Effectiveness of Providing Cash Incentives and Training To Community Health Workers on Active Case Finding for Tuberculosis In Nigeria: A Cluster-Randomized Control Trial

Christie Akwaowo; Victor Umoh; Idongesit Umoh; Eno Usoroh; Olugbemi Motilewa; Victory Ekpin; Stella Adeboye; Etop Antia

doi:10.12688/f1000research.53822.2

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Research Article

Revised

Effectiveness of Providing Cash Incentives and Training To Community Health Workers on Active Case Finding for Tuberculosis In Nigeria: A Cluster-Randomized Control Trial

[version 2; peer review: 1 approved with reservations, 2 not approved]

Previously titled: A Randomized Control Trial to Test Effect of Cash Incentives and Training on Active Casefinding for Tuberculosis among Community Health Workers in Nigeria

Christie Akwaowo ^1,2, Victor Umoh^1,3, Idongesit Umoh^1,3, [...] Eno Usoroh⁴, Olugbemi Motilewa^1,2, Victory Ekpin¹, Stella Adeboye^1,3, Etop Antia⁵

Christie Akwaowo ^1,2, Victor Umoh^1,3, [...] Idongesit Umoh^1,3, Eno Usoroh⁴, Olugbemi Motilewa^1,2, Victory Ekpin¹, Stella Adeboye^1,3, Etop Antia⁵

PUBLISHED 12 Sep 2024

Author details Author details

¹ Health Systems Research Hub, University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria
² Community Medicine Department, University of Uyo, Uyo, Akwa Ibom State, Nigeria
³ Department of Internal Medicine, University of Uyo, Uyo, Akwa Ibom State, Nigeria
⁴ Public Private Mix, KNCV Tuberculosis Foundation, Abuja, Nigeria
⁵ State Tuberculosis and Leprosy and Buruli Ulcer Control Program Control, Idongesit Nkanga Secretariat, Ministry of Health, Uyo, Akwa Ibom State, Nigeria

Christie Akwaowo
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Victor Umoh
Roles: Conceptualization, Data Curation, Funding Acquisition, Investigation, Methodology, Supervision, Validation, Writing – Review & Editing

Idongesit Umoh
Roles: Conceptualization, Data Curation, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Writing – Review & Editing

Eno Usoroh
Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – Review & Editing

Olugbemi Motilewa
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing

Victory Ekpin
Roles: Writing – Original Draft Preparation, Writing – Review & Editing

Stella Adeboye
Roles: Investigation, Validation, Writing – Review & Editing

Etop Antia
Roles: Data Curation, Methodology, Resources, Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the TDR gateway.

Abstract

Background

Case detection for Tuberculosis remains low in high-burden communities. Community Health Workers (CHWs) are the first point of contact for many rural Nigerians and have been useful in active case finding. This study assessed the effectiveness of cash incentives and training on tuberculosis case detection by CHWs in six Local Government Areas in Nigeria.

Materials and Methods

A cluster randomized control trial with three arms was conducted. Arm A received cash incentives and training, Arm B received only training, and the control arm (C) received neither. CHWs already working in the communities participated. TB case notification and number of community outreaches held were used to assess intervention effects. Data were analyzed using STATA (v.13) and GraphPad Prism (v.8). Effect sizes were calculated using odds ratios and 95% confidence intervals. Associations were tested using Chi-square (χ²) tests, with significance set at P=0.05.

Results

Arm A had a 14.4% increase in case notification, Arm B showed a 7.4% increase, and the control arm showed a 39.7% increase from the previous year. Arms A and B had lower odds of TB case notification post-intervention, compared to the control (OR = 0.819 and 0.769, respectively), with no significant difference between them. Arm A also saw a 144.8% increase in community outreaches, compared to 46.7% in Arm B and 22.7% in Control Arm C. Arms A and B had higher odds of carrying out community outreaches post-intervention compared to the control (OR = 1.995 and 1.195, respectively), but no significant differences were found between the groups regarding community outreach.

Conclusion

While the interventions resulted in an increased number of community outreaches compared to the control, case notification improved more in the control arm than in the intervention arms. Nevertheless, the findings highlight the potential of combining cash incentives with training to improve TB control efforts at the community level. Further exploration of the implementation process may shed light on the observed outcomes and guide future intervention strategies.

Keywords

Tuberculosis, Active Case finding, Cash incentives, Community Health workers

Corresponding author: Christie Akwaowo

Competing interests: Dr. Eno usoroh works for the KNCV TB program, Dr. Etop Antia is the State TB Leporsy control officer. All other authors are academics and service providers for TB and declare no conflicts of interests.

Grant information: This study was supported by a grant from the WHO/TDR Joint AFRO, EDTCP Small Grants (2017) as follows:
World Health Organization: Award Number: 2019/898382-0
TDR: Award Number: 2019/898382-0
European and Developing Countries Clinical Trials Partnership
Award Number: 2019/898382-0

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2024 Akwaowo C et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Akwaowo C, Umoh V, Umoh I et al. Effectiveness of Providing Cash Incentives and Training To Community Health Workers on Active Case Finding for Tuberculosis In Nigeria: A Cluster-Randomized Control Trial [version 2; peer review: 1 approved with reservations, 2 not approved]. F1000Research 2024, 10:1154 (https://doi.org/10.12688/f1000research.53822.2) First published: 15 Nov 2021, 10:1154 (https://doi.org/10.12688/f1000research.53822.1) Latest published: 12 Sep 2024, 10:1154 (https://doi.org/10.12688/f1000research.53822.2)

Revised Amendments from Version 1

The second version of the article was improved based on the reviewers' comments. The following areas were enhanced:

Title: The title was revised in order to better reflect the study's aim to ascertain the effectiveness of the interventions.

Abstract: The methods section in the abstract was updated to accurately describe the interventions each arm received and the data analysis plan, correcting previous confusion. The results and conclusion sections were revised to accurately represent the study's findings. Odds ratios were included to quantify effect sizes, and the conclusion was revised to align with the study findings and provide appropriate recommendations.

Author list: This remains unchanged, however changes to figures, tables, text and data are stated below.

Introduction: This section was shortened to focus more on the study's rationale rather than the problem statement, in order to improve readability.

Methods: Additional clarifications were made as suggested by the reviewers. It was specified that the unit of randomization was the Local Government Area. The study outcomes were clearly defined as TB case notifications and the number of community outreaches in each cluster. The data analysis plan was improved to include the calculation of odds ratios and 95% confidence intervals to measure effect sizes, and chi-square tests were used to assess associations.

Results: Odds ratios and 95% confidence intervals were calculated to measure the intervention's effect size. Information on presumptive TB case notifications was removed as it did not address the research question.

Discussion and Conclusion: The conclusion and recommendations in the first version did not align adequately with the study findings. In this version, the discussion was adjusted to reflect the study findings accurately, and the conclusions and recommendations were derived from these findings.

This version maintains clarity while directly addressing the reviewers' comments.

See the authors' detailed response to the review by Angela Oyo-Ita
See the authors' detailed response to the review by Mihir P Rupani

Introduction

Background

Tuberculosis (TB) remains the leading cause of death from a single infectious disease globally, with an estimated 10 million cases in 2018¹. The WHO African region accounts for over 20% of TB cases, with Nigeria alone contributing 4%¹. Despite a decline in TB mortality in Nigeria², the incidence has stagnated since 2000, mainly due to delayed diagnosis and treatment³. Many TB-infected individuals are asymptomatic and unlikely to seek care, leading to significant underdiagnosis and posing a major challenge to TB control efforts⁴.

In 2018, 7 million new TB cases were reported globally, meeting the UN's target under the WHO initiative "Find. Treat. All. #EndTB"¹. However, an estimated gap of about 10 million cases persists between reported and estimated cases, with Nigeria, India, Indonesia, and the Philippines, accounting for over 50% of the underreported cases¹. This under-detection hampers national TB programs and highlights the limitations of traditional case-finding methods^3,5.

Active case-finding, recommended by the WHO, aims to bridge this gap by screening high-risk individuals, such as contacts of TB patients and people living with HIV. This method identifies and treats those with TB who would not otherwise seek healthcare, effectively detecting both active and latent TB⁶. Screening tools include history taking, sputum smears, and chest X-rays, enhancing early diagnosis and treatment⁶.

Rationale

Nigeria has a low TB case detection rate of 25%, contributing to 12% of the global gap between TB incidence and reported cases in 2018⁷. The South-South region of Nigeria reported 12% of the country's TB cases⁸. Furthermore, Akwa Ibom has the highest HIV prevalence at 5.5%⁸, which increases TB risk. There are pockets of high TB burden communities in some LGAs in the state, making Akwa Ibom one of the states with persistently low case detection of all forms of TB. Active case detection has been initiated in high-risk patient groups⁴. However, there are still gaps in active case-finding.

