Between November 2017 and August 2018, we conducted 29 semi-structured interviews with front line health workers and mid-level managers. We also held three small group discussions and five key informant interviews with policy makers and senior health service administrative staff (Additional File 4 for summary of participants). Observation notes were obtained from the two day-long paediatric TB sensitisation meetings, two CIN meetings, two paediatric TB trainings and two-week visits to the two hospitals of interest. In our interviews and discussions with the various cadres of health-workers about their experiences diagnosing TB in children and using diagnostics including Xpert®, participants described at length the challenges they faced but also provided some suggestions on what could potentially be done to improve the situation.
Context: Our observations helped provide an understanding of the context of typical Kenyan county hospitals. In brief, the hospitals selected were both very busy (>1,000 paediatric admissions a year) and came from counties that reported a high incidence of TB. We noted that they had similar constraints in terms of low staffing, periodic stock-out of Xpert® cartridges and reagents and bottlenecks in work flows. The main distinguishing factor in the hospital that detected more TB cases was their localized norms and culture of teaching, mentorship and teamwork. Our observations also helped describe the flow that a patient presumed to have TB would be processed in a typical county hospital (Additional File 5).
Findings were summarised into 25 themes, representing the factors that influence TB case detection in children (chart in Additional File 3). These themes were then grouped into eight broad analytic categories, illustrating how the emerging themes had potential to impact Capability, Motivation and/or Opportunity to diagnose TB in children, and whether the influences were at individual, hospital or community level and are further described in the subsection that follows.
Individual level influences
i) Knowledge and skills
Knowledge/awareness of paediatric TB did not appear to be a major challenge: most health workers across the cadres were aware of the manifestations of TB in children and how to arrive at a TB diagnosis. Most were also aware of the Kenyan paediatric TB guidelines and had had some form of TB-specific training, either from medical school or on- the- job training:
“… So, after you’ve enquired everything, contact with the person, loss of weight, see those things actually lead you to TB…since they have a cough and all that you’ll do a chest x-ray. A chest x-ray might actually show …you might get a miliary picture or something like that. So, after that you can do the skin test but here we don’t do it, but we do sputum for Xpert. So, we do the sputum and if it comes back positive we treat the baby for tuberculosis...” Clinical Officer Intern_SSI_21
Many participants, both junior and senior however reported difficulties in actual specimen collection, as illustrated in the following comment:
“...the biggest problem is specimen collection. It’s invasive, whether you are doing gastric, bronchoalveolar, because most of them…those are the things…. it’s not very easy...” Paediatrician_SSI_10
According to most participants and what we observed, training provided by the National TB programme and other partners was mainly didactic with little opportunity to gain competence in specimen collection. Some participants therefore suggested a review of the content of paediatric TB training and how it is delivered, and this feedback was given to the National TB programme representatives.
ii) Experience, confidence and competence
Where TB was more commonly detected in children, the health workers were not only knowledgeable but seemed more alert to the possibility of the disease, possibly because they had increased confidence and greater individual experience of investigating and diagnosing TB in children. Interestingly, this pattern seemed self-reinforcing, helping sustain efforts to identify TB as a shared local norm among health workers in that hospital:
“It all boils down to…if you provide exposure to as many cases as possible then you’ll see actually day becoming…being as clear as day and night... it comes with experience [[okay]] it comes with skills, it comes with seeing many patients…” Paediatrician_SSI_01
In most places however, TB was rarely a differential diagnosis until the child had been seen several times for un-resolving diseases like pneumonia:
“And you know when I get a first contact, like it will not hit to me that this is TB initially, I will treat first then from there the second time she comes…that is when I will think like, ooh this kid has been seen in the clinics outside, has been treated probably twice or thrice with antibiotics, I have also treated with antibiotics, but this is the fourth time the baby is back with a cough and a fever.” Clinical Officer_SSI_23
Where health workers experienced marked improvement in children in whom they decided to start anti-TB medication, this affirmed their decision, making them more likely to consider TB as a diagnosis in the future (positive feedback):
“Positive experiences…getting a child who’s doing very bad, send to nutrition, child not improving…. the moment you initiate anti-TBs, the third week, the fourth week the child is good, putting on weight. You see that child and you feel so encouraged and you’d really want to see, even if it’s a hundred and one you’ll still see tomorrow...” Clinical Officer_SSI_31
Reflecting on their experience in using Xpert® in children, many health workers from the meetings and the various hospitals reported to have never actually never seen a positive test result:
“I have never gotten a positive GeneXpert…All of them. In my many years by the way, I have never gotten a positive GeneXpert in our work place...” Paediatrician_SSI_09
Consequently, the clinicians both junior and senior, had little faith in the diagnostic test leading them to rely on their clinical acumen and treat presumptively:
“…especially even that GeneXpert I’ve told you it usually doesn’t help much but we have also had, you know, those x-rays sometimes you are not sure...But when you are in that dilemma you do…you give treatment and see what happens...” Paediatrician_SSI_07
