Integration of COVID-19 and TB screening in Kampala, Uganda - Healthcare provider perspectives.

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Fred C Semitala, Rodgers Katwesigye, Dennis Kalibbala, Mary Mbuliro, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1448831/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Jan, 2023 Read the published version in Implementation Science Communications → Version 1 posted 8 You are reading this latest preprint version Abstract Background: Following the first wave of 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 (HCP) at a National Referral Hospital in Kampala, Uganda. Design/Methods: We conducted a cross sectional study using in-depth interviews with 12 HCP 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 the emergent themes were denoted 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; HCP knowledge of how to separately screen for TB and COVID-19, availability of TB focal persons and interest in learning how to provide integrated screening for TB and COVID-19. The barriers included; HCP inadequate knowledge on how to integrate screening of TB and COVID-19, absence of simple standard operating procedures and data collection tools for integrated screening, inconsistent supply of personal protective equipment (PPE), under staffing, 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 provide 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. Tuberculosis COVID-19 healthcare providers integrated screening Figures Figure 1 Figure 2 Contributions To The Literature We utilized the widely used and validated COM-B model to assess determinants of integrated COVID-19 and TB screening at a national referral hospital To our knowledge, this is the first qualitative study to explore barriers and facilitators to integrated screening of TB and COVID-19 using the COM-B model. The barriers and facilitators identified provide a basis for developing stakeholder informed and contextually appropriate interventions targeting factors that are likely to influence HCP’s decisions and willingness to conduct TB screening in the context of COVID-19. 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 – 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 of patients presenting with COVID-19 like symptoms from other causes such as TB[ 10 ]. Following the COVID-19 outbreak, like has been documented elsewhere [ 9 , 11 , 12 ], Uganda experienced a 40% drop in TB screening by June 2020; based on the unpublished Ministry of Health programmatic data from the District Health information system version 2 (DHIS2)[ 13 ]. In response to this very significant drop in screening for TB, the National TB and Leprosy Program (NTLP) at the Ministry of Health (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, ret 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 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). The aim of this qualitative study was to identify facilitators of and barriers to integrated COVID-19 and TB screening from the perspective of HCP at a Referral Hospital in Kampala, Uganda and map these onto the COM-B model and Behavior Change Wheel (BCW) framework to identify suitable intervention functions. We utilized the Capability, Opportunity, Motivation - Behavior (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 [ 14 ]. Thus, the COM-B model (Fig. 2 ) provides a coherent basis for exploring barriers to and facilitators [ 15 ]. 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 amongst HCP. 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[16] (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[17]. We recruited different cadres of eligible HCP including medical officers, nurses and TB community linkages facilitators. While observing the COVID-19 prevention guidelines we approached HCP face to face and we informed all of them that the goal of the study was 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), HCP perspectives regarding 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 COVID19-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 to 40 minutes. 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 of 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 health care 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 prior to 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 [14, 16] We adopted an inductive approach using open coding that facilitated the identification of themes in 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 and then exported the transcriptions to Atlas.ti version 8. The team then met to debrief and compare the initial codes generated by each analyst. We discussed Coding discrepancies and resolved with the other members of the research team (FCS and DO). 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 linkages 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 HCP reported having knowledge of how to screen for TB and COVID-19 as independent diseases. “My experience in screening TB in the presence of COVID-19 is that some times 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) “So, of course COVID-19 has masked the TB and screening of TB. People have now put much emphasis on COVID-19 leaving out the TB. So we have seen some decline in the cases of TB cases. But it does not mean that these cases have gone down, But because people have put much emphasis on COVID-19 leaving out TB.” (Medical Doctor at the hospital) Most healthcare providers reported that TB focal persons were available to support HCP to provide integrated screening for TB and COVID-19. “… 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 and the rest. So, having the focal persons take up another responsibility could also be another key issue for implementation because you may tell people; you conduct your workshop then you leave.” (Medical Doctor at the hospital) Healthcare providers also mentioned that having training, mentorships and workshops will help build the capacity for people to understand the relevance of integrated COVID-19 and TB screening. “The most important thing is knowledge, so you have to give out knowledge. Dispense knowledge to the health workers which means you will have to have a lot of workshops or maybe mentorships throughout the country and training for all the health workers to do the activity.” (Medical Doctor at the hospital) Healthcare provider-reported barriers to integrating COVID-19 and TB screening Most HCP reported a lack of simple Standard operating procedures and data collection tools to integrate screening of TB and COVID-19. Healthcare provider-reported barriers to and facilitators of integrating COVID-19 and TB screening are summarized in Table 1. “…So, you find depending on the workload of the staff. If you have a very tedious tool for screening, they 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 easy to maneuver throug h. ” (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. “If it can be facilitated, it is better but also how long that is not sustainable. If the government can equip the hospital with SOP equipment like sanitizers, temperature guns, like PPE, gloves, cotton. I think it would help health workers accept because they will know that at least our health is well protected” (Nurse at the hospital) HCP also reported inadequate staffing levels, coupled with very busy outpatient and emergency departments at the hospital as a hindrance to integrated screening of COVID-19 and TB. “One of the concerns is the heavy workload because at the end of the day, doing two things at ago while in PPE and 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) Most HCP feared contracting COVID-19 infection during integrated screening of COVID-19 and TB. “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 will not be seen, treatment will not be given. For me with COVID-19, this government does not care for people, doesn’t care for health workers in case you fall a victim.” (Nurse at the hospital) Most 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 won't be compensated. “.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 COVID-19 is in the communities, yet we treat COVID-19 here. That’s one of the factors that limits health worker involvement in screening for COVID-19. Screening for both is okay, but for COVID-19, most health workers are not interested.” (Medical Doctor at the hospital). 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 personal protective Equipment (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. We linked the behavioral diagnosis obtained using the COM-B model (Table 2) to the behavioral change wheel (BCW) framework and identified appropriate potential interventions 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 Table 3 and Table 4. For example, HCP reported inadequate knowledge on how to integrate screening of TB and COVID-19. 