Many high-risk people such as co-infected, co-morbid, malnourished persons, and children with active TB do not experience typical TB symptoms in the early stages of the disease. They are therefore unlikely to seek care early and may not be properly diagnosed when they eventually seek care. Poor knowledge of symptoms and where to access care also affects the uptake of TB services in our communities.

Community health workers (CHWs) are crucial for providing primary health services in Nigeria, particularly in rural areas. There are different categories of CHWs, including Community Health Extension Workers (CHEWs), Community Pharmacists (CPs), and Patent Medicine Vendors (PMVs). CHEWs are formally trained and typically employed by the government, although many in Akwa Ibom state serve as volunteers⁹. Community Pharmacists offer medical services, dispense medications, and provide healthcare advice, often serving as the first point of contact due to their accessibility and shorter wait times^10–13. PMVs, on the other hand, are self-trained lay health workers who diagnose and treat various ailments with no formal qualifications, though the Pharmaceutical Society of Nigeria regulates their activities¹⁴.

Effective training of frontline health workers is essential for improving tuberculosis (TB) control. Studies have shown that enhanced knowledge and attitudes towards TB among health workers lead to better treatment and prevention outcomes. For instance, a training program in Mozambique found a 14.6% increase in TB case notification rate in the intervention group compared to a decrease of 16.5% in the control group¹⁵. A similar initiative in Enugu led to a doubling of TB presumptive cases and diagnoses three months after a health worker training was done¹⁶.

Incentives, particularly cash incentives, have been shown to boost the commitment, innovation, and accountability of health workers^17,18. While these incentives have proven effective in various health programs, there is limited evidence of their impact on improving TB case detection rates among community health workers in low- and middle-income countries.

This study aimed to assess the effectiveness of training and cash incentives for the improvement of TB case notification among CHWs in Akwa Ibom State, Nigeria. The main research questions were: Can cash incentives and training be used to motivate CHWs to increase TB case detection? The specific objectives were i) to determine the effect of cash incentives plus training on TB case detection ii) to determine the effect of training-only CHWs on TB case detection.

Methods

Setting/context

Akwa Ibom State is located in the South-South region of Nigeria, one of the states in the oil-rich Niger Delta region with a population of about 5.5 million based on 2006 National population census report⁷. The state has 31 local governments distributed across the three senatorial districts. It has 368 primary health centers (PHCs), unevenly distributed across the local government areas (LGAs)¹⁹.

Akwa Ibom state has a high burden of TB and HIV⁸. At the time of this study, the USAID was carrying out TB control activities in 15 LGAs and TB Reach had projects in three of the remaining 16 LGAs. The study population was the 13 LGAs that were not covered by the ongoing TB programs.

The interventions took place in the PHCs and catchment communities where the CHEWs, PMVs and CPs practised. While most of the CHEWs worked in the public sector PHCs, the CPs and PMVs worked in the private sector, setting up their drug stores with the sole aim of making a profit. The baseline interventions were carried out in April 2019 and follow-up was carried out quarterly until March 2020. The trial ended as scheduled after one year, although the COVID-19 pandemic lockdown interrupted endline data collection and close-out of the project.

Study design

The study was designed as a three-arm parallel cluster randomised control study. The interest in evaluating training and cash incentives concurrently informed the choice of a multi-arm cluster randomised trial. The advantages of this design include lowering costs as the two arms run at the same time and having one control arm which reduces the sample size relative to performing separate 2-arm trials²⁰.

It was conducted in six high-TB-burden Local Government Areas (LGAs). These LGAs were purposively selected from the sampling frame of 13 LGAs with the assistance of the State Tuberculosis and Leprosy Control Officer. Each local government area served as a cluster for this study, and they included Esit Eket and Uyo (Arm A), Ibiono Ibom and Ibesikpo (Arm B), and Nsit Ibom and Uruan (Arm C-Control).

The study clusters were randomised by the researchers using the balloting technique into one of the three arms. In each participating local government area, three PHCs offering DOTS treatment services were selected by simple random sampling and included in the study. In total, 18 PHCs and their catchment communities were used, with PHCs clusters per arm. The allocation of PHCs can be seen in Figure 1. Recruitment of CHWs in each arm was facilitated by the PHC focal persons, who worked with the Chairman of the Patent Medicine Vendors (PMVs).

Figure 1. Allocation of Primary Health Centres in the study.

Invitations were sent to all CHWs in the intervention PHCs (Arm A and B) and their catchment communities for a centrally conducted workshop in Uyo, the capital city. Blinding of participants to their allocated arms was not possible. To mitigate bias from non-blinding, clusters were allocated to the study arms by LGA, and selected LGAs were not contiguous. The workshop was conducted on two separate days: Arm A on Day 1, and Arm B on Day 2. Blinding assessors to the different arms was also not possible.

The PHCs served as the focal point and referral centre for any cases identified in the community by the CHWs.

Interventions

1. Training of CHWs: A total of 158 HCWs were trained, 85 in Arm A and 73 in Arm B (Figure 2) via a one-day training session conducted separately for each of the two intervention arms. This face-to-face workshop was facilitated by researchers in collaboration with the State Tuberculosis and Leprosy Control Program office.

Figure 2. Allocation of Community Health Workers by Arm.

Before the workshop, the research team and the Akwa Ibom State TB, Leprosy, and Buruli Ulcer Control Program (AKSTLBCP) State Coordinator conducted a “training of trainers’ session with workshop facilitators. The facilitators were trained on the course content to ensure a shared understanding of the workshop's aims and to familiarize them with the workshop materials.

Training manuals were developed specifically for the research and distributed to participants. Facilitators used both the training manuals and PowerPoint presentations developed from the manuals. Facilitators also used participatory learning methods to deliver the course contents. The contents of the training were based on the module developed for active TB case finding for community health workers through house-to-house search for community-based organizations (CBOs) and CHWs by the National Tuberculosis and Leprosy Control Program (NTBLCP)²¹. The sessions included training on basic symptoms, misconceptions diagnosis and treatment of TB, identification of presumptive TB cases, sputum collection and transportation and linking TB patients to care and treatment.

Participants were also taught how to collect and transport sputum samples by the State Laboratory Focal Person for TB, using sputum cups and transportation media (plastic bowls that could contain 4 sputa cups). At the end of the training, each participant was given a container for transporting sputum, 4 sputa cups, a presumptive case referral booklet and information, education and communication (IEC) materials to be used in educating clients.

Participants were instructed to conduct community education campaigns, identify presumptive TB cases in communities, collect sputum, and transport the sputum to the PHCs from where they were transported to designated laboratories. The results were sent back through the PHC TB focal persons, and all individual positive results were offered treatment at home or the local health post.

2. Cash incentives: The intervention Arm A (85) received cash incentives of 200 naira (USD0.78) for every presumptive case referred to the PHC for screening.

Other interventions

In addition, CHWs in the intervention arms received periodic supervisory visits by the research team, where their activities were assessed and encouraged and supported (financially) to carry outreaches.

Outcomes

The primary outcome of this study was initially the number of presumptive cases referred to the PHCs by the CHWs. However, TB case notification was used in the analysis instead of presumptive cases as many of the PHCs were new DOTS facilities and had no presumptive cases pre-intervention for comparison. The secondary outcome included the number of outreaches conducted per cluster. The outcomes were analyzed by cluster.

Data collection

This study was initially designed as a panel survey; however, this was not possible as there was a large in-and-out migration of the PMVs, especially those who originally sent their apprentices to the training. At the endline, the same method used in recruitment at baseline was used, where all CHWs in the PHC catchment areas were targeted. This design was used to minimize sampling error, take into account the design effect, and prevent contamination across the three study arms. Hence, two independent cross-sectional surveys were used to obtain data from the CHWs.

Data on the number of outreaches carried out was collected from April 2019 to March 2020 during supportive supervisory visits. Data on the number of outreaches conducted between April 2018 and March 2019 was also obtained. Case notification data was accessed from the State TB program database. This included the number of TB cases notified from the selected PHCs between April 2018 and March 2019 (as pre-intervention Data) and between April 2019 and March 2020 (as post-intervention data).

Additionally, the study assessed changes in CHWs' knowledge of TB. A pre-intervention assessment was conducted using a pre-tested, self-administered structured questionnaire, standardized and validated by the national TB program for the 2017 TB Prevalence Survey in Nigeria. The questionnaires were administered just before the training workshop for study arms A and B and at the six PHC facilities for the control arm. A post-intervention assessment using the same tool was conducted after 12 months at the PHC facilities in each cluster. The results have been reported in another article.

