Designing tuberculosis elimination framework through participatory processes in Ethiopia: Results from stakeholders'...

Tuberculosis elimination requires implementation of multi-pronged, complex interventions, but there is limited understanding of frameworks for guiding implementation. Our aim was to explore the feasibility of applying multipronged package of TB elimination interventions guided using the Medical Research Council (MRC) framework.

This study is a component of a larger quasi-experimental study aimed at demonstrating what TB elimination interventions would entail under routine TB program conditions titled Demonstrating Multipronged and Optimized Novel Strategies to Reinforce Actions Targeted at Eliminating Tuberculosis. During its preparatory phase in February 2023, we employed a participatory action research design which involved gathering feedback and insights from TB program managers, healthcare workers and community representatives about the study interventions. The study participants were selected from three districts of Amhara, Oromia, and Southern Nations, Nationalities and Peoples Regions of Ethiopia. Two senior researchers took detailed notes during the meetings using topic guided questions. Each topic guided question was thoroughly explored until no new issues emerged. Thematic analysis was conducted to summarize the reflections of the study participants from the three sessions conducted in the three regions.

108 participants attended the preparatory phase discussions which were summarized under five sub-themes under the main theme of "Looking for local evidence compulsory for TB elimination." These included; (1) the importance of community engagement which describes the need to include health extension workers, health development army, and other community structures to support the study, (2) government interest toward local evidence, which describes how local evidence is essential to support the TB program and address challenges, (3) homogeneity of officials' commitment across the regions which is reflected in their immense support to undertake the study and suggested working together for the study follow-up,(4) cross-cutting issues or multiple factors such as nutrition, sociocultural factors, livelihood, and housing, were considered, and (5) the importance of establishing TB treatment supporter, which describes the critical role that TB treatment supporters play in ensuring successful treatment outcomes.

This study highlights the importance of MRC tailored protocol development and feasibility in effective implementation. Key lessons include the need for early stakeholder engagement, streamlined communication, and proactive risk management. Strong community engagement, government commitment, and addressing social determinants were critical to TB elimination. These findings emphasize the value of a collaborative, multi-pronged approach during the adoption and implementation of the TB elimination framework.