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 simple standard operating procedures for integrated screening of TB and COVID-19, provided adequate supply of PPE and improving the staffing levels in these departments as enablers to facilitate integrated screening for TB and COVID-19. Discussion In this formative cross-sectional study, we explored HCP work experience in the setting of COVID-19, 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 COVID-19 and TB screening[ 15 ]. We found that COVID-19 was a real threat to TB related services since HCP at this large hospital were not very well prepared to integrate TB and COVID-19 services at the time. The key potential barriers to integrating COVID-19 and TB screening included; Lack of simple standard operating procedures for integrated screening of TB and COVID-19, Lack of consistent supply of personal protective Equipment (PPE), Understaffing and HCP fear of contracting COVID-19 infection. The key potential facilitators for integrating COVID-19 and TB screening included; availability of TB focal persons to support healthcare providers to provide integrated screening for TB and COVID-19 and their interest and goodwill to be supported and trained to provide integrated screening for TB and COVID-19. Most HCP had knowledge of how to screen for TB and COVID-19 however; they also reported lack of simple tools such as Standard operating procedures, screening algorithms and data collection tools to support integrated screening of TB and COVID-19. Simple tools such as protocols have been shown to facilitate integration of different programs in clinical settings[ 18 ]. Generally, the HCP reported lack of consistent supply of PPE and most of them feared contracting the COVID-19 infection if they were to provide 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 [ 19 – 21 ]. Our findings add to the growing evidence showing that countries and communities should design contextually appropriate and stakeholder informed interventions that adapt active case finding for TB during the COVID-19 pandemic for continuity of TB services [ 22 – 26 ]. In a summary of three operation researches conducted in the capital cities of three African countries (Kenya, Zimbabwe and Malawi), to assess whether a real-time monthly surveillance of TB and HIV activities instead of the usual quarterly surveillance might help to counteract the anticipated negative impact on TB and HIV services, Harries et al [ 27 ] demonstrated that there was a decline of 31.2%, 45.6% and 40.6% in the numbers of people presenting with presumptive pulmonary TB for investigation in the three respective countries from March 2020–February 2021 compared to the immediate pre COVID-19 period of March 2019–February 2020. Following the institution of measures 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 while the numbers in Zimbabwe and Malawi remained far below the baseline period. These studies however, do not describe the steps taken to understand the perspectives of key stakeholders such as HCP in this setting and this may have resulted in suboptimal outcomes. We have utilized the identified facilitators for and barriers to integrated screening of COVID-19 and TB and the BCW intervention functions to develop the following interventions that are currently being implemented. We have trained 37 HCP on the COVID19-TB algorithm through a series of short interactive sessions to close the knowledge and skills gap; we have printed and distributed job aids of COVID-19-TB algorithm and data collection tools at all the screening points to overcome absence of guidelines on how to screen for TB in the context of COVID-19 and absence of tools for data collection; we have procured and appropriately distributed PPE to the health care providers to overcome the lack consistent supply of PPE and fear of contracting COVID-19 infections. The Strengths 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 HCP who are key stakeholders to understand the contextual factors that may affect their willingness to integrate screening of 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, fosters ownership of the intervention and the intervention is more likely to be effective when compared to interventions that are designed without key stakeholder input. 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. The findings from our study are from a single urban national referral hospital and some contextual factors may not be generalizable in different settings. Conclusions The findings of our study highlight the barriers to and facilitators for integrated COVID-19 and TB screening and 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 to use of this algorithm for integrated COVID-19 and TB screening in Uganda and other low and middle income countries. Future studies should evaluate the effect of addressing these barriers to integration of COVID-19 and TB as well as the impact of this on TB case finding in high burden TB settings. Abbreviations BCW: Behavior Change Wheel framework COM-B: Capability Opportunity Motivation Behavior COVID-19: Coronavirus disease 2019 HCP: Health Care Providers 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 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 Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests 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’s contributions: FCS, RK and MS designed the study. DK, ST, RO 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 RO critically reviewed the manuscript. All authors read and approved the final manuscript. 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. References Cucinotta, D. and M. Vanelli, WHO declares COVID-19 a pandemic. Acta Bio Medica: Atenei Parmensis, 2020. 91 (1): p. 157. GlobalFund, 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. Glaziou, P., Predicted impact of the COVID-19 pandemic on global tuberculosis deaths in 2020. MedRxiv, 2020. Cilloni, L., et al., The potential impact of the COVID-19 pandemic on the tuberculosis epidemic a modelling analysis. EClinicalMedicine, 2020. 28 : p. 100603. 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Atkins, and S. de Lusignan, Applying the COM-B behaviour model and behaviour change wheel to develop an intervention to improve hearing-aid use in adult auditory rehabilitation. International journal of audiology, 2016. 55 (sup3): p. S90-S98. Michie, S., M.M. Van Stralen, and R. West, The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science, 2011. 6 (1): p. 1-12. Tong, A., P. Sainsbury, and J. Craig, Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care, 2007. 19 (6): p. 349-357. Lincoln, Y.S. and E.G. Guba, Naturalistic inquiry. 1985. Maust, A., et al., Severe and moderate acute malnutrition can be successfully managed with an integrated protocol in Sierra Leone. The Journal of nutrition, 2015. 145 (11): p. 2604-2609. Liu, Q., et al., The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. The Lancet Global Health, 2020. 8 (6): p. e790-e798. Wahed, W.Y.A., et al., Assessment of knowledge, attitudes, and perception of health care workers regarding COVID-19, a cross-sectional study from Egypt. Journal of community health, 2020. 45 (6): p. 1242-1251. Amin, S., The psychology of coronavirus fear: Are healthcare professionals suffering from corona-phobia? International Journal of Healthcare Management, 2020. 13 (3): p. 249-256. Gidado, M., et al., Early experience in implementation of an integrated COVID-19 and TB community-based active case finding in Nigeria. African Journal of Respiratory Medicine, 2020. 15 (2). Malik, A.A., et al., Tuberculosis control and care in the era of COVID-19. Health Policy and Planning, 2020. 35 (8): p. 1130-1132. Keene, C., et al., How COVID-19 could benefit tuberculosis and HIV services in South Africa. The Lancet Respiratory Medicine, 2020. 8 (9): p. 844-846. Reid, M., Tackling TB and COVID-19: US leadership is needed on global health, now more than ever. Public Health Action, 2021. 11 (2): p. 53-54. Chan, G., et al., Adapting active case-finding for TB during the COVID-19 pandemic in Yogyakarta, Indonesia. Public Health Action, 2021. 11 (2): p. 41-49. Harries, A.D., et al., Real-Time Operational Research: Case Studies from the Field of Tuberculosis and Lessons Learnt. Trop Med Infect Dis, 2021. 