Skip to main content
Download PDF
Download ePub

Integration of COVID-19 and TB screening in Kampala, Uganda: healthcare provider perspectives

Implementation Science Communications volume 4, Article number: 8 (2023) Cite this article

Abstract

Background

Following the first wave of the COVID-19 outbreak, Uganda experienced a 40% drop in tuberculosis (TB) screening by June 2020. We sought to identify barriers to and facilitators of integrated COVID-19 and TB screening from the perspective of healthcare providers (HCPs) at a National Referral Hospital in Kampala, Uganda.

Design/methods

We conducted a cross-sectional study using in-depth interviews with 12 HCPs involved in TB activities in the outpatient and emergency departments at Kiruddu National Referral Hospital, Kampala, Uganda. We explored the HCP experiences at work in the setting of COVID-19, HCP perceived effect of COVID-19 on TB screening activities at the hospital, and perceptions about social and contextual factors that might influence the willingness of HCP to integrate screening of COVID-19 and TB. We analyzed the data using an inductive thematic approach and we denoted the emergent themes as barriers to and facilitators of COVID-19/TB integrated screening. We then mapped the themes to the Capability, Opportunity, Motivation, and Behavior (COM-B) model.

Results

The facilitators to integrated COVID-19 and TB screening included the availability of TB focal persons and already existing training forums at the hospital that could be utilized to strengthen the capacity of HCP to integrate COVID-19 and TB screening. The barriers included HCP’s inadequate knowledge on how to integrate screening of COVID-19 and TB, the absence of simple easy-to-use standard operating procedures and data collection tools for integrated screening, inconsistent supply of personal protective equipment (PPE), understaffing, and fear of contracting COVID-19 infection. The identified intervention functions to address the facilitators or barriers included education, persuasion, enablement, and training.

Conclusions

These findings provided a basis for designing contextually appropriate interventions targeting factors that are likely to influence HCP decisions and willingness to conduct TB screening in the context of COVID-19. Future studies should evaluate the effect of addressing these barriers to the integration of COVID-19 and TB as well as the effect of this on TB case finding in high-burden TB settings.

Peer Review reports

Background

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and is a disease of global concern since early 2020. In March 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic [1]. Since then, the global and local response to COVID-19 has caused severe disruptions to the service delivery for other diseases including tuberculosis (TB) [2,3,4,5,6]. The commonest symptoms of TB (fever and cough) are similar to those exhibited by COVID-19 patients [7], which may negatively affect people’s health-seeking behavior for fear of stigmatization [8, 9]. This may also make healthcare providers less receptive to patients presenting with COVID-19-like symptoms from other causes such as TB [10]. Furthermore, there is an increased prevalence and a higher fatality risk for TB/COVID-19 co-infection than with patients infected with COVID-19 alone [11].

Following the COVID-19 outbreak, as has been documented elsewhere [5, 6, 9], Uganda experienced a 40% drop in TB screening by June 2020, based on the unpublished Ministry of Health (MOH) programmatic data from the District Health information system version 2 (DHIS2) [12]. In response to this very significant drop in screening for TB, the National TB and Leprosy Program (NTLP) at the Uganda MoH developed a health facility TB management plan in the context of COVID-19. The plan included the development of an algorithm to integrate screening for COVID-19 and TB (COVID-19/TB screening algorithm) (Fig. 1). Using this algorithm, all patients who present to the health facility should be screened for COVID-19. For patients who screen positive for COVID-19, the MoH guidance on the management of COVID-19 suspects should be followed. Patients who screen negative for COVID-19 should subsequently undergo TB symptom screening using the TB intensified case finding guide. Patients with a positive TB symptom screen (presumptive TB cases) should be followed by confirmatory testing with Gene Xpert MTB/RIF (Xpert; Cepheid, USA).

