Study setting and period

The study took place in Illubabor Zone health facilities in the Oromia region, South-West Ethiopia, from March 15, 2021, to October 1, 2021. The zone is 600 kilometers from Ethiopia’s capital city, Finfinnee/Addis Ababa. In 2021, there were 13 rural districts and one town administration in the Illubabora Zone. Currently, forty (40) public health facilities and five private clinics in the Illubabor zone provide DOT diagnosis and treatment.

Sample size and sampling techniques

Data collection method and tool

Piloted interview guide questions were utilized for both the KIIs and the observations. We employed a variety of approaches to collect data. First, key informants in charge of directing or coordinating tuberculosis control programs at various levels, as well as those responsible for delivering DOT at the facility level and TB patients, were interviewed. All of the participants were approached face-to-face, and none of them declined to participate in the study. The interview guide was translated into Afan Oromo by an English language expert who is also an Afan Oromo native speaker and then re-translated into English.

The authors conducted in-depth interviews using the local language to learn about health workers’ and patients’ experiences and perspectives on the reasons for diagnosis delays. Various people were interviewed in order to gain as many opinions as possible on the study’s ultimate goal. After transcribing the day’s work and preliminary analysis, redundancy of responses was considered saturated and was deleted every evening.

The data gathering team consisted of Principal Investigators (male lecturers) with secondary level qualifications (MPH). The study offered confidentiality to participants, and the interviews took place in a private setting. We did our best to make the study participants feel at ease by engaging them in small conversation for the first few minutes. To ensure triangulation of the data with the record, the team captured the data and took notes, including memos of participant behaviour and context. The interviews were done as a dialogue rather than asking and answering questions. The interviews lasted 60 to 90 minutes and were audio-taped and transcribed verbatim, with descriptive field notes written after each of the interviews.

Second, governmental health facilities were inspected using a predetermined checklist to gain an overview of the current condition in terms of the availability of necessary infrastructure and other resources, such as electricity, human resources, and TB diagnostic reagents. It was conducted by observing the TB room, laboratory room, outpatient department (OPD), patient waiting area, and general infrastructure, as well as interviewing the responsible individuals in the relevant facilities’ units. Each facility’s observation lasted 50 to 70 minutes. The authors were in charge of the facility inspection. The data gathering methods were created using national and WHO TB control program guidelines, as well as existing research [6–8].

Data analysis, data quality control and trustworthiness

The data analysis for the in-depth interview began with daily transcription and preliminary analysis during the data collection phase. The writers transcribed all of the audio-taped interviews and then double-checked the transcript by listening to the recordings. Descriptive notes were recorded when reviewing the transcripts. This included the addition of new probing questions as well as the consolidation of some of the interview guide’s other questions. A health management specialist who is a native speaker of the local language (Afan Oromo) assessed de-identified audio-taped interviews for peer debriefing (transcripts).

The data coding and categorization were done manually by the authors. The material was identified and analyzed using a thematic analysis approach. The information was organized into sample collection procedures, poor competency of health professionals, absences/scarcity of health professionals, scarcity of medical products/technologies, and absence/scarcity of basic infrastructures. Finally, we attempted to provide a general picture of what all of the survey participants described as their perspectives and experiences with regard to the reasons for TB diagnosis delays. The information was supplied in the form of descriptions of events and experiences that were pertinent to the study’s goal [9].

The frequency of presence and absence of specified resources, as well as an acid fast bacilli (AFB) reagent stock-out, were checked and computed using facility observation data. Narrative data was also compiled based on observations of each health institution and its surroundings. As a result, the observations from the facilities were used to confirm the conclusions from the in-depth interviews, as well as to enhance and deepen the data interpretation.

Triangulating data sources and data collection methods helps to challenge data from a variety of sources. The information gathered from many people at various levels was used to obtain experiences of those working in the TB control program, as well as the patients who received care [10]. The interviewers (authors) also made every effort to ensure that their relationship with the study participants was founded on trust so that they felt safe.

The interviewers were familiar with the local languages and cultures, and they believed they had established an "optimal" (insider-outsider) distance from the study [11]. They considered themselves insiders because they spoke the native languages fluently, which helped them grasp the situation. By not collaborating with DOT providers and program administrators, the outsider status was kept in part.

Ethics approval and consent to participate

Ethical approval was obtained from the Research and community Service Coordination Office (RCS) of Mettu University Faculty of Public Health and Medical Sciences with Ref. No RCS/114/13. Before the start of data collection, written informed consent was obtained from each of the study participants after information was provided about the nature and the study’s goal. Participants were informed that they have the right not to participate in the study or can withdraw at any time. Furthermore, privacy and confidentiality were ensured by using numbers to identify and describe the study participants.