All materials used for training and data collection have been made available in the Dryad and Zenodo repositories²².

Data analysis

Data was collected and entered into Microsoft excel spreadsheet, version 2013, then collated and analyzed using STATA version 13 (Stata, RRID: SCR_012763) and GraphPad Prism version 8 (GraphPad Prism, RRID: SCR_002798). The statistician was blinded to the study allocation until the data set was ready for final analysis. Descriptive data were analysed using summary statistics and presented in tables and figures. Effect sizes for outcome variables were calculated using odds ratios and 95% confidence intervals, and associations were tested using Chi-square (χ²) tests.

Ethical approval

Ethical Approval was sought and obtained from the University of Uyo Institutional Health Ethics Research Board (UUTH/AD/S/93/VOLXXI/253). Approval was also obtained from the State Ministry of Health Ethics Review Board (MH/PRS/99/VOL.5/511). Individual verbal and written consent were sought and obtained from all participants. Verbal permission was also sought and granted by the Local Government PMV chairmen.

Only CHWs who consented to participate were recruited into the study. All presumptive cases identified were referred for screening and positive cases were linked up to the State TB program for treatment with DOTS. Following the study, CHWs in the control arm received the training.

Results

Participants were recruited in April 2019, and the trial ended in a year as intended. All clusters were analyzed as intended, six PHCs and their catchment areas per Arm. A total of 240 CHWs were recruited as follows: Arm A (85), Arm B (73) and Arm C (82). See Figure 2.

A total of 158 CHWs were trained at the beginning of the intervention, clustered as Arm A and Arm B. Table 1 shows the socio-demographic characteristics of participants. Of these, 62.5% were females, 87.9% were less than 40 years old and 33.3% had a tertiary level of education. Majority of the participants were PMVs (78.8%), while 17.9% were CHEWs and 3.3% identified themselves as students, or auxiliary nurses and were categorized as ‘others’. The total number of CHWs who had received training on TB within the last two years was 72, representing 30% of the population. A significantly higher proportion of these were in the Control Arm (43.9%). Also, 24.2% of the CHWs had access to TB guidelines, with a higher proportion of those in the control group stating that they had access to TB guidelines (31.7%).

Table 1. Baseline Socio-demographic Characteristics of the Health workers.

Variables	Arm A Training and Cash Incentives (n=85)	Arm B Training (n=73)	Control (n=82)	Total (n=240)	Statistical indices
Sex Male Female	38 (44.7) 47 (55.3)	30 (41.1) 43 (58.9)	22 (26.8) 60 (73.2)	90 (37.5) 150 (62.5)	Df=2 X² =3.7864 P value=0.151
Age (years) ≤30 31–40 ≥41	32 (37.7) 38 (44.7) 15 (17.6)	39 (53.4) 24 (32.9) 10 (13.7)	44 (53.7) 34 (41.5) 4 (4.9)	115 (47.9) 96 (40.0) 29 (12.1)	Df=2 P value=0.108
Level of education Primary Secondary Tertiary	1 (1.2) 54 (63.5) 30 (35.3)	4 (5.5) 43 (58.9) 26 (35.6)	0 (0.0) 58 (70.7) 24 (29.3)	5 (2.1) 155 (64.6) 80 (33.3)	Df=2 P value=0.389
Job title PMVs PHC workers Others	68 (80.0) 15 (17.7) 2 (2.3)	57 (78.1) 14 (19.2) 2 (2.7)	64 (78.0) 14 (17.1) 4 (4.9)	189 (78.8) 43 (17.9) 8 (3.3)	Df=4 P value=0.936
Duration at the current position Less than 1year 1–4 years 5–9 years 10–14 years ≥15 years	12 (14.1) 26 (30.6) 16 (18.8) 17 (20.0) 14 (16.5)	15 (20.5) 29 (39.7) 16 (21.9) 4 (5.5) 9 (12.3)	8 (9.8) 22 (26.8) 34 (41.5) 10 (12.2) 8 (9.8)	35(14.6) 77(32.1) 66(27.5) 31 (12.9) 31(12.9)	Df=8 P value=0.035*
Type of facility PHC Patent medicine store Others	17 (20.0) 44 (51.8) 24 (28.2)	16 (21.9) 56 (76.7) 1 (1.4)	16 (19.5) 66 (80.5) 0 (0.0)	49(20.4) 166(69.2) 25(10.4)	Df=4 P value<0.0001*
Trained on TB Yes No	15 (17.7) 70 (82.3)	21 (28.8) 52 (71.2)	36 (43.9) 46 (56.1)	72(30.0) 168(70.0)	Df=2 X² =9.7982 P value=0.007*
Have access to TB guideline Yes No	11 (12.9) 74 (87.1)	21 (28.8) 52 (71.2)	26 (31.7) 56 (68.3)	58(24.2) 182(75.8)	Df=2 X² =8.0613 P value=0.018*

*=Statistically significant

Table 2 shows the socio-demographic characteristics of participants at endline across the three arms. At endline, there was female preponderance (53.4%), 81.9% were below 40 years old, the majority of them had attained secondary education (64.3%) and 77.4% of them were PMVs. There was a statistically significant difference in the duration of the current job of the CHWs across the three arms (p=0.006), and in the type of health facility across the three arms (p<0.001).

Table 2. Endline Socio-demographic characteristics of the HCWs.

	Training and Cash Incentives (n=72)	Training only (n=77)	Control (n=72)	Total (n=240)
Sex Male Female	32 (44.4) 40 (55.6)	39 (50.6) 38 (49.4)	32 (44.4) 40 (55.6)	103 (46.6) 118 (53.4)	Df=2 X²=0.7762 P value=0.7762
Age (years) 30 and below 31–40 ≥41	24 (33.3) 36 (50.0) 12 (16.7)	36 (46.8) 26 (33.8) 15 (19.5)	23 (31.9) 36 (50.0) 13 (18.1)	83 (37.6) 98 (44.3) 40 (18.1)	Df=6 X²=6.2618 P value=0.395
Level of education Primary Secondary Tertiary	3 (4.2) 44 (61.1) 25 (34.7)	3 (3.9) 46 (59.7) 28 (36.4)	0 (0.0) 52 (72.2) 20 (27.8)	6 (2.7) 142 (64.3) 73 (33.0)	Df=4 X²=4.8985 P value=0.298
Job title Health workers PMVs Others	13 (18.1) 52 (72.2) 7 (9.7)	8 (10.4) 60 (77.9) 9 (11.7)	11 (15.3) 59 (81.9) 2 (2.8)	32 (14.5) 171 (77.4) 18 (8.4)	Df=4 X²=5.9548 P value=0.203
Duration of current job Less than 1year 1–4 years 5–9 years 10–14 years 15 years and above	7 (9.7) 31 (43.1) 16 (22.2) 8 (11.1) 10 (13.9)	16 (20.8) 28 (36.4) 14 (18.2) 7 (9.1) 12 (16.6)	1 (1.4) 25 (34.7) 16 (22.2) 18 (25.0) 12 (16.7)	24 (10.9) 84 (38.0) 46 (20.8) 33 (14.9) 34 (15.4)	Df=8 X²=21.6794 P value=0.006*
Type of health facility Primary Patent medicine store Others	14 (19.4) 52 (72.2) 6 (8.3)	13 (16.9) 7 (9.1) 57 (74.0)	12 (16.7) 58 (80.6) 2 (2.8)	39 (17.7) 117 (52.9) 65 (29.4)	Df=4 X²= 123.9411 P value<0.0001*

Data from the State TB program database showed an increase of 14.4% in case notification rates between 2019 and 2020 for Arm A (Cash incentives and Training) and an increase of 7.5% in Arm B. However, the control arm saw a 39.7% increase compared to the previous year. However, as seen in Table 3, the difference between the three arms was not statistically significant.

Table 3. Comparison of Case Notification in the three intervention arms.

	Arm A (Cash Incentives + Training)	Arm B (Training only)	Control	Test statistic
Pre-Intervention	362 (46.7)	134 (48.2)	131(41.7)	X²=2.976 P value=0.2258
Post-Intervention	414 (53.3)	144 (51.8)	183 (58.3)
Difference	52	10	52
% change	14.4%	7.5%	39.7%

As shown in Table 4, the cash incentives plus training arm had lower odds of TB case notification compared to the control arm (OR = 0.819). Similarly, the training-only arm also had lower odds of TB case notification compared to the control arm (OR = 0.769). However, when comparing the cash incentives plus training arm to the training-only arm, the former had slightly higher odds of TB case notification (OR = 1.064). Chi-square tests indicated that there was no significant difference between the groups.

Table 4. Comparison of Case Notification across the study arms.

