A total of 16 participants were interviewed for the study: 11 healthcare providers and 5 healthcare administrators. The overall median age for healthcare providers was 48 (IQR: 42–51) years but age was not collected for healthcare administrators. The median length of time that healthcare providers and administrators had worked in their posts was 15 (IQR: 4–29) and 8 (IQR: 8–11) years, respectively. All participants had a clinical background with majority being nurses (Table 1).
| || |
Health Care Provider
N = 11
N = 5
Median Age (IQR)
48 years (42,51)
Median Length of Time at Current Post
15 years (4, 29)
8 years (8, 11)
Trial Clinic Assignment for Focal TB Nurses
Overall, the primary findings outline healthcare providers and administrators’ varied opinions around symptom-based versus TST-based screening for child TB contacts and high acceptability of the trial implemented child contact record and audit and feedback system. Additionally, participants discussed barriers and potential solutions to optimizing screening of child TB contacts with a focus on the supervision and training of CHWs and the role and responsibility of nurses for child TB care.
Mixed opinions about symptom-based TB screening
Healthcare providers had varied views when asked to reflect on their experiences with symptom-based screening (both during and after the trial). When compared to TST-based screening, symptom-based screening was deemed more favorable as it mitigated the delays in triaging and losses to follow-up that are associated with the skin test. “Screening like that [symptom screening] means you have the child in front of you and you can do what is right for the child. For the TST, you know how many don't even come back for the reading? So the child is here, and you can do what is necessary for the child” (nurse, female, symptom arm). Furthermore, no additional resources were regarded as being necessary for performing a symptom screen, “TST you need the equipment. If you don't have TST it means you are not going to screen for that child. Yeah” (nurse, female, TST arm).
Though symptom-based screening was perceived to be a simpler method, providers feared missing a symptomatic child. Nurses had limited pediatric history and physical exam skills and felt uncomfortable with the fact that young children are unable to directly communicate their symptoms to the provider, “Symptom screening is easier [than TST], but you can miss…A patient, you can miss. Because now remember with symptom screening, we are relying on the mother” (nurse, female, symptom arm). In particular, healthcare providers were concerned that caregivers might not disclose a child’s medical history, “if the mother is openly enough there's no way that you're going to miss a child who's sick” (nurse, female, TST arm). Additionally, providers were concerned that caregivers experience screening fatigue, “I can tell you where a problem is already. The problem is, patients are not truthful. They will just say no, no, no, no, no, no, already knowing that if you say one yes, you’re going to go to the back and you’re going to be tested for TB. So some patients do that. Or they run out of the facility when people start screening. They do that, honestly, they do that. People do funny things.” (nurse, female, TST arm).
To deal with the subjective uncertainty of a clinical symptom screen, some providers in the symptom-based screening arm instituted an objective second test during the trial. Several providers noted using the TST as a confirmatory test after performing the symptom screen, “I think both [symptom- and TST-based screening] are important because immediately, they can be– I have those symptoms but I can't confirm by just symptoms, there must be a test done. So immediately after you find out that [the child] presented this [symptoms], is whereby TST will confirm those tests, those symptoms of the child” (nurse, female, symptom arm). Another provider described performing gastric aspirates on all household child contacts, irrespective of whether they had symptoms. “I was doing everyone even if the screening tool says there are no signs there. After screening and there are no signs of TB I was doing the gastric washing just to be on the safe side, you see.” (nurse, female, symptom arm). In general, providers feared the consequences of missing a sick child and in particular were worried about children dying as a result of not being diagnosed with TB disease “The child is going to be more sick, and then is going to end up dying. And then, sometimes, the family thinks the child died because you couldn't help the child. And when we hear that some child was here, and how he's dead, ugh” (nurse, male, TST arm). Providers also blamed themselves if TB diagnoses were missed in children, again highlighting their desire to provide quality care to child contacts, “it’s like you didn’t fulfill and then you didn’t do the right thing to that child” (nurse, female, TST arm).
Willingness to adopt new clinical records and processes
Willingness to adopt new clinical records and processes emerged as a key theme and facilitator to child TB contact management. Healthcare providers and administrators had positive perceptions of the child contact record and register and the audit and feedback sessions. These are important factors in the scale-up of symptom-based screening and child TB contact management.
Child contact record
When discussing the child contact record, many providers considered it to be beneficial for patient care and easy to implement. The contact record provided a clinic-based method through which to track and manage patients through screening, evaluation, and their TPT course, allowing for identification of children lost to follow-up during the process, “For the obvious reason that I said earlier. Like, it helped us in managing those children, like better than before, because like before it was chaotic. You will give the child isoniazid prophylaxis. The child will not come. After four months, the(y) come back, then you … -- you are not sure whether to start afresh …” (nurse, male, TST arm). The contact record was based at the clinic for nurses to manage and was also recognized as being easy to complete, as compared to the existing caregiver-managed, pediatric medical record, “- we used to use the road to health chart. It's a book. You have to go through the pages. [Healthcare providers] find that pink form its better, because like I said, [if there] are any symptoms, we have to screen the child every time he comes for treatment. [Pink file] It's not that much. Unlike, we have to go through the book, looking for the page.” (nurse, male, TST arm). Additionally, providers utilized the child contact record and register to self-audit patient outcomes and manage follow-up appointments, “Then you take your files, you sit, you check, oh, this one I haven't seen. This one. Then you write your list. Already on Monday, you know gore (that) they must go and look for those that didn't come.” (nurse, female, symptom arm). Most healthcare providers described continuing to use the child contact record post-trial, further demonstrating its perceived usefulness.
