Quantitative results
We estimated to reach a total of 904 Eritrean migrants through all strategies employed in the five PHS settings. In total, 401 (44%) persons attended LTBI education and 257 persons (64% of attendees; 28% of number envisioned to reach) received LTBI screening. The uptake of LTBI education differed between strategies from 13% (Strategy 3.3) to 75% (Strategy 5). Invitations through mail and social media (strategy 1) and church meetings (strategy 6.1 and 6.2) were most promising in reaching large numbers of the target population. However, only strategy 6.1 succeeded in screening many persons (n=70). Strategies 2.1, 2.2 (face-to-face), 4.3 (group housing) and 5 (sport club) were most successful and screened respectively 84%, 89%, and 50% of the envisioned target group. PHS staff encouraged individuals who participated in the education sessions of strategies 2.1, 2.2, and 4.3 to motivate and bring family and friends to the LTBI screening. This resulted in more individuals attending the LTBI screening than the education session (uptakes up to 124% of those educated). (Table 3)
Of 257 persons screened for LTBI, 30 (12%) were diagnosed with LTBI. (Figure 1) Additional file 2 presents characteristics of the population screened and treated for LTBI. Of those diagnosed with LTBI, 29 (97%) participants started and 28 (97%) completed LTBI treatment. (Figure 1) Seven (24%) participants had reported side-effects(hepatotoxicity: n=3). To overcome language barriers, professional interpreters translated during 13 (45%) consultations, while Ethiopian/Eritrean TB nurses from the PHS translated during 14 (48%) consultations. All clients received demand-driven LTBI treatment support. Additional file 3 shows results from LTBI treatment evaluation.
Qualitative results
Overall experience with the program
Overall, interview respondents appreciated the opportunity to be educated and tested for LTBI. They perceived the education as eye-opening and important, and hoped the program would continue to reach more Eritreans. Some respondents expressed their desire to be tested for other diseases, particularly HIV. Participants who received the LTBI treatment perceived the treatment support as important and respectful. Furthermore, respondents were thankful for the reimbursement of screening and treatment costs; some indicated they would not have been able to cover those costs themselves.
Eritrean respondent: “I think it is a huge support for us to get it for free! How would we have paid for this? I don't know if these medicines exist in our country? So, I consider myself lucky to get this opportunity.” [Individual interview 1]
Overall, PHS staff perceived the program as relevant for this target population. However, they experienced the organization and execution of strategies as time-consuming. All strategies required a flexible attitude from TB care staff to organize promotion activities — and some LTBI screenings — on location or outside office hours. Most PHS staff doubted feasibility to execute the activities in regular practice with current available resources. Furthermore, PHS staff questioned the effectiveness of the program because of low LTBI screening uptake.
Program facilitators
Between the different strategies, we identified the following overarching facilitators: 1) active, face-to-face outreach to the community, and 2) engagement of key figures. Furthermore, respondents suggested that repeating the information and screening opportunities would increase uptake of the program.
Eritrean respondent: “People keep saying they are healthy, but we all said the same thing. I never had any complaints, I was not coughing. Still it was sleeping in my body. Now we can prevent it from developing into the TB disease. Therefore, we should share our experience with those who didn’t come, if you could organize a health education seminar again.” [Individual interview 7]
Key figure 2: “They need time to really understand the purpose and importance. (…) So, several announcements and several registration opportunities. After the first time, they will share their experience [with LTBI screening] among each other. Then organize a second time. Eventually, it will gain publicity and then they will cooperate.” [Group interview PHS 4]
1) Active face-to-face outreach to the community
Strategies that actively approached smaller groups in a face-to-face manner (Strategies 2, 4, 5) had highest uptake of LTBI education and screening. Key figures explained that face-to-face explanation is effective as it allows them to explain and emphasize the importance of the program, and immediately address misunderstandings or scepticism. Contrary strategies (strategies 1, 3.3 and 6.2) used written materials such as letters, flyers and posters. Respondents described those strategies as less effective because of the overload of information from different organizations that is sent to Eritreans who recently migrated (61% of those screened for LTBI, migrated less than 3 years ago). Many Eritreans have difficulties understanding and prioritizing invitations. Consequently, they only take letters from the municipality into consideration, which can be recognized by their envelope and are known to contain compulsory appointments.
2) Engagement of key figures and community members
Most PHS staff said that the key figures were crucial in approaching and reaching the target population. Key figures from PHS 3 were very well connected to the community: they were young, from the same generation of migrants, and thus their acquaintance already originated during the journey to the Netherlands. However, respondents from PHS 1 and 2 reported mistrust and lack of respect towards key figures. Eritrean key figures — often also functioning as interpreters — who migrated during the nineties are often perceived as supporters of the current Eritrean regime, from which the new generation of Eritrean migrants fled. Mistrust towards those key figures is further perpetuated by media and public discourse of incidents where Dutch immigration authorities have expelled interpreters because of their connection to the Eritrean government.
Key figure: “The young generation do not trust the key figures who have been in the Netherlands for 20 years. They [young generation] think that certain things happen to them personally because of the key figures, because they are the translators and are always around procedures such as housing.” [Group interview PHS 1]
To overcome the issue of mistrust and to make future campaigns more appealing, some interview respondents suggested to engage Eritreans from the same generation who have participated in the program, for example through short promotion films.
Program barriers
We identified the following overarching barriers: 1) competing priorities, 2) perceived good health and poor risk perception, and 3) scepticism about the project’s purpose. Additional file 4 provides an overview of strategy specific facilitators, barriers and suggestions for future improvements.
1) Competing priorities of the target population
Key figures said that it was sometimes difficult to motivate the target population to participate in the program because of competing priorities (Strategy 3.1 and 4.2). Some community members are occupied with pressing issues such as housing, family reunification, Dutch language school appointments and examinations, and employment, hence influencing participation in the program.
TB nurse: “The men said: ‘I thought you guys came to tell us something about TB related to our housing condition. If not, why would I come? I don’t care if I have TB, anything better than living in this house’.” [Group interview PHS 2]
2) Perceived good health and poor risk perception
Some key figures said that at first the target population did not understand the relevance of attending the education about TB because they felt healthy, had a normal chest X-ray for TB at entry, and were unfamiliar with LTBI. Furthermore, the young age of some participants (Strategy 3.1) influenced the ability to relate the information to one’s own health: despite the education they felt the disease would not affect them.
Eritrean respondent: “I participated only because I was at home. If I had a trip somewhere, I would not have come. I always thought I was healthy, and the education was not important. (…) I only found out that I had LTBI because I did the blood test. So, I learned a lesson from my situation, and I try to explain it to others.” [Individual interview 6]
3) Stigma and scepticism about the project’s purpose
Some respondents felt stigmatized by the fact that the program targeted only Eritreans and not Arabic migrants. It made them feel like only Eritreans “brought TB to the Netherlands”. Furthermore, some respondents were sceptical about the project’s purpose. They suspected the “real” project’s goal was to test a new diagnostic test for TB. One key figure explained that this scepticism comes from gossip in the community about Western countries testing medical devices on African refugees, such as vaccines. Despite addressing these concerns, the scepticism may have resulted in negative peer pressure to participate in LTBI education and screening, especially in Strategy 6.2.
Eritrean participant: “They said this is a pilot project to do a blood test for TB. What do you say about the fact that they are testing it on us? They did not test it on the Arab people? What if the virus stays in the needle they are using to test this new method, and it infects us? It is normal to be sceptical about this.” [Group interview PHS 3]