The Feasibility and Acceptability of a New Fluorence Microscopy Technology for TB Diagnosis in Fragile States: A Somaliland Case Study

Background: Tuberculosis is a growing public health problem and one of the major causes of death globally, killing close to 1.5 million people each year and infecting another 10.4 million, particularly in settings with weak health systems. The best way to cut TB transmission is to identify infectious TB cases early, in order to diagnose and treat them effectively. To overcome the growing TB challenge, global control efforts have shifted from disease burden reduction to eradication, with the gradual introduction of robust diagnostic technologies in high TB burden countries (HBCs), including fragile states. One such technique was the light-emitting diode fluorescence microscopy (LED). However, empirical evidence linking LED with feasibility and acceptability for regular utilization in fragile states appeared lacking. Aim: The primary aim of this study was to help improve access to good quality care (diagnosis and treatment) for TB patients in fragile states, specifically in the north-west of Somalia (Somaliland) which had introduced and implemented LED technology for regular TB testing at primary care facilities as a pilot intervention. Methods: The study utilised a theory-informed mixed method approach for data collection and analysis and included systematic literature review, analysis of routine data, key informant interviews and facility observations. Findings: The literature review revealed a weak relationship between LED technology usage and increased TB case detection in resource-poor and fragile health system settings, but otherwise little evidence of feasibility and acceptability. The analysis of routine data on LED implementation and use found no difference in the proportion of patients with negative and positive outcomes between LED and the traditional ZN technology. Iinterviews with facility staff found health workers’ attitudes, perceptions and opinions on LED use generally positive. However, staff attitudes were largely negative toward the future introduction and implementation of new technologies for routine utilisation without improving the systematic and programmatic readiness of the existing health system. Interviews with policy-makers identified serious resource, structural and environmental constraints to the feasibility of LED use in fragile health systems. Conclusion: This study is the first of its kind in a fragile state to assess the feasibility and acceptability of LED, and shed light on constraints to both feasibility and acceptability of new technologies such as LED. The findings of this study add to an existing body of knowledge from other settings related to the diagnostic performance and operational feasibility of LED as a diagnostic strategy to improve patient access to quality TB diagnosis.