Table 1 Themes, summary of key findings and proposed solutions to barriers identified
Main theme | Sub-theme | Summary of key findings | Proposed solutions |
|---|---|---|---|
Health system-related barriers | Lack of diagnostic facilities in rural health | Contextual barriers: specific to rural health facilities • Led to referral of presumed TB clients to the municipal hospital 10–20 km away for sputum testing, involving time away from livelihoods (e.g. fishing) and transport cost • Differences in referral processes, with referral to chest clinic and/or task-shifting officer more efficient than referral to OPD | • Transport subsidies • Training to make referral processes consistent |
Suboptimal screening for TB symptoms and sputum test request | Contextual barriers: specific to rural health facilities • Clients reporting cough were not screened with the TB symptom screening tool • TB symptom screening tool not available Contextual barriers: specific to municipal hospital • Clients not asked about cough at the OPD and in the consulting rooms and TB symptom screening tool not used because HCWs felt it was not their job • Only the task shifting officer asked about cough and used the screening tool | • Training on SOP for TB case detection • Provision of screening tool to rural facilities • Proper integration of task shifting concept into routine OPD care | |
Sub-optimal infection prevention and control practices | Contextual barriers: rural health facilities and municipal hospital • Clients visibly coughing at the waiting area not isolated and attended to (e.g. due to lack of space in rural health facilities) • Clients reporting a cough were not fast-tracked through the process of seeing a doctor because it created misunderstanding with other clients already in the queue or HCWs at the OPD | • Structural provisions (e.g. well-ventilated space or room) should be made for isolation of clients who visibly cough at the waiting area • Education of clients and HCWs on the need to fast-track clients visibly coughing through the process at the OPD | |
Insufficient monitoring and supervision of TB work | Contextual barriers: specific to rural health facilities • No TB team or TB focal person to ensure SOP on case detection was followed • Poor documentation in TB registers Contextual barriers: specific to municipal hospital • Non-functional TB team which led to poor supervision of TB case detection activities | • Formation of TB teams or appointment of TB focal persons to monitor adherence to SOP for TB case detection • Reactivation of the TB team at the municipal hospital to supervise TB case detection activities and ensure adherence to guidelines | |
Healthcare worker-related barriers | Gaps in TB knowledge and lack of training in case detection guidelines | Contextual barriers: specific to rural health facilities • Majority of HCWs had not received training on TB case detection and had no idea about the SOP for case detection which led to missed opportunities for early detection of persons with TB • SOP on case detection not present in any of the facilities • Reported bad treatment by municipal hospital staff put clients off • Clients reportedly suppress symptoms to avoid referral | • Training on SOP for TB case detection • Providing the SOP to all health facilities for reference • Training to address staff attitude to TB services and clients • Health education to facilitate clients being open about symptoms |
Fear of infection and attitude towards TB work | Contextual barriers: specific to municipal hospital • HCWs reluctant to attend to TB clients in isolation ward due to lack of PPE (e.g. N95 respirators). They feared they would get infected and would not be well compensated • This attitude led to HCWs at the OPD not also being interested in attending to clients presumed to have TB for the same reasons • The fear of infection could possibly lead to stigmatization of TB patients or clients with cough • HCWs felt it was the duty of the task shifting officer and staff of the chest clinic to attend to TB and presumed TB clients with the assumption that they received incentives for TB work | • Training to address staff attitude towards TB or presumed TB clients • Sensitizing HCWs on the need for collaboration between all units in the hospital to improve TB services • Hospital management should provide the appropriate PPE for TB work to alleviate fear of infection | |
Patient-related barriers | Gaps in TB knowledge | • Poor knowledge on signs and symptoms of TB led to patients buying cough syrups and herbal medicines • Led to some patients not seeking care from health facilities • Led to refusal by some patients reporting a cough to be screened for TB | • Education and sensitization of community members through community durbars (gatherings in the community organized by community leaders) as well as local radio stations on the signs and symptoms of TB and the need to seek care early from the health facilities |
Traditional beliefs | • Beliefs that TB was a spiritual disease or a punishment from the gods for wrong doing • Led to people seeking care from shrines or prayer camps which worsened their symptoms | ||
Stigma | • TB associated stigma in the community led to people hiding their symptoms and not seeking care from health facilities • Association of TB with HIV led to people not seeking care and some people of high social status refused to accept TB diagnosis and treatment |