Background Detection of tuberculosis (TB) in children in Kenya is sub-optimal. Xpert MTB/RIF® assay (Xpert®) has potential to improve speed of TB diagnosis due to its sensitivity and fast turnaround for results. Significant effort and resources have been put into making it widely available in Kenya, but its use remains low, especially in children. We set out to explore the reasons for the under-detection of TB and underuse of Xpert® in children, identifying challenges that may be relevant to other newer diagnostics in similar settings.
Methods This was an exploratory qualitative study and data collection involved semi-structured interviews; small-group discussions; key informant interviews; observations of TB trainings, sensitisation meetings, policy meetings, hospital practices; and desk review of guidelines, job aides and policy documents. The Capability , Opportunity and Motivation (COM-B) framework was used to interpret emerging themes.
Results At individual level, knowledge, skill, competence and experience, as well as beliefs and fears impacted on capability (physical & psychological) as well as motivation (reflective) to diagnose TB in children and use diagnostic tests. Hospital level influencers included hospital norms, processes & patient flows and resources which affected how individual health workers attempted to diagnose TB in children by impacting on their capability (physical & psychological) , motivation (reflective & automatic) and opportunity (physical & social). At the wider system level, community practices & beliefs, and implementation of TB programme directives impacted some of the decisions that health workers made through capability (psychological) , motivation (reflective & automatic) and opportunity (physical).
Conclusion We used comprehensive approaches to identify influencers of TB case detection and use of TB diagnostic tests in children in Kenya. These results are being used to design a contextually-appropriate intervention to improve TB diagnosis, which may be relevant to similar low-resource, high TB burden countries.