Community-based active case finding for tuberculosis in rural western China: A cross-sectional study

Active case finding (ACF) for tuberculosis (TB) was implemented in 60 selected high TB burden wards of Kolkata, India. Community volunteers called TOUCH (Targeted Outreach for Upliftment of Community Health) agents (TAs) identified and referred presumptive TB patients (PTBPs) to health facilities for TB diagnosis and treatment. We aimed to describe the “care cascade” of PTBPs that were identified during July to December 2018 and to explore the reasons for attrition as perceived by TAs and PTBPs. An explanatory mixed-methods study with a quantitative phase of cohort study using routinely collected data followed by descriptive qualitative study with in-depth interviews was conducted. Of the 3,86242 individuals that were enumerated, 1132 (0.3%) PTBPs were identified. Only 713 (63.0%) PTBPs visited a referred facility for TB diagnosis. TB was diagnosed in 177 (24.8%). The number needed to screen for one TB patient was 2183 individuals. The potential reasons for low yield were stigma and apprehension about TB, distrust about TA, wage losses for attending health facilities, and substance abuse among PTBPs. The yield of ACF was suboptimal with low PTBP identification rate and a high attrition rate. Interviewing each individual for symptoms of TB and supporting PTBPs for diagnosis through sputum collection and transport can be adopted to improve the yield.

Background Active case finding (ACF) for tuberculosis (TB) is a promising tool to enhance early case detection among marginalized populations. As opposed to passive case finding, it involves systematically searching for TB in individuals who would not spontaneously present for care. The National TB Program (NTP) of India has initiated ACF for TB through the existing general health system since the end of 2017. However, prior to scale-up, there is need for exploring the implementation challenges and solutions to improve the efficiency of this program. Objectives (1) To explore the enablers and challenges in the implementation of ACF for TB by NTP in the Bengaluru rural district of Karnataka, South India, and (2) to explore the perceived solutions to improve the efficiency of ACF activity. Methods A qualitative descriptive study was conducted in the Bengaluru rural district during July 2018. In-depth interviews using purposively selected health care providers involved in active case finding (n = 9) and presumptive TB patients (n = 9) and presumptive TB patients (Results The challenges in conduct of ACF were as follows: inadequate training of health care workers, shortage of staff, indifferent attitude of community due to stigma, lack of awareness about TB, illiteracy, inability to convince patients for sputum test, and delay in getting CBNAAT results. The field staff recommended the installation of mobile CBNAAT machine, involvement of general health staff in activity, training of health workers on counseling of patients, and issue of identity cards for community health workers/volunteers so that people recognize them. Conclusion The health system challenges in conduct of ACF need to be addressed by training the health staff involved in activity and also improving the access to TB diagnostics.

BackgroundThe objective of this study was to determine the relationship between the quality of feeding practices and children’s nutritional status in rural western China.MethodsA sample of 12,146 pairs of 6- to 35-month-old children and their mothers were recruited using stratified multistage cluster random sampling in rural western China. Quantile regression was used to analyze the relationship between the Infant and Child Feeding Index (ICFI) and children’s nutritional status.ResultsIn rural western China, 24.37% of all infants and young children suffer from malnutrition. Of this total, 19.57%, 8.74% and 4.63% of infants and children are classified as stunting, underweight and wasting, respectively. After adjusting for covariates, the quantile regression results suggested that qualified ICFI (ICFI > 13.8) was associated with all length and HAZ quantiles (P<0.05) and had a greater effect on the following: poor length and HAZ, the β-estimates (length) from 0.76 cm (95% CI: 0.53 to 0.99 cm) to 0.34 cm (95% CI: 0.09 to 0.59 cm) and the β-estimates (HAZ) from 0.17 (95% CI: 0.10 to 0.24) to 0.11 (95% CI: 0.04 to 0.19). Qualified ICFI was also associated with most weight quantiles (P<0.05 except the 80th and 90th quantiles) and poor and intermediate WAZ quantiles (P<0.05 including the 10th, 20th 30th and 40th quantiles). Additionally, qualified ICFI had a greater effect on poor weight and WAZ quantiles in which the β-estimates (weight) were from 0.20 kg (95% CI: 0.14 to 0.26 kg) to 0.06 kg (95% CI: 0.00 to 0.12 kg) and the β-estimates (WAZ) were from 0.14 (95% CI: 0.08 to 0.21) to 0.05 (95% CI: 0.01 to 0.10).ConclusionsFeeding practices were associated with the physical development of infants and young children, and proper feeding practices had a greater effect on poor physical development in infants and young children. For mothers in rural western China, proper guidelines and messaging on complementary feeding practices are necessary.