Child contact register
Providers reported that similar to the contact record, the register also served as a prompt tool for some nurses to ensure continued patient care, “It reminds you of your patient, because you see so many patients every day, it's easy to forget” (nurse, female, TST arm). However, post-trial feedback indicated that the register was less utilized than the contact record due to time constraints “I was unable to use it. Yes, really, I was unable to use it. It's still there. I tried to use it, but I didn't have enough time to. I relied only on the pink form [child contact record].” (nurse, male, TST arm).
Audit and feedback sessions
In addition to provider self-audits, healthcare administrators favorably viewed the study-initiated audit and feedback sessions, where captured information was used to hold clinic staff accountable for patient outcomes “…and the minute you do quarterly reviews you are shaking people to say Can you see what's happening? Maybe you thought that you are doing what you're supposed to do, but this is the proof that it's not happening…" (administrator, female). The child contact record and register were also recognized by providers as facilitating reporting mechanisms during feedback sessions by making additional information on IPT follow up available to the them, “… especially with the TB indicators, it's part of our IPT and we need to report on those, so it's affecting our overall performance.” (administrator, female).
Overall, participant feedback highlighted the willingness of healthcare providers to adopt new clinical records and processes within the clinic setting with the intention of improving child outcomes.
Barriers and solutions to optimizing screening of child TB contacts
Several key themes related to roles and responsibilities within the health system emerged as barriers to effectively implementing or optimizing the pediatric TB screening process. These barriers are important in considering how a clinic-based screening intervention cannot improve TPT uptake without also taking in to account existing challenges within the health system.
Challenges with utilizing community health workers
Healthcare providers discussed a number of their concerns with utilizing community health workers, responsible for much of the child contact tracing and linkage to care activities performed both in the clinic and in the community. Many of these concerns focused around CHWs identifying child contacts; a critical precursor to the success of clinic-based screening. A of lack training and supervision needed to perform their jobs satisfactorily was highlighted by most healthcare providers. “Where was he [the CHW] when this particular person comes so ill in the facility…So where are they? Are they doing– when they go, are they screening? Are they? (nurse, female, symptom arm). Many healthcare providers also discussed practical challenges to using CHWs for screening. “I once discovered that the CHWs– because they are assisting us with this [TB symptom screening] also– I had to correct them, with some of the [screening] questions, that they didn't really explain properly to the clients. It was just like a quick thing for them, but it was corrected. It's [the screening tool] not problematic. It's just that for them, it was a too quick thing. They just did it. Like [the question reads], “do you cough for two weeks?” “Do you sweat?” It's just [they ask], “do you cough?” They don't read the full question.” (nurse, female, symptom arm). In line with concerns about the work of CHWs, some healthcare providers felt that CHWs required additional training, particularly related to identifying child contacts to ensure that they are able to be appropriately assessed at the clinic, either by TST or symptom screen. “CHWs are our link [to patients]. We need to intensify their training.” (nurse, female, symptom arm).
Identifying and managing TB contacts – everyone’s responsibility?
Both healthcare providers and administrators stressed that for the benefit of child screening, all clinic staff should be competent in identifying and managing TB contacts, not just dedicated TB healthcare providers. If child TB contacts were to be appropriately managed, whether via TST or symptom screening, participants felt that: “Everybody should know TB, not just the focal nurse. They all run away from TB.” (nurse, female, TST arm). In line with the need for increased competency in TB across all healthcare providers, some administrators discussed the negative consequences for child identification and contact tracing when responsibility for TB is siloed. “The minute there is borders between programs people get lost at those borders.” (administrator, female).
Despite the pervasive feeling across participants that everyone in the clinic should be competent in screening and managing child TB contacts, healthcare providers highlighted challenges when discussing their own experiences with integrated care and being expected to help out across the clinic. “Usually, I help in front, when I'm busy pushing lines because we're short staffed. I'll be sitting in front doing chronics the whole day, or either I'll be pulled to do ANC [antenatal care] or I'll be pulled to do babies. Like, I'm always the one to have to fill holes. So it takes me away from TB quite a lot.” (nurse, female, TST arm)
The scope of the nurse role
Most nurse healthcare providers expressed a desire to take on broader responsibilities for contact tracing and assessment of contacts outside of the clinic, particularly conducting household visits. The desire to take on additional responsibility in identifying child contacts revealed healthcare provider perceptions of gaps in the process of identifying child TB contacts and thus barriers to increased uptake of TPT. “To go there [the household] and go and see for myself…see ourselves there are no under fives. Because you can say, the way we ask is, we might say at home, are there no what, what, what [children]? But you'll find that the very same person is minding somebody's child. When you come there [the household], there is a child.” (nurse, female, symptom arm). This was also echoed by some health administrators “I do not know if all the children actually come to the clinic at the end. So I think it would be better if we can take our bag with our [nasogastric] tubes and whatever and go and do the investigations there.” (administrator, female). Most healthcare providers discussed how resources and demands on their time at the clinic limited activities like household visits that they perceived would improve child contact tracing and assessment. “If you [nurses] can be offered cars and then enough personnel– because sometimes you don't do those house visits because when you leave the clinic you're going to have more work. It’s just that you have to be full-time in the clinic, whereas you have to go in the community to go and check and look for the clients.” (nurse, female, TST arm).