We present our findings on the factors that shape the integration of systematic screening into the OPDs of primary healthcare facilities. The themes have been organized around the constructs of Atun’s framework (30) on integration of health interventions into health systems, namely: characteristics of the problem, attributes of the intervention, the adoption system, the health system characteristics and the broader context (Table 2). Although data were collected from various participant categories, no major differences in the discussions were noted and views specific to a particular participant category are noted within the manuscript.
Factors that shape the integration of systematic screening for Tuberculosis in OPDs of primary healthcare facilities
1. Nature of the TB problem
Perception of the TB burden
It was interesting to find differing perceptions of the burden of TB among HCWs in the same healthcare facilities. Most clinicians perceived the TB burden to be high and considered TB to be a serious public health problem both at district and health facility level due to the high numbers of TB patients seen in the OPDs. The surrounding environment, mostly low social-economic housing from which these patients originated also played a role in driving TB. Some facility in-charges thought that the burden was lessening because of the effective community TB screening programs that had been implemented in the past. This perception of a high TB burden increased the index of suspicion for TB and facilitated integration as stated by a clinician:
“Looking at …the environment of this community and the number of [TB] cases that I see, I would say the burden is high and so I make sure I do my best...to catch them.” Clinician-02, LP
The facility in-charge from the same facility argued that;
“As for TB, I can say not so much. Why? Because we don't have a lot of TB patients due to various community screening programs conducted in the past.” IC-02, LP
2. The intervention
Alignment with HCWs’ training, skills and work schedules
Most HCWs agreed that the principles and concepts of the systematic screening for TB were relatively easy to understand and apply. They were within their in-service training and skills, making it easy for them to adopt and apply it. The compatibility of systematic screening for TB with clinicians’ and laboratory staff’s routine work schedule facilitated the integration process as they did not have to change the flow of patients.
“…our training is enough. Our work is not disturbed…We just need to keep in mind that we need to ask about TB in all patients who come through.” Clinician-06, LP
However, the intervention was not compatible in most cases with the pre-service training and work schedules of the appointed facility TB focal point persons who were all nurses. They had to adapt by learning completely new concepts such as TB drugs and their side effects, the treatment algorithms, follow-up of patients, reporting systems and templates through in-service trainings. Those who could not adapt well were thus unable to integrate the intervention into the OPDs. Moreover, some of them were still attached to and working in their routine departments thus having a divided work schedule which hindered full implementation and integration of systematic screening for TB into the OPD.
“I am a nurse but now I need to work like a clinical officer, I had to learn the drugs and how to treat a TB patient…through mentorship. I also write all the TB reports for the facility. I never thought I could change like this…” TB-FPP-01, HP
Complexity in screening of children
All clinicians noted that it was difficult to integrate systematic screening for children in the OPDs because children presented with atypical symptoms which were not included in the screening tools. In addition, children who suspected cases were unable to expectorate sputum and it was time-consuming and difficult to perform a gastric lavage. The additional time required to conduct the systematic screening for TB effectively created pressure of work, especially in high volume healthcare facilities, which was a barrier to integration.
“With the adults, it's a straightforward thing, but with the children, there are hiccups because they are presenting not with all the features of TB on the screening tools and lavage is time-consuming, difficult and uncomfortable.” Clinician-05, HP.
3. The adopting system
Stakeholders’ interests, values and power
Stakeholders’ knowledge of each other’s interests, values and power facilitated integration as stakeholders adopted activities and strategies in a bid to fulfill the interest of others which sustained the consistent implementation of the systematic screening for TB in the OPDs. For instance, the district team’s knowledge of the funders’ financial power and interest to achieve project targets and improve the district TB indicators encouraged them to ensure HCWs sustain TB screening and notification.
“Our partners want results…we are making sure that all our TB programs are done and the facilities are doing what they are supposed to do as far as TB screening and notifications are concerned.” Manager-01
Similarly, HCWs aligned their activities to the district and partners’ values and interests to meet the TB targets set for them in order to receive more funding and recognition. By so doing they increased the extent of assimilation of the systematic screening into the OPDs while meeting the community expectations of satisfactory TB services.
“Someone [a CBV] goes out …will collect any sputum… just to meet the quarterly target and get paid but that defeats science. So, we put more incentives for a positive TB result…for them to do it right always.” Lab-02, HP
Incentivization mechanisms
Most OPD clinicians noted that there was an imbalance in incentivization structures among the implementers of the intervention because the TB focal point persons in the health facilities enjoyed more incentives through workshops and trainings. The TB focal point persons would receive more recognition from the district team and funders for targets achieved than the clinicians. This incentivization mechanisms created differences which demotivated clinicians from routinely screening for TB and hindered sustainability of integration.
“…you see, these guys, the focal persons when they see that this workshop involves money, they will go, yet they don't screen. Instead of sending the actual people who screen the patients. …It is very demotivating...” Clinician-05, HP
Further, HCWs knowledge of the financial incentives provided to the CBVs in relation to meeting targets enabled the them to allocate more incentives to positive TB results than absolute numbers screened, thus maintaining quality through fidelity and encouraging integration.