Fig. 1
figure 1

Health facility tuberculosis (TB) management plan in the context of COVID-19 guidance by Uganda Ministry of Health (MoH)

Full size image

This qualitative study aimed to identify facilitators of and barriers to integrated COVID-19 and TB screening from the perspective of an HCP at a referral hospital in Kampala, Uganda, and map these onto the Capability, Opportunity, and Motivation model of Behavior (COM-B) and Behavior Change Wheel (BCW) framework to identify suitable intervention functions. We utilized the COM-B model to explore facilitators of and barriers to integrating COVID-19 and TB screening in behavioral terms. We chose the COM-B model, which forms part of the Behavior Change Wheel framework, to understand the capabilities, opportunities, and motivations for HCP to integrate screening of COVID-19 and TB.

The central principle for the COM-B is that changing any behavior requires changing capability, opportunity, and/or motivation to perform that behavior [12]. Thus, the COM-B model (Fig. 2) provides a coherent basis for exploring barriers to and facilitators [13]. This behavioral analysis based on the COM-B would inform the necessary interventions that need to be implemented to promote integrated screening of COVID-19 and TB among HCP. Furthermore, the COM-B model is key in understanding influences on individual behavior and in our case the HCPs who are the frontline stakeholders in conducting integrated screening of COVID-19 and TB.

Fig. 2
figure 2

The COM-B model of behavior. Adapted from the original figure (Michie et al.)

Full size image

The goal was to inform the design of a contextually appropriate strategy to integrate screening of COVID-19 and TB in Uganda.

Methods

Study design and setting

We conducted in-depth interviews between January 2021 and March 2021 with HCP involved in TB-related care activities (TB screening and treatment) at Kiruddu National Referral Hospital (KNRH) in Kampala, Uganda. KNRH is a 200-bed capacity hospital in Makindye Division, one of the five administrative units of Kampala, the Capital City of Uganda. The hospital specializes in Internal Medicine, burns, and plastic surgery and provides up to 500 outpatient consultations daily.

We used the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines in reporting this qualitative study [13] (see Additional file 1). The study received ethical approvals from The AIDS support organization (TASO) Research and Ethics Committee (TASO REC 082/2020-UG-REC-009) and the Uganda National Council of Science and Technology (HS1152ES).

Study participants and sampling

We purposively sampled HCP involved in TB-related care activities in the outpatient and emergency departments at KNRH. The maximum sample of HCP was determined by data saturation as proposed by Lincoln and Guba [14]. Lincoln and Guba propose a naturalistic inquiry as an alternative to traditional positivistic inquiry. This naturalistic inquiry is characterized by research in natural settings, purposive sampling, and inductive analysis.

We recruited different cadres of eligible HCP including medical officers, nurses, and TB community linkage facilitators. While observing the COVID-19 prevention guidelines, we approached HCP face to face as a group and we informed them that the goal of the study was to explore their perspectives that would inform the design of a contextually appropriate strategy to integrate screening for COVID-19 and TB.

Study instruments and data collection

We developed interview guides with open-ended questions, designed to explore barriers to and facilitators of integrated COVID-19 and TB screening as perceived by HCP involved in TB-related care activities at KNRH. These included questions about HCP work experience in the setting of COVID-19 (i.e., how COVID-19 activities had affected routine TB screening) and HCP perspectives regarding the integration of COVID-19 and TB screening (i.e., their thoughts on its importance, how it could be achieved at their departments, factors that could influence their decisions to accept it or not, concerns and likely challenges to the acceptability, feasibility, and scaling up the use of the COVID-19/TB screening algorithm).

The interview guide was drafted in English, piloted, and refined using a convenience sample of HCP at the hospital who were not participating in the study. Interviews with HCP lasted between 25 and 40 min. Informed verbal consent was obtained from all participants. All interviews including the informed verbal consent were audio-recorded and transcribed verbatim.

All transcripts were de-identified and stored in a secure digital folder accessible only by the research team.

Research team

All interviews were conducted at the Kiruddu National Referral Hospital, a setting familiar to study participants, by the local study team. The team comprised social scientists, implementation scientists, physicians, national TB policy implementers, and other health scientists. A Masters-trained social scientist (DK, male) trained the team before the data collection and supervised the data collection process. A bachelor’s trained social scientist (MM, female) conducted the initial interviews with healthcare providers while the study nurse (JN, female) attended the sessions to take notes. The social scientist and the study nurse conducted subsequent interviews with healthcare providers. The interviewers did not know the study participants before the study commencement.