The purposes of this study are to investigate and analyze the status of reproductive tract infections (RTIs) in married women in rural western China, and to develop effective strategies for improving the ability of married women to prevent RTIs in this region. We conducted in-depth interviews of 142 married women from four villages in three townships. Two questionnaires were used to gather data on married women's health care status, family income, knowledge about RTIs, relevant behaviors, and attitudes toward RTIs. Descriptive, parallel, and logistic regression analyses and the Chi-square test were applied to analyze the relationships between basic conditions and several influential factors. Over 80% of the respondents were of limited income and had with poor knowledge of and a lack of experience in preventing RTIs. Some 83.3% of the married women had experienced menstrual irregularities; 70.3% of those interviewed had experienced malodorous vaginal discharge with or without perineal itching. It was found that 80.7% of the interviewees did not have good personal hygiene habits in daily living regarding RTIs. It was found that the prevalence of RTIs was lower in women who had accurate information about RTIs. Most married women lacked basic knowledge of ways to prevent RTIs, and this, together with the limited support of the health care system and the absence of medical insurance schemes, was responsible for the observed high prevalence of RTIs. There is an urgent need to improve the capability of married women in rural China to prevent RTIs, and it is important to find effective ways to prevent these diseases. Three health promotion strategies are presently being implemented to prevent RTIs and to build capacity for disease prevention among married women in rural western China.

Impact of a Scalable Intervention Package, Including a Point-of-Care Molecular Diagnostic Tool, on Community-Based Active Case Finding for Tuberculosis: A Pragmatic Randomized Controlled Trial

Background In remote rural China, a micronutrient home fortification program has been implemented to prevent childhood anemia by providing free micronutrient powders (MNP) to caregivers. Effective information dissemination is essential for improving caregivers’ knowledge, beliefs, and MNP feeding adherence. However, evidence on how different communication channels and content influence these outcomes among caregivers remains limited in rural settings. This study aimed to examine the associations between MNP information dissemination and caregivers’ knowledge, health beliefs, and adherence to recommended MNP feeding practices, providing evidence to inform future health communication strategies in nutrition interventions. Methods A cross-sectional study was conducted in 2019 among 1,229 caregivers of children aged 6–36 months in six counties in western China, selected using a multistage sampling method. Data were collected through face-to-face interviews using structured questionnaires. Propensity score matching and regression analyses were performed to examine the associations between different channels and content of MNP information dissemination and caregivers’ MNP-related knowledge, health beliefs, and adherence to recommended MNP feeding practices. Results Receiving information from a doctor was positively associated with caregivers’ MNP-related knowledge (β = 0.75, 95%CI = 0.59–0.91), health beliefs (β = 0.75, 95%CI = 0.57–1.58), and adherence to recommended MNP feeding practices (OR = 1.96, 95%CI = 1.48–2.61). Receiving information from the mass media and wider community were both positively associated with caregivers’ MNP-related knowledge (βmass media = 0.46, 95%CI = 0.13–0.79; βwider community = 0.25, 95%CI = 0.04–0.46) and health beliefs (βmass media = 2.05, 95%CI = 0.85–3.24; βwider community = 0.83, 95%CI = 0.11–1.56). For MNP content, information on the benefits of MNP and how to use them were both positively associated with caregivers’ MNP-related knowledge (βbenefits = 0.62, 95%CI = 0.47–0.77; βfeeding method = 0.22, 95%CI = 0.05–0.40), health beliefs (βbenefits = 1.73, 95%CI = 1.23–2.23; βfeeding method = 1.27, 95%CI = 0.66–1.89) and adherence (ORbenefits=1.37, 95%CI = 1.03–1.83; ORfeeding method=1.56, 95%CI = 1.01–2.39). Conclusions Targeted MNP dissemination strategies—especially those delivered by doctors and emphasizing key content such as the benefits of MNP and proper feeding methods—may help to promote caregivers’ MNP-related knowledge, health beliefs, and adherence to recommended MNP feeding practices, which may contribute to improved child health in low-resource settings. These findings can inform the optimization of future information dissemination strategies for the micronutrient powder program in rural western China, contributing to healthier child development in these areas.