	Arm A (Cash Incentives + Training)	Control	Odds ratio (95% Confidence Interval	Test statistic
Pre-Intervention	362 (46.7)	131(48.2)	0.819 (0.628 – 1.067)	X²= 1.999 P value=0.1575
Post-Intervention	414 (53.3)	183(51.8)	0.819 (0.628 – 1.067)	X²= 1.999 P value=0.1575
	Arm B (Training only)	Control
Pre-Intervention	134(48.2)	131(48.2)	0.769 (0.556 – 1.045)	X²=2.250 P value=0.1336
Post-Intervention	144(51.8)	183(51.8)	0.769 (0.556 – 1.045)	X²=2.250 P value=0.1336
	Arm A (Cash Incentives + Training)	Arm B (Training only)
Pre-Intervention	362(46.7)	134(48.2)	1.064 (0.809 – 1.400)	X²=0.2000 P value=0.6547
Post-Intervention	414(53.3)	144(51.8)	1.064 (0.809 – 1.400)	X²=0.2000 P value=0.6547

A total of 120 community outreaches were conducted during the intervention period. Arm A saw a 144.8% increase in the number of outreaches compared to the previous year (pre-intervention). Arm B recorded a 46.7% increase, while control Arm C showed a 22.7% increase (Table 5). However, these differences were not statistically significant.

Table 5. Outreach Activities across the 3 study arms pre and post-intervention.

	Arm A (Cash Incentives + Training	Arm B (Training only)	Control	Statistic
Pre-intervention	29 (29.0)	15 (40.5)	22 (44.9)	X²= 4.147 P value=0.1258
Post-intervention	71 (71.0)	22 (59.5)	27 (55.1)
Difference in outreach (percentage increase)	42 (144.8%)	7 (46.7%)	5 (22.7%)

As shown in Table 6, the cash incentives plus training arm had higher odds of carrying out community outreaches post-intervention compared to both the control arm (OR = 1.995) and the training-only arm (OR = 1.669). Additionally, the training-only arm had higher odds of conducting community outreaches post-intervention compared to the control arm (OR = 1.195). However, Chi-square tests indicated that there was no significant difference between the groups.

Table 6. Comparison of community outreach activities across the study arms.

	Arm A (Cash Incentives + Training)	Control	Odds ratio (95% Confidence Interval	Test statistic
Pre-Intervention	29 (29.0)	22 (44.9)	1.995 (0.981 – 4.056)	X²= 3.690 P value=0.0547
Post-Intervention	71 (71.0)	27 (55.1)	1.995 (0.981 – 4.056)	X²= 3.690 P value=0.0547
	Arm B (Training only)	Control
Pre-Intervention	15 (40.5)	22 (44.9)	1.195 (0.503 – 2.837)	X²=0.163 P value=0.6892
Post-Intervention	22 (59.5)	27 (55.1)	1.195 (0.503 – 2.837)	X²=0.163 P value=0.6892
	Arm A (Cash Incentives + Training)	Arm B (Training only)
Pre-Intervention	29 (29.0)	15 (40.5)	1.669 (0.761 – 3.662)	X²=1.650 P value=0.1989
Post-Intervention	71 (71.0)	22 (59.5)	1.669 (0.761 – 3.662)	X²=1.650 P value=0.1989

Discussion

This study provides valuable insights into the effectiveness of using cash incentives and training for CHWs to enhance tuberculosis TB control efforts, particularly in resource-constrained settings. The observed increase in community outreach activities following the implementation of cash incentives and training highlights the potential of these strategies to improve TB detection in high-burden communities.

Interestingly, while the intervention arms demonstrated improvements in community outreach activities, the control arm exhibited a much higher increase in TB case notification. Although not statistically significant, this unexpected result prompts further investigation into the underlying factors contributing to these outcomes. Possible explanations include variations in implementation fidelity across intervention arms or unanticipated contextual factors influencing TB case reporting. Additionally, a higher proportion of CHWs in the control group had received prior TB training and had access to TB guidelines, suggesting that another TB intervention might have been ongoing in the control communities. These findings highlight the need for nuanced approaches to evaluating interventions, taking into account implementation and contextual factors.

Several studies have documented evidence that community-based interventions for active case finding such as training, supervision and incentives, lead to improved outcomes for TB control programs^23–25. For instance, the use of performance-based cash incentives of $3 per case notified increased the annual public case notification rate in the intervention region from 45.8 to 105.8/100 000 population, whereas it decreased from 50.7 to 45.3 in the control region²⁶. Also, a study in China found that training improved knowledge of TB definitions, case detection, and laboratory diagnosis up to a year after training²⁷. Similarly, studies in Fiji showed significant increases in TB case notification rates during training activities compared to years without training activities²⁸. Furthermore, in Mozambique, a 14.6% increase in TB notifications was observed following training and engagement of CHWs with a 16.5% decrease in control districts¹⁵.

This study utilized case notification instead of case detection rates (CDR). This is because CDR uses incidence as a denominator, which is a very uncertain estimate as it is not measured but estimated. Similar observations have been made in previous studies^17,29.

Regarding TB outreach activities, there was a marked increase across all study arms, with the cash incentive plus training arm showing the highest increase at about 145%, compared to 46.7% in the training-only arm and 22.7% in the control arm. Some studies have found that community outreach programs improve the detection of symptomatic and infectious TB cases²¹, although others have noted that cases detected through outreach are often less infectious and may be reluctant to commence or complete treatment³⁰. Tracking and notifying all forms of TB in the community is however crucial for achieving the End TB Strategy goal of reducing incidence by 80%³¹.

Supportive supervision and cash support for outreaches were also provided to both intervention arms (A and B). Despite mixed evidence on the effectiveness of supportive supervision³², some studies have demonstrated improved performance of CHWs with supportive supervision³³. It is suggested that CHW productivity is influenced by knowledge and skills, motivation, and the work environment, with supportive supervision being critical for creating and maintaining an enabling work environment^34,35. Hence this component of the intervention was included.

A limitation of this study was the inability to retain all CHWs recruited at baseline, as they were not employed by the project. This affected the planned follow-up of CHWs but did not impact the outcome variables for this paper as the analysis was done at the cluster level. Nevertheless, this highlights the need for refresher training and supervisory visits for interventions done at the community level, especially when using already existing CHWs as the turnover rate is quite high. Another limitation was the possibility of an ongoing parallel active case-finding intervention in the control communities during the study period, which may explain the paradoxical findings. In retrospect, agreements could have been made with the State TB program to delay interventions in the control communities for the duration of the study, as the control communities were also trained after our intervention. Lastly, the lack of data for presumptive TB cases pre-intervention limited our ability to directly compare the presumptive cases referred by the CHWs before and after the intervention.

Conclusion

This study revealed that while cash incentives and training for CHWs increased TB community outreach activities, the control arm without these interventions saw a higher increase in TB case notification. This unexpected outcome suggests that factors beyond the interventions themselves may have played a significant role.

The results indicate that cash incentives and training can enhance CHWs' activities related to TB detection, but these strategies alone may not directly translate to higher TB case notification. The findings highlight the importance of integrating disease control activities at the community level and utilizing existing resources when designing and implementing disease control interventions at the community level.

Future research should explore the implementation processes in greater detail to understand the contextual factors influencing intervention effectiveness. Additionally, studies should investigate the cost-effectiveness of combining cash incentives with training and the potential for integrating these approaches into broader TB control programs in high-burden settings. Comparative analyses with other studies exploring TB control interventions across different settings could provide valuable insights into the factors influencing intervention effectiveness and help identify best practices for implementation.

Consent

Written informed consent for publication of the participants' details was obtained from the participants.

Trial registration

This study was registered in the Pan African Clinical Trial Registry (www.pactr.org) database, with the unique identification number PACTR202010691865364.

Data availability

Dryad: Improving Tuberculosis case finding in Nigeria. https://doi.org/10.5061/dryad.tht76hf07.

This project contains the following underlying data.

Readme_Improving Tuberculosis case finding in Nigeria.xlsx (files of all variables in csv file)
TB Community data Post intervention.xlsx (data from post intervention community survey in csv file)
TB Community data pre-intervention.xlsx (data from post intervention community survey in csv file)
TB Health care workers Baseline.xlsx (data from baseline survey of health care workers in csv file)
TB Health care workers endline.xlsx (data from endline survey of health care workers in csv file)
TB study Outcome (summary data from intervention and state TBL program).xlsx

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

Extended data

Zenodo: Improving Tuberculosis case finding in Nigeria²². https://doi.org/10.5281/zenodo.5062448.

