Barriers to tuberculosis case finding in primary and secondary health facilities in Ghana: perceptions, experiences and practices of healthcare workers

Abstract

Background Ghana’s national tuberculosis (TB) prevalence survey conducted in 2013 showed higher than expected TB prevalence indicating that many people with TB were not being identified and treated. Responding to this, we assessed barriers to TB case finding from the perspective, experiences and practices of healthcare workers (HCWs) in rural and urban health facilities in the Volta region, Ghana. Methods We conducted structured clinic observations and in-depth interviews with 12 HCWs (including five trained in TB case detection) in four rural health facilities and a municipal hospital. Interview transcripts and clinic observation data were manually organised, triangulated and analysed into health system-related and HCW-related barriers. Results The key health system barriers identified included lack of TB diagnostic laboratories in rural health facilities and no standard referral system to the municipal hospital for further assessment and TB testing. In addition, missed opportunities for early diagnosis of TB were driven by suboptimal screening practices of HCWs whose application of the national standard operating procedures (SOP) for TB case detection was inconsistent. Further, infection prevention and control measures in health facilities were not implemented as recommended by the SOP. HCW-related barriers were mainly lack of training on case detection guidelines, fear of infection (exacerbated by lack of appropriate personal protective equipment [PPE]) and lack of motivation among HCWs for TB work. Solutions to these barriers suggested by HCWs included provision of at least one diagnostic facility in each sub-municipality, provision of transport subsidies to enable patients’ travel for testing, training of newly-recruited staff on case detection guidelines, and provision of appropriate PPE. Conclusion TB case finding was undermined by few diagnostic facilities; inconsistent referral mechanisms; poor implementation, training and quality control of a screening tool and guidelines; and HCWs fearing infection and not being motivated. We recommend training for and quality monitoring of TB diagnosis and treatment with a focus on patient-centred care, an effective sputum transport system, provision of the TB symptom screening tool and consistent referral pathways from peripheral health facilities.

Barriers and motivation for presumptive tuberculosis case referral: qualitative analysis among operators of community medicine outlets in Ghana

“…The lack of TB training could partly explain why over 30% of our participants attributed their non-referral to not having seen a presumptive TB case yet, which is reflected by the high number of respondents who could not give the right case definition. Although staff turnover was highlighted as creating a knowledge gap in TB case detection in a study on barriers to TB case finding in Ghana [24], this did not come up as a barrier to referral in our study. Of the respondents, 10.5% and 26.3% in the pre-defined and free text responses respectively attributed non-referral to a lack of financial support by the TB programme leading to some operators reporting to have to bear the cost of transportation for the customers they referred.…”

Tuberculosis infection prevention and control in rural Papua New Guinea: An evaluation using the Infection Prevention and Control Assessment Framework

“…Limited infrastructure is not unique to PNG; other studies in South Africa, Pakistan, China, and Bangladesh found that inadequate isolation and ventilation facilities in healthcare facilities have limited the operationalization of recommended TB-IPC measures(35, 36). Another similar situation was observed in Ghana, where similar shortcomings increased TB transmission(37). A continuing lack of essential health infrastructure, such as a TB ward in district hospitals, will signi cantly impact TB-IPC strategies and, in turn, the development and transmission of TB among patients, HCWs, and communities.…”

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

“…Lack of community awareness about tuberculosis was reported as one of the factors related to delays in care seeking for tuberculosis and diagnosis in a study conducted in Indonesia [34]. Many HCWs further reported that stigma associated with tuberculosis and fear of COVID-19 may have prevented parents from accurately reporting on symptoms among their children at screening, as was shown recently in Ghana [35]. Transport, distance, and electricity supply were repeatedly mentioned as barriers to the acceptability of decentralization, hampering referral of patients – including for chest X-Ray, samples and test results between PHCs and DHs, in both directions.…”