Facilitators and Barriers to Implementation of Childhood Tuberculosis Control Program in Bangladesh: A Mixed-Methods Study from BRAC Urban DOTS Centres in Dhaka

Abstract Background: World Health Organisation (WHO) estimates childhood tuberculosis (tb) in high burden countries to be at least 10-15% of all cases. Despite intensive efforts on the childhood tb control program in Bangladesh, case detection rates stand below 5%. This study investigated the implementation pathway of childhood tb in Bangladesh. The study aims to identify the factors that enable and hinder the diagnosis and treatment of childhood tb in Bangladesh.Methods: An exploratory-explanatory mixed-methods study was carried out in eight (top four and bottom four based on new case identification) urban DOTS (Directly Observed Treatment, Short-course) centres of the BRAC tb program in Dhaka Metropolitan City, Bangladesh. The study was conducted between September and December 2017. The knowledge, attitude, and practice (KAP) assessment on diagnosis and treatment of childhood tb were conducted among 111 Shasthya Shebika (SS), frontline health care workers engaged in the tb program. Field workers (n=32) and mothers of tb patients (n=4) participated in In-Depth Interviews. Key Informant Interviews (n=9) were conducted with program managers of BRAC and other key stakeholders involved in implementing the tuberculosis program in Bangladesh. Results: The survey showed a low level of knowledge on routes of transmission. The knowledge score was significantly associated with the recall of the components of training (p=0.02). Government stewardship, the presence of specific guidelines, capacity building of health workers, knowledge of frontline health workers were identified as key facilitators for the diagnosis and treatment of childhood tuberculosis. Major constraints identified included the presence of stigma, delays in seeking care, lack of diagnostic facilities, and poor engagement of private practitioners in the national tuberculosis program.ConclusionA triad of strategies including capacity building of frontline health care workers, use of recent technological advances in diagnosis, and continuous monitoring of the suspected or identified cases in the field have resulted in increased case notification of childhood tb in Bangladesh over the past few years. Frequent turnover and change of key positions in National Tuberculosis Program (NTP) and absenteeism of paediatricians in government hospitals were important barriers to implementation of childhood tb program.