Study design, population and sample

This was a cross-sectional qualitative study [13] conducted from January to February 2019.

The target population was the health staff from the Beira Central Hospital dealing with TB matters. Therefore, there were a total of 71 healthcare workers including managers and decision-makers. Among them, there were 11 medical doctors, 16 nurses, 13 laboratory technicians and 31 hospital auxiliary workers. We used a convenience sampling approach to select our sample [13]. The selected categories of health workers represent the full range of healthcare staff with different levels of training and experience in relation to TB. They also had different responsibilities and possibly had different perceptions and practices related to TB diagnosis, treatment and infection control measures within the central hospital.

Our sample was purposively only made of staff working in the medical wards and TB laboratory, hence, 20 hospital auxiliary workers, 10 nurses, 5 medical doctors, 9 TB laboratory technicians. Additionally, 7 managers and 3 hospital decision-makers were also selected and asked to participate in the focus group discussions (FGD) and individual in-depth interviews (IDI).

Study setting, TB diagnosis and treatment capabilities

The study was carried out in Beira Central Hospital. Beira city (the capital of Sofala province) is located in the central region of Mozambique (about 1,200 km northern of Maputo, the capital city of Mozambique). Beira is the second largest city in Mozambique with a population estimated in about 463,442 inhabitants in 2017. The TB incidence rate (659/100,000 inhabitants) and TB/HIV co-infection rate (about 63%) in Beira city are above the national average [14].

The Beira Central Hospital, a quaternary level health facility, is a referral facility for 3 provinces and partly for Northern region of Inhambane province. This hospital is equipped with high skilled personal (Infectious Disease Doctor, Pulmonologists, Laboratory Technicians, Imagiologist, etc.) and TB laboratory technology, including GeneXpert MTB/Rifampicin, culture and drug sensitivity testing in TB and, where most of TB suspected patients from these provinces are referred to and diagnosed. The Beira Central Hospital has 4 medical wards with approximately 250 beds and 1 separate TB ward with about 34 beds [14].

Data collection and procedures

FGD were used to assess a broad range of views about TB within medical wards from auxiliary workers, nurses and TB laboratory technicians. IDI were used to address individual experiences or feelings from those very busy staff like medical doctors, managers and hospital decision-makers. The FGD and IDI guides were previously discussed with Infectious Disease Doctor, TB and Laboratory Experts, piloted and approved for its use.

There were two FGD with auxiliary workers (10 females and 10 males), one with nurses (5 females and 5 males), and one with TB laboratory technicians (4 femeles and 5 males). We conducted fifteen IDI with five medical doctors, seven managers and three hospital decision-makers. All FGD and IDI were carried out in Portuguese.

The FGD and IDI were held in the meeting room and individual offices respectively, depending on the availability of the health-care workers. During the FGD, one moderator led each discussion using a standard guide and two investigators were observing and taking notes from the discussion. For IDI, one moderator led the sessions and one investigator observed and took notes during the interviews. The moderator and observers were the same in all FGD and IDI. Each FGD and IDI was conducted in an average time of 80 and 60 minutes, respectively.

In undertaking the FGD and IDI sessions digital recordings were done. A guide was used containing the following areas: general situation of nosocomial TB, in-hospital TB care cascade gaps, probable factors associated with in-hospital delayed TB diagnosis and treatment, acceptability of auxiliary workers and 24-hour TB services and, what should be done to ensure feasibility of these last two approaches.

After finishing each FGD, the study team discussed the points as a way of preparing for the forthcoming discussions. Data were processed on a daily basis, immediately after the FGD or IDI. There was no need to change the FGD and IDI guide.

Data analysis

Discussions and interviews were transcribed verbatim. After transcription, content analysis using inductive analysis [13] initially consisted of the identification of transcripts that were linked to the objectives of the study, preparation of analysis codes, transcript text encoding and analysis between the codes. Then, the study team again discussed all codes and agreed the final code for the encoding and the final analysis. Code group in comprehensive themes representing the contents of the objectives (the factors associated with in-hospital poor-quality TB care cascade and explore local sustainable suggestions to improve in-hospital TB care services) was conducted subsequently.

