Barriers to childhood tuberculosis case detection and management in Cambodia: the perspectives of healthcare providers and caregivers

We conducted a qualitative study between November and December 2020 in four operational districts of two provinces and the capital of Phnom Penh in Cambodia. The selection of respondents from the four operational districts was based on their knowledge score on childhood TB, reported in a quantitative survey. Cambodia’s public health system is divided into the national level (central), provincial level, and operational district level [14]. Operational districts provide management and technical support to referral hospitals, health centers, and health posts in providing health services, including TB care [14].

We purposively selected 16 healthcare providers with high knowledge scores about childhood TB, including four operational district TB supervisors, four TB clinicians, four TB nurses from the referral hospitals, and four TB nurses from health centers. The participants' childhood TB knowledge scores were determined based on the answers to the questions related to causes of TB, transmission routes, signs and symptoms, characteristics of lymph nodes that implied TB, diagnostic criteria for childhood TB, and TB prevention, such as how to prevent TB transmission, the use of TB preventive treatment (TPT), the target group for TPT, medicines used for TPT, contraindication of TPT, and possible side effects of TPT. The detailed knowledge score has been reported separately [15]. We recruited a convenience sample of 28 caregivers of children under 15 years old with previous or undergoing TB treatment and children in close contact with people with bacteriologically-confirmed pulmonary TB. Caregivers of children with close contact with TB index cases had experiences of accompanying the children under their care to undergo TB screening. Based on Cambodia’s national guidelines on latent TB infection, people with close contact with TB index cases, including children, are required to undergo TB screening. Caregivers who resided in the catchment area of selected health facilities and were 18 years old or older were eligible for the study. Healthcare providers pre-identified eligible caregivers, and the research team selected caregivers based on their availability and geographical convenience. Caregivers were persons who provided care to the children during sickness and accompanied them to seek health care, TB diagnosis, and treatment, not limited to parents and immediate family members. The recruitment of caregivers was done under the facilitation of local healthcare providers.

We developed semi-structured interview guides (see Additional file 1) in consultations with the Cambodia Committee for TB Research. The interview guides included questions on socio-demographic characteristics of respondents, barriers to childhood TB case detection and management, and barriers to TPT implementation among children. The findings on the barriers to TPT implementation have been reported in a separate manuscript. We used inductive approach to generate the themes on the barriers to childhood TB case detection and management. We pre-tested the tools before the actual data collection to ensure that the language used was contextually understandable, validate the content, estimate the interview time, and ensure data quality and the familiarity of the data collection teams with the tools.

Face-to-face in-depth interviews (IDIs) were conducted in Khmer by well-trained, experienced Cambodian interviewers with medical backgrounds. Prior arrangements were made with the participants. The interviews with healthcare providers were done at their working places and with caregivers at their houses. All interviews were conducted in a private room or place with audio recordings and field notes taken. It took between 30 to 40 min to complete the interview. During data collection, meetings were held at the end of each day to discuss the interview processes, including the interview content. The confirmation of data saturation was done during the data collection period.

Recorded data were transcribed verbatim and then translated into English. Key themes were verified against Khmer transcription, and data were analyzed using thematic analyses. First, we developed a codebook of themes based on the semi-structured interview guides. Then, we coded the transcripts manually through discussions between two researchers. We performed inductive thematic analysis and also considered emerging themes and sub-themes.

This study was approved by the National Ethics Committee for Health Research (NECHR) (ref. 234/NECHR) in Cambodia and the Ethics Review Committee of the World Health Organization Western Pacific Regional Office (WPRO-ERC 2020.8.CAM.3.STB). All participants provided written informed consent for the study. All methods were carried out in accordance with the Declaration of Helsinki. The objectives, procedures, risks, and benefits of participating in this study were explained to all participants. A written informed consent form was read or verbally explained to each participant, and written consent was obtained from all participants before the interviews. All data, including name, address, and personal information, were treated anonymously and strictly handled confidentially. Each participant received a compensation gift valued at about US$ 1 after the interview.

The characteristics of respondents are presented in Table 1. The mean age of healthcare providers was 40.2 years (SD 11. 9), and 93.8% were male. Among caregivers, the mean age was 47.9 years (SD 14.6), and 75.0% were female. Eight out of twenty-eight caregivers were grandparents, one-fourth had no formal education, and 60.7% were farmers. Three of out 28 or (10.71%) caregivers cared for more than one child.