BackgroundThis study examines gender differences in early childhood cognitive development in rural China, focusing on the role of sibling structure. While gender disparities have narrowed in recent decades, concerns remain regarding unequal household resource allocation in low- and middle-income countries, particularly in contexts shaped by traditional son preference.MethodsData from 1,320 children aged 3 to 7 years across 11 nationally designated poverty counties in the Qinling Mountain region of western China were analyzed. Cognitive ability was assessed using the Chinese version of the Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition (WPPSI-IV). Descriptive statistics and multivariate regression models were employed to investigate the associations between sibling structure and cognitive outcomes by gender.ResultsA negative association was observed between the number of siblings and cognitive scores, with a substantially larger effect for girls. Gender disparities were also evident across sibling composition and age spacing: girls with older siblings, especially those within a three-year age gap, exhibited lower cognitive scores than boys. With respect to birth order, both boys and girls demonstrated first-born and last-born advantages, though the cognitive benefits were less pronounced for girls. These disparities are likely shaped by resource dilution, reduced parental investment, and lower educational expectations for girls.ConclusionsGender differences in early cognitive development persist in rural western China and appear to be significantly influenced by family structure. Traditional norms may continue to affect intra-household resource allocation, often to the detriment of girls. These findings underscore the need for gender-sensitive policy interventions aimed at promoting equitable early childhood development and supporting long-term human capital accumulation.Trial registrationNot applicable.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12889-025-23599-y.

BackgroundThere is a dearth of comparative effectiveness research examining the implementation of different strategies for active tuberculosis (TB) case finding, particularly in rural settings, which represent 60% of the population of sub-Saharan Africa.Methods and findingsWe conducted a pragmatic, cluster-randomized comparative effectiveness trial of two TB case finding strategies (facility-based screening and contact tracing) in 56 public primary care clinics in two largely rural districts of Limpopo Province, South Africa. In the facility-based screening arm, sputum Xpert MTB/RIF was performed on all patients presenting (for any reason) with TB symptoms to 28 study clinics, and no contact tracing was performed. In the contact-tracing arm, contacts of patients with active TB were identified (via household tracing in 14 clinics and using small monetary incentives in the other 14 clinics), screened for TB symptoms, and offered Xpert MTB/RIF testing. The primary outcome was the number of newly identified patients with TB started on treatment. The analysis used multivariable Poisson regression adjusted for historical clinic-level TB case volumes and district. The trial was registered with ClinicalTrials.gov (NCT02808507). From July 18, 2017, to January 17, 2019, a total of 3,755 individuals started TB treatment across 56 study clinics in the 18-month period. Clinic characteristics and clinic-level averages of patient characteristics were similar across the two arms: 40/56 (71%) clinics were in a rural location, 2,136/3,655 (58%) patients were male, and 2,243 (61%) were HIV positive. The treatment initiation ratio comparing the yield of TB patients started on treatment in the facility-based arm compared to that from the contact-tracing arm was 1.04 (95% confidence interval [CI] 0.83–1.30, p = 0. 73). In the contact-tracing arm, 1,677 contacts of 788 new TB index patients were screened, yielding 12 new patients with TB. Prespecified subgroup analyses resulted in similar results, with estimated treatment initiation ratios of 0.96 (95% CI 0.64–1.27; p = 0.78) and 1.23 (95% CI 0.87–1.59; p = 0.29) among historically smaller and historically larger clinics, respectively. This ratio was 1.02 (95% CI 0.66–1.37; p = 0.93) and 1.08 (95% CI 0.74–1.42; p = 0.68) in the Vhembe and Waterberg districts, respectively. The estimated treatment initiation ratio was unchanged in sensitivity analyses excluding 24 records whose TB registration numbers could not be verified (1.03, 95% CI 0.82–1.29; p = 0.78) and excluding transfers-in (1.02, 95% CI 0.80–1.29; p = 0.71). Study limitations include the possibility of imbalance on cluster size owing to changes in catchment population over time and the inability to distinguish the independent effects of the two contact investigation strategies.ConclusionsContact tracing based on symptom screening and Xpert MTB/RIF testing did not increase the rate of treatment initiation for TB relative to the less resource-intensive approach of facility-based screening in this rural sub-Saharan setting.Trial registrationClinicalTrials.gov NCT02808507.