Background characteristics of the study participants

From total 35 study participants took part in the in-depth interview, 28(80%) are health professionals, of which 23(82.8%) of them were male and 19(66.7%) of them were between the ages of 25 and 34. In terms of educational attainment, 20(72.8%) had a bachelor’s degree, and 19(68.2%) had > 5 years of work experience for their current position or responsibility (Table 1).

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Table 1. Characteristics of the study participants for in-depth interviews in the Illubabor Zone, 2021.

https://doi.org/10.1371/journal.pone.0278592.t001

Qualitative findings

From the analysis of the in-depth interviews, five major themes were identified. The major themes were: sample collection procedures, poor competency of health professionals, absences/scarcity of health professionals, scarcity of medical products/technologies and absence/scarcity of basic infrastructures. Each was narrated with expressive quotes from participants.

The sample collection method

Some laboratory professionals reported that the current approach to sputum collection might lead them to report false negative results. They explained that in the previous approach (spot-morning-spot), morning sample had a high chance of getting the mycobacterium tuberculosis under the microscope. They mentioned that the morning sample was highly concentrated. In contrast to this, the current approach (spot-spot) is susceptible to collecting saliva only, which has a low probability of getting the mycobacterium tuberculosis under the microscope. One participant stated:" We are collecting saliva, which is inappropriate sample."

Consequently, the participants suggested that more advanced research has to be done. According to their reports, the difference between the results of a sample from spot-spot and spot morning spot was significant. One participant said:"… As to me, it is better to conduct sophisticated research."

Poor competency of health professionals

Most of the study participants mentioned poor competency of health workers who were failing to request a necessary diagnostic investigation. They emphasized patients are suffering in the health facilities after consulting the health professionals.

One participant said:"… in our health facility, diagnosis delays are happening because of misdiagnosis at OPD level.”

Additionally, respondents reported that the laboratory professionals’ slide preparation led them to false negative reports. That means they are not preparing the slide with the appropriate procedure. One participant said:"… for instance, if you observe their slide preparation, it is very poor in some health centers."

The participants (program managers, DOT providers, and laboratory professionals) described possible causes for the lack of health workers’ competency. The first reason mentioned was an absence of in-service TB training for all general practitioners, health officers, and laboratory professionals to provide quality TB services for their clients. One participant explained:"… concerning the quality starting from the OPD, they are not well updated with the new algorism method, including the general practitioner.” Another participant said, "According to our health center, only one health professional was trained on tuberculosis from the outpatient department." AS participants said if the managers think proactively, it is possible to give training for all health workers.

The Second complaints by seniors about professionals’ competency were that higher education institutions are not producing competent graduates. They also underscored that the ministries of health and education have to take the necessary measures to correct the issues. One participant said:"… compared with the past, higher education institutions are producing professionals with unsatisfactory skills."

The third reasons raised by the participants were non-utilization of national TB control program guideline. According to their idea among health professionals who have taken the training most of them are not doing accordingly. Even they have already dumped the guidelines to their home from which have taken the training. They are not doing according to guidelines which leading them to inappropriate history taking so that they miss right diagnosis and, miss diagnosis is the possible reason for diagnosing the other upper respiratory tract infections. Then prescribing antibiotics for the patients and patients back home without having the right diagnosis and treatment and then come back again after days or weeks for the patient is not relieved form his/her complaint. These not utilizing guidelines in turn explained due to the lack of close supervision.

Evidence from observation mentioned, that national TB control program(NTCP) guideline was not available in 16(72.7%) outpatient departments, 18(81.8%) laboratory rooms, and 12(54.5%) TB rooms of the facilities.

Absence/Scarcity of health professionals

A majority of the study participants among the DOT providers and program managers at various levels reported that there was a scarcity or absence of trained health professionals, particularly in the outpatient and laboratory departments, which caused TB diagnosis delay.

One participant explained, "The main reason for diagnosis delays happening in our health facilities is the scarcity of laboratory health professionals."

Moreover, our findings from observations at health facilities show that there was an absence of trained professionals at OPD in 18(81.8%) of the facilities. The respondents gave emphasis on the reason for health professional scarcity, which they mentioned as the cause of diagnosis delay. The scarcity of health professionals is related to high turnover as a result of joining non-governmental institutions, education, and transfers to urban health facilities. The other reason for the delay in diagnosis is related to the absence of recruitment as per usual. The government is not recruiting health professionals immediately after graduation as a result of the scarcity of budgets. Additionally, significant numbers of university graduates are not passing the competency exam. According to the participant’s explanation, this condition is creating a huge gap in the midst of high professional demands.

One participant stated:"… the reason for health professionals’ scarcity could be the unemployment of university graduates immediately after graduation."

Consequently, almost all the participants stated that high work overload is making it challenging to diagnose TB early. According to their reports, health professionals are not doing their work with adequate time because their intention was just to address the high patient flow.

One participant said, "… because of high patient flow, we are missing the opportunity to request an appropriate laboratory investigation, which is the reason for misdiagnosis."