6 (2). Tables Table 1 Healthcare provider-reported facilitators of and barriers to integrated COVID-19 and TB screening at Kiruddu National Referral Hospital Kampala, Uganda. Potential facilitators Potential barriers Healthcare providers have knowledge of how to screen for TB and COVID-19 as independent diseases “My experience in screening TB in the presence of covid-19 some times you could 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) Healthcare Providers lacked adequate knowledge on how to integrate screening of TB and COVID-19 “So of course COVID_19 has masked the TB, screening of TB. people have now put much emphasis on COVID_19 leaving out the TB. So we have seen some decline in the cases of TB cases. But it does not mean that these cases have gone down, But because people have put much emphasis on COVID_19 leaving out TB.” ( Medical Officer at the hospital ) TB focal persons are available to support Healthcare providers to provide integrated screening for TB and COVID-19 “… 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 and the rest. So having the focal persons take up another responsibility could also be another key issue for implementation because you may tell people, you conduct your workshop then you leave.” ( Medical Officer at the hospital ) Lack of simple Standard operating procedures for integrated screening of TB and COVID-19 “…So you find depending on the workload of the staff. If you have a very tedious tool for screening, they may not because it consumes a lot of time. But if it is a simplified tool then it can be well utilized, it is easy to maneuver throug h. ” ( Medical Officer at the hospital ) Healthcare providers are interested in being supported to provide integrated screening for TB and COVID-19 “The most important thing is knowledge, so you have to give out knowledge. Dispense knowledge to the health workers which means you will have to have a lot of workshops or maybe mentorships throughout the country and training for all the health workers to do the activity.” ( Medical Officer at the hospital ) Lack of consistent supply of personal protective Equipment (PPE) “If it can be facilitated, it is better but also how long that is not sustainable. If the government can equip the hospital with SOP equipment like sanitizers, temperature guns, like PPE, gloves, cotton. I think it would help health workers accept because they will know that at least our health is well protected” ( Nurse at the hospital ) Understaffing at the outpatient and emergency departments “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 Officer at the hospital ) Lack of simple Standard operating procedures for integrated screening of TB and COVID-19 “…So you find depending on the workload of the staff. If you have a very tedious tool for screening, they may not because it consumes a lot of time. But if it is a simplified tool then it can be well utilized, it is easy to maneuver throug h. ” ( Medical Officer at the hospital ) Healthcare providers fear of contracting COVID-19 infection during integrated screening “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 will not be seen, treatment will not be given. Says this government doesn’t care for people, doesn’t care for health workers in case you fall a victim. ( Nurse at the hospital ) Lack of risk allowance for healthcare providers to conduct integrated screening of TB and COVID-19 “..of course, people need allowances, without allowances they are not going to …actually for us we don’t have COVID allowances at this hospital, because they say we don’t treat COVID because COVID is in the communities yet we treat COVID here. That one of the factors that limit health workers involved in screening for COVID, screening for both can be there so no problem but COVID mostly health workers are not interested.” ( Medical Officer at the hospital ). Abbreviations; HCP: Health care providers, TB- Tuberculosis, PPE- Personal Protective Equipment Table 2 Barriers to and facilitators for integrated COVID-19 and TB screening at Kiruddu National Referral Hospital mapped to the COM-B model COM-B constructs Barriers Facilitators Psychological capability Healthcare Providers lacked adequate knowledge on how to integrate screening of TB and COVID-19 Healthcare providers have knowledge of how to screen for TB and COVID-19 as independent diseases Physical capability Healthcare providers have adequate skills to screen for TB and COVID-19 Physical opportunity Lack of simple Standard operating procedures for integrated screening of TB and COVID-19 Inconsistent supply of personal protective Equipment (PPE) Understaffing at the outpatient and emergency departments Lack of data collection tools and databases for integrated screening of TB and COVID-19 Social opportunity TB focal persons are available to support Healthcare providers to provide integrated screening for TB and COVID-19 Reflective motivation Healthcare providers fear of contracting COVID-19 infection during integrated screening Healthcare providers are interested in being supported to provide integrated screening for TB and COVID-19 Automatic motivation Lack of risk allowance for healthcare providers to conduct integrated screening of TB and COVID-19 Abbreviations; HCP: Health care providers, TB- Tuberculosis, PPE- Personal Protective Equipment Table 3 Summary of identified facilitators and linked intervention functions Capability Opportunity Motivation Intervention functions Psychological Physical Social Reflective HCP have knowledge of how to screen for TB and COVID-19 as independent diseases HCP have adequate skills to screen for TB and COVID-19 Availability of TB focal persons are available to support HCP HCP interested in being supported to provide integrated screening for TB and COVID-19 Education X X Persuasion X X X X Enablement Training Abbreviations, HCP: Health care providers, TB- Tuberculosis Table 4 Summary of identified barriers and linked intervention functions Capability Opportunity Motivation Intervention functions Psychological Physical Reflective Automatic Inadequate knowledge to integrate screening of TB and COVID-19 Lack of SOPs Lack of consistent supply of (PPE) Understaffing Lack of data collection tools Fear of contracting COVID-19 infection Lack of risk allowance X X Education X X Persuasion X X X X X Enablement X Training Abbreviations: PPE-Personal protective equipment, SOPs- Standard Operating Procedures, TB -Tuberculosis Supplementary Files COREQCHECKLIST.docx Cite Share Download PDF Status: Published Journal Publication published 17 Jan, 2023 Read the published version in Implementation Science Communications → Version 1 posted Editorial decision: Major revision 22 Aug, 2022 Reviewers agreed at journal 02 Jul, 2022 Reviewers invited by journal 01 Jul, 2022 Submission checks completed at journal 04 Apr, 2022 Editor invited by journal 04 Apr, 2022 Editorial decision: Reject before peer review 19 Mar, 2022 Editor assigned by journal 16 Mar, 2022 First submitted to journal 13 Mar, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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07:11:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1448831/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1448831/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s43058-023-00391-w","type":"published","date":"2023-01-17T18:23:35+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":22361884,"identity":"4bc47b4c-f056-4705-ab69-056233f9a044","added_by":"auto","created_at":"2022-06-07 16:03:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":49288,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHealth facility Tuberculosis (TB) Management Plan in the Context of COVID-19 guidance by Uganda Ministry of Health (MoH);\u0026nbsp;DHO District Health Officer;\u0026nbsp;ICF- Intensified Case Finding \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"11.png","url":"https://assets-eu.researchsquare.com/files/rs-1448831/v1/d04da81153a6d9b554d44d0a.png"},{"id":22361886,"identity":"4eb58566-9a6b-4da2-9d8c-e3b4590573d3","added_by":"auto","created_at":"2022-06-07 16:03:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":185699,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe COM-B model of Behavior. Adapted from the original figure (Michie et al.) [8]\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-1448831/v1/95bf823bd42f4b7dd550fb3c.png"},{"id":44716977,"identity":"b307832d-29f3-48bd-83e4-0686dbbd8ca9","added_by":"auto","created_at":"2023-10-16 18:32:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1133847,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1448831/v1/aad6a5b6-ccb3-49ab-816a-9515cf882931.pdf"},{"id":22361885,"identity":"2d3c399e-8247-4d2c-8f62-888ecc8e0270","added_by":"auto","created_at":"2022-06-07 16:03:18","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":30650,"visible":true,"origin":"","legend":"","description":"","filename":"COREQCHECKLIST.docx","url":"https://assets-eu.researchsquare.com/files/rs-1448831/v1/93ae2c21f3f1e49bd4dd68ce.docx"}],"financialInterests":"","formattedTitle":"Integration of COVID-19 and TB screening in Kampala, Uganda - Healthcare provider perspectives.","fulltext":[{"header":"Contributions To The Literature","content":"\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eWe utilized the widely used and validated COM-B model to assess determinants of integrated COVID-19 and TB screening at a national referral hospital\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo our knowledge, this is the first qualitative study to explore barriers and facilitators to integrated screening of TB and COVID-19 using the COM-B model.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe barriers and facilitators identified provide a basis for developing stakeholder informed and contextually appropriate interventions targeting factors that are likely to influence HCP\u0026rsquo;s decisions and willingness to conduct TB screening in the context of COVID-19.