Prisons offer a fertile setting for the transmission of tuberculosis due to the presence of many classic risk factors for both infection and disease: overcrowding, poor ventilation, and little sunlight. Prisoners are often malnourished and have poor hygiene and are more likely to have a background of alcohol and drug abuse. To determine the prevalence of prisoners with respiratory symptoms and pulmonary tuberculosis (PTB) through active case finding in a prisoner population of the county jail of Carapicuíba, and to study possible related variables. This was a cross-sectional study, and respiratory symptomatic individuals (RSI) were detected through active case finding. Socio-demographic data were collected from inmates' judicial history using a specific questionnaire. The RSI provided sputum specimens for detection of acid fast bacilli and culture for mycobacterium identification. Among the 397 prisoners studied, 154 reported respiratory symptoms for more than three weeks, and were considered RSI; the variables associated with RSI were: having already been tried and incarcerated for more than six months and seven were diagnosed as PTB (1,763 cases/ 100,000 inhabitants). The prevalence of RSI and PTB cases were respectively 39 and 35 times greater than the general population.

BackgroundTo investigate the association between coping styles, gender, their interactions and non-suicidal self-injurious (NSSI) behaviors among middle school students in rural western China under COVID-19.MethodsA multicentre cross-sectional study method was used to conduct an online survey of 8,361 students from 23 middle schools in the northern Sichuan region by clustering sampling, using the General Information Questionnaire, the Ottawa Self-Injury Inventory, and the Coping Style Scale for Middle School Students.ResultsThe past year prevalence of NSSI among middle school students in rural west China was 5.7%. The differences in scores between those with and without NSSI on all dimensions of coping styles were statistically significant (p < 0.001). Multivariate logistic regression analysis revealed that vocational high school (OR = 1.67), girls (OR = 2.5), single parent with divorced parents (OR = 1.89), remarriage with divorced parents (OR = 1.81), and tolerance (OR = 1.17), venting emotions (OR = 1.15) and fantasy/denial (OR = 1.07) in coping styles may increase the risk of NSSI among middle school students, while problem solving (OR = 0.9) and seeking social support (OR = 0.9) among coping styles may reduce the risk of NSSI among middle school students. The interaction results show that gender has a moderating role in the process of endurance, avoidance, venting of emotions, and fantasy/denial influencing non-suicidal self-injury in middle school students.ConclusionThere is an association between coping styles and self-injury among middle school students in rural areas in western China, with gender playing a moderating role. Active attention should be paid to students' coping styles and encouraging them to adopt positive coping styles as well as avoid negative coping styles, especially in the case of girls, which can help prevent self-injury.

Background: Prenatal anaemia causes serious consequences for both mother and foetus, and dietary factors are suggested to be associated with anaemia. However, research in pregnant women living in rural areas is limited. We aim to assess the contribution of dietary diversity to the magnitude of prenatal anaemia in rural China and identify the interactions between dietary diversity and several sociodemographic and maternal characteristics in relation to anaemia. Methods: A multi-stage random cluster sampling method was used to select pregnant women in rural western China. The Woman’s Dietary Diversity Score was created to measure dietary diversity, which was recoded into terciles. Multinomial logistic regression models were used to assess the associations between dietary diversity score terciles and the magnitude of prenatal anaemia. Multiplicative interactions were tested by adding the product term of dietary diversity and several sociodemographic and maternal characteristics into the regression models. Results: Out of 969 participants, 54.3% were measured as anaemic, with 28.6% mildly anaemic and 25.7% moderately to severely anaemic. There was an absence of agreement between self-reported and measured anaemia status (κ = 0.28, 95% CI [0.22–0.34]). Participants in the highest dietary diversity score tercile had lower odds of being moderately to severely anaemic after adjusting for potential confounders (RRR = 0.65, 95% CI [0.44, 0.98]). In participants with moderate to severe anaemia, significant interactions were found between dietary diversity score terciles, age, and parity (p for interaction < 0.05). Conclusions: The prevalence of prenatal anaemia in rural China remains high, and pregnant women living in these areas are insufficiently aware of their anaemia status. Improving dietary diversity is needed to manage prenatal anaemia in rural areas.