One patient said, "… I visited three health facilities before my case was known; just as I entered the examination room, the health professionals gave me a prescription without asking me to address a lot of patients in the waiting area."

The participants reported that the work load was caused by the absence of the required health worker-to-population ratio standard by WHO. The DOT providers emphasized that their managers were ordering them to clerk more than sixty patients per day. This problem in turn happened as a result of not strictly requesting workers, and on the other hand, when the front line manager requests human power, the higher managers raise the budget scarcity issue. Accordingly, if the problem is not resolved, early tuberculosis diagnosis is out of the question, as per the participants.

Scarcity of medical products/technologies

The absence of diagnostic tools like updated or functional microscopes, X-rays, functioning Gene expert machines, and a shortage of AFB reagents were major reasons for the delayed diagnosis of TB, as reported by many of the laboratory professionals and program managers.

One participant mentioned that "the absence of diagnostic tools like X-ray, AFB reagents, and microscopes is the reason for the delay in diagnosis of TB."

From observation, in 7(31.8%) health facilities, microscopes were not functional and only 2(9.1%) health facilities had X-rays. The AFB reagents were not available in the drugstores of most health facilities: acid alcohol in 15(68.2%), carbol-fuchsion in 17(77.3%), and methylene blue in 14(63.6%) health facilities on the day of observation. Functional weighing scales and masks were not present in 11(50%) and 13(59.1%) of the TB rooms of the facilities, respectively. Nevertheless, these resources are supposed to be available in all 22 health facilities.

According to participants, the possible causes of the shortage of reagents were a failure to timely distribute them to the health facilities, which was related to the absence of timely requests. Even though the reagents are prepared in decentralized local regions, the transportation mechanism does not maintain their quality. Additionally, participants were complaining about the lack of a vehicle or motorcycle for the laboratory department to bring the reagents to the Zonal level.

"Most of the time, we are not supplied with AFB reagent on time, and even when it comes, they only supply us with local bottles that are not packed appropriately," one participant explained.

Participants also mentioned the cause of scarce diagnostic tools like microscopes and gene experts as the absence of timely maintenance for failed machines. One participant said, "Now the time you are interviewing me, the Gen expert machine is not functioning, which is only found in hospitals and used for all health centers in the zone.”

One patient undergoing directed observed treatment describes his ordeal: […].My result was delayed after I came to the health facility because of the machine not functioning, which is used for drug initiation. […](A TB patient)

Participants explained the lack of timely machine maintenance as not having trained technicians who maintain it. They stated that now they are calling for technicians from Addis to fix these machines. As a result, delays happen until the technician comes from a long distance. One participant stated: "We are calling the technicians from Addis Abeba to fix the machines which are resulting in the tuberculosis diagnosis delay."

The other idea, according to the participants, was that most of the microscopes being used in their healthcare set up are out-dated. They emphasized that our country is not using advanced technologies that are coming with new versions of machines. For this reason, they mentioned these out-dated machines may be the possible cause of the TB diagnosis delay. One participant mentioned that, "to your surprise, most of the microscopes working in our health facilities are out-dated.”

Absence/Scarcity of basic infrastructure

Most of the participants mentioned the absence of adequate rooms, water supply, and electricity. Several rural health centers lacked clean water, electricity, a patient waiting area, and a sputum collection area.

From observation, there were no waiting areas for patients in 7(31.8%) of the health facilities. Of those who had patient waiting areas, none of the health facilities had a separate waiting area for TB patients. Moreover, no health centre had a sputum collection area, and only one hospital had a separate laboratory room for sputum examination. The 12(54.5%) and 8(36.4%) health facilities didn’t have water supply and electricity, respectively.

The majority of study participants mentioned that limitations in laboratory room space and a separate sputum collection area were the causes of delayed diagnostics at health facilities. They said this could happen as a matter of poor building design. This led patients to give the samples using the same window. They said since limited space increases the chance of transmission for other patients, we appoint suspected cases after a certain time when patient flow decreases. One participant said, "We are intentionally delaying the diagnosis of TB to decrease the chance of index case contact with other patients because they bring samples via one window.”

Several participants gave emphasis to the absence of electricity and a standby generator as major factors in the diagnosis delay.

One participant explained, "One day I had scheduled the suspected TB patients for the next day because there was no light."

One patient said: […]. In fact, my results were delayed in the health facility due to appointments. [..]. (A TB patient)

According to the participants, the causes of limited basic infrastructure like water and electricity are scarcity of budget allocation and low community participation in fostering the basic infrastructure. Other issues identified were a lack of engagement with other aiding agencies or non-governmental organizations. Also, a lack of regular supervision was raised by participants. Most of them reported a lack of vehicles as the main obstacle to conducting supervision. Also, the COVID-19 impact was mentioned significantly. When the pandemic struck the country, most of the usual plans were disrupted.