“…Never, never…I don’t know if it’s our samples that don’t have enough bacteria, I don’t know what the problem is, but it’s never positive. Even in someone who you are so sure this can’t be anything else…this is TB. Lakini [but] Xpert is showing you negative. We usually just continue treating as a presumptive…” Medical officer_SSI_24
iii) Fears and Beliefs
Alongside perceived competencies, some individuals also held certain beliefs or fears that influenced their practices, including the fear of acquiring TB:
“...one of the things people [health workers] fear is getting sick. Because, you know, once you see how the TB patients struggle, finishing the 6-month medication, if you fail you have to roll over and get in your drug resistant medication. It’s crazy…” Public Health Officer_KII_02
In addition, for some, there was a reluctance to diagnose and treat TB in children linked to a fear of the side effects of the drugs:
“…We didn’t treat because we were afraid that...the liver was an issue. I think we learnt that we should treat regardless…” Medical Officer_SSI_32
Relatedly, the reluctance to diagnose was often linked to underlying beliefs that children do not usually get TB as shown below;
“To be honest, I think I have been a bit reluctant. I’ve not been that vigilant to identify this child[ren] with TB, which I’ll start from now… We are so reluctant on our part. Or maybe we may overlook these children; maybe we may think…we may not suspect a child may be having TB…” Nursing Officer_SSI_30
However, as described above, fears were allayed as health workers observed children improving with treatment:
“I don’t think I have that fear anymore in terms of saying yes, start this child on anti-TB. I think our confidence levels with time and having observed children, you know there are some you see, you start on anti-TB then the improvement within a month or two is like magical...” Paediatricians_SGD_11
These examples show that at individual level, experiences affect one’s knowledge, skill and competence and can increase or decrease one’s perceived capability (psychological) to make a child TB diagnosis. This is often reinforced by positive experiences of improvement where treatment had been initiated and in other cases discouraged by negative test results. Positive experiences therefore contribute to the health worker’s motivation (reflective) to keep trying to diagnose TB in children, especially if they can see or receive news of the clinical results of their practice. This in turn affects their opportunity (social), because no culture of Xpert® use is established and so they fail to gain competence. Strongly held fears and beliefs about TB possibly affected motivation (reflective & automatic) negatively.
Hospital influences
i) Hospital norms
In the hospital that reported higher numbers of child TB cases, established localized norms guided work practices. Senior clinical leads offered teaching and mentoring, fostered multi-professional teamwork, with every member having shared responsibility for ensuring patient well-being; and National TB guidelines used as standard practice. These local working practices enhanced individual capabilities as they created a conducive environment where good practices were taught and encouraged:
“When you get to the ward you are trained and now you are the one who will be getting it…They definitely teach us... Clinical officer [X] is very helpful…he’s the one who taught us how to collect the sputum after Dr [M] had taught us…he also repeated the whole thing as in physically...” Clinical Officer Intern_SSI_21
A key feature of this conducive environment was facilitative teamworking where team members relied on each other, for example, in making a diagnosis:
“…then since us we are interns we have people who are more experienced than us…the clinical officers…and the MO [Medical Officer] who is in paediatrics and also Dr. K so you just talk to…your immediate-most senior like an MOI [Medical Officer Intern] if he’s unable…we talk to our MO and then maybe them they can do it [specimen collection] ...” Clinical Officer Intern_SSI_21
Of note in several hospitals, leadership and mentorship was missing as some senior clinicians were not at-ease doing specimen collection procedures themselves. This lack of competence by seniors consequently lead to challenges in diagnosing TB in children:
Interviewer: “Have you ever participated in the sample collection process?”
Respondent: “No. I am used to giving instructions and go. Maybe now I should participate to see how it is being done. Because I am now suspecting, could it be the sample collection which is causing the issue?” Paediatrician_SSI_07
ii) Organisational processes and resource management
In the hospitals we visited, we noted there was poor patient flow, no designated procedure on when or where investigations should be done for children seen in the outpatient department of both hospitals (patient flow process map Additional File 5). Consequently, as reported by some of the participants, this led to a lack of continuity of care:
“...So, I was feeling the challenge that is there in making the diagnosis of TB is that when the child leaves here, you don’t know when…if the child is going to the next…will get to the next place, and if they are going to have a Mantoux [TB skin test] done, is the report going to come back to you? You know if it doesn’t come back to you directly, you’ll find…the child might get lost somewhere along the way…because if you are not the same person seeing that same patient again, you don’t know what the decision of the next person will be. And you’ve sent them for a Mantoux, the interpretation, who will interpret it and are they going to use the same thought that you had?” Clinical Officer_SSI_24
The lack of proper post-discharge follow-up was common in most of the other hospitals:
“Now there is a gap in this child at out-patient at this level, once treatment is initiated in the ward the child is discharged. Linking them to a TB clinic sometimes becomes an issue, so they may fall by the way side, they may not end up in the TB clinic, or they may interrupt TB treatment because of that...” Public Health Officer_KII_01
Where key resources were available (equipment; reagents; skilled manpower; guidelines/job aides), clinicians could more comfortably make a TB diagnosis (psychological capability and motivation), like in the following example:
Respondent 2: “…yes, yes, yes. There are some charts even in the nursing station I think you’ve seen one. There is a chart on the wall. Yeah, but basically as she has said, these are things we do almost every day so most of them actually stick...”