External partners influence
Most facility level participants sited the ever-increasing influence of external partners in what activities were implemented when and who could be involved as a hinderance to the integration of systematic screening for TB in their health facilities. HCWs’ lack of involvement at the planning stage coupled with prioritization of funders’ activities over their own made them question the ownership of the TB screening program and the legitimacy of the TB screening targets given to them by the district and cooperating partners. The dependence on donor-funding for most of the TB programs including training of HCWs and TB screening activities seemed to validate their concerns of ownership. This compromised the acceptability, adoption and fidelity of the systematic screening for TB and its integration into the routine OPD services as it would be done only when it was closely supervised.
“Sometimes we have programs but partners come in with other programs... They even come with targets that we do not know where they came from…” IC-03, LP
4. Characteristics of the health system
Consistent and decentralized performance management
HCWs agreed that regular monitoring and supervision by the district team motivated them to consistently screen for TB in the OPD. Decentralizing this performance management to the health facilities through facility in-charges and heads of departments within the primary healthcare facilities was effective in ensuring fidelity and sustainability. The decentralized supervision further fostered the adoption of systematic screening for TB into all entry points of the health facility. Regular data reviews at facility level enabled quick adaptive measures and effective integration of TB screening into the OPDs.
“Before the district come...I am the center of the supervision for screening; but in each department, we have heads. So, with the help of those heads in those departments, we are the ones who are doing it... every head of the Department has been given the responsibility to ensure that such activities [TB screening] are going on every day.” TB-FPP-1, HP.
Continuous capacity building
Continuous capacity building through on-site mentorship of HCWs maintained high index of suspicion for TB and ensured compatibility of the intervention and fidelity at all times with less TB patients being missed. The competences built in the HCWs made them more confident to accept and adopt the systematic screening for TB into their routine work. Onsite mentorship within the facility was considered to be a good initiative for building capacity and fostered integration because it involved all HCWs and brought up contextualized solutions to challenges faced by HCWs in the integration process.
“…So, the onsite membership, for me, it has really helped us. … it makes me confident to do it [integrate systematic screening for TB into routine work]. They [the district mentorship team] keep on coming for mentorship and technical support… to maintain high suspicion index for TB…” IC-01, HP
Integrated outreach TB screening services
All participants noted that combining mobile TB screening services in the community with under-5 clinics and other periodic programs like child health week increased its acceptance in the health facilities which facilitated integration. Some TB focal point persons and facility in-charges further added that the use of CBVs and the involvement of traditional healers, who are trusted members of society, in referring suspected TB patients were found to be good ways of increasing demand and acceptability of the systematic screening for TB.
“So, when you use community members [CBVs] in outreach TB screening and education while doing other programs like under-5 clinics and child health week…It will be very easy for them to accept even when they come to the facility.” IC-03, HP
Negative health worker attitudes
Facility in-charges lamented over the lack of interest and poor attitude towards systematic screening for TB among some HCWs in the OPDs who only screened when there was someone monitoring them. This lack of interest in TB screening by the HCWs compromised their acceptance, adoption and consistent application of the intervention and thus was a barrier to its integration int the OPDs. The lack of interest bred a negative attitude towards patients making it hard for patients to accept TB screening.
“Some have no interest in screening for TB…because we may know how to screen quite alright but …if we don’t care how we treat them [patients]… can they accept it? …I think the main reason is just the attitude.” IC-04, LP
5. The Broader Context
Political will
District managers were encouraged by the political will from the government to ensure that all facilities had infrastructure, HCWs, commodities and equipment to provide TB screening services despite financial constraints. They stated that the provision of these supplies in the facilities would increase the integration of systematic screening for TB into the OPDs because the testing would be quicker and of good quality.
“…when you look at equipment and staff, I think we have been given. I think we have more than fifteen or so laboratories which are actually doing screening using the GeneXpert for instance, it has helped us to do tests faster and I think with quality... We may need more but I am saying… I think the government is doing quite well.” Manager-01
Socio-cultural misconceptions and gender norms
Most participants confirmed the persistent presence and negative effects of socio-cultural misconceptions despite the sensitizations on TB. Beliefs that TB was contracted by sleeping with a woman during their menses or by being bewitched prompted patients to seek help from traditional healers and reduced the acceptability of the systematic screening. The association of TB to HIV also propagated stigma which hindered people from screening for TB for fear of societal rejection and humiliation. Some TB focal point persons and facility in-charges noted that women were more affected by TB-associated stigma because society placed the “burden of marriage” on them. Most women would refuse to test for TB due to the possible consequences they would face from their partners such as shame, beatings and even divorce if they were found with it.
“…So even when you find them with TB, they wouldn't want to disclose to the partners because they are …scared that those partners may chase them away or divorce, or things like that. … some would …totally refuse to test.” IC-05, HP
The COVID-19 pandemic
All participants agreed that during the peak period of COVID-19 in the first and second quarters of 2020, OPD attendances, health education sessions and duration of clinical assessment reduced for fear of contracting the disease. The guideline not to wear masks while processing TB samples conflicted with the COVID guidelines to were masks at all times making laboratory personnel reluctant to process TB samples. Further, there was a shift in clinician concentration to COVID which compromised the integration of systematic screening for TB into the OPDs.
“…COVID has caused a lot of challenges … the concentration has slightly shifted…from these other causes… Instead …you tend to screen faster so that the patient leaves your room {laughing}.” Clinician-05, HP