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Table 3 Challenges faced during the implementation of EXIT-TB Package

From: Implementation of evidence-based multiple focus integrated intensified TB screening to end TB (EXIT-TB) package in East Africa: a qualitative study

Challenges

Specific issues

Illustrative Quotes

Supply side challenges

Service delivery barriers

• Disorganized services

• Delayed consultations

• Short consultation time

• Missed screening

• Missed investigations

• Poor screening integration in routine care

• Limited space for TB services

• COVID-19 pandemic

The barriers were so many, but the main barrier was limited contact tracing after identifying patients and starting them on treatment. Since we had small human resources, very few contacts tracing was done, and some clients were not followed up very well (Clinician, Kenya)

The challenge emerged when COVID-19 started because we were told to close our facility for three months. After all, this was a dedicated COVID-19 care centre. Patients were shifted to another hospital (name) therefore we did not have time to serve them well (TB Focal Person, Tanzania)

The challenge was COVID-19. You see signs suggesting TB but when you look at the patient and ask some questions about TB there are no symptoms of TB but when you do the COVID-19 test it comes out positive. So, you need to go through both COVID-19 and TB registers (Clinical Officer, Uganda)

Human resource barriers

• Negativity towards the project due to unmet financial expectations

• Fear of TB infection among HCWs

• Inadequate staffing and workload

• Inadequate knowledge

• Fear among providers during COVID-19

• Inadequate financial motivation/incentives to HCWs

• Technical barriers

Inadequate expertise among some screeners

Inadequate expertise in operating some TB diagnostic equipment (e.g., GeneXpert machines)

Inadequate expertise in collecting sputum samples from children

Inadequate expertise for interpretation of CXR and absence of radiologists in some facilities

The health workers in (name) Hospital especially the clinicians at the OPD did not welcome the (EXIT-TB) package at the beginning. They were arguing that young children of 7 years and below are not allowed to undergo X-rays as they may face negative health consequences and they were telling us to get sputum samples instead. Nevertheless, those who were unable to provide samples were required to undergo chest X-Ray, but clinicians insisted that it will hurt them if they are aged between 5 and 9 years. This created a disagreement for some time but later the EXIT-TB focal person and District TB focal person enlightened them on the purpose of the study, and that chest is also used routinely to diagnose diseases even among young children, and later started showing cooperation by accepting children for X-Ray services (CHW, Uganda)

The challenge was a negative attitude among providers towards TB disease; I don't know why. But the attitude of healthcare workers towards TB disease is so negative. Not many HCWs are interested in offering TB care.… healthcare workers sometimes neglect TB cases (because of fear of infection) and this also makes it difficult to treat them (Stakeholder, Uganda)

What I can say is the people who were helping us in the identification of clients lacked the technical skills. Therefore, we needed frequent mentorship to improve their knowledge and smoothen the implementation of the program (OPD Incharge, Uganda)

The unavailability of radiologists for urgent cases was a challenge. As a physician, I could go to the X-Ray room and read the results correlating with patients’ symptoms. But other health professionals-health officers and Nurses, might not be able to read the result. Thus, the availability of full-time radiologists or training other cadres was very important (Physician, Ethiopia)

Equipment and supply barriers

• Inadequate supply of stool containers particularly in Tanzania;

• Absence of X-ray machines or dysfunctional X-ray machines

• Stock-out of X-ray films and cartilages for GeneXpert machines

Equipment and supplies were troubling sometimes…., Sputum containers for children were inadequate. X-ray films were another barrier because we did not have enough expertise to read X-rays and we had to go where there is a screen (TB Focal person, Tanzania)

For children under five years of age, we were taking stool samples for testing in the laboratory and if the results come out positive, we initiated treatment but if negative, s/he was counselled by the doctors. We screened young children by asking questions to their parents. We hand them with stool containers … but sometimes we run out of containers (CHW, Tanzania)

There were times when many patients were screened and sent for X-rays and GeneXpert, however, the radiologist couldn’t interpret the results from X-rays and therefore could not give the results on time…. There was also a shortage of supplies, shortage of x-ray films, malfunctioning of GeneXpert, cartilage shortage, X-ray machine failure and service interruption. Most of these challenges were because of machine failures (TB Focal Person, Ethiopia)

Demand side challenges

Negative clients’ behaviours

• Delayed care seeking

• Late clinic attendance

• Coming on non-clinic days

• Defaulting care

The challenge was that patients had less understanding of the disease which necessitated health education. Once you give education and direct them to screening points, some of them refuse because their understanding is poor. They thought that going for screening is an indication that they have TB therefore they started self-stigmatisation but after intensive education, this improved a little bit (TB Focal Person, Tanzania)

A major challenge within the community was a lack of awareness about the disease. They correlated any weight loss with HIV infection. Also, some of us believe that TB might expose us to stigma and discrimination (EXIT-TB patient, Ethiopia)

[Patients] fear (to screen) because of fear of stigmatization because they have TB symptoms. You find people fear saying that maybe they have a cough. But we used health education sessions to minimise the fears. People with TB symptoms were separated and seen quicker to reduce the rate of maybe transmission if they have TB” (Clinical Officer, Kenya)

[Patients] fear (to screen) because of fear of stigmatisation because they have TB symptoms. You find people afraid to say that maybe they have a cough. But we used health education sessions to minimise the fears. People with TB symptoms were separated and seen quicker to reduce the rate of maybe transmission if they have TB” (Clinical Officer, Kenya)

Another challenge is when you are told to go do an X-ray in a different facility because there are no such services in the screening facility. Some of us could not go to the referral facility because of high transport costs (EXIT-TB patient, Uganda)

Limited community awareness and negative beliefs and fears

• Poor knowledge of TB diagnosis, treatment, and prevention

• Equating screening to having a TB infection

• Fear of coming to the facility

• Fear of stigma

Financial barriers

• Failure to meet the cost of care

• Failure to meet the cost of transport