This project contains the following extended data:

Ethical_Approval_2_SMOH.jpg (ethical approval from the Akwa Ibom State Ministry of Health)
Ethical_Approval_TB_1.pdf (ethical approval from the University of Uyo Teaching Hospital)
FINAL_RESEARCH_PROTOCOL._FOR_TB_STUDYdocx.docx (Research protocol used for the study)
Questionnaires_for_the_TB_Study.zip (Health care worker and community questionnaires used for the survey)
Training_Kit.zip (copy of modules used for training intervention)
TrialApprovalLetter3.pdf (Trial approval letter from PanAfrican Clinical Trial Registry)

Reporting guidelines

CONSORT checklist for ‘A Randomized Control Trial to Test Effect of Cash Incentives and Training on Active Casefinding for Tuberculosis among Community Health Workers in Nigeria’ https://doi.org/10.5281/zenodo.5062448.

Acknowledgements

The authors acknowledge Mr. Edidiong Umoh and Mrs Ekom Ekwo for the coordination of the fieldwork and database for the entire project roles. We also acknowledge the Health Systems Research Hub, University of Uyo for providing the platform to conduct this study.

Faculty Opinions recommended

References

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19. AKSMOH IPD: RI performance report Akwa Ibom State; August, 2020. 2020.
20. Delea MG, Snyder JS, Belew M, et al.: Design of a parallel cluster-randomized trial assessing the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia: Andilaye study protocol. BMC Public Health. 2019; 19(1): 801. PubMed Abstract | Publisher Full Text | Free Full Text
21. FMOH: Participants’ module for community based organizations and community health workers for active TB case finding through house-to-house search. FMOH; 2015.
22. Akwaowo C, Umoh V, Umoh I, et al.: Improving tuberculosis case finding in Nigeria. 2021. http://www.doi.org/10.5281/zenodo.5062448
23. Mhimbira FA, Cuevas LE, Dacombe R, et al.: Interventions to increase Tuberculosis case detection at primary healthcare or community-level services. Cochrane Database Syst Rev. 2017; 11(11): CD011432. PubMed Abstract | Publisher Full Text | Free Full Text
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25. Delai MY, Gounder S, Tayler-Smith K, et al.: Relationship between education and training activities and Tuberculosis case detection in Fiji, 2008–2011. Public Health Action. 2012; 2(4): 142–4. PubMed Abstract | Publisher Full Text | Free Full Text
26. Garg T, Bhardwaj M, Deo S: Role of community health workers in improving cost efficiency in an active case finding tuberculosis programme: an operational research study from rural Bihar, India. BMJ Open. 2020; 10(10): e036625. PubMed Abstract | Publisher Full Text | Free Full Text
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28. Khan AJ, Khowaja S, Khan FS, et al.: Engaging the private sector to increase Tuberculosis case detection: an impact evaluation study. Lancet Infect Dis. 2012; 12(8): 608–16. PubMed Abstract | Publisher Full Text
29. Creswell J, Sahu S, Blok L, et al.: A multi-site evaluation of innovative approaches to increase Tuberculosis case notification: summary results. PLoS One. 2014; 9(4): e94465. PubMed Abstract | Publisher Full Text | Free Full Text
30. Saunders MJ, Tovar MA, Collier D, et al.: Active and passive case-finding in tuberculosis-affected households in Peru: a 10-year prospective cohort study. Lancet Infect Dis. 2019; 19(5): 519–28. PubMed Abstract | Publisher Full Text | Free Full Text
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33. Musoke D, Ssemugabo C, Ndejjo R, et al.: Strengthening the community health worker programme for health improvement through enhancing training, supervision and motivation in Wakiso district, Uganda. BMC Res Notes. 2019; 12(1): 812. PubMed Abstract | Publisher Full Text | Free Full Text
34. Perry H, Crigler L: (eds.). Developing and strengthening community health worker programs at scale: a reference guide and case studies for program managers and policy makers. Washington, DC: USAID/MCHIP, 2014. Reference Source
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Version 2

VERSION 2 PUBLISHED 15 Nov 2021

Author details Author details

Victor Umoh
Roles: Conceptualization, Data Curation, Funding Acquisition, Investigation, Methodology, Supervision, Validation, Writing – Review & Editing

Idongesit Umoh
Roles: Conceptualization, Data Curation, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Writing – Review & Editing

Eno Usoroh
Roles: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Writing – Review & Editing

Olugbemi Motilewa
Roles: Data Curation, Formal Analysis, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing

Victory Ekpin
Roles: Writing – Original Draft Preparation, Writing – Review & Editing

Stella Adeboye
Roles: Investigation, Validation, Writing – Review & Editing

Etop Antia
Roles: Data Curation, Methodology, Resources, Supervision, Writing – Review & Editing

Competing interests

Dr. Eno usoroh works for the KNCV TB program, Dr. Etop Antia is the State TB Leporsy control officer. All other authors are academics and service providers for TB and declare no conflicts of interests.

Grant information

This study was supported by a grant from the WHO/TDR Joint AFRO, EDTCP Small Grants (2017) as follows:
World Health Organization: Award Number: 2019/898382-0
TDR: Award Number: 2019/898382-0
European and Developing Countries Clinical Trials Partnership
Award Number: 2019/898382-0

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (2)

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Published: 12 Sep 2024, 10:1154

https://doi.org/10.12688/f1000research.53822.2

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https://doi.org/10.12688/f1000research.53822.1

© 2024 Akwaowo C et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Akwaowo C, Umoh V, Umoh I et al. Effectiveness of Providing Cash Incentives and Training To Community Health Workers on Active Case Finding for Tuberculosis In Nigeria: A Cluster-Randomized Control Trial [version 2; peer review: 1 approved with reservations, 2 not approved]. F1000Research 2024, 10:1154 (https://doi.org/10.12688/f1000research.53822.2)

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Key to Reviewer Statuses VIEW HIDE

ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

Version 2

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PUBLISHED 12 Sep 2024

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Reviewer Report 23 Oct 2024

Anuj Kumar Pandey, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Approved with Reservations

https://doi.org/10.5256/f1000research.166909.r329202

I would like to congratulate authors for a nice study on role of incentive in TB-ACF. I am surprised to know that the control group performed better in ACF. Investigators have provided the reason behind the same. I also think that a larger sample size and many other reasons will be the probable explanation for the same; authors can find other reasons in the article [Pandey A, et al., 2024 (Ref 1]). There are many typographical and grammatical errors throughout the manuscript; please correct it. First spell out the word, then write its short form only.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

References

1. Pandey A, Verma A: How to increase the efficacy and effectiveness of active TB case finding. Indian Journal of Tuberculosis. 2024; 71 (4): 375-379 Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Respiratory medicine, Toxicology, Public health, Clinical biochemistry

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report 30 Sep 2024

Angela Oyo-Ita, Department of Community Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria

Not Approved

https://doi.org/10.5256/f1000research.166909.r323132

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Reviewer Report 25 Jul 2022

Angela Oyo-Ita, Department of Community Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria

Not Approved

https://doi.org/10.5256/f1000research.57244.r143447

TITLE: Should be amended to read “Effect of training of Community Health workers and cash incentive on active case finding of Tuberculosis in Nigeria: a cluster randomized control trial”

ABSTRACT: Description on the three arms of study imply that Arm “A” received cash incentive, Arm “B” received training and Arm “C” received none of the two interventions. Full description in the text shows that Arm “A” received both training and cash incentive and both Arms “B” and “C” received training. This needs to be clarified.
In the materials and methods section authors state that “mean increases in case notification rates was calculated.” This statement is not clear.
Only presumptive cases of Tb increased from the study sites which is expected. It is uncertain how this improved Tb case finding in the study as indicated in the title. Non statistically significant differences between study arms are reported as increase in effect; conclusion is therefore faulty.

STUDY DESIGN: This needs more clarification. Are the 13 LGAs the high burden LGAs? The unit of clustering is not clear. On one hand it is said to be “PHC with availability of DOTS treatment plus the catchment communities” and on the other it is the LGA (“… the clusters were allocated by LGA”). The latter is further supported that the LGAs were non-contiguous. The statement on blinding is also contradictory. The training should be moved to the intervention sub-section.

INTERVENTION: The three arms of study are reported as receiving training. This implies that there was no control arm with no intervention as stated in the abstract.
Sampling was not necessary as all the eligible health workers were included in the study except those who declined.

DATA COLLECTION: There was a change in the primary outcome from number of presumptive cases referred to Tb case notification, but the former is what is presented in the abstract. There should be consistency in reporting the outcomes that were studied.

RESULTS: The report of training of 158 participants contradicts what is presented in the “intervention” sub section. Odds or Risk Ratio analysis is preferable to chi square test.