Data analysis

Four members of the research team (FCS, RK, DK, and DO) analyzed the data using a thematic approach. We preferred thematic analysis because it is suitable for examining the perspectives of different research participants, highlighting similarities and differences, and generating unanticipated insights [15]. We adopted an inductive approach using open coding that facilitated the identification of themes within the data. Initially, two analysts (RK, DK) read three similar transcripts independently familiarizing themselves with the data and documenting thoughts on potential codes and themes. Thereafter, the transcriptions were exported to Atlas. ti version 8. The team (FCS, RK, DK, and DO) then met to debrief and compare the initial codes generated by each analyst. The team discussed coding discrepancies and resolved them among themselves. We developed a coding framework and applied it to the remaining transcripts. We noted the themes emerging during the coding processes and reviewed them in subsequent team meetings where we discussed and developed a consensus on the themes documented.

We categorized the emergent themes as either potential facilitators or barriers to integrating COVID-19 and TB screening. Themes that positively influenced integrating COVID-19 and TB screening were denoted facilitators, and those that negatively influenced integrating COVID-19 and TB screening were denoted barriers. We extracted specific quotations from the transcripts to illustrate verbatim expressions of matters that appeared important.

We developed a behavioral diagnosis by mapping the emergent facilitators and barriers onto their associated COM-B domains. We then used the Behavioral Change Wheel (BCW) framework to identify potential interventions to promote the facilitators of and overcome the barriers to integrating COVID-19 and TB screening.

Results

Demographic characteristics of study participants

Twelve healthcare providers participated in the interviews. They included seven medical doctors, three nurses, and two community linkage facilitators. Six healthcare providers (50%) were female. The duration in service at the current post ranged from 3 months to 8 years (median 2.25 years; IQR: 1.5–4 years).

Healthcare provider-reported facilitators of integrating COVID-19 and TB screening

Most healthcare providers reported that TB focal persons (health workers assigned to coordinate all TB-related activities at the health facility) [16] were available to support HCP to provide integrated screening for COVID-19 and TB. The presence of TB focal persons plays a facilitative role in the integration of screening for COVID-19 and TB through organizing, mentoring, encouraging, and influencing other HCP on the need for integrated COVID-19 and TB screening.

… Just like we have the TB focal persons that are already in existence. We have focal persons at the facility level, sub-health district, district, etc. The focal persons will support HCP to provide integrated screening for TB and COVID-19. (Medical Doctor at the hospital)

Healthcare providers also suggested that utilizing the already existing training forums at the health facility would strengthen the capacity of HCP to integrate COVID-19 and TB screening.

…... you will have to use existing workshops or mentorships and training for all the health workers to integrate COVID-19 and TB screening. (Medical Doctor at the hospital)

Healthcare provider-reported barriers to integrating COVID-19 and TB screening

Most HCP reported having knowledge gaps on how to screen for TB in the context of COVID-19. As a result of these knowledge gaps, HCPs could not easily differentiate TB and COVID-19 symptoms during screening due to the overlapping symptoms in both diseases.

My experience in screening TB in the presence of COVID-19 is that sometimes you may not be sure whether you are dealing with TB or COVID-19. Because the presentations are a bit similar…but where we have some doubts, we have been referring those clients for COVID-19 testing. (Nurse at the hospital).

The knowledge gaps may also have contributed to HCP’s tendency to put more emphasis on screening for COVID-19 than TB.

….COVID-19 has masked the TB. People have now put much emphasis on COVID-19 leaving out TB. So we have seen some decline in the cases of TB cases. But it does not mean that these cases have gone down. (Medical Doctor at the hospital)

Although there was an existing TB screening tool and a recently developed COVID-19 screening algorithm, HCPs expressed a need for simple, easy-to-use standard operating procedures and data collection tools to integrate screening of COVID-19 and TB. The absence of a simple-to-use tool for integrated screening for COVID-19 and TB made it difficult to implement integrated screening.