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eCoronavirus 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[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Since then, the global and local response to COVID-19 has caused severe disruptions to the service delivery for other diseases including Tuberculosis (TB) [\u003cspan additionalcitationids=\"CR3 CR4 CR5\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The commonest symptoms of TB (fever and cough) are similar to those exhibited by COVID-19 patients[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], which may negatively affect people\u0026rsquo;s health-seeking behavior for fear of stigmatization[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This may also make healthcare providers less receptive of patients presenting with COVID-19 like symptoms from other causes such as TB[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFollowing the COVID-19 outbreak, like has been documented elsewhere [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], Uganda experienced a 40% drop in TB screening by June 2020; based on the unpublished Ministry of Health programmatic data from the District Health information system version 2 (DHIS2)[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In response to this very significant drop in screening for TB, the National TB and Leprosy Program (NTLP) at the Ministry of Health (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) \u003cb\u003e(Fig.\u0026nbsp;1)\u003c/b\u003e. Using this algorithm, ret 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 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).\u003c/p\u003e \u003cp\u003eThe aim of this qualitative study was to identify facilitators of and barriers to integrated COVID-19 and TB screening from the perspective of HCP at a Referral Hospital in Kampala, Uganda and map these onto the COM-B model and Behavior Change Wheel (BCW) framework to identify suitable intervention functions. We utilized the Capability, Opportunity, Motivation - Behavior (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.\u003c/p\u003e \u003cp\u003eThe central principle for the COM-B is that changing any behavior requires changing capability, opportunity and/or motivation to perform that behavior [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Thus, the COM-B model (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e) provides a coherent basis for exploring barriers to and facilitators [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. 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 amongst HCP.\u003c/p\u003e \u003cp\u003eThe goal was to inform the design of a contextually appropriate strategy to integrate screening of COVID-19 and TB in Uganda.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and setting\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe 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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe used the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines in reporting this qualitative study[16]\u0026nbsp;(see Additional file 1). The study received ethical approvals from the AIDS support organization (TASO) research and Ethics Committee \u003cstrong\u003e(TASO REC 082/2020-UG-REC-009)\u003c/strong\u003e and the Uganda National Council of Science and Technology \u003cstrong\u003e(HS1152ES).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy participants and sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe 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[17].\u003c/p\u003e\n\u003cp\u003eWe recruited different cadres of eligible HCP including medical officers, nurses and TB community linkages facilitators. While observing the COVID-19 prevention guidelines we approached HCP face to face and we informed all of them that the goal of the study was to integrate screening for COVID-19 and TB.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy instruments and data collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe 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), HCP perspectives regarding 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 COVID19-TB Screening Algorithm).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe 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 to 40 minutes. Informed verbal consent was obtained from all participants. All interviews including the informed verbal consent were audio-recorded and transcribed verbatim.\u003c/p\u003e\n\u003cp\u003eAll transcripts were de-identified and stored in a secure digital folder accessible only by the research team.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch team\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll interviews were conducted at the Kiruddu National Referral Hospital, a setting familiar to study participants, by the local study team. The team comprised of 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\u0026rsquo;s trained social scientist (MM, female) conducted the initial interviews with health care 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 prior to study commencement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour 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\u0026nbsp;[14, 16]\u0026nbsp;We adopted an inductive approach using open coding that facilitated the identification of themes in 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 and then exported the transcriptions to Atlas.ti version 8. The team then met to debrief and compare the initial codes generated by each analyst. We discussed Coding discrepancies and resolved with the other members of the research team (FCS and DO). 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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe 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.\u003c/p\u003e\n\u003cp\u003eWe developed a behavioral diagnosis by mapping the emergent facilitators and barriers onto their associated COM-B domains.\u003c/p\u003e\n\u003cp\u003eWe 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.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographic characteristics of study participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwelve healthcare providers participated in the interviews. They included seven medical doctors, three nurses and two community linkages 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 \u0026ndash; 4 years\u003cstrong\u003e).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare provider-reported facilitators of integrating COVID-19 and TB screening\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost HCP reported having knowledge of how to screen for TB and COVID-19 as independent diseases.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My experience in screening TB in the presence of COVID-19 is that some times you may not be sure whether you are dealing with TB or COVID-19. Because the presentations are a bit similar\u0026hellip;but where we have some doubts, we have been referring those clients for COVID-19 testing.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Nurse\u0026nbsp;at the hospital)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So, of course COVID-19 has masked the TB and screening of TB. People have now put much emphasis on COVID-19 leaving out the TB. So we have seen some decline in the cases of TB cases. But it does not mean that these cases have gone down, But because people have put much emphasis on COVID-19 leaving out TB.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Medical Doctor at the hospital)\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost healthcare providers reported that TB focal persons were available to support HCP to provide integrated screening for TB and COVID-19.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; 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 and the rest. So, having the focal persons take up another responsibility could also be another key issue for implementation because you may tell people; you conduct your workshop then you leave.\u0026rdquo;\u003c/em\u003e (Medical Doctor at the hospital)\u003c/p\u003e\n\u003cp\u003eHealthcare providers also mentioned that having training, mentorships and workshops will help build the capacity for people to understand the relevance of integrated COVID-19 and TB screening.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The most important thing is knowledge, so you have to give out knowledge. Dispense knowledge to the health workers which means you will have to have a lot of workshops or maybe mentorships throughout the country and training for all the health workers to do the activity.\u0026rdquo;\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(Medical Doctor at the hospital)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare provider-reported barriers to integrating COVID-19 and TB screening\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost HCP reported a lack of simple Standard operating procedures and data collection tools to integrate screening of TB and COVID-19. Healthcare provider-reported barriers to and facilitators of integrating COVID-19 and TB screening are summarized in \u003cstrong\u003eTable 1.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;So, you find depending on the workload of the staff. If you have a very tedious tool for screening, they 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 easy to maneuver throug\u003c/em\u003eh.\u003cstrong\u003e\u0026rdquo;\u0026nbsp;\u003c/strong\u003e(Medical Doctor at the hospital)\u003c/p\u003e\n\u003cp\u003eThe HCP also reported an inconsistent supply of personal protective Equipment (PPE) as a constraint in integrating COVID-19 and TB screening.