Several healthcare providers reported a lack of human resources for TB as a barrier to providing TB services. The lack of human resources included a shortage of staff in charge of TB, limited staff capacity in childhood TB, and the lack of collaboration within the health facilities in providing TB services for children.

"But what is lacking for him [healthcare provider] is knowledge [on childhood TB], I want to say that the staff is new and has been trained late. Some staff took the role for about two to three years but had not yet received any training (both adult and childhood TB). So, this is the obstacle” (Operational district TB supervisor, IDI-1, female, 35).

"Our human resources are still lacking. From the beginning, I had not been involved with TB work. However, the hospital director transferred me to handle TB. By the time, TB training [childhood TB] was limited … our skills remained limited." (Doctor working at referral hospital, IDI-16, male, 35).

"The problem is TB screening. When the patients first come to the health centers, they go to the Outpatient Department or Triage section. The doctors don't help us screen the patients for TB unless he/she is a doctor in charge of TB. So, we lose the cases even we try hard to do it. Our aim is to screen TB for everyone with symptoms or with presumptive TB." (Operational district TB supervisor, IDI-7, male, 31).

Caregivers also perceived that the unavailability of staff in charge of TB at health facilities was a barrier to getting TB services. The shortage of service providers results in a long waiting time and multiple visits to get the services.

"It is also difficult … When my daughter reached the hospital, one doctor did not come to see her; other doctors did not come to see her. My daughter traveled three to four times to meet doctors successfully. The healthcare providers said the other doctors did not come when my daughter met one doctor. We traveled a long way from here to the hospital." (Caregiver IDI-4, female, 49, with an 11-year-old child on TPT).

“I waited from 9 AM until 12 PM to get the result. And they told me to get the medicines (for my kid) at the health center.” (Caregiver IDI-2, male, 40 with children aged 8 years old, 6 years old and 2 years old on TPT).

Almost all healthcare provider respondents reported a lack of TB diagnostic tools such as good quality chest X-ray machines, limited access to rapid molecular diagnostic systems such as the GeneXpert® MTB/RIF, low or irregular supplies of X-ray films, poor quality microscopes, and lack of other support materials for making TB diagnosis.

"…. because the X-ray machine is too old, we cannot take many pictures. So, when many children came, they had to wait for days to get X-ray." (Operational district TB supervisor, IDI-1, female, 35).

"We want to request GeneXpert® because it is easy for TB diagnosis. In this hospital, there is no film for X-rays. We bought X-ray films using the hospital’s budget. On the other hand there was a problem with microscopes in the hospital during this last period. The other day, we asked someone to check, and we also put a request to the upper level." (Operational district TB supervisor, IDI-2, male, 39).

Several challenges in providing TB services were also due to the low community participation and collaboration in TB case detection and management. This low involvement could be due to caregivers' movement or busyness, ignorance of providers' advice, poor understanding of TB in the community, or low-risk perception of TB.

“My challenge is from patients' families. They are busy. They work at the factories. They don't have enough time to take care of their children and cannot come to the hospital regularly. Sometimes, health center staff explain them, and volunteers bring them to the hospital and back, but they don't come. This happens because of the patients themselves…..sometimes, we refer them …….. they just say yes, yes, but in fact, they don't go". (Health center nurse in charge of TB, IDI-3, male, 31).

"Although we try hard to encourage parents to bring their kids for TB screening, only some of them listen to our advice and bring their kids to see us. … The most common reason is their economic status; their parents are too poor and have to immigrate to work in other countries. Thus, it isn’t easy to bring the kids to the hospital as appointed". (Doctor working at a referral hospital in charge of TB, IDI-9, male, 36).

“Another problem is related to their thought. Caregivers think that TB is not a serious issue. Therefore, they didn’t bring their kids to us for TB work up”. (Health center nurse in charge of TB, IDI-12, male, 28).

Providers reported a short period of childhood TB medicine unavailability due to poor or late distribution from higher levels. In addition, some childhood TB medicines had a short shelf-life. These interruptions of supplies posed challenges in providing treatment for childhood TB.