If you have a very tedious tool for screening, they (HCP) may not do it because it consumes a lot of time. But if it is a simplified tool then it can be well utilized, it is easier to use. (Medical Doctor at the hospital)

The HCP also reported an inconsistent supply of personal protective equipment (PPE) as a constraint in integrating COVID-19 and TB screening. This caused HCPs to be less willing to screen patients for TB due to fear of contracting COVID-19 infection in the process.

If the government can equip the hospital with supplies like sanitizers, temperature guns, PPE. I think it would help health workers accept because they will know that at least our health is well protected (Nurse at the hospital)

The HCP also reported inadequate staffing levels, coupled with very busy outpatient and emergency departments at the hospital as a hindrance to the integrated screening of COVID-19 and TB. This is because the HCP perceived integrated screening for TB and COVID-19 as an additional workload to the already overworked staff.

One of the concerns is the heavy workload because at the end of the day… You find that it’s one person who is at the unit to do the screening of several patients. (Medical Doctor at the hospital)

We are still understaffed in most places because you have two nurses treating patients on the whole floor or level and yet they want to remove one nurse and take her somewhere else. (Medical Doctor at the hospital)

Even where there was an adequate supply of PPE, some HCPs were afraid of contracting COVID-19 infection during integrated screening for COVID-19 and TB due to a concern that integrated screening would increase their time of exposure to COVID-19 infection.

Anything to do with COVID-19, I don’t want to know, even the ones we are working with [health workers], if she reads a file and sees the word COVID-19 anywhere, that patient may not be seen and may not or delay to receive treatment…. (Nurse at the hospital)

Some healthcare providers also raised the concern of unclear compensation for health workers who contract COVID-19 while on duty. They added that their safety is a concern because they are likely to be infected with COVID-19 yet they will not be compensated. This is likely to demotivate HCP to conduct integrated screening of COVID-19 and TB.

Of course, people need allowances, without allowances they are not going to work [screen for COVID-19 and TB], actually for us we don’t have COVID-19 allowances at this hospital, because they say we don’t treat COVID-19 because it is in the communities, yet we treat COVID-19 here. Screening for both COVID-19 and TB is okay… (Medical Doctor at the hospital).

Healthcare provider-reported barriers to and facilitators of integrating COVID-19 and TB screening are summarized in Table 1.

Table 1 Healthcare provider-reported facilitators of and barriers to integrated COVID-19 and TB screening at Kiruddu National Referral Hospital, Kampala, Uganda
Full size table

Behavioral diagnosis and intervention functions

We categorized the reported barriers and facilitators of integrated COVID-19 and TB screening within the domains of the COM-B model to obtain the behavioral diagnosis. For example, identified barriers including lack of simple standard operating procedures for integrated screening of TB and COVID-19, inconsistent supply of PPE, and understaffing at the outpatient and emergency departments were mapped to the physical opportunity construct of the COM-B model. Table 2 summarizes the HCP-reported facilitators and barriers expressed in terms of their behavioral determinants within the COM-B model.

Table 2 Barriers to and facilitators for integrated COVID-19 and TB screening at Kiruddu National Referral Hospital mapped to the COM-B model
Full size table

We linked the behavioral diagnosis obtained using the COM-B model (Table 2) to the Behavioral Change Wheel (BCW) framework and identified appropriate potential intervention functions that could serve to address the reported barriers and facilitators and thereby enhance the acceptance of integrating screening of COVID-19 and TB. These are summarized in Tables 3 and 4. For example, HCP reported inadequate knowledge on how to integrate screening for COVID-19 and TB. As summarized in Table 5 using education and training as intervention functions, HCP can be equipped with the necessary knowledge and skills through training sessions. Similarly, using enablement as an intervention function, HCP can be provided simplified standard operating procedures for integrated screening of COVID-19 and TB, provided an adequate supply of PPE, and improve the staffing levels in these departments as enablers to facilitate integrated screening for COVID-19 and TB.