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If it can be facilitated, it is better but also how long that is not sustainable. If the government can equip the hospital with SOP equipment like sanitizers, temperature guns, like PPE, gloves, cotton. I think it would help health workers accept because they will know that at least our health is well protected\u0026rdquo;\u003c/em\u003e (Nurse at the hospital)\u003c/p\u003e\n\u003cp\u003eHCP also reported inadequate staffing levels, coupled with very busy outpatient and emergency departments at the hospital as a hindrance to integrated screening of COVID-19 and TB.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;One of the concerns is the heavy workload because at the end of the day, doing two things at ago while in PPE and you find that it\u0026apos;s one person who is at the unit to do the screening of several patients.\u0026rdquo;\u003c/em\u003e (Medical Doctor at the hospital)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;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.\u0026rdquo;\u003c/em\u003e (Medical Doctor at the hospital)\u003c/p\u003e\n\u003cp\u003eMost\u0026nbsp;HCP feared contracting COVID-19 infection during integrated screening of COVID-19 and TB.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Anything to do with COVID-19, I don\u0026rsquo;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 will not be seen, treatment will not be given. For me with COVID-19, this government does not care for people, doesn\u0026rsquo;t care for health workers in case you fall a victim.\u0026rdquo;\u003c/em\u003e (Nurse at the hospital)\u003c/p\u003e\n\u003cp\u003eMost healthcare providers also raised the concern of unclear compensation for health workers who contract covid-19 while on duty. \u0026nbsp;They added that their safety is a concern because they are likely to be infected with COVID-19 yet they won\u0026apos;t be compensated.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;.Of course, people need allowances, without allowances they are not going to work [screen for COVID-19 and TB], actually for us we don\u0026rsquo;t have COVID-19 allowances at this hospital, because they say we don\u0026rsquo;t treat COVID-19 because COVID-19 is in the communities, yet we treat COVID-19 here. That\u0026rsquo;s one of the factors that limits health worker involvement in screening for COVID-19. Screening for both is okay, but for COVID-19, most health workers are not interested.\u0026rdquo;\u003c/em\u003e (Medical Doctor at the hospital).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBehavioral Diagnosis and Intervention functions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe 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 personal protective Equipment (PPE) and Understaffing at the outpatient and emergency departments were \u0026nbsp;mapped to the physical opportunity construct of the COM-B model. \u003cstrong\u003eTable 2\u003c/strong\u003e summarizes the HCP reported facilitators and barriers expressed in terms of their behavioral determinants within the COM-B model.\u003c/p\u003e\n\u003cp\u003eWe\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003elinked\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ethe behavioral diagnosis obtained using the COM-B model \u003cstrong\u003e(Table 2)\u003c/strong\u003e to the behavioral change wheel (BCW) framework and identified appropriate potential interventions 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 \u003cstrong\u003eTable 3 and Table 4.\u003c/strong\u003e\u0026nbsp; For example, HCP reported inadequate knowledge on how to integrate screening of TB and COVID-19. Using \u003cstrong\u003e\u003cem\u003eeducation and training\u003c/em\u003e\u003c/strong\u003e as intervention functions, HCP can be equipped with the necessary knowledge and skills through training sessions. \u0026nbsp;Similarly, using \u003cstrong\u003e\u003cem\u003eenablement\u003c/em\u003e\u003c/strong\u003e as an intervention function, HCP can be provided simple standard operating procedures for integrated screening of TB and COVID-19, provided adequate supply of PPE and improving the staffing levels in these departments as enablers to facilitate integrated screening for TB and COVID-19.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this formative cross-sectional study, we explored HCP work experience in the setting of COVID-19, 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 COVID-19 and TB screening[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe found that COVID-19 was a real threat to TB related services since HCP at this large hospital were not very well prepared to integrate TB and COVID-19 services at the time. The key potential barriers to integrating COVID-19 and TB screening included; Lack of simple standard operating procedures for integrated screening of TB and COVID-19, Lack of consistent supply of personal protective Equipment (PPE), Understaffing and HCP fear of contracting COVID-19 infection. The key potential facilitators for integrating COVID-19 and TB screening included; availability of TB focal persons to support healthcare providers to provide integrated screening for TB and COVID-19 and their interest and goodwill to be supported and trained to provide integrated screening for TB and COVID-19.\u003c/p\u003e \u003cp\u003eMost HCP had knowledge of how to screen for TB and COVID-19 however; they also reported lack of simple tools such as Standard operating procedures, screening algorithms and data collection tools to support integrated screening of TB and COVID-19. Simple tools such as protocols have been shown to facilitate integration of different programs in clinical settings[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGenerally, the HCP reported lack of consistent supply of PPE and most of them feared contracting the COVID-19 infection if they were to provide 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 [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings add to the growing evidence showing that countries and communities should design contextually appropriate and stakeholder informed interventions that adapt active case finding for TB during the COVID-19 pandemic for continuity of TB services [\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In a summary of three operation researches conducted in the capital cities of three African countries (Kenya, Zimbabwe and Malawi), to assess whether a real-time monthly surveillance of TB and HIV activities instead of the usual quarterly surveillance might help to counteract the anticipated negative impact on TB and HIV services, Harries et al [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] demonstrated that there was a decline of 31.2%, 45.6% and 40.6% in the numbers of people presenting with presumptive pulmonary TB for investigation in the three respective countries from March 2020\u0026ndash;February 2021 compared to the immediate pre COVID-19 period of March 2019\u0026ndash;February 2020. Following the institution of measures 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 while the numbers in Zimbabwe and Malawi remained far below the baseline period. These studies however, do not describe the steps taken to understand the perspectives of key stakeholders such as HCP in this setting and this may have resulted in suboptimal outcomes.\u003c/p\u003e \u003cp\u003eWe have utilized the identified facilitators for and barriers to integrated screening of COVID-19 and TB and the BCW intervention functions to develop the following interventions that are currently being implemented. We have trained 37 HCP on the COVID19-TB algorithm through a series of short interactive sessions to close the knowledge and skills gap; we have printed and distributed job aids of COVID-19-TB algorithm and data collection tools at all the screening points to overcome absence of guidelines on how to screen for TB in the context of COVID-19 and absence of tools for data collection; we have procured and appropriately distributed PPE to the health care providers to overcome the lack consistent supply of PPE and fear of contracting COVID-19 infections.\u003c/p\u003e \u003cp\u003eThe Strengths 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 HCP who are key stakeholders to understand the contextual factors that may affect their willingness to integrate screening of 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, fosters ownership of the intervention and the intervention is more likely to be effective when compared to interventions that are designed without key stakeholder input.\u003c/p\u003e \u003cp\u003eBy 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. The findings from our study are from a single urban national referral hospital and some contextual factors may not be generalizable in different settings.