Finally, relationships between topics using the technique of examination and re-examination of the relevant parts were established. Quotes that represented the emerging themes were selected for inclusion in the manuscript.

Atlas-ti version 7 for Windows was used to facilitate the search, classification and organization of the data.

Ethical statement

The study protocol was approved by the Institutional Bioethics Committee for Health of the National Institute of Health of Mozambique and by WHO Ethics Review Committee. The Mozambique Ministry of Health, the Sofala Provincial Health and Beira Central Hospital authorities provided administrative approval. After an introduction of the participants, researchers and the objectives of the study, written informed consent procedures were ensured. Therefore, all participants signed an informed consent form. Participants were allowed to decline to take part of the FGD or IDI. To ensure that every healthcare worker had the opportunity to contribute freely in the FGD, the groups were homogeneous in terms of responsibilities.

The anonymity of the participants was guaranteed by their identification with the initial letters of their professional category followed by the numeral, according to the chronological order of the interviews or sitting position during the focus discussion groups, for example, MD1 (Medical Doctor 1), DM3 (Decision-Maker 3), AW5 (Auxiliary Worker 5), M3 (Manager 3), LT9 (Laboratory Technicians 9), and so on.

Sociodemographic attributes of the respondents

A total 54 key informants were purposively selected and volunteered to participate. Fifteen participated in IDI and 39 in FGD. From the total, 52% (n = 54) were male, the mean (±SD) age was 34 (±7) years and 68.5% of the participants had more than four years working experience in TB matters—Table 1.

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Table 1. Sociodemographic attributes of the respondents from Beira, Mozambique, 2019.

https://doi.org/10.1371/journal.pone.0228927.t001

Main themes emerged

The agreed emerged themes were in-hospital TB care cascade gaps, lack of TB staff and task shifting, centralized and limited time of TB laboratory services and fear of healthcare workers getting infected by TB.

In-hospital TB care cascade gaps

From suspected TB patient admission to the treatment initiation, according to interviewees, there are four mandatory steps. These steps and its related factors are possible TB care cascade gaps that may contribute to increased in-hospital delays to TB diagnosis and treatment, onward TB transmission and TB mortality in the Beira Central Hospital–Fig 1.

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Fig 1. Current steps and perceived factors associated with in-hospital delays to TB diagnostic and treatment in Beira, Mozambique, 2019.

https://doi.org/10.1371/journal.pone.0228927.g001

Additionally, the TB care cascade is getting worse as there is a lack of motivated TB taskforce responsible for organizing and coordinating regular discussion of TB data, supervision, monitoring and evaluation of the TB activities within the health facilities.

Lack of staff and task shifting

Interviewees were first asked to identify which category of the health workers should be considered for task shifting of TB care provision and what needs to be done. Almost all respondents (n = 51) indicated that staff shortage, particularly of nurses, is negatively impacting the quality of the TB care delivery. Therefore, as opposed to an in-ward nurse, in-hospital expedition of TB related issues could best be acceptable if hospital auxiliary workers are carefully selected, trained and assigned to logistic and operational issues in relation to sputum collection from medical ward to TB laboratory, and examination results collection from TB laboratory to medical doctors or any other trained staff for early TB treatment initiation, TB patient isolation and education.

The task shifting was also suggested from higher-trained professionals (ID doctors, Pneumologist doctors, etc) to lower-trained workers (technicians of medicine, laboratory, nursing, etc) specially those working at peripheral health facilities.

As five out of seven managers during a focus group also supported engagement and task shifting from nurses to hospital auxiliary workers. This is illustrated by the speech of one of the interviewees—a manager during a focus group discussion:

Auxiliary workers have always been involved in sputum sample collection and sending to the TB laboratory (…), however, they are not seriously assigned to this task and they don´t feel as their own responsibility (…). What should be done is to select, train, engage on TB matters as expediter and supervise them. To ensure supervion, every health facility should have a high-quality TB care committee and regular coordination/discussion and evaluation meetings (…)

(M2).

