Effect Evaluation And Key Factors Study Of "Xinjiang Model" For Tuberculosis Prevention And Control Based On The Implementation Science Framework

Objective:To comprehensively and objectively evaluate the implementation effect of"Xinjiang model"of tuberculosis prevention and control,the study was based on a Type I effect-implementation hybrid design,and focusing on the five dimensions of the RE-AIM framework.Effectiveness indicators were used for effect evaluation,and the causal inference method of policy evaluation was used to quantitatively evaluate the causal effect of"Xinjiang Model"on the prevention and control of TB in Xinjiang,to provide quantitative data support for the continuation of"Xinjiang Model".The process evaluation was conducted using the indicators of reach,adoption,implementation,and maintenance to analyze the key factors influencing the implementation of"Xinjiang model",so as to provide reference information for the optimization and improvement of"Xinjiang model".Methods:（1）Taking the 14 prefectures（cities）of Xinjiang as the basic data collection unit,we collected data on the registration rate and fatality rate of PTB patients in Xinjiang from the Infectious Disease Reporting Information Management System for the period of 2012-2021,and collected total completed referral rate and pathogenetic positivity rate from the Xinjiang Tuberculosis Surveillance Report for the period of 2013-2021,which was used as an effect indicator of the effectiveness of TB prevention and treatment,described the spatial distribution,and analyzed the temporal trend by using APC and AAPC values.（2）Interrupted time series（ITS）was constructed to quantitatively evaluate the effect of"Xinjiang model"using the effect indicators as outcome variables,and CITS and DID model were constructed to compare the differences in causal effects in different TB burden regions.（3）Selected two counties with average implementation effect and better implementation effect from Kashgar region,which has the highest burden of PTB in Xinjiang,to collect data using a questionnaire on factors affecting the treatment outcome of PTB patients,to compare and analyze factors affecting the implementation outcome;and selected staff members of the tuberculosis departments of the CDCs of various prefectures of Xinjiang as the target of the interview in October 2023,and used the individual semi-structured in-depth interview method to collect the opinions of tuberculosis prevention and control personnel on the implementation of"Xinjiang Model"for existing problems and suggestions.Results:（1）From 2012 to 2021,Xinjiang’s PTB registration rate,fatality rate,total completed referral rate,and pathogenetic positivity rate were unevenly distributed among different prefectures,with areas with high TB registration rate and fatality rate,as well as areas with low total completed referral rate and pathogenetic positivity rate,mainly located in the four southern prefectures of Xinjiang.The overall temporal trend of PTB registration rate in Xinjiang from 2012 to 2021 showed a decreasing trend（AAPC=-3.4%,P<0.05）,and t total completed referral rate and pathogenetic positivity rate showed an increasing trend（AAPC>0,P<0.05）.The turning points of the time trends of Xinjiang’s PTB registration rate,fatality rate,and pathogenetic positivity rate were all in 2018,with registration rate and fatality rate showing a significant upward trend before 2018（APC were 12.1%,21.3%,respectively）,and the pathogenetic positivity rate showing a significant downward trend（APC=-4.9%,P<0.05）;and the registration rate and fatality rate showing a rapid downward trend after 2018（APC were-28.3%,-27.0%,respectively）,and a rapidly increasing trend in pathogenetic positivity rate（APC=55.7%,P<0.05）.There were positive correlations（r_s>0,P<0.05）between the PTB registration rate and fatality rate in Xinjiang and the number of medical institutions,the proportion of the agricultural population,the annual average temperature,and the number of days with mild air quality pollution or higher in the year,and negative correlations（r_s<0,P<0.05）with the number of health technicians per 1,000population,the per capita gross regional product,and the disposable income of rural residents.In Xinjiang,the total completed referral rate and the primary positive rate were positively correlated with per capita GDP,disposable income of urban residents and disposable income of rural residents（r_s>0,P<0.05）,and negatively correlated with the number of medical institutions（r_s<0,P<0.05）.（2）The ITS model showed that there was a causal relationship between"Xinjiang model"policy intervention and TB registration rate,death rate,overall availability,and pathogenetic positivity in Xinjiang,with an immediate effect of increasing the TB registration rate and total completed referral rate（β₃ were 13.806,3.483,respectively,P<0.05）,and a long-term effect of decreasing registration and fatality rates and increasing pathogenetic positivity rate（β₃ were-0.746,-0.036,and 15.266,respectively,P<0.05）.The mean policy effects of registration rate,total completed referral rate,and pathogenetic positivity rate were significantly greater in high-burden compared with low-burden areas（P<0.05）;the long-term effects of the policy interventions were a significantly greater rate of decline in registration and fatality rates,and a significantly greater rate of increase in pathogenetic positivity rate than in low-burden areas（β₇ were-1.548,-0.041,and 8.245,respectively,P<0.05）,and the rate of increase in pathogenetic positivity was significantly greater than in low-burden areas.（3）Comparison of the factors between the two counties with average and better policy implementation shows that there is a significant difference in the level of monthly per capita household income between the respondents in Shache and Zephyr County（P<0.05）,and the proportion of patients with a per capita monthly income of<3,000 yuan in Shache County is larger than that in Zepu County;the proportion of Zepu County patients with TB whose health status has improved significantly compared with that of the pre-treatment period is significantly greater than that of Shache County（P<0.05）;patients in Shache County were significantly less aware than those in Zepu County of how to take anti-tuberculosis drugs,precautions,adverse reactions,and regular reviews during treatment;the factor that accounted for a larger proportion of patients with a heavy treatment burden in both Shache and Zepu Counties was discomfort caused by taking or injecting drugs,accounting for 12.8%and 8.7%,respectively.The results of qualitative interviews with TB control staff showed that the reasons why PTB patients did not participate in TB control were patients’physical health status,influence on the normal rhythm or order of life,lack of understanding of TB knowledge and policies,socio-economic factors,and stigma of the disease,etc.;the main factors that reduce the motivation of TB control personnel are work factors,staffing problems,low emphasis on leadership and recognition of TB work,low patient compliance with treatment,and problems with the use of funds;the problems that exist in the implementation of"Xinjiang model"are mainly personal factors and psychological factors of the patients,the staffing and treatment of TB control personnel,and insufficient financial and policy support;the implementation recommendations put forward by TB control personnel are mainly to strengthen financial and policy support,and to improve the welfare and treatment of TB control personnel.The implementation recommendations put forward by TB control staff are mainly to strengthen financial and policy support,improve the welfare and comprehensive capacity of TB control staff,enhance social support,and improve patient management methods.Conclusion:The implementation of the scientific RE-AIM framework has good practical value in the study of the effectiveness and determinants of the implementation of"Xinjiang model"of tuberculosis control.The effectiveness evaluation quantitatively demonstrated that"Xinjiang model"of TB control was effective in controlling TB epidemic in Xinjiang,especially in PTB high burden areas,and that long-term implementation of the model could reduce PTB registration and fatality rates.Important factors affecting the implementation of"Xinjiang model"are financial and policy support for TB work,patients’economic status and psychological factors,knowledge of TB treatment,and adverse drug reactions.