BackgroundThe micronutrient home fortification programs contribute to the prevention of childhood anemia. WHO suggested applying culturally appropriate strategies to implement the micronutrient home fortification programs in various communities. However, there is little knowledge on evidence-based effective diffusion strategies of the micronutrient home fortification programs in multi-ethnic populations. This study aims to examine the diffusion of a micronutrient home fortification program with micronutrient powder (MNP) in a multi-ethnic population by investigating factors associated with being an ‘early’ or a ‘later’ adopter of MNP.MethodsWe conducted a cross-sectional study in rural western China. Multistage sampling was used to select children’s caregivers in Han, Tibetan, and Yi ethnic communities (N = 570). The diffusion of innovations theory informed the data collection on caregivers’ decision process and was applied to classify participants into the MNP adopter categories of ‘leaders’, ‘followers’, ‘loungers’, and ‘laggards’. The ordered logistic regression model estimated the factors associated with the MNP adopter categories.ResultsCaregivers from the Yi ethnic subgroup were likely to adopt MNP relatively late (AOR = 1.67; 95%CI = 1.09, 2.54) compared with Han and Tibetan ethnic subgroups. Caregivers with more knowledge regarding the MNP feeding method (AOR = 0.71; 95%CI = 0.52, 0.97) and those with stronger self-efficacy in adopting MNP (AOR = 0.85; 95%CI = 0.76, 0.96) were more likely to adopt MNP earlier than others. The following messages and channels also tend to make caregivers adopt MNP earlier: hearing that ‘MNP was free’ from villagers (AOR = 0.45; 95%CI = 0.20, 0.98), and learning ‘MNP feeding method’ from township doctors (AOR = 0.16; 95%CI = 0.06, 0.48).ConclusionsDisparities in adopting MNP existing among different ethnic groups require more effective diffusion strategies in disadvantaged minority ethnic groups. Enhancing self-efficacy in adopting MNP and knowledge on feeding method of MNP have the potential to make caregivers adopt MNP earlier. Peer networks and township doctors can be effective agencies to facilitate the diffusion and adoption of MNP.

Current approaches are unlikely to achieve the aggressive global tuberculosis (TB) control targets set for 2035 and beyond. Active case finding (ACF) may be an important tool for augmenting existing strategies, but the cost-effectiveness of ACF remains uncertain. Program evaluators can often measure the cost of ACF per TB case detected, but how this accessible measure translates into traditional metrics of cost-effectiveness, such as the cost per disability-adjusted life year (DALY), remains unclear. We constructed dynamic models of TB in India, China, and South Africa to explore the medium-term impact and cost-effectiveness of generic ACF activities, conceptualized separately as discrete (2-year) campaigns and as continuous activities integrated into ongoing TB control programs. Our primary outcome was the cost per DALY, measured in relationship to the cost per TB case actively detected and started on treatment. Discrete campaigns costing up to $1,200 (95% uncertainty range [UR] 850-2,043) per case actively detected and started on treatment in India, $3,800 (95% UR 2,706-6,392) in China, and $9,400 (95% UR 6,957-13,221) in South Africa were all highly cost-effective (cost per DALY averted less than per capita gross domestic product). Prolonged integration was even more effective and cost-effective. Short-term assessments of ACF dramatically underestimated potential longer term gains; for example, an assessment of an ACF program at 2 years might find a non-significant 11% reduction in prevalence, but a 10-year evaluation of that same intervention would show a 33% reduction. ACF can be a powerful and highly cost-effective tool in the fight against TB. Given that short-term assessments may dramatically underestimate medium-term effectiveness, current willingness to pay may be too low. ACF should receive strong consideration as a basic tool for TB control in most high-burden settings, even when it may cost over $1,000 to detect and initiate treatment for each extra case of active TB.

IntroductionParental marital status is a pivotal determinant of adolescent maladaptive behaviors. However, the specific correlation between parental marital status and Non-Suicidal Self-Injury (NSSI) among adolescents in western China has not been thoroughly investigated.MethodsA cross-sectional study was conducted involving 7,274 students from non-divorced families and 1,332 from divorced families. Participants were assessed using the Ottawa Self-Injury Inventory (OSI) and the Depression, Anxiety, and Stress Scale-21 Items (DASS-21). Propensity score matching (PSM) was applied to control for confounders, and logistic regression was used to analyze associations.ResultsThe prevalence of non-suicidal self-injury (NSSI) was higher in adolescents from non-divorced families (4.1%) than in those from divorced families (1.6%). However, propensity score matching analysis revealed that parental divorce was associated with a significantly increased odds of NSSI after controlling for confounders. Furthermore, depression and anxiety were identified as independent risk factors for NSSI. Mediation analysis indicated that the emotional distress (depression, anxiety, and stress) did not significantly mediate the relationship between parental divorce and NSSI. Additional significant predictors of NSSI included girls and age.DiscussionAdolescents from divorced families in western China show a higher incidence of NSSI, though this relationship is not mediated by emotional distress. These findings highlight the need for families and society to enhance attention to the psychological well-being of this vulnerable adolescent population.

Active case finding for Tuberculosis among migrant brick kiln workers in South India