1. System related factors.

System-related factors need to be addressed and supported at the system level, which covers external factors, stakeholder collaboration, healthcare workers, and client affecting factors.

External factors. The external factor affecting implementation of TB contact investigation in this study was the COVID-19 pandemic. As a response to the pandemic, the government of Malaysia enforced a movement control order (MCO) as a preventive measure, which prohibited mass gatherings and restricted movement. The MCO resulted in the closure of all but essential services, which ultimately disrupted routine TB treatment and prevention services. Many healthcare staff involved in TB contact investigations were reassigned to COVID-19 response activities, and roadblocks and inter-district border closures prevented patients and contacts from attending their TB clinic appointments.

"All is well apart from this covid-19 pandemic problem. This makes the number of contacts in the clinic decrease because most of the time, everyone is instructed to stay at home." (Clinic staff)

"Since the COVID-19 pandemic our IK (health inspector) is always unavailable and busy. Also, due to this pandemic Covid-19, it’s difficult for us to do home visits." (Clinic staff).

Stakeholder collaboration. Healthcare workers valued alliances with other stakeholders, such as non-governmental organizations (NGOs) and private practitioners, to provide additional support in implementing contact investigation. However, they noted the limitations of existing arrangements. In Sabah, there is an NGO formed specifically to aid the state TB control program, known as Sabah Tuberculosis Association (SABATA). This organization offers financial and welfare support to households affected by TB, but only if the patient is of Malaysian nationality possessing a legitimate identification card, or a permanent resident in Malaysia.

"For contacts who live far from the clinic, they usually have transportation problem. We usually provide SABATA aid for them but only for the locals." (Clinic staff)

The adoption of a public-private mix system, whereby clinics without onsite x-ray facilities refer contacts to private clinics with x-ray facilities, was seen as a facilitator in contact investigation. This initiative is led by the State TB Control Unit, which identifies clinics with a high TB burden without onsite x-ray facilities, and matches them to private clinics with x-ray capacity. The State TB Control Unit subsides patients to have their x-ray at the private clinic through provision of an x-ray coupon. However, the number of participating private clinics and the number of x-ray coupons available varies year to year, based on the initiative’s fluctuations in available budget allocated by the Ministry of Health. As noted in the following section, while cooperation between sites to share facilities is valued, a preferred solution would be x-ray capability at all sites.

"Since the government provide free coupons for a chest x-ray, it is feasible for them to do the x-ray in private clinics. The number of contacts screened is also increased." (Clinic staff)

Healthcare workers. Many staff identified a lack of human resources and not having diagnostic facilities onsite (Facilities B and C) as barriers to contact investigation. In contrast, staff at Facility A, the only clinic with complete diagnostic facilities onsite (x-ray and laboratory) perceived these facilities to be enablers in the contact investigation process.

"There is a critical insufficiency of staff; [Facility B] is the clinic with the highest TB burden in KK. The clinic has to prioritize attending to TB cases instead of contacts which affects contact investigation." (Clinic staff)

"In my opinion, the contact tracing system needs to be improved by adding the number of staff. We often face the problem of lack of staff to handle the contact tracing, so I recommend increasing the number of staff to reduce the workload, and contact tracing can be updated without any delay." (Health inspector)

"One of the usual barriers faced during contact investigation is due to no x-ray in the clinic and also lack of nearby x-ray facilities." (Clinic staff)

"Since we have x-ray and laboratory here, it is easy for us to implement the investigation." (Clinic staff, Facility A)

Clinic staff raised concerns about the safety and wellbeing of unregistered immigrants attending the TB clinics as a challenge to implementing contact investigation. This was because undocumented immigrants in Sabah face detention and deportation if identified.

"Illegal immigrants are afraid that they might get caught on the way to the clinic." (Clinic staff)

"Cases who are illegal immigrants do not have a permanent address and are always moving around as they face a high risk of being caught and getting deported if their whereabouts are known, thus causing the difficulty to track and trace contacts." (Health inspector)

Healthcare workers reported that not having a clear and systematic contact investigation process, with proper guidelines on TPT implementation, was a challenge to contact investigation implementation.

"Too many work processes; first case investigation, then send contact notification form to the clinic, then input the case notification into E-notice (National Communicable Disease Control Information System, CDCIS) then update MyTB (National Tuberculosis Information System)." (Health inspector)

"There are no proper guidelines or protocol to refer in terms of TPT implementation." (Clinic staff, doctor)

"There’s no proper system to follow up for contact screening.” (Clinic staff)

Clients. The role of social factors, including stigma, access to social support, and social status of undocumented non-Malaysians (illegal immigrants) in the community, was also brought up in the interviews as a contributing factor to delays in clinical evaluation and initiation of preventive therapy among TB contacts.

“Family members have a stigma towards the case and refuse to provide any support or admit that they have been in contact.” (Health inspector)

“Case is worried of social stigma from the community and is ashamed to provide the real information for contact screening.” (Health inspector)

Social support played an important role in ensuring contacts attended the TB clinic for the necessary clinic assessment and follow-up appointments.