Table 3 Summary of identified facilitators and linked intervention functions
Full size table
Table 4 Summary of identified barriers and linked intervention functions
Full size table
Table 5 Summary of potential strategies for each intervention function to address identified barriers to integrated COVID-19 and TB screening at Kiruddu National Referral Hospital
Full size table

Discussion

In this formative cross-sectional study, we explored HCP work experience in the setting of COVID-19, the perceived effect of COVID-19 on TB screening, and perceptions about social and contextual factors that might influence their willingness to screen for both diseases at Kiruddu National Referral Hospital, Kampala, Uganda. We utilized the COM-B model to explore barriers to and facilitators of integrating screening for COVID-19 and TB [17].

We found that COVID-19 was a real threat to the provision of TB services since HCP at this large hospital were not very well prepared to integrate COVID-19 and TB services at the time. The key barriers to integrating COVID-19 and TB screening included a lack of simple standard operating procedures for integrated screening of COVID-19 and TB, inconsistent supply of PPE, understaffing, and HCPs’ fear of contracting COVID-19 infection. The key facilitators for integrating COVID-19 and TB screening included the availability of TB focal persons to support HCP to provide integrated screening for COVID-19 and TB and already existing training forums at the hospital. These would be utilized to strengthen the capacity of HCP to integrate screening for both COVID-19 and TB.

Many of the HCP also reported a lack of simple-to-use tools such as standard operating procedures, screening algorithms, and data collection tools to support integrated screening of COVID-19 and TB. Simple tools in the form of protocols have been shown to facilitate the integration of different programs in clinical settings [18, 19].

Generally, the HCP reported a lack of consistent supply of PPE, and most of them feared contracting the COVID-19 infection as hindrances to the provision of integrated screening for COVID-19 and TB. These fears expressed by the HCPs are consistent with what has been reported from studies in other settings [20,21,22]. Two studies have previously affirmed that appropriate provision of PPE, training in its appropriate use, and comprehensive and consistent guidance is fundamental in reducing the fear of contracting COVID-19 among HCPs [23, 24]. Some HCPs were not willing to evaluate patients suspected to have COVID-19 for TB. This, however, may not have huge negative implications on the wider care of patients with COVID-19 since it was expressed by only two out of the 12 HCPs interviewed for the study.

Our findings add to the growing evidence showing that countries and communities need to design contextually appropriate and stakeholder-informed strategies that adapt active case finding for TB during the COVID-19 pandemic for the continuity of TB services [25,26,27,28,29]. In a summary of three operation research studies conducted in the capital cities of three African countries (Kenya, Malawi, and Zimbabwe), Harries et al. assessed whether real-time monthly surveillance of TB and HIV activities compared with quarterly surveillance would minimize the anticipated negative impact of COVID-19 pandemic on TB and HIV services [30]. The three studies showed a decline of 31.2%, 40.6%, and 45.6% in the numbers of people presenting with presumptive pulmonary TB for investigation in the three respective countries for the two periods (March 2020–February 2021 compared to the immediate pre-COVID-19 period of March 2019–February 2020).

Following the institution of measures (integrated screening and fast-tracking of investigations for COVID-19 and TB in patients presenting with respiratory symptoms; active TB case finding in hot spots in the city and improved contact tracing in selected facilities) to improve TB case detection, there was only a 5% increase in the numbers of people presenting with presumptive pulmonary TB for investigation in Kenya. On the other hand, the numbers in Malawi and Zimbabwe remained far below the baseline period. However, these studies do not describe the steps taken to understand the perspectives of key stakeholders such as HCP in this setting and this might have contributed to suboptimal improvement in the target outcomes.

We utilized the identified facilitators for and barriers to the integrated screening of COVID-19 and TB, and the BCW intervention functions to develop strategies that can be easily implemented. We trained 37 HCPs on the COVID19-TB algorithm through a series of short interactive sessions to close the knowledge and skills gap [31]; we printed and distributed job aids of the COVID-19/TB algorithm and simple-to-use data collection tools at all the screening points to overcome the absence of guidelines on how to screen for TB in the context of COVID-19 and absence of tools for data collection, to promote integrated screening. Finally, we procured and distributed PPE to the HCP to overcome the lack of consistent supply of PPE and the related fear of contracting COVID-19 infections [23, 24].

