].

However, it was found in this study that there may be negative feedback in the community and that using the PDX machine will only expose people to unnecessary radiation, especially pregnant women. Epidemiological studies on populations exposed to radiation, such as the survivors of the atomic bombings or radiotherapy patients, showed a significant increase in cancer risk at doses above 100 mSv. More recently, some epidemiological studies in individuals exposed to medical exposure during childhood (pediatric CT) have suggested that the cancer risk may increase even at lower doses (between 50 and 100 mSv). Prenatal exposure to ionizing radiation may induce brain damage in fetuses following an acute dose exceeding 100 mSv between weeks 8 and 15 of pregnancy and 200 mSv between weeks 16 and 25 of pregnancy. Before week eight or after week 25 of pregnancy, human studies have not shown radiation risk to fetal brain development. Epidemiological studies indicate that the cancer risk after fetal exposure to radiation is similar to the risk after exposure in early childhood [28].

Fortunately, it was established by [29] that the PDX machine operated within the manufacturer’s reported emission parameters and reported leakage doses, which were below the threshold doses for participants and health workers. For the participants, the reported exposure and leakage doses were well below the average annual radiation dose from the environment (3 mSv) and the yearly accepted dose of ionizing radiation for the general public (1 mSv). Regarding health workers and especially the radiographers, the leakage doses were similarly below international guidelines on the stochastic limits for occupational exposure of <20 mSv/year over five years [30]. However, a prospective cohort study needs to be conducted to determine the likelihood of radiation effects on the African population.

The refusal of TB contacts to be screened due to the stigmatization attached to having TB disease in society was also identified in this study as part of the foreseen challenges that may be associated with PDX implementation. Other studies have also reported that the stigma against tuberculosis threatens contact investigation and the effort to end tuberculosis because index patients keep their illness confidential and conceal information about their contacts. As a result, contacts at high risk of tuberculosis, such as children younger than five years of age, do not benefit from tuberculosis prevention and care [31,32]. The stigma alone remains a significant barrier to healthcare access and has impacts on the physical, social, and mental health and the overall quality of life of individuals with TB [33]. The stigma may lead the patient to often hide their disease from others and isolate themselves to escape from negative public perceptions [34,35,36]. The TB-related stigma has a significant impact on the diagnosis, patient adherence to treatment, and recovery from the disease and it can also affect the care given by the family and healthcare provider–patient relationship [37,38].

However, routine community awareness and health education about the benefits of the project to the community members were suggested that can help mitigate the predicted challenges during the project implementation. It has also been reported that good health education to improve knowledge, awareness, and belief and minimize barriers to health-seeking behavior is essential to optimize early detection of TB [39,40]. A change in health-seeking behavior is required to improve household contact participation in the early detection of TB; therefore, health education intervention should be developed using relevant health behavior theories and evidence-based planning [41,42]. This highlights the need for awareness and education campaigns about the benefits of PDX machines and TB contact tracing to help overcome barriers to adoption and encourage widespread use.

In addition, proper advocacy visits to community gatekeepers and the engagement of community members were also identified as ways to mitigate the challenges identified. Previous research similarly identified partnerships with relevant stakeholders, such as healthcare providers and community organizations, that can help promote the adoption of the technology and build trust in the system [43]. It is therefore important to carry out implementation research to determine the effectiveness of community gatekeepers’ involvement in the uptake of TB screening, treatment, and TPT among contacts of TB patients.

5. Conclusions

In conclusion, deploying the PDX machine for screening TB contacts at the community level is the best means for implementation because it will offer a level of proximity convenience and assuage concerns about the cost of transportation to the health facility. However, this presents several challenges that need to be carefully considered and addressed to ensure the success of the intervention. Implementing the suggested mitigation strategies, such as community awareness creation about the project, health education, and proper engagement of community gatekeepers, are essential considerations for the successful implementation of PDX machines in TB contact tracing efforts.