DISCUSSION: The reported increase in the number of reported presumptive cases is not supported by the data. It should be reported in the perspective of the analyzed data.
It is indicated that the interventions were not limited to training and cash incentive to the Community Workers but included supportive supervision and cash support for outreaches. The extent to which the different arms of study were impacted with these added interventions cannot be ascertained. Whatever “effect” there may be, therefore, cannot be attributed to the training and cash incentive only.

LIMITATIONS: Authors should state the number loss-to-follow up. In reference to the comment on sampling in the intervention sub section all participants should have been followed up at pre and post intervention. Having a pre and post demography data implies that it was not the same people that were trained that the investigators followed up with.

CONCLUSION: this is not supported by the available data. It needs to be reviewed.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Maternal and Child Health

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Author Response 25 Jun 2024

Christie Akwaowo, Community Medicine Department, University of Uyo, Uyo, Nigeria

25 Jun 2024

Author Response

We have revised the title to: “Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a cluster randomized control trial.”
... Continue reading We have revised the title to: “Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a cluster randomized control trial.”

The abstract now clearly describes that Arm A received both training and cash incentives, while Arm B received training only, and Arm C received no intervention.

The abstract now explicitly states that none of the results were statistically significant and the conclusion is based on observed results.

We have clarified that the unit of randomization was the Local Government Area (LGA).

We have updated the intervention section to indicate that two arms received some form of training, with only Arm A receiving both training and cash incentives and Arm C was the control with no intervention

The primary outcome is now consistently reported as the number of TB cases notified from the study PHCs, and the secondary outcome is the number of community outreaches held in the study communities by the CHWs.

The results section now accurately reflects the number of participants trained and the total number in the study. It also uses odds ratios and 95% confidence intervals for the analysis.

The discussion has been revised to accurately reflect the analyzed data. We have also clarified the extent of additional interventions and their potential impact on the results.

Since the outcomes of the study were not focused on the community health workers, the number of CHWs that left during the intervention was not ascertained.

The conclusion has been revised to accurately reflect the data, acknowledging that the results were not statistically significant but suggesting potential trends for future research.
We have revised the title to: “Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a cluster randomized control trial.”

The abstract now clearly describes that Arm A received both training and cash incentives, while Arm B received training only, and Arm C received no intervention.

The abstract now explicitly states that none of the results were statistically significant and the conclusion is based on observed results.

We have clarified that the unit of randomization was the Local Government Area (LGA).

We have updated the intervention section to indicate that two arms received some form of training, with only Arm A receiving both training and cash incentives and Arm C was the control with no intervention

The primary outcome is now consistently reported as the number of TB cases notified from the study PHCs, and the secondary outcome is the number of community outreaches held in the study communities by the CHWs.

The results section now accurately reflects the number of participants trained and the total number in the study. It also uses odds ratios and 95% confidence intervals for the analysis.

The discussion has been revised to accurately reflect the analyzed data. We have also clarified the extent of additional interventions and their potential impact on the results.

Since the outcomes of the study were not focused on the community health workers, the number of CHWs that left during the intervention was not ascertained.

The conclusion has been revised to accurately reflect the data, acknowledging that the results were not statistically significant but suggesting potential trends for future research.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 25 Jun 2024

Christie Akwaowo, Community Medicine Department, University of Uyo, Uyo, Nigeria

25 Jun 2024

Author Response

We have revised the title to: “Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a cluster randomized control trial.”
... Continue reading We have revised the title to: “Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a cluster randomized control trial.”

The abstract now clearly describes that Arm A received both training and cash incentives, while Arm B received training only, and Arm C received no intervention.

The abstract now explicitly states that none of the results were statistically significant and the conclusion is based on observed results.

We have clarified that the unit of randomization was the Local Government Area (LGA).

We have updated the intervention section to indicate that two arms received some form of training, with only Arm A receiving both training and cash incentives and Arm C was the control with no intervention

The primary outcome is now consistently reported as the number of TB cases notified from the study PHCs, and the secondary outcome is the number of community outreaches held in the study communities by the CHWs.

The results section now accurately reflects the number of participants trained and the total number in the study. It also uses odds ratios and 95% confidence intervals for the analysis.

The discussion has been revised to accurately reflect the analyzed data. We have also clarified the extent of additional interventions and their potential impact on the results.

Since the outcomes of the study were not focused on the community health workers, the number of CHWs that left during the intervention was not ascertained.

The conclusion has been revised to accurately reflect the data, acknowledging that the results were not statistically significant but suggesting potential trends for future research.
We have revised the title to: “Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a cluster randomized control trial.”

The abstract now clearly describes that Arm A received both training and cash incentives, while Arm B received training only, and Arm C received no intervention.

The abstract now explicitly states that none of the results were statistically significant and the conclusion is based on observed results.

We have clarified that the unit of randomization was the Local Government Area (LGA).

We have updated the intervention section to indicate that two arms received some form of training, with only Arm A receiving both training and cash incentives and Arm C was the control with no intervention

The primary outcome is now consistently reported as the number of TB cases notified from the study PHCs, and the secondary outcome is the number of community outreaches held in the study communities by the CHWs.

The results section now accurately reflects the number of participants trained and the total number in the study. It also uses odds ratios and 95% confidence intervals for the analysis.

The discussion has been revised to accurately reflect the analyzed data. We have also clarified the extent of additional interventions and their potential impact on the results.

Since the outcomes of the study were not focused on the community health workers, the number of CHWs that left during the intervention was not ascertained.

The conclusion has been revised to accurately reflect the data, acknowledging that the results were not statistically significant but suggesting potential trends for future research.
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 11 Jul 2022

Mihir P Rupani, Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University, Gujarat, India; ICMR - National Institute of Occupational Health (NIOH), Indian Council of Medical Research, Ahmedabad, Gujarat, India

Not Approved

https://doi.org/10.5256/f1000research.57244.r143446

Title and abstract

In the title, replace the word “effect” with “effectiveness”.
Proposed title - “Effectiveness of providing cash incentives and training to community health workers on active case finding for

Title and abstract

In the title, replace the word “effect” with “effectiveness”.
Proposed title - “Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a randomized control trial”
In the abstract, make it clear whether the community health workers are contracted or employed under the national TB program, or, are health workers associated with the primary health centers.
Clarify PHC ‘clusters’ in the abstract. Why use the term clusters for PHC? It is giving an impression as if a group of PHCs was included in the trial.
“Descriptive data were presented in tables and bivariate data was analyzed using chi-square. Mean increases in case notification rates were calculated Statistical significance was set as P=0.05.” - this reads quite non-impressive and simple. Authors can avoid mentioning “descriptive data was presented in tables”. In this section, the authors need to elaborate on the analysis plan.
“bivariate data were analyzed using chi-square” - what were the primary exposure and outcome variables? The authors need to mention that ‘abc’ was compared with ‘xyz’ using the ‘pqr’ test of statistical significance.
What is “LGAs”? Please refrain from using unstandardized abbreviations.
None of the results were statistically significant. However, the authors have not mentioned this in words in the results section, which is compulsory.
What was the effect size? The authors should report Odds Ratios and the adjusted Odds Ratios with 95% confidence intervals.
None of the results are statistically significant, however, the authors conclude that “training and cash incentives for CHWs in high burden TB settings to improve TB case detection rates”, which is a wrong conclusion. Authors should state that “though statistically insignificant, in our study setting of a high burden of TB with low incomes, we found improvement in percentages of active case finding through training and cash incentive interventions. Future research should test the effectiveness of these interventions to determine their impact on active case finding in other high-burden settings to confirm statistically significant associations.”
The full text mentions the use of both STATA and graph pad prism, whereas the abstract mentions only one. Please clarify and correct it.

Introduction

Background and context - both increase the word count and decrease readability. Authors should be very precise and succinct in their writing. Focus on the rationale, rather than on the problem statement.

Materials and methods

Please refer to all comments given in the abstract, many of them might need correction in the full text as well.
“An open access alternative software than can perform these same functions would be R (R Project for Statistical Computing, RRID:SCR_001905).” - why this sentence?
Why was a multivariable analysis not planned by the investigators? Any bivariate analysis should be followed by multivariable analysis.

Results

Please refer to all comments given in the abstract, many of them might need correction in the full text as well.

Discussion

“The study findings are generalizable and applicable to other high burden TB settings.” - so, are the authors suggesting that there is no effect of cash incentives and training on active case finding. The authors should cautiously interpret their data in light of the insignificant results presented in the results section.

Conclusion

Please refer to all comments given in the abstract and discussion sections, many of them might need correction in the full text as well.