The strength of our study is that it utilizes implementation science approaches including stakeholder engagement and the COM-B model in this formative assessment. We engaged the HCPs who are key stakeholders to understand the contextual factors that may affect their willingness to integrate screening for COVID-19 and TB. Several implementation science studies have demonstrated that engaging key stakeholders in the development of interventions leads to buy-in from the stakeholders and fosters ownership of the intervention and the intervention is more likely to be effective when compared to interventions that are designed without the involvement of the key stakeholder input [32, 33].

By using the widely applied COM-B model, we made a behavioral diagnosis of the possible challenges to implementing integrated screening for COVID-19 and TB. The framework also provides the behavioral change techniques, which we utilized to design contextually appropriate interventions.

A potential limitation of our study is that the findings from our study are from a single urban national referral hospital and some contextual factors may not be generalizable in different settings. However, many such centers in Uganda and other sub-Saharan African countries often have similar challenges [34, 35].

Another limitation of this study is the inability of us to explain the potential influence of organizational-level behavior on HCPs’ behavior and perceptions. The use of other models like the social-ecological model appreciates that individual behavior is a multifaceted and bidirectional relationship between individuals and their environments [36, 37]. As a result, individual behavior is affected by multiple levels of influence and can be shaped by the wider social environment. This formative study, however, focused on frontline HCPs, who were directly responsible for the delivery of the service. Therefore, using the COM-B, we were able to identify the key barriers to and facilitators of implementing integrated screening for COVID-19 and TB.

Lastly, perceptions do not always match up with behaviors and the COM-B model may not explicitly explain the link between perception and HCP behavior.

Conclusions

The findings of our study highlight the barriers to and facilitators for integrated COVID-19 and TB screening. These findings provide a key stakeholder-informed basis for designing contextually appropriate interventions targeting factors that are likely to influence HCP decisions and willingness to accept the use of this algorithm for integrated COVID-19 and TB screening in similar settings. Future studies should evaluate the effect of addressing these barriers to the integration of COVID-19 and TB as well as the effect of this on TB case finding in high-burden TB settings.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

BCW:

Behavior Change Wheel framework

COM-B:

Capability, Opportunity, Motivation, and Behavior

COVID-19:

Coronavirus disease 2019

HCP:

Healthcare provider

KNRH:

Kiruddu National Referral Hospital

MoH:

Ministry of Health

NTLP:

National TB and Leprosy Program

PPE:

Personal protective equipment

TB:

Tuberculosis

WHO:

World Health Organization

References

  1. Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed. 2020;91(1):157.

    Google Scholar 

  2. Global Fund. The impact of covid-19 on HIV, TB and malaria services and systems for health: a snapshot from 502 health facilities across Africa and Asia. 2021:18.

  3. Glaziou P. Predicted impact of the COVID-19 pandemic on global tuberculosis deaths in 2020. MedRxiv. 2021:2020–04.

  4. Cilloni L, et al. The potential impact of the COVID-19 pandemic on the tuberculosis epidemic a modeling analysis. EClinicalMedicine. 2020;28:100603.

    Article  Google Scholar 

  5. Thekkur P, et al. Assessing the impact of COVID-19 on TB and HIV programme services in selected health facilities in Lilongwe, Malawi: operational research in real time. Trop Med Infect Dis. 2021;6(2):81.

    Article  Google Scholar 

  6. Mbithi I, et al. Assessing the real-time impact of COVID-19 on TB and HIV services: the experience and response from selected health facilities in Nairobi, Kenya. Trop Med Infect Dis. 2021;6(2):74.

    Article  Google Scholar 

  7. Chen N, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507–13.

    Article  CAS  Google Scholar 

  8. Lubega M, J.E. Ekol Preparing communities to receive persons recently suspected or diagnosed with COVID-19. Pan Afr Med J. 2020;35(Suppl 2):21.

