Facilitators of a successful childhood TB prevention program
Provider understanding of the importance of TB prevention and receiving enhanced provider training on CCM were the major themes regarding a successful childhood TB prevention program. Providers in this study agreed that TB prevention services, including contact tracing, early detection of child TB contacts, and provision of IPT to eligible children, are essential to controlling the TB epidemic in Lesotho. They emphasized the importance of IPT in confronting TB and spoke of the deleterious consequences of TB and the value of the protection that IPT confers to children exposed to TB. Some of the providers believed that CCM is feasible in Lesotho and suggested expanding IPT to all household contacts of TB cases and not just to children.
I see IPT… as a weapon that will protect children. [LVHW, individual interview]
It [IPT] is good so that they can be safe and protected … all children in their [household] should be put on preventive therapy… [LVHW, individual interview]
It [CCM] prevents spread of TB, eh, because if we are targeting children… it is easier for them to catch the disease … so if they are being targeted, to be screened or to be supplied with isoniazid for 6 months, I think it will help us control the disease and reduce number of TB cases. [Nurse, individual interview]
IPT, if it can be given to every contact in the house… everybody that we screened in that house found with no TB should get on IPT. [LVHW, individual interview]
Providers reported that having enhanced training on CCM, including an emphasis on ruling out TB disease in child contacts, is imperative. They were especially concerned about missing cases of child TB disease and wanted to know more about managing potential side effects from isoniazid (INH).
I think when we have engaged in trainings, it is then that… we are able to attend to side effects… as early as possible. Then we will be equipped with skills… what are the complaints that might come up, those that we are able to identify earlier. [Nurse, group interview]
It is difficult to diagnose children, because if you are going to start IPT without any X-ray or sputum samples, we only base ourselves on signs and symptoms… not knowing in depth what is happening to the child. [Nurse, group interview]
We compared attitudes of nurses and LVHW and did not discern any meaningful differences between the two cadres regarding facilitators of a successful program.
Challenges to CCM provision and strategies for addressing them
Providers reported multiple challenges to CCM provision and suggested strategies for addressing them. Four themes emerged from the interviews: limited access to care, supply-chain issues, barriers to identification and screening of child contacts, and difficulty with IPT adherence.
Limited access to care
Providers reported that caregivers’ ability to bring children to health facilities for CCM was a challenge. In some villages, community-based village health workers (CB-VHW) provide child-related services, such as weighing children. Expanding such community-based services by VHW to include screening and follow-up of child contacts was viewed as potentially advantageous, especially for those experiencing long or difficult journeys to the health facility and in situations where caregivers lack the resources to bring the children for monthly follow-up appointments if IPT is initiated.
At times it is because these… [caregivers] come from far remote areas where transport issues hinder them from making several trips to the clinic. [LVHW, individual interview]
They will tell you that they walk long distances, so they cannot carry children from that far. [LVHW, individual interview]
Providers reported stock-outs and shortages of pediatric formulations of INH and vitamin B6, which make it difficult for them to provide IPT to children. Having to adjust adult doses to pediatric ones can be challenging as the INH pills have to be cut in two or four depending on the child’s weight. They indicated that availability of a reliable drug supply would facilitate IPT implementation.
The challenges are… inconsistent supply of appropriate drugs. [Nurse, individual interview]
It becomes very difficult for us. It [INH] takes a long time to be replaced. Also, to reduce the adult dose for children is so difficult. [Nurse, group interview]
Identification and screening of child contacts
Providers believed that identifying and screening children for TB was the main challenge and that once children come to the clinic, providing IPT is feasible. Community education and the CB-VHW were seen as pivotal to supporting caregivers to bring their children to the clinic for evaluation.
The problem is contacting or tracing of contacts. But those who have been inside here, there are no problems. [Nurse, group interview]
I usually ask the parent to come so that we have a one-on-one health talk so that I explain clearly the benefits of getting into the preventive therapy and the risks of denying this therapy. So with persuasion, we see some do bring their children, but some are just hard-hearted and they don’t. [Nurse, individual interview]
In cases where caregivers do not bring in the child contacts for evaluation, CB-VHW are deployed to assist, and when they have difficulty tracing patients, the village chief is informed so that he can assist in finding them.
We use our CB-VHW to help us bring them. Those are the ones who assist us most of the time. [Nurse, group interview]
If they [CB-VHW] are unable to find and bring them, then we inform the village chief that we have a TB patient in his village and that we need [to assess] their children. [Nurse, group interview]
Nurses and LVHW emphasized the need for health education as they believed that community members do not recognize the importance of preventing TB in child contacts, including the need for infection control in situations where a presumptive or confirmed TB case has been identified in the household. Providers suggested that community-based health education can reach more people and have a greater impact, especially by strengthening the role of CB-VHW to educate families in the community.
We have to educate them… so that they understand why, because then if while a child is on IPT, it means it is a long period of time. [Nurse, group interview]
There is a need to go out to schools, during public gatherings, wherever we are able to go and reach out to provide health education. [Nurse, group interview]
We also ask the CB-VHW to give the health education at the village so that the parent will end up understanding that it is important to have the children on IPT. [Nurse, group interview]
Providers indicated that IPT adherence was another major challenge, possibly because of fear of the drug’s side effects such as a severe rash. To tackle this issue, they suggested continuous enhancement of health literacy for caregivers about the importance of adherence and the possibility of side effects from IPT.
The challenge is the child cannot come regularly. She comes once, skips a month. When you follow the child again, the child reappears so there is drug interruption. [Nurse, individual interview]
The challenge is that we find later after they have missed doses of IPT because of experiencing side effects. [Nurse, group interview]
When we compared attitudes of nurses and LVHW regarding challenges to CCM, LVHW were more focused on issues of access-to-care whereas nurses were more concerned about supply-chain issues.
Stigma was not reported as a CCM challenge. When providers were specifically questioned about the role that stigma plays, they indicated that stigma related to TB prevention is generally not perceived as an issue in the community. However, some providers acknowledged that stigma may play a role in some situations where caregivers did not bring children to the clinic. Others believed that lack of knowledge, not stigma, is the reason that caregivers did not bring children to the clinic. Providers felt that community health education campaigns could help to increase knowledge regarding TB and dispel any possible stigma.
TB these days is no longer stigmatized; everybody is willing… so they do not have a problem if you want to screen them in the community. [Nurse, group interview]
Not stigma as such, lack of knowledge maybe… I don’t think stigma is still a problem. [Nurse, individual interview]
It [IPT] won’t put them at risk of stigma because they would have accepted that their children should be initiated [on IPT]. [LVHW, individual interview]
Those who are bringing their children do not have the problem [stigma], but I could see or sense that these ones who don’t want to bring in their children, they think in some way of stigma. [Nurse, individual interview]