Acceptability of decentralizing childhood tuberculosis diagnosis in low-income countries with high tuberculosis incidence: experiences and perceptions from health care workers in sub-Saharan Africa and South-East Asia

Background Decentralizing childhood tuberculosis services, including diagnosis, is now recommended by the WHO and could contribute to increasing tuberculosis detection in high burden countries. However, implementing microbiological tests and clinical evaluation could be challenging for health care workers (HCWs) in Primary Health Centers (PHCs) and even District Hospitals (DHs). We sought to assess the acceptability of decentralizing a comprehensive childhood tuberculosis diagnosis package from HCWs’ perspective. Design/Methods We conducted implementation research nested within the TB-Speed Decentralization study. HCWs from two health districts of Cambodia, Cameroon, Côte d’Ivoire, Mozambique, Sierra Leone, and Uganda implemented systematic screening, nasopharyngeal aspirates (NPA) and stool sample collection with molecular testing, clinical evaluation and chest X-ray (CXR) interpretation. We investigated their experiences and perceptions in delivering the diagnostic package components in 2020-21 using individual semi-structured interviews. We conducted thematic analysis, supported by the Theoretical Framework of Acceptability. Results HCWs (n=130, 55% female, median age 36 years, 53% nurses, 72% PHC-based) perceived that systematic screening, although increasing workload, was beneficial as it improved childhood tuberculosis awareness. Most HCWs shared satisfaction and confidence in performing NPA, despite procedure duration, need to involve parents/colleagues and discomfort for children. HCWs shared positive attitudes towards stool sample-collection but were frustrated by delayed collection associated with cultural practices, transport and distance challenges. Molecular testing, conducted by nurses or laboratory technicians, was perceived as providing quality results, contributing to diagnosis. Clinical evaluation and diagnosis raised self-efficacy issues and need for continuous training and clinical mentoring. HCWs valued CXR, however complained that technical and logistical problems limited access to digital reports. Referral from PHC to DH was experienced as burdensome. Conclusion HCWs at DH and PHC-levels perceived and experienced decentralized childhood tuberculosis diagnosis as acceptable. Implementation however could be hampered by feasibility issues, and calls for innovative referral mechanisms for patients, samples and CXR. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT04038632 ### Clinical Protocols ### Funding Statement The TB-Speed Decentralization Study is funded by UNITAID. The funders and sponsor did not play any role in the study design data collection, data management, data analysis, data interpretation report writing or the decision to submit reports for publication. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Global: WHO Research Ethics Review Committee (WHO ERC) Sponsor: Inserm - Comité d'évaluation éthique de l'Inserm (CEEI-IRB) Cambodia: National Ethics Committee for Health Research Cameroon: National Ethics Committee on Human Health Research Côte d’Ivoire: Comité National d'Ethique de la Recherche Mozambique: Comité Institucional de Bioética para Saude do INS Comité Nacional de Bioética para a Saude (CNBS) Uganda: Uganda National Council for Science and Technology Joint Clinical Research Center REC Sierra Leone: Sierra Leone Ethics and Scientific review committee I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Not Applicable Study qualitative data will not be publicly available. Data can be made available by the sponsor (Inserm) to any researcher interested. Deidentified participant data can be made available and shared under a data transfer agreement. Requests for access to the TB-Speed Decentralisation study qualitative data should be sent to the corresponding author.