    Google Scholar 

  9. Chopra KK, Arora VK. Covid-19 and social stigma: role of the scientific community. Indian J Tuberc. 2020;67(3):284–5.

    Article  CAS  Google Scholar 

  10. Soko RN, Burke RM, Feasey HRA. Early Release-Effects of coronavirus disease pandemic on tuberculosis notifications. 2021.

  11. Wang Q, et al. Global prevalence, treatment and outcome of tuberculosis and COVID-19 coinfection: a systematic review and meta-analysis (from November 2019 to March 2021). BMJ Open. 2022;12(6):e059396.

    Article  Google Scholar 

  12. Haberer JE, et al. Alignment of adherence and risk for HIV acquisition in a demonstration project of pre-exposure prophylaxis among HIV serodiscordant couples in Kenya and Uganda: a prospective analysis of prevention-effective adherence. J Int AIDS Soc. 2017;20(1):21842.

    Article  Google Scholar 

  13. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.

    Article  Google Scholar 

  14. Lincoln YS, Guba EG. Naturalistic inquiry; 1985.

    Book  Google Scholar 

  15. Clarke V, Braun V, Hayfield N. Thematic analysis. Qualitative psychology: A practical guide to research methods. 2015:222–48.

  16. Uganda Ministry of Health, National Tuberculosis and Leprosy Program. Manual for management and control of tuberculosis and leprosy. 3rd Ed. 2017. Available from: https://www.health.go.ug/cause/manual-for-management-and-control-of-tuberculosis-and-leprosy-3rd-edition-march-2017/. Accessed 21 Oct 2022. 

  17. Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterizing and designing behaviour change interventions. Implement Sci. 2011;6(1):1–12.

    Article  Google Scholar 

  18. Maust A, et al. Severe and moderate acute malnutrition can be successfully managed with an integrated protocol in Sierra Leone. J Nutr. 2015;145(11):2604–9.

    Article  CAS  Google Scholar 

  19. Muddu M, et al. Improved hypertension control at six months using an adapted WHO HEARTS-based implementation strategy at a large urban HIV clinic in Uganda. BMC Health Serv Res. 2022;22(1):1–14.

    Article  Google Scholar 

  20. Liu Q, et al. The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. Lancet Glob Health. 2020;8(6):e790–8.

    Article  Google Scholar 

  21. Wahed WYA, et al. Assessment of knowledge, attitudes, and perception of health care workers regarding COVID-19, a cross-sectional study from Egypt. J Community Health. 2020;45(6):1242–51.

    Article  Google Scholar 

  22. Amin S. The psychology of coronavirus fear: are healthcare professionals suffering from corona-phobia? Int J Healthcare Manage. 2020;13(3):249–56.

    Article  Google Scholar 

  23. Cawcutt KA, Starlin R, Rupp ME. Fighting fear in healthcare workers during the COVID-19 pandemic. Infect Control Hosp Epidemiol. 2020;41(10):1192–3.

    Article  Google Scholar 

  24. Hoernke K, et al. Frontline healthcare workers’ experiences with personal protective equipment during the COVID-19 pandemic in the UK: a rapid qualitative appraisal. BMJ Open. 2021;11(1):e046199.

    Article  Google Scholar 

  25. Gidado M, et al. Early experience in implementation of an integrated COVID-19 and TB community-based active case finding. African J Respir Med. 2020;15(2):18–23.

  26. Malik AA, et al. Tuberculosis control and care in the era of COVID-19. Health Policy Plan. 2020;35(8):1130–2.

    Article  Google Scholar 

  27. Keene C, et al. How COVID-19 could benefit tuberculosis and HIV services in South Africa. Lancet Respir Med. 2020;8(9):844–6.

    Article  CAS  Google Scholar 

  28. Reid M. Tackling TB and COVID-19: US leadership is needed on global health, now more than ever. Public Health Action. 2021;11(2):53–4.

    Article  CAS  Google Scholar 

  29. Chan G, et al. Adapting active case-finding for TB during the COVID-19 pandemic in Yogyakarta, Indonesia. Public Health Action. 2021;11(2):41–9.

