HHCs had a general positive attitude towards HHCT and home visits were preferred in comparison to attending clinics. HHCs gained valuable knowledge and understanding about TB disease that ultimately lead to their acceptance of a family member effected by TB. Initially HHCs felt obligated to care for their family member who had TB but later felt empowered by the knowledge gained from the home visit. Additionally, HHCs felt that the home visits provided an opportunity for TB screening for their children or referral to the health facility for investigation.
Our study findings are consistent with other qualitative studies in Africa and South-East Asia, which found that community members supported the concept of HHCT11,18,19,20. A common reason for appreciation of TB services at home was it removed barriers of access and cost. Community members did not have to travel long distances to access clinic services. Despite the overall positive attitude in these studies11,18,19,20, there have been examples in South Africa where HHCs were not comfortable with home visits from research staff, specifically concerned with associated stigma and the opinions of their community members19. In contrast, our study participants did not express this same concern implying that there was no stigma attached to HHCT.
The willingness of HHCs to want more education on TB in our study is consistent with other studies in South Africa, Cambodia and Columbia, where participants wanted healthcare workers to educate their whole community on TB19,20,21. Such evidence has demonstrated the value of HHCT as a platform for distributing information on TB, which ultimately increases patient empowerment. By having better knowledge of TB, HHCs were able to cope with caring for their PLTB, despite an initial sense of obligation. They felt hopeful and encouraged by having professionals come to their home to talk to them about TB. HHCs knowledge about the curability of TB enabled better acceptance of their PLTB, improving their overall care for them. Therefore, by improving people’s knowledge of TB, we are empowering them to know when to seek healthcare.
Despite the referral of children to the clinic for TB screening during the parent study, HHCs seemed to prefer that TB screening of children take place at the household. However, the HHCs may not be aware of the complexities on screening children for TB at home. Children under five are a high-risk group and even after exclusion of TB disease, Isoniazid preventive therapy (IPT) is provided22. Therefore, additional education around screening children for TB will be beneficial.
When considering a patient-centered approach to HHCT, this study showed that HHCs want to be empowered with knowledge on caring for PLTB, TB screening of children and provision of services for other diseases. HHCT may thus provide a platform for a more holistic approach to healthcare beyond TB screening alone. Expanding the services of HHCT may enable case finding to transcend the household and reach other members of the community by creating awareness and encouraging TB screening.
The overall strength of the study is that it provided a HHC perspective that could help refine approaches to HHCT. We included a diverse group of participants based on age and gender that provided a balance of views and perspectives on household provision of TB care. We conducted interviews a month after the household visit to minimize recall bias of their experience.
Staff who conducted the HHCT and the participant interviews were from the same organization. Participants may have felt obligated to respond positively, suggesting a level of social desirability bias. However, we attempted to overcome this limitation by having different research staff conduct the interviews instead of those who conducted the home visits. Although we conducted 24 in-depth interviews, we did not revise probes during data collection. However, during data analysis we found that themes started to recur based on the in-depth interview guide.