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Feasibility and Acceptability of a Comprehensive Childhood Tuberculosis Diagnostic Package at District Hospital and Primary Health Center Level in Low-Income Settings in Africa and South East Asia


Author: Joshi, Basant
Under the direction of: Joanna Orne-Gliemann et Olivier Marcy
Bordeaux University
English Language English text

Keywords : Epidemiology, Southeast Asia, Tuberculosis, Implementation research, Mixed methods, Decentralization, Resource-constrained countries, Southeast Asia, Africa.


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Tuberculosis (TB) is an infectious disease and a major global cause of morbidity and mortality. According to the 2022 Global tuberculosis report, out of 10.6 million estimated TB cases globally, only 6.4 million were notified to the World Health Organization (WHO). Only 54% of the five-year (2018-2022) treatment target of 3.5 million children was achieved in that four-year period. This indicates a large case detection gaps in adult and child TB. In children, the case detection gap is largely due to diagnosis challenges and difficulties in sample collection, that leads to diagnosis and treatment delays. In resource-limited settings, access to innovative sample collection and testing methods is limited at decentralized level, and poorly utilized for the diagnosis of TB in children. The TB-Speed Decentralization study was an operational research implemented in six countries of Sub-Saharan Africa and South East Asia with the aim to increase childhood TB diagnosis at low levels of care. My PhD research was embedded in its large implementation research programme, and aimed to assess the acceptability and feasibility of this diagnosis approach among Health Care Workers (HCWs). The TB-Speed decentralization study intervention was conducted at two levels. The patient-level component included a comprehensive childhood TB diagnosis package (systematic screening, naso-pharyngeal aspirates (NPA) and stool sample collection methods, microbiological testing using Xpert Ultra, chest X-Ray, referral of children and clinical evaluation). The health system level consisted in two distinct decentralization strategies, randomly allocated to one of the two districts included in each country. In the DH-focused district, the diagnosis of childhood TB was performed at DH for presumptive children found at DH and those referred from PHCs (n=4 in each district). In the PHC-focused district, the diagnosis of childhood TB was performed at DH as well as at PHC-level. We conducted a pre-post intervention mixed methods research, based on a Knowledge Attitudes Practices (KAP) survey and individual interviews with HCWs in the 59 health facilities, both approaches allowing for a comprehensive assessment of acceptability and feasibility, based on reported perceptions and experiences of the intervention. Knowledge levels on childhood TB were not very high pre-intervention, however HCWs reported positive attitudes and overall pre-intervention acceptability of the diagnosis approach. This was confirmed post-intervention, with overall positive experience reported on the delivery of each step of the diagnosis intervention. Pre-interventions concerns regarding foresee feasibility issues (both structural and organizational), around electricity cut-offs, insufficient human resources, workload and incentive management, were largely confirmed during the intervention phase. This work showed that although decentralizing childhood TB diagnosis is acceptable among HCWs, the latter also reported burden and feasibility issues that may challenge the effective implementation and scale-up of such interventions at low levels of care.