"For childhood TB treatment, the medicines [for childhood TB] were not available last semester. Medicines [for childhood TB] at the national TB program were unavailable, and central medical store (CMS) also did not supply because the medicines were out of stock." (Operational district TB supervisor, IDI-1, female, 35).

“During this last period, we faced problems with expired medicines for childhood TB. We requested the national TB program, but the delivery was late, so we requested it from the province. We then received some medicines [for childhood TB] from the provincial health department, but the medicines were almost expired … now, many medicines are in stock.” (Operational district TB supervisor, IDI-2, male, 39).

Caregivers similarly reported that the unavailability of childhood TB medicines was a barrier when accessing TB services.

"My husband was the one who went to get the medicines [for my son]. I only stayed at home. When he went to get the medicines, they ran out, so he did not get the medicines immediately. We got the medicines after the next few days." (Caregiver IDI-9, female, 32 with a 9-year-old child on TB treatment).

“Only one concern, when I go to get medicines… Normally, the doctor said TB medicines were out of stock, so he could not give me on time, so I am afraid that ….. since the doctor told me that taking TB medicines need to be well adhered, …. my kid may take medicines on and off (one day take, one day not), so he may need to restart the treatment.” (Caregiver IDI-1, female, 25 with a 4-year-old child on TB treatment).

In this study, eight out of 28 caregivers interviewed were grandparents. Both healthcare providers and caregivers reported that caregivers’ old age was a barrier in childhood TB case detection and management. One grandparent who took care of his grandchild with TB reported that it was difficult to bring his grandchild to the health center to get TB services since he was too old. Another caregiver, a grandmother of a child with TB, reported forgetting everything as she was too old. Healthcare providers reported similar constraint.

“…but it is difficult for me to travel there [health center] because I am old.” (caregiver IDI-2, male, 62 with a 5 years old child on TB treatment)

“The main challenge for childhood TB is identifying them as their parents move around for work, and it is not easy to refer them [children] to TB services because their grandparents are old and cannot come. In this village, almost 90% of the children are taken care of by elderly people when their parents go to work.” (Operational district TB supervisor, IDI-1, female, 35).

Several healthcare providers suggested that increasing community awareness and strengthening TB screening at triage, outpatient, and inpatient departments were key strategies for improving childhood TB detection. Improving contact investigation, performing active case detection, strengthening human resources, and providing incentive support were also suggested by a few healthcare providers to improve childhood TB case detection.

"We can go to the villages to provide health education. If a child is a presumptive TB case, ask him/her to get TB services at health centers or referral hospitals as soon as possible." (Operational district TB supervisor IDI-2, male, 39).

"….we have to provide health education to parents and caregivers. We must provide education to the local authorities if they have time. The chiefs of communes and village health support groups can participate and provide health education." (Health center nurse, IDI-5, male, 62).

"……. expanding the screening. As I said, doctors at the triage departments should ask if the patients have coughs because we want to capture 100% of presumptive TB cases. So, I want to refer the (presumptive TB) cases from the triage directly to the TB doctor. I want to screen as much as possible, even the patient with flu symptoms”. (Operational district TB supervisor, IDI-7, male, 31).

“….. first, I want my human resources to be stable. If the human resources are not stable as nowdays, then I do not know how to strengthen them because the staff always changes. I want to have TB staff who could stay longer”. (Operational district TB supervisor, IDI-7, male, 31).

This study has some limitations. First, reporting bias may occur since data were collected through face-to-face interviews. Second, this study collected the personal perspectives of healthcare providers and caregivers in Cambodia. Some identified barriers are context-specific for Cambodia or the selected study sites; hence they may not be directly generalized to other settings. Third, there was a gender imbalance among the respondents. Most caregiver participants (75%) were female and may experience fewer barriers to accessing childhood TB services than male caregivers. In Cambodia, men are usually the family’s breadwinners and may work far from home or health facilities resulting in difficulty accessing TB services during operating hours. Finally, recruiting caregivers by local healthcare providers may lead to selection bias. To reduce reporting bias, the interviewers reiterated the study’s objectives and the implications of the findings and reassured the participants regarding privacy and that whatever they said would not have any negative repercussions on them.