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe findings of our study highlight the barriers to and facilitators for integrated COVID-19 and TB screening and 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 to use of this algorithm for integrated COVID-19 and TB screening in Uganda and other low and middle income countries. Future studies should evaluate the effect of addressing these barriers to integration of COVID-19 and TB as well as the impact of this on TB case finding in high burden TB settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBCW: Behavior Change Wheel framework\u003c/p\u003e\n\u003cp\u003eCOM-B: Capability Opportunity Motivation Behavior\u003c/p\u003e\n\u003cp\u003eCOVID-19: Coronavirus disease 2019\u003c/p\u003e\n\u003cp\u003eHCP: Health Care Providers\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKNRH: Kiruddu National Referral Hospital\u003c/p\u003e\n\u003cp\u003eMoH: Ministry of Health\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNTLP: National TB and Leprosy Program\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePPE: personal protective equipment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTB: Tuberculosis\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u0026nbsp; 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was supported by a grant from the Government of Uganda through the Makerere University Research and Innovation Fund (Mak RIF). Dr. Semitala\u0026rsquo;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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions:\u0026nbsp;\u003c/strong\u003eFCS, RK and MS designed the study. DK, ST, RO and EA oversaw the collection of data. \u0026nbsp;MM and JN collected the data. \u0026nbsp;FCS, RK, DK and DO analyzed the data and wrote the manuscript with input from all authors. \u0026nbsp;ST, MS and RO critically reviewed the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements: \u0026nbsp;\u003c/strong\u003eThe 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.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCucinotta, D. and M. 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Arora, \u003cem\u003eCovid-19 and social stigma: Role of scientific community.\u003c/em\u003e Indian J Tuberc, 2020. \u003cstrong\u003e67\u003c/strong\u003e(3): p. 284-285.\u003c/li\u003e\n\u003cli\u003eSoko, R.N., et al., \u003cem\u003eEarly Release-Effects of Coronavirus Disease Pandemic on Tuberculosis Notifications, Malawi.\u003c/em\u003e 2021.\u003c/li\u003e\n\u003cli\u003eMbithi, I., et al., \u003cem\u003eAssessing the Real-Time Impact of COVID-19 on TB and HIV Services: The Experience and Response from Selected Health Facilities in Nairobi, Kenya.\u003c/em\u003e Trop Med Infect Dis, 2021. \u003cstrong\u003e6\u003c/strong\u003e(2).\u003c/li\u003e\n\u003cli\u003eThekkur, P., et al., \u003cem\u003eAssessing the Impact of COVID-19 on TB and HIV Programme Services in Selected Health Facilities in Lilongwe, Malawi: Operational Research in Real Time.\u003c/em\u003e Trop Med Infect Dis, 2021. \u003cstrong\u003e6\u003c/strong\u003e(2).\u003c/li\u003e\n\u003cli\u003eHaberer, J.E., et al., \u003cem\u003eAlignment 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.\u003c/em\u003e J Int AIDS Soc, 2017. \u003cstrong\u003e20\u003c/strong\u003e(1): p. 21842.\u003c/li\u003e\n\u003cli\u003eBarker, F., L. Atkins, and S. de Lusignan, \u003cem\u003eApplying the COM-B behaviour model and behaviour change wheel to develop an intervention to improve hearing-aid use in adult auditory rehabilitation.\u003c/em\u003e International journal of audiology, 2016. \u003cstrong\u003e55\u003c/strong\u003e(sup3): p. S90-S98.\u003c/li\u003e\n\u003cli\u003eMichie, S., M.M. Van Stralen, and R. West, \u003cem\u003eThe behaviour change wheel: a new method for characterising and designing behaviour change interventions.\u003c/em\u003e Implementation science, 2011. \u003cstrong\u003e6\u003c/strong\u003e(1): p. 1-12.\u003c/li\u003e\n\u003cli\u003eTong, A., P. Sainsbury, and J. Craig, \u003cem\u003eConsolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.\u003c/em\u003e International journal for quality in health care, 2007. \u003cstrong\u003e19\u003c/strong\u003e(6): p. 349-357.\u003c/li\u003e\n\u003cli\u003eLincoln, Y.S. and E.G. Guba, \u003cem\u003eNaturalistic inquiry.\u003c/em\u003e 1985.\u003c/li\u003e\n\u003cli\u003eMaust, A., et al., \u003cem\u003eSevere and moderate acute malnutrition can be successfully managed with an integrated protocol in Sierra Leone.\u003c/em\u003e The Journal of nutrition, 2015. \u003cstrong\u003e145\u003c/strong\u003e(11): p. 2604-2609.\u003c/li\u003e\n\u003cli\u003eLiu, Q., et al., \u003cem\u003eThe experiences of health-care providers during the COVID-19 crisis in China: a qualitative study.\u003c/em\u003e The Lancet Global Health, 2020. \u003cstrong\u003e8\u003c/strong\u003e(6): p. e790-e798.\u003c/li\u003e\n\u003cli\u003eWahed, W.Y.A., et al., \u003cem\u003eAssessment of knowledge, attitudes, and perception of health care workers regarding COVID-19, a cross-sectional study from Egypt.\u003c/em\u003e Journal of community health, 2020. \u003cstrong\u003e45\u003c/strong\u003e(6): p. 1242-1251.\u003c/li\u003e\n\u003cli\u003eAmin, S., \u003cem\u003eThe psychology of coronavirus fear: Are healthcare professionals suffering from corona-phobia?\u003c/em\u003e International Journal of Healthcare Management, 2020. \u003cstrong\u003e13\u003c/strong\u003e(3): p. 249-256.\u003c/li\u003e\n\u003cli\u003eGidado, M., et al., \u003cem\u003eEarly experience in implementation of an integrated COVID-19 and TB community-based active case finding in Nigeria.\u003c/em\u003e African Journal of Respiratory Medicine, 2020. \u003cstrong\u003e15\u003c/strong\u003e(2).\u003c/li\u003e\n\u003cli\u003eMalik, A.A., et al., \u003cem\u003eTuberculosis control and care in the era of COVID-19.\u003c/em\u003e Health Policy and Planning, 2020. \u003cstrong\u003e35\u003c/strong\u003e(8): p. 1130-1132.\u003c/li\u003e\n\u003cli\u003eKeene, C., et al., \u003cem\u003eHow COVID-19 could benefit tuberculosis and HIV services in South Africa.\u003c/em\u003e The Lancet Respiratory Medicine, 2020. \u003cstrong\u003e8\u003c/strong\u003e(9): p. 844-846.\u003c/li\u003e\n\u003cli\u003eReid, M., \u003cem\u003eTackling TB and COVID-19: US leadership is needed on global health, now more than ever.\u003c/em\u003e Public Health Action, 2021. \u003cstrong\u003e11\u003c/strong\u003e(2): p. 53-54.\u003c/li\u003e\n\u003cli\u003eChan, G., et al., \u003cem\u003eAdapting active case-finding for TB during the COVID-19 pandemic in Yogyakarta, Indonesia.\u003c/em\u003e Public Health Action, 2021. \u003cstrong\u003e11\u003c/strong\u003e(2): p. 41-49.\u003c/li\u003e\n\u003cli\u003eHarries, A.D., et al., \u003cem\u003eReal-Time Operational Research: Case Studies from the Field of Tuberculosis and Lessons Learnt.\u003c/em\u003e Trop Med Infect Dis, 2021. \u003cstrong\u003e6\u003c/strong\u003e(2).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable align=\"left\" border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Healthcare provider-reported facilitators of and barriers to integrated COVID-19 and TB screening at Kiruddu National Referral Hospital Kampala, Uganda.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePotential facilitators \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePotential barriers \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare providers have \u0026nbsp;knowledge of how to screen for TB and COVID-19 as independent diseases\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;My experience in screening TB in the presence of covid-19 some times you could not be sure whether you are dealing with TB or covid-19. Because the presentations are a bit similar\u0026hellip;but where we have some doubts, we have been referring those clients for COVID-19 testing.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cstrong\u003e(Nurse at the hospital)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare Providers lacked adequate knowledge on how to integrate screening of TB and COVID-19\u003c/strong\u003e\u003cem\u003e\u0026ldquo;So of course COVID_19 has masked the TB, screening of TB. people have now put much emphasis on COVID_19 leaving out the TB. So we have seen some decline in the cases of TB cases. But it does not mean that these cases have gone down, But because people have put much emphasis on COVID_19 leaving out TB.\u0026rdquo; \u003cstrong\u003e(\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;Medical Officer at the hospital\u003cem\u003e)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTB focal persons are available to support Healthcare providers to provide integrated screening for TB and COVID-19\u003c/strong\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; 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 and the rest. So having the focal persons take up another responsibility could also be another key issue for implementation because you may tell people, you conduct your workshop then you leave.\u0026rdquo;\u003c/em\u003e \u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Medical Officer at the hospital\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of simple Standard operating procedures for integrated screening of TB and COVID-19\u003c/strong\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;So you find depending on the workload of the staff. If you have a very tedious tool for screening, they may not because it consumes a lot of time. But if it is a simplified tool then it can be well utilized, it is easy to maneuver throug\u003c/em\u003eh.