Kiosk: An Innovative Client Centric Approach to Tuberculosis Prevention and Care

Kiosk is a client centric drop-in centre for TB information and services established in urban and peri-urban (slum) settings to provide outreach services under project Axshya. The main objective of the study was to demonstrate the efficacy and feasibility of scaling-up of the model to provide TB services. The assessment was carried out with the help of project recording and reporting formats used to document the information and services provided in the Kiosk from April 2016 to March 2017. The results from retrospective data analysis for services provided at 20 kiosks benefited 16,871 clients; of these 11,252 (66.7%), 1339 (7.9%), 848 (5%), 2911 (17.2%), (1.4%), 273 (1.6%) benefited with TB information, Flexi-DOT, sputum-collection-transportation (SCT), counselling, and domiciliary care respectively. Through active case finding (ACF); 126,893 households were visited and 3593 presumptive-TB-patients received SCT services. A total of 329 TB patients were identified and linked to treatment services of national TB programme. “Kiosk” as a client centric approach would be a novel concept to ensure TB information, TB related services and contribute to ongoing efforts of TB case finding.


Introduction
Tuberculosis is a global public health crisis and India alone has 25% of the global TB burden [1]. TB continues to be a devastating health crisis with more than 300,000 deaths and 2.2 million new cases along with an economic loss of $23 bn (£14.9 bn; €20.3 bn) each year [2]. Efforts of National TB programme of India to avert deaths by ensuring early detection and treatment is challenged by growing urban population, migration, over-crowding and client driven (behaviour, socio-economic status) and market driven factors (supply-demand factor). Most often client/s would reach public health facility after taking treatment from multiple healthcare providers [3]. Upon reaching the public health facility one has to go through the long waiting hours in out-patient department and, later to see doctor and this is often cited as reasons for delay [4]. Furthermore the analysis of District Level Household and Facility Survey Data (DLHFS 4) highlights, maximum number of TB patients were taking medications from secondary level care centres (district hospitals) [5]. However there is limited literature to inform the actual number of TB patients taking medications at district hospitals and their treatment outcome. Programmatically, in few states, the first week or first month of directly-observed-treatment short course (DOTS) is provided at the district hospital or secondary level hospital to review the progress, counselling of TB patients and provide additional supplements (if any) to ensure that the patients complete the treatment. Comprehending this operational mechanism, under Project Axshya, a novel client centric approach-"Kiosk" was designed and implemented to create awareness about TB, link to TB prevention, diagnosis and care services. In this paper we elaborate the experience of implementing Kiosk and feasibility of scaling-up of the model.

About the Intervention
Axshya Kiosk (AK) was designed and implemented as a human interface Kiosk with an aim to support clients who are visiting high-workload health facilities for taking TB treatment and other related services. Based on the operational feasibility and in consultation with TB programme officer-District TB officers (DTOs) the centres were established at health facility and in community with high TB burden. The community kiosk centres were established within 5 km radius of the health-facility (usually district hospitals) with an aim to reach urban slum population. In addition, conducted Active TB case finding (ACF) exercise in households of catchment area through verbal screening with cough ≥ 2weeks as basic criteria (same method was adopted as in Project Axshya) [6].
Axshya Kiosk services are provided from 6 -7 am in morning to 6 -7 pm in the evening. During the out-patient department (OPD) service hours i.e., be-

Results
A total of 16,871 beneficiaries visited the facility for different types of services as outlined in description of activity. Of these, 66.7% (n = 16,871) beneficiaries visited the kiosk to obtain TB related information (Table 1)    Through these services at health-facility kiosk, we identified 40 TB patients (13 female and 27 male) from 848 SCTs. Of all the services provided in the kiosk we were not able to link any TB patient directly with government's social security schemes.
A total of 126,893 households were visited by 80 volunteers who provided information about TB using interpersonal communication materials. The Table 2 delineates the output of ACF services done through kiosks (  respectively. This also includes 94 SCT conducted through contact-tracing exercise where 4 TB patients were identified. The treatment services were provided as outlined by the programme guideline.

Discussion
Axshya Kiosk, a novel innovative approach for identifying and linking of presumptive TB patients (PTBPs) at public health-facility and at community. The results highlight that nearly, 8% of TB patients were identified by examining 4500 PTBPs who could have missed by the system due to high work-load. Secondly, 11,000 beneficiaries at facility-kiosk and 126,893 households at community-kiosk were informed about TB related information and the services available at government facilities (free services) using interpersonal communication tools (IPC). IPC tools are more preferred choice therefore we used "human" interface as one of the key strategy in our kiosk, both at facility and community [7].
Albeit the innovative concept delineated in this research is not exceptionally new in Indian context however the same is very scarcely practiced.  [18]. Studies have shown that community kiosks have been useful in providing health education and dissemination of health related services [8]- [14]. Our experience shows that the services at community kiosk need to be designed as per the needs of catchment population for kiosk model to be effective [19].
The contact screening yielded better result which is in lieu with other Indian studies. A similar study in Kolhapur district of Maharashtra highlight that eighteen contacts of 521 (3.45%) had symptoms suggestive of TB. Of these, 6 contacts were diagnosed with TB; 5 being sputum positive cases and one with X-ray suggestive of TB [20]. Similarly another study in Chennai showed that a total of 29/544 (5.3%) contacts were found to have TB among whom 23/29 (79%) were sputum smear positive [21].
Axshya Kiosk is different from usual programme DOT centers where diagnosed TB patients reach the centres for medications; kiosk in addition to providing DOT also provided information and other related services. Through these services, 329 TB patients were diagnosed and were on treatment at these facilities (contact tracing was one of the key feature). Male patients were more than female and this is similar to observation in the National Tuberculosis Programme [22]. We therefore envisage the concept of kiosk to be used to deliver additional services, like counselling, domiciliary care and facilitating in linking TB patients to available social welfare schemes. These were experimented in our study; however, results were appreciable if we had documented the treatment outcomes. This is one of our limitations as there was no regular visit of same client/beneficiary to the centre for taking medications. Secondly, if the patient came in regular OPD hours for DOTS, s/he would be counted in our recording system as regular service and not included in our flexi-DOTS service [the concept was to provide DOTS during non-OPD hours or flexi-hours]. For these reasons we cannot attribute successful outcome of TB treatment to our kiosk. A mix of community based DOTS and community kiosk based DOT is followed and the onus of ensuring treatment completion is on the DOT provider, who is monitored under programme as well as through project. During the intervention few reasons for initial loss to follow up were recognised these include; limited trust in DOTS, adverse effect of drugs, dissatisfaction with public health system, and disbelief in diagnosis are important areas that programme has to address [23] [24]. India, with high TB burden and with goal to END-TB by 2025, some of the out-of-the box innovations is needed. Axshya Kiosk or Kiosk could be one Journal of Tuberculosis Research such innovation to have a client centric drop-in centre for TB information and services.

Conclusion
Given the magnitude of the burden of TB in India the role of kiosks in providing TB information and other services is appreciable. Establishment of Kiosks in health-facility and community settings have identified 329 TB patients in addition to the providing DOTS during flexi-timings at health facility, TB information to clients, counselling services, contact tracing and domiciliary visits. Both health-facility and community-kiosk services could reach to a larger section of the community and invariably contribute and compliment the efforts of national Tuberculosis programme.