Figures and tables

No comments, however, tables of univariable and multivariable analysis (preferably logistic regression) are compulsory.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Tuberculosis, epidemiology, public health

CITE

Report a concern

Author Response 25 Jun 2024

Christie Akwaowo, Community Medicine Department, University of Uyo, Uyo, Nigeria

25 Jun 2024

Author Response

Title and Abstract:
The title has been revised to "Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a randomized ... Continue reading Title and Abstract:
The title has been revised to "Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a randomized control trial."

The abstract now specifies that community health workers are associated with primary health centers under the national TB program, and also include community pharmacists and patent medicine vendors who are self employed in the communities.

We have clarified that each Local Government Area constituted a cluster. But within each Local Government Area, 3 PHC and their catchment communities were used for the study.

The abstract has been revised to detail the analysis plan, mentioning that odds ratios and 95% confidence intervals were calculated.

The abstract now includes that the primary exposure was the intervention (training and/or cash incentive), and the outcome was the number of TB cases notified.

The term “Local Government Areas (LGAs)” is now spelled out in full.

The abstract now clearly states that the results were not statistically significant.

The abstract now includes odds ratios and adjusted odds ratios with 95% confidence intervals.

The conclusion in the abstract has been revised to reflect the results.

The abstract now mentions both STATA and GraphPad Prism, aligning with the full text.

Introduction:
The introduction has been condensed to focus on the rationale for the study, reducing background information and context to improve readability.

Materials and Methods:
We have reviewed and corrected the full text to align with the changes made in the abstract.

The sentence regarding R software has been removed.

We did not include multivariable analysis. We recognize that multivariable analysis would give more information on cluster-level factors that may impact the result. However, data on possible confounders at the cluster level was not obtained, hence we cannot carry out this analysis.

Results:
The results section has been updated to reflect all changes mentioned in the abstract, including the reporting of odds ratios and confidence intervals.

Discussion:
The discussion now cautiously interprets the data, acknowledging the lack of statistically significant results and suggesting that the results observed should be further investigated.

Conclusion:
The conclusion has been revised to align with the abstract and discussion, emphasizing the need for further research.

Figures and Tables:
We did not include multivariable analysis. We recognize that multivariable analysis would give more information on cluster-level factors that may impact the result. However, data on possible confounders at the cluster level was not obtained, hence we cannot carry out this analysis.
Title and Abstract:
The title has been revised to "Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a randomized control trial."

The abstract now specifies that community health workers are associated with primary health centers under the national TB program, and also include community pharmacists and patent medicine vendors who are self employed in the communities.

We have clarified that each Local Government Area constituted a cluster. But within each Local Government Area, 3 PHC and their catchment communities were used for the study.

The abstract has been revised to detail the analysis plan, mentioning that odds ratios and 95% confidence intervals were calculated.

The abstract now includes that the primary exposure was the intervention (training and/or cash incentive), and the outcome was the number of TB cases notified.

The term “Local Government Areas (LGAs)” is now spelled out in full.

The abstract now clearly states that the results were not statistically significant.

The abstract now includes odds ratios and adjusted odds ratios with 95% confidence intervals.

The conclusion in the abstract has been revised to reflect the results.

The abstract now mentions both STATA and GraphPad Prism, aligning with the full text.

Introduction:
The introduction has been condensed to focus on the rationale for the study, reducing background information and context to improve readability.

Materials and Methods:
We have reviewed and corrected the full text to align with the changes made in the abstract.

The sentence regarding R software has been removed.

We did not include multivariable analysis. We recognize that multivariable analysis would give more information on cluster-level factors that may impact the result. However, data on possible confounders at the cluster level was not obtained, hence we cannot carry out this analysis.

Results:
The results section has been updated to reflect all changes mentioned in the abstract, including the reporting of odds ratios and confidence intervals.

Discussion:
The discussion now cautiously interprets the data, acknowledging the lack of statistically significant results and suggesting that the results observed should be further investigated.

Conclusion:
The conclusion has been revised to align with the abstract and discussion, emphasizing the need for further research.

Figures and Tables:
We did not include multivariable analysis. We recognize that multivariable analysis would give more information on cluster-level factors that may impact the result. However, data on possible confounders at the cluster level was not obtained, hence we cannot carry out this analysis.
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 25 Jun 2024

Christie Akwaowo, Community Medicine Department, University of Uyo, Uyo, Nigeria

25 Jun 2024

Author Response

Title and Abstract:
The title has been revised to "Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a randomized ... Continue reading Title and Abstract:
The title has been revised to "Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a randomized control trial."

The abstract now specifies that community health workers are associated with primary health centers under the national TB program, and also include community pharmacists and patent medicine vendors who are self employed in the communities.

We have clarified that each Local Government Area constituted a cluster. But within each Local Government Area, 3 PHC and their catchment communities were used for the study.

The abstract has been revised to detail the analysis plan, mentioning that odds ratios and 95% confidence intervals were calculated.

The abstract now includes that the primary exposure was the intervention (training and/or cash incentive), and the outcome was the number of TB cases notified.

The term “Local Government Areas (LGAs)” is now spelled out in full.

The abstract now clearly states that the results were not statistically significant.

The abstract now includes odds ratios and adjusted odds ratios with 95% confidence intervals.

The conclusion in the abstract has been revised to reflect the results.

The abstract now mentions both STATA and GraphPad Prism, aligning with the full text.

Introduction:
The introduction has been condensed to focus on the rationale for the study, reducing background information and context to improve readability.

Materials and Methods:
We have reviewed and corrected the full text to align with the changes made in the abstract.

The sentence regarding R software has been removed.

We did not include multivariable analysis. We recognize that multivariable analysis would give more information on cluster-level factors that may impact the result. However, data on possible confounders at the cluster level was not obtained, hence we cannot carry out this analysis.

Results:
The results section has been updated to reflect all changes mentioned in the abstract, including the reporting of odds ratios and confidence intervals.

Discussion:
The discussion now cautiously interprets the data, acknowledging the lack of statistically significant results and suggesting that the results observed should be further investigated.

Conclusion:
The conclusion has been revised to align with the abstract and discussion, emphasizing the need for further research.

Figures and Tables:
We did not include multivariable analysis. We recognize that multivariable analysis would give more information on cluster-level factors that may impact the result. However, data on possible confounders at the cluster level was not obtained, hence we cannot carry out this analysis.
Title and Abstract:
The title has been revised to "Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a randomized control trial."

The abstract now specifies that community health workers are associated with primary health centers under the national TB program, and also include community pharmacists and patent medicine vendors who are self employed in the communities.

We have clarified that each Local Government Area constituted a cluster. But within each Local Government Area, 3 PHC and their catchment communities were used for the study.

The abstract has been revised to detail the analysis plan, mentioning that odds ratios and 95% confidence intervals were calculated.

The abstract now includes that the primary exposure was the intervention (training and/or cash incentive), and the outcome was the number of TB cases notified.

The term “Local Government Areas (LGAs)” is now spelled out in full.

The abstract now clearly states that the results were not statistically significant.

The abstract now includes odds ratios and adjusted odds ratios with 95% confidence intervals.

The conclusion in the abstract has been revised to reflect the results.

The abstract now mentions both STATA and GraphPad Prism, aligning with the full text.

Introduction:
The introduction has been condensed to focus on the rationale for the study, reducing background information and context to improve readability.

Materials and Methods:
We have reviewed and corrected the full text to align with the changes made in the abstract.

The sentence regarding R software has been removed.

We did not include multivariable analysis. We recognize that multivariable analysis would give more information on cluster-level factors that may impact the result. However, data on possible confounders at the cluster level was not obtained, hence we cannot carry out this analysis.

Results:
The results section has been updated to reflect all changes mentioned in the abstract, including the reporting of odds ratios and confidence intervals.

Discussion:
The discussion now cautiously interprets the data, acknowledging the lack of statistically significant results and suggesting that the results observed should be further investigated.

Conclusion:
The conclusion has been revised to align with the abstract and discussion, emphasizing the need for further research.