Respondent 2: “… any time you think you have forgotten something. You know there is the paediatrics bible, that is the paediatrics protocol…” Small group discussion with interns
However, where there were resource shortages, health workers struggled:
“Against us again is the X-rays, because X-rays are a mainstay of diagnosis for TB in children. Unfortunately, they have not been readily available all over the country. They are available in very few sites and in those sites, there is a cost implication to the children which sort of acts as a deterrent or a limitation to the same...” Public Health Officer_KII_01
For the diagnostic tests, commonly reported issue was frequent stock-out of Xpert® cartridges and reagents (nation-wide) which in turn led to delays in making a diagnosis and reinforced a reluctance in ordering the tests in future. This shows how age-old system issues like stock-outs potentially affect adoption of new diagnostics:
“…Most times no coz sometimes we have stock outs of Xpert… when there are stock outs you might want to send the patient to another place, where… maybe a private facility where they have to pay for it out of pocket…” Medical Officer_SSI_14
The influences of hospital capacities in diagnosing TB therefore span hospital norms including multi-professional teamwork, leadership and mentorship; as well as processes and resource management. The hospital environment thus affected both group and individual work practices around diagnosing TB in children by influencing opportunity (physical & social) which in turn affects psychological capability as well as motivation (reflective) to keep at it.
Community influences and implementation of policies and directives
Beyond individual and hospital levels, we identified themes spanning two aspects of the broader health system: the policy level and characteristics of the population seeking care.
i) Community beliefs and practices
Stigma, health-seeking behaviour and community awareness of TB manifestations in children made some health workers reluctant to test and treat for TB as illustrated in this example:
“...in a few instances you tell the parent the child has TB and they get very mad. They don’t want to believe it, ‘You can’t say my child has TB, kwetu hakuna TB [there is no TB where come from]’ ...in fact there are some who even refuse treatment arguing that their place people don’t get TB, especially the rich people …” Paediatrician_SSI_07
Of note, TB is stigmatised in this setting due its presumed association with HIV, which increased reluctance by health workers to give a TB diagnosis, as health workers feared it may lead to emotional burden for their patients as seen in this illustration:
“…And then there is that thing people thinking TB is equal to HIV, so when now someone has been told that they have TB now everyone thinks that they are HIV positive, so there is that even being shunned by the family. I have a mother right now who was actually chased away by her extended family because of the TB diagnosis...” Paediatrician_SSI_03
ii) Implementation processes by the National TB programme
At policy level, we found that that some of the National TB programme implementation decisions affected health workers’ capacity to use TB diagnostic tools. For instance, when Xpert® was being introduced in Kenya, the selection of participants to take part in trainings inadvertently left out key actors like clinicians, resulting in low demand for use of the diagnostic reported here:
“…We realized that when we rolled out Xpert, we focused a lot of our training on the lab personnel, thereby leaving out the drivers of the service use. So, the clinicians initially were not part of the target population for training and so what we have realized as a programme is that therefore the demand for the service is skewed and is not actually being availed to the people who need the service…” Public Health Officer_KII_01
Policy -related directives from the National TB programme that encourage data use for audit purposes could subsequently motivate quality improvement initiatives in hospitals which lead to increased number of children diagnosed with TB:
“…But in terms of feedback… we do data quality audits and they are done together with the health care workers so it is a participatory sort of quality audit. And the feedback [about performance] is given on the spot…” Public Health Officer_KII_02
We therefore found that health worker practices are influenced by what was happening in the wider communities and from policy implementation processes led by the National TB programme which affect the opportunity (physical) and motivation to diagnose TB in children.
In summary, we have described influencers of diagnosing TB in children at different levels: (individual, hospital and the wider community and policy level) and shown how these factors interact to influence the behaviour of health workers through impacting capability, opportunity and motivation (illustrated in figure 2 and chart in Additional File 3). At individual level, knowledge, skill, competence and experience, as well as beliefs and fears impacted on capability (physical & psychological) to diagnose TB in children and use diagnostic tests, and eventually their motivation (reflective then automatic) to keep doing it will lead to sustained practice. Most of the issues of processes and resources at hospital level we thought had potential to impact capability (physical & psychological) and opportunity (physical & social), because of breaks in the care, and this in turn could influence motivation (reflective and eventually automatic) through impaired decision making. Community beliefs and practices as well as policies, we thought influenced capability (psychological), motivation (reflective & automatic) and opportunity (physical) and because of these, the health workers seemed hesitant/reluctant to make a TB diagnosis in children.