\u003cstrong\u003e\u0026rdquo; (\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Medical Officer at the hospital\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare providers are interested in being supported to provide integrated screening for TB and COVID-19\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The most important thing is knowledge, so you have to give out knowledge. Dispense knowledge to the health workers which means you will have to have a lot of workshops or maybe mentorships throughout the country and training for all the health workers to do the activity.\u0026rdquo;\u003c/em\u003e\u003cstrong\u003e\u0026nbsp;(\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Medical Officer at the hospital\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of consistent supply of personal protective Equipment (PPE)\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;If it can be facilitated, it is better but also how long that is not sustainable. If the government can equip the hospital with SOP equipment like sanitizers, temperature guns, like PPE, gloves, cotton. I think it would help health workers accept because they will know that at least our health is well protected\u0026rdquo;\u003c/em\u003e \u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Nurse at the hospital\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnderstaffing at the outpatient and emergency departments\u003c/strong\u003e \u003cem\u003e\u0026ldquo;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.\u0026rdquo;\u003c/em\u003e \u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Medical Officer at the hospital\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of simple Standard operating procedures for integrated screening of TB and COVID-19\u003c/strong\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;So you find depending on the workload of the staff. If you have a very tedious tool for screening, they may not because it consumes a lot of time. But if it is a simplified tool then it can be well utilized, it is easy to maneuver throug\u003c/em\u003eh.\u003cstrong\u003e\u0026rdquo; (\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Medical Officer at the hospital\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare providers fear of contracting COVID-19 infection during integrated screening\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Anything to do with COVID-19, I don\u0026rsquo;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 will not be seen, treatment will not be given. Says this government doesn\u0026rsquo;t care for people, doesn\u0026rsquo;t care for health workers in case you fall a victim.\u003c/em\u003e \u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Nurse at the hospital\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of risk allowance for healthcare providers to conduct integrated screening of TB and COVID-19\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;..of course, people need allowances, without allowances they are not going to \u0026hellip;actually for us we don\u0026rsquo;t have COVID allowances at this hospital, because they say we don\u0026rsquo;t treat COVID because COVID is in the communities yet we treat COVID here. That one of the factors that limit health workers involved in screening for COVID, screening for both can be there so no problem but COVID mostly health workers are not interested.\u0026rdquo;\u003c/em\u003e \u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003eMedical Officer at the hospital\u003c/strong\u003e\u003cstrong\u003e).\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAbbreviations;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHCP: Health care providers, TB- Tuberculosis, PPE- Personal Protective Equipment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" width=\"100%\"\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eBarriers to and facilitators for integrated COVID-19 and TB screening at Kiruddu National Referral Hospital\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;mapped to the COM-B model\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.19191919191919%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOM-B constructs\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"35.35353535353536%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"45.45454545454545%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacilitators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.19191919191919%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychological\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ecapability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"35.35353535353536%\"\u003e\n \u003cp\u003eHealthcare Providers \u0026nbsp;lacked adequate knowledge on how to integrate screening of TB and COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"45.45454545454545%\"\u003e\n \u003cp\u003eHealthcare providers have knowledge of how to screen for TB and COVID-19 as independent diseases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.19191919191919%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ecapability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"35.35353535353536%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"45.45454545454545%\"\u003e\n \u003cp\u003eHealthcare providers have adequate skills to screen for TB and COVID-19\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"bottom\" width=\"19.19191919191919%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eopportunity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"35.35353535353536%\"\u003e\n \u003cp\u003eLack of simple Standard operating procedures for integrated screening of TB and COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"bottom\" width=\"45.45454545454545%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"100%\"\u003e\n \u003cp\u003eInconsistent supply of personal protective Equipment (PPE)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"100%\"\u003e\n \u003cp\u003eUnderstaffing at the outpatient and emergency departments\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"100%\"\u003e\n \u003cp\u003eLack of data collection\u003c/p\u003e\n \u003cp\u003etools and databases for integrated screening of TB and COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.19191919191919%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eopportunity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"35.35353535353536%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"45.45454545454545%\"\u003e\n \u003cp\u003eTB focal persons are available to support Healthcare providers to provide integrated screening for TB and COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.19191919191919%\"\u003e\n \u003cp\u003e\u003cstrong\u003eReflective\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003emotivation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"35.35353535353536%\"\u003e\n \u003cp\u003eHealthcare providers fear of contracting COVID-19 infection during integrated screening\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"45.45454545454545%\"\u003e\n \u003cp\u003eHealthcare providers are interested in being supported to provide integrated screening for TB and COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"19.19191919191919%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAutomatic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003emotivation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"35.35353535353536%\"\u003e\n \u003cp\u003eLack of risk allowance for healthcare providers to conduct integrated screening of TB and COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"45.45454545454545%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviations;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHCP: Health care providers, TB- Tuberculosis, \u0026nbsp;PPE- Personal Protective Equipment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eSummary of identified facilitators and linked intervention functions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"37.755102040816325%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCapability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpportunity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.428571428571427%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMotivation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention functions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.75%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychological\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"27.