In addition, all medical doctors, during an interview, have supported the need of training the TB front line staff, particularly at peripheral health facilities and district levels, on proper management of multidrug resistant TB. One of the medical doctors stated:

(…) TB cases are everywherewe and effective management is lacking due to the shortage of well-trained health workers on TB matters, especially when multidrug resistant (MDR) TB is suspected/diagnosed at district or peripheral levels (…), task shifting from medical doctors to lower health workers for high-quality TB care at rural areas is urgent to overcome the challenges of the MDR TB management

(MD3).

Centralized and limited time of TB laboratory services

Due to shortage of laboratory technicians there is a lack of availability of TB services compared to other clinical services, which was emphasised as an important factor affecting negatively the early diagnostic and treatment of TB in Beira. Thus, the respondents believe that the lack of 24-hour TB laboratory services provision seems to contribute to underutilisation of the scarceness molecular diagnostic tools and lately, on delay in TB diagnosis and treatment initiation.

Importantly, beside the resource constrainsts, the current centralized molecular diagnostic tools (e.g. GeneXpert) approach was mentioned to be one of the most potential shortcomings, as the first door of entrance of the most of patients is at peripheral level, within the primary healthcare, decentalization of the molecular diagnostic tools are seen to be urgent.

This finding shortfall was raised as a concern by almost all participants (n = 38) during all focus groups and in most of the interviews (n = 12) as illustrated by the following interviews of a physician:

As a national routine, during working-days, TB laboratories are open from 7:30 AM, and close at 3:30 PM, but sputum sample delivery to the TB laboratory ends at 9:00 AM every day. Additionally, sputum sample examination is not performed on weekend or (inter)national holidays. How can we reduce nosocomial TB or in-hospital TB mortality?

(MD4).

All laboratory technicians during a focus group also emphasized the following after a laboratory techinician said:

We are happy to guarantee 24-hour TB laboratory services, but it would be necessary to install a micro-TB laboratory in the emergency department and train the lower laboratory technician to use the rapid molecular diagnostic tools (Xpert). (…) working on shift/schedule basis, we should overcome the period of time that TB laboratory is closed and Xpert is underused

(LT9).

In addition, a decision-maker during an interview stated:

(…) ideally, every districts and/or peripheral health facilities should be equipped with Xpert machine and its 24-hours availability for early and proper TB diagnosis and treatment. Old TB diagnostic tools (microscopes) are not helping anymore as most of TB cases are HIV co-infected or are drug resistant TB, which is not diagnosed through acid-fast bacilli smear microscopy

(DM2).

Fear of healthcare workers getting infected by TB

Interviewees said that the poor-quality of TB care delivery and associated in-hospital TB delays seem to be also due to fear of healthcare workers getting infected by TB, poor motivation, lack of supervision to perform their normal duties on TB services swiftly. Frequent stockout of N95 respiratory masks and irregular provision of them to the healthcare workers, particularly for the front-line TB staff, is believed to be one of the causes of in-hospital TB delays at Beira central hospital. Therefore, healthcare workers may neglect to be in contact or managing TB patient due to fear of getting infected by TB.

A general practicioner during an interview stated:

(…) Very importantly, regular provision of N95 masks is an essential condition to motivate HCW to be in closer contact with the TB patients and to work willingly, overcoming the fear of contamination (…)

(MD2).

On the other hand, an auxiliary worker (with strong support from other auxiliary workers) during a focus group discussion said:

(…) we have learnt from several trainings and now not looking after in good manner the TB patients as just we´re protecting ourselves… (…) we are ready to keep much more attention and seriously the TB logistic and operational issues, if the hospital directorate provides the N95 masks and gloves for our own protection

(HAW7).