    Article  CAS  Google Scholar 

  30. Harries AD, et al. Real-Time Operational Research: Case Studies from the Field of Tuberculosis and Lessons Learnt. Trop Med Infect Dis. 2021;6(2):97.

  31. Argimon-Pallàs JM, et al. Effectiveness of a short-course in improving knowledge and skills on evidence-based practice. BMC Fam Pract. 2011;12(1):1–7.

    Article  Google Scholar 

  32. Hickey G, et al. Strengthening stakeholder buy-in and engagement for successful exploration and installation: a case study of the development of an area-wide, evidence-based prevention and early intervention strategy. Child Youth Serv Rev. 2018;91:185–95.

    Article  Google Scholar 

  33. Lowes L, et al. Involving lay and professional stakeholders in the development of a research intervention for the DEPICTED Study. Health Expect. 2011;14(3):250–60.

    Article  Google Scholar 

  34. Majer J, et al. Operational challenges and considerations for COVID-19 research in humanitarian settings: a qualitative study of a project in eastern Democratic Republic of the Congo and South Sudan. PLoS One. 2022;17(6):e0267822.

    Article  CAS  Google Scholar 

  35. El-Sadig SM, et al. Obstacles faced by healthcare providers during COVID-19 pandemic in Sudan. J Infect Dev Countries. 2021;15(11):1615–7.

    Article  CAS  Google Scholar 

  36. McLeroy KR, et al. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351–77.

    Article  CAS  Google Scholar 

  37. Stokols D. Translating social ecological theory into guidelines for community health promotion. Am J Health Promot. 1996;10(4):282–98.

    Article  CAS  Google Scholar 

Download references

Acknowledgements

The authors are grateful to the administration and staff at Kiruddu National Referral Hospital for their time and participation. We also thank the Government of Uganda through the Makerere University Research and Innovations Fund for providing the funding and the Uganda National Tuberculosis and Leprosy Program for supporting the study.

Funding

This study was supported by a grant from the Government of Uganda through the Makerere University Research and Innovation Fund (Mak RIF). Dr. Semitala’s training in implementation science was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43 TW010037. The funders had no role in the design, collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit this manuscript for publication.

Author information

Author notes

  1. Fred C. Semitala and Rodgers Katwesigye contributed equally to this work.

Authors and Affiliations

  1. Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda

    Fred C. Semitala & Rejani Lalitha

  2. Makerere University Joint AIDS Program (MJAP), Kampala, Uganda

    Fred C. Semitala, Rodgers Katwesigye, Dennis Kalibbala, Mary Mbuliro, Edgar Atine & Josephine Nassazi

  3. Kiruddu National Referral Hospital, Kampala, Uganda

    Darius Owachi

  4. Ministry of Health Uganda, National Tuberculosis and Leprosy Program, Kampala, Uganda

    Stavia Turyahabwe & Moorine Sekadde

Authors
  1. Fred C. Semitala
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rodgers Katwesigye
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dennis Kalibbala
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mary Mbuliro
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Rejani Lalitha
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Darius Owachi
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Edgar Atine
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Josephine Nassazi
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Stavia Turyahabwe
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Moorine Sekadde
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

FCS, RK, and MS designed the study. DK, ST, RLO, and EA oversaw the collection of data. MM and JN collected the data. FCS, RK, DK, and DO analyzed the data and wrote the manuscript with input from all authors. ST, MS, and RLO critically reviewed the manuscript. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Fred C. Semitala.

Ethics declarations

Ethics approval and consent to participate

This study received ethical approvals from the AIDS support organization (TASO) Research and Ethics Committee (TASO REC 082/2020-UG-REC-009) and the Uganda National Council of Science and Technology (HS1152ES). All participants provided informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1.

Consolidated Criteria for Reporting Qualitative Research (COREQ): 32-item checklist.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Semitala, F.C., Katwesigye, R., Kalibbala, D. et al. Integration of COVID-19 and TB screening in Kampala, Uganda: healthcare provider perspectives. Implement Sci Commun 4, 8 (2023). https://doi.org/10.1186/s43058-023-00391-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s43058-023-00391-w

Keywords

Implementation Science Communications

ISSN: 2662-2211