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.25%\"\u003e\n \u003cp\u003e\u003cstrong\u003eReflective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"23.75%\"\u003e\n \u003cp\u003eHCP have \u0026nbsp; \u0026nbsp; knowledge of how to screen for TB and COVID-19 as independent diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.5%\"\u003e\n \u003cp\u003eHCP have adequate skills to screen for TB and COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"27.5%\"\u003e\n \u003cp\u003eAvailability of TB focal persons are available to support HCP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"26.25%\"\u003e\n \u003cp\u003eHCP interested in being supported to provide integrated screening for TB and COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.387755102040817%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.428571428571427%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eEducation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.387755102040817%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.428571428571427%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003ePersuasion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.387755102040817%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.428571428571427%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eEnablement\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"19.387755102040817%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.448979591836736%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.428571428571427%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eTraining\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviations,\u0026nbsp;\u003c/strong\u003eHCP: Health care providers, TB- Tuberculosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" width=\"100%\"\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003c/p\u003e\n \u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSummary of identified barriers and linked intervention functions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.124816446402349%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCapability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" width=\"45.37444933920705%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpportunity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" width=\"25.25697503671072%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMotivation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"14.243759177679882%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention functions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"17.636986301369863%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychological\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" width=\"52.91095890410959%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.068493150684931%\"\u003e\n \u003cp\u003e\u003cstrong\u003eReflective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"14.383561643835616%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAutomatic\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.080527086383603%\"\u003e\n \u003cp\u003eInadequate knowledge to integrate screening of TB and COVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.881405563689604%\"\u003e\n \u003cp\u003eLack of SOPs\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.859443631039532%\"\u003e\n \u003cp\u003eLack of consistent supply of \u0026nbsp;(PPE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.226939970717423%\"\u003e\n \u003cp\u003eUnderstaffing\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.420204978038067%\"\u003e\n \u003cp\u003eLack of data collection\u003c/p\u003e\n \u003cp\u003etools\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.88433382137628%\"\u003e\n \u003cp\u003eFear of contracting COVID-19 infection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.298682284040996%\"\u003e\n \u003cp\u003eLack of risk allowance\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"14.348462664714495%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.080527086383603%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.881405563689604%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.859443631039532%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.226939970717423%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.420204978038067%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.88433382137628%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.298682284040996%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"14.348462664714495%\"\u003e\n \u003cp\u003eEducation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.080527086383603%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.881405563689604%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.859443631039532%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.226939970717423%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.420204978038067%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.88433382137628%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.298682284040996%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"14.348462664714495%\"\u003e\n \u003cp\u003ePersuasion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.080527086383603%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.881405563689604%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.859443631039532%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.226939970717423%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.420204978038067%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.88433382137628%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.298682284040996%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"14.348462664714495%\"\u003e\n \u003cp\u003eEnablement\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.080527086383603%\"\u003e\n \u003cp\u003e\u003cstrong\u003eX\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"6.881405563689604%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.859443631039532%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"15.226939970717423%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.420204978038067%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.88433382137628%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.298682284040996%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"14.348462664714495%\"\u003e\n \u003cp\u003eTraining\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" width=\"100%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviations:\u0026nbsp;\u003c/strong\u003ePPE-Personal protective equipment, SOPs- Standard Operating Procedures, TB -Tuberculosis\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tuberculosis, COVID-19, healthcare providers, integrated screening","lastPublishedDoi":"10.21203/rs.3.rs-1448831/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1448831/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003e\u003c/p\u003e\u003cp\u003eFollowing the first wave of 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 (HCP) at a National Referral Hospital in Kampala, Uganda.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDesign/Methods: \u003c/strong\u003e\u003c/p\u003e\u003cp\u003eWe conducted a cross sectional study using in-depth interviews with 12 HCP 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 the emergent themes were denoted 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. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe facilitators to integrated COVID-19 and TB screening included; HCP knowledge of how to separately screen for TB and COVID-19, availability of TB focal persons and interest in learning how to provide integrated screening for TB and COVID-19. The barriers included; HCP inadequate knowledge on how to integrate screening of TB and COVID-19, absence of simple standard operating procedures and data collection tools for integrated screening, inconsistent supply of personal protective equipment (PPE), under staffing, and fear of contracting COVID-19 infection. The identified intervention functions to address the facilitators or barriers included education, persuasion, enablement, and training.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThese findings provide 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.\u003c/p\u003e","manuscriptTitle":"Integration of COVID-19 and TB screening in Kampala, Uganda - Healthcare provider perspectives.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-07 16:03:16","doi":"10.21203/rs.3.rs-1448831/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-08-23T02:14:22+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2022-07-02T12:54:23+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-07-01T17:49:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-04-04T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-04-04T23:00:00+00:00","index":"","fulltext":""},{"type":"decision","content":"Reject before peer review","date":"2022-03-19T23:29:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-03-16T07:34:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Implementation Science Communications","date":"2022-03-14T03:11:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"82dd4ccb-23c4-45ea-b962-88aa18d4e7a7","owner":[],"postedDate":"June 7th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T18:27:29+00:00","versionOfRecord":{"articleIdentity":"rs-1448831","link":"https://doi.org/10.1186/s43058-023-00391-w","journal":{"identity":"implementation-science-communications","isVorOnly":false,"title":"Implementation Science Communications"},"publishedOn":"2023-01-17 18:23:35","publishedOnDateReadable":"January 17th, 2023"},"versionCreatedAt":"2022-06-07 16:03:16","video":"","vorDoi":"10.1186/s43058-023-00391-w","vorDoiUrl":"https://doi.org/10.1186/s43058-023-00391-w","workflowStages":[]},"version":"v1","identity":"rs-1448831","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1448831","identity":"rs-1448831","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}