Figures and Tables:
We did not include multivariable analysis. We recognize that multivariable analysis would give more information on cluster-level factors that may impact the result. However, data on possible confounders at the cluster level was not obtained, hence we cannot carry out this analysis.
Competing Interests: No competing interests were disclosed. Close
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Version 2

VERSION 2 PUBLISHED 15 Nov 2021

Open Peer Review

Reviewer Status

Reviewer Reports

	Invited Reviewers
	1	2	3
Version 2 (revision) 12 Sep 24		read	read
Version 1 15 Nov 21	read	read

Mihir P Rupani, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University, Gujarat, India; Indian Council of Medical Research, Ahmedabad, India
Angela Oyo-Ita, University of Calabar Teaching Hospital, Calabar, Nigeria
Anuj Kumar Pandey, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India

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Reviewer Report

2 Views

23 Oct 2024 | for Version 2

Anuj Kumar Pandey, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

2 Views Cite this report Responses(0)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

References

1. Pandey A, Verma A: How to increase the efficacy and effectiveness of active TB case finding. Indian Journal of Tuberculosis. 2024; 71 (4): 375-379 Publisher Full Text

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Respiratory medicine, Toxicology, Public health, Clinical biochemistry

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Reviewer Report

5 Views

30 Sep 2024 | for Version 2

Angela Oyo-Ita, Department of Community Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria

5 Views Cite this report Responses(0)

Not Approved

The authors' response has not addressed the issues highlighted earlier. The conclusions drawn by the authors are still not supported by the results presented. Despite the non-statistical significance of the difference, the authors still conclude that there was an increase in TB case detection. With the high dropout rate of the Patent Medicine Vendors who constituted almost 80% of the study participants, the implementation fidelity is doubtful. The supervision and support (probably financial) provided in the intervention arm was not extended to the control arm. Since the intervention arm received more than training and cash incentive the effect cannot be attributed to the intervention (training and cash) alone.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Maternal and Child Health

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Reviewer Report

13 Views

25 Jul 2022 | for Version 1

Angela Oyo-Ita, Department of Community Medicine, University of Calabar Teaching Hospital, Calabar, Nigeria

13 Views Cite this report Responses(1)

Not Approved

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Maternal and Child Health

Respond to this report

Responses (1)

Author Response

25 Jun 2024

Christie Akwaowo, Community Medicine Department, University of Uyo, Uyo, Nigeria

We have revised the title to: “Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a cluster randomized control trial.”

The abstract now clearly describes that Arm A received both training and cash incentives, while Arm B received training only, and Arm C received no intervention.

The abstract now explicitly states that none of the results were statistically significant and the conclusion is based on observed results.

We have clarified that the unit of randomization was the Local Government Area (LGA).

We have updated the intervention section to indicate that two arms received some form of training, with only Arm A receiving both training and cash incentives and Arm C was the control with no intervention

The primary outcome is now consistently reported as the number of TB cases notified from the study PHCs, and the secondary outcome is the number of community outreaches held in the study communities by the CHWs.

The results section now accurately reflects the number of participants trained and the total number in the study. It also uses odds ratios and 95% confidence intervals for the analysis.

The discussion has been revised to accurately reflect the analyzed data. We have also clarified the extent of additional interventions and their potential impact on the results.

Since the outcomes of the study were not focused on the community health workers, the number of CHWs that left during the intervention was not ascertained.

The conclusion has been revised to accurately reflect the data, acknowledging that the results were not statistically significant but suggesting potential trends for future research.

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

38 Views

11 Jul 2022 | for Version 1

38 Views Cite this report Responses(1)

Not Approved

Title and abstract

In the title, replace the word “effect” with “effectiveness”.
Proposed title - “Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a randomized control trial”
In the abstract, make it clear whether the community health workers are contracted or employed under the national TB program, or, are health workers associated with the primary health centers.
Clarify PHC ‘clusters’ in the abstract. Why use the term clusters for PHC? It is giving an impression as if a group of PHCs was included in the trial.
“Descriptive data were presented in tables and bivariate data was analyzed using chi-square. Mean increases in case notification rates were calculated Statistical significance was set as P=0.05.” - this reads quite non-impressive and simple. Authors can avoid mentioning “descriptive data was presented in tables”. In this section, the authors need to elaborate on the analysis plan.
“bivariate data were analyzed using chi-square” - what were the primary exposure and outcome variables? The authors need to mention that ‘abc’ was compared with ‘xyz’ using the ‘pqr’ test of statistical significance.
What is “LGAs”? Please refrain from using unstandardized abbreviations.
None of the results were statistically significant. However, the authors have not mentioned this in words in the results section, which is compulsory.
What was the effect size? The authors should report Odds Ratios and the adjusted Odds Ratios with 95% confidence intervals.
None of the results are statistically significant, however, the authors conclude that “training and cash incentives for CHWs in high burden TB settings to improve TB case detection rates”, which is a wrong conclusion. Authors should state that “though statistically insignificant, in our study setting of a high burden of TB with low incomes, we found improvement in percentages of active case finding through training and cash incentive interventions. Future research should test the effectiveness of these interventions to determine their impact on active case finding in other high-burden settings to confirm statistically significant associations.”
The full text mentions the use of both STATA and graph pad prism, whereas the abstract mentions only one. Please clarify and correct it.

Introduction

Background and context - both increase the word count and decrease readability. Authors should be very precise and succinct in their writing. Focus on the rationale, rather than on the problem statement.

Materials and methods

Please refer to all comments given in the abstract, many of them might need correction in the full text as well.
“An open access alternative software than can perform these same functions would be R (R Project for Statistical Computing, RRID:SCR_001905).” - why this sentence?
Why was a multivariable analysis not planned by the investigators? Any bivariate analysis should be followed by multivariable analysis.

Results

Please refer to all comments given in the abstract, many of them might need correction in the full text as well.

Discussion

“The study findings are generalizable and applicable to other high burden TB settings.” - so, are the authors suggesting that there is no effect of cash incentives and training on active case finding. The authors should cautiously interpret their data in light of the insignificant results presented in the results section.

Conclusion

Please refer to all comments given in the abstract and discussion sections, many of them might need correction in the full text as well.

Figures and tables

No comments, however, tables of univariable and multivariable analysis (preferably logistic regression) are compulsory.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Tuberculosis, epidemiology, public health

Respond to this report

Responses (1)

Author Response

25 Jun 2024

Christie Akwaowo, Community Medicine Department, University of Uyo, Uyo, Nigeria

Title and Abstract:
The title has been revised to "Effectiveness of providing cash incentives and training to community health workers on active case finding for tuberculosis in Nigeria: a randomized control trial."

The abstract now specifies that community health workers are associated with primary health centers under the national TB program, and also include community pharmacists and patent medicine vendors who are self employed in the communities.

We have clarified that each Local Government Area constituted a cluster. But within each Local Government Area, 3 PHC and their catchment communities were used for the study.

The abstract has been revised to detail the analysis plan, mentioning that odds ratios and 95% confidence intervals were calculated.

The abstract now includes that the primary exposure was the intervention (training and/or cash incentive), and the outcome was the number of TB cases notified.

The term “Local Government Areas (LGAs)” is now spelled out in full.

The abstract now clearly states that the results were not statistically significant.

The abstract now includes odds ratios and adjusted odds ratios with 95% confidence intervals.

The conclusion in the abstract has been revised to reflect the results.

The abstract now mentions both STATA and GraphPad Prism, aligning with the full text.

Introduction:
The introduction has been condensed to focus on the rationale for the study, reducing background information and context to improve readability.

Materials and Methods:
We have reviewed and corrected the full text to align with the changes made in the abstract.

The sentence regarding R software has been removed.

We did not include multivariable analysis. We recognize that multivariable analysis would give more information on cluster-level factors that may impact the result. However, data on possible confounders at the cluster level was not obtained, hence we cannot carry out this analysis.

Results:
The results section has been updated to reflect all changes mentioned in the abstract, including the reporting of odds ratios and confidence intervals.

Discussion:
The discussion now cautiously interprets the data, acknowledging the lack of statistically significant results and suggesting that the results observed should be further investigated.

Conclusion:
The conclusion has been revised to align with the abstract and discussion, emphasizing the need for further research.

Figures and Tables:
We did not include multivariable analysis. We recognize that multivariable analysis would give more information on cluster-level factors that may impact the result. However, data on possible confounders at the cluster level was not obtained, hence we cannot carry out this analysis.

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Effectiveness of Providing Cash Incentives and Training To Community Health Workers on Active Case Finding for Tuberculosis In Nigeria: A Cluster-Randomized Control Trial

Abstract

Background

Materials and Methods

Results

Conclusion

Keywords

Revised Amendments from Version 1

Introduction

Background

Rationale

Methods

Setting/context

Study design

Figure 1. Allocation of Primary Health Centres in the study.

Interventions

Figure 2. Allocation of Community Health Workers by Arm.

Other interventions

Outcomes

Data collection

Data analysis

Ethical approval

Results

Table 1. Baseline Socio-demographic Characteristics of the Health workers.

Table 2. Endline Socio-demographic characteristics of the HCWs.

Table 3. Comparison of Case Notification in the three intervention arms.

Table 4. Comparison of Case Notification across the study arms.

Table 5. Outreach Activities across the 3 study arms pre and post-intervention.

Table 6. Comparison of community outreach activities across the study arms.

Discussion

Conclusion

Consent

Trial registration

Data availability

Extended data

Reporting guidelines

Acknowledgements

References

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