“Every time I need to go to the clinic, nobody is going to take care of my other kids so, I have to bring them all to the clinic, which is difficult for me.” (Parent of a child on TPT)

“I ask my sister-in-law to pick up the medication (TPT) on my behalf when I’m unable to collect it myself.” (Parent of a child on TPT)

A lack of valid migration status of TB contacts was one of the most consistent problems identified by clinic staff. It was noted that undocumented immigrants had a social status that was deemed unfavourable by the community and often tied with stigma.

“For non-locals, some do not come to the clinic for fear of being arrested by the police due to not having a valid passport.” (Clinic staff)

The clients (TB patients and contacts) described financial difficulties as a barrier to attending the clinics. Cost and availability of transport to the clinic and distance from the place of residence to the clinic were reported as challenges to clinic attendance.

“When it comes to transportation and picking up the medication, it is hard for me because I need to take three buses before I can go to the clinic.” (Parent of a child on TPT)

“I couldn’t go to the clinic when my husband is not around because there is no public transport there.” (Parent of a child on TPT)

“I find it hard to come to the clinic when I have no money.” (TB contact)

2. Clinic related factors.

These factors can be influenced at the clinic level. They included the perceived performance of the clinic, the clinic schedule, and the physical space of the clinic. Clinic staff perceived deficiencies in their performance at TB contact investigation to primarily resulting from insufficient time available to carry out this activity. Clinic staff reported that this affected the mental health of some of them.

“It’s time-consuming for contact screening and we don’t have time to update MyTB (online TB information system).” (Clinic staff)

“The health facility is always late in filling up necessary forms and handing it to the necessary parties on time.” (Health inspector)

“A lot of the staff are stressed out and have trouble sleeping.” (Clinic staff)

Clinic staff reiterated a lack of space in the TB clinics, which hindered implementation of contact investigation and their performance in delivering care to clients.

“I have to share a clinic room with 2 other doctors and assist with other patients. I always avoid giving long advice to patients because it is not a priority and I’m afraid that my other colleagues and patients would get infected as our clinic room has no window, is air-conditioned and is very small.” (Clinic staff, doctor)

“It is difficult for parents or guardians to bring children for TPT as there is no parking space and the clinic is located on top of a hill despite them agreeing to start IPT for the children.” (Clinic staff, doctor)

The healthcare workers also acknowledged issues in time management as a limiting factor in the implementation of contact tracing. A more systematic approach to scheduling clinic activity and patient appointments was seen as a potential solution to improving clinic performance.

“The main barrier usually faced during contact investigation is the lack of time. Sometimes there are too many patients come in a day. So, the investigation needs to be done faster.” (Clinic staff)

“The insufficient amount of time to attend the contacts. Sometimes the contacts are from workplace, school, office, there are too many of them so we divide them into a group to come for screening.” (Clinic staff)

“No specific day for TPT follow up; we have to combine the appointments with pulmonary and extrapulmonary TB patients’ appointments which causes the parents and guardians to be unwilling as they’re afraid the children might get infected.” (Clinic staff, doctor)

3. Healthcare worker related factors.

These factors can be influenced at the health care worker level. The barriers and facilitators which emerged in this area were: cooperation, knowledge, misconception, counselling, and communication.

Cooperation and commitment. Some participants perceived a lack of cooperation among parties involved and a lack of commitment to achieving the goals of TB contact investigation.

“Investigating officers are inefficient and refuse to share and report their investigation findings with each other regularly and to supervising officer.” (Health inspector)

Clinic staff, however, indicated cooperation from all parties involved in TB management to strengthen the contact investigation process.

“So far, management for the contact investigation at this clinic is still at a satisfactory level. Each incoming contact will be screened and followed up until the end of the screening period. But all this requires the cooperation of many parties, such as patients themselves, close contacts, clinic staff, and health inspectors. It is crucial to strengthen contact tracing.” (Clinic staff, medical assistant)

Knowledge. When interviewed, most healthcare workers felt they had adequate knowledge of TB transmission and disease to enable them to provide effective health education to patients and contacts. Their perception of the benefits of contact investigation was a motivating factor in their implementation of the process.

“Tuberculosis investigation is essential to control this infectious disease. It is vital for us to know who lives in the same house, works in the same place, and hangs out with the patient. When this contact investigation is done, it will help reduce the risk of infection.” (Clinic staff, medical assistant)

“Yes, TB contact investigation is worthwhile. For their family and close contacts are able to get screened and treated earlier to prevent them for infecting other people.” (Clinic staff, staff nurse)

However, one of the interviews revealed the potential for misconceptions to impact implementation, with one clinic staff commenting, “If we continue to force them to take TPT and they fail to come to the clinic to get the medicine supply, it will bring more problems such as MDR risk.”

The clinic staff also identified the inability to provide proper counselling and health education to clients as a barrier to effective contact investigation and TPT implementation.

“It is difficult to counsel or educate non-locals.” (Clinic staff, medical assistant)

“On average on a day, I will see 20 patients with appointments and 30 walk-in patients; there is very limited time for me to give proper advice and counselling.” (Clinic staff, doctor)

“Commonly noted barriers include insufficient space in the clinic for counselling.” (Clinic staff, nurse)

Healthcare workers also reported communication between relevant parties as a factor influencing contact investigation. Clinics have to send a notification form to the health inspectors in cases where contacts did not show up for their clinic appointment, and health inspectors are obliged to investigate and provide feedback to the clinic. It was revealed that frequently, the contact attended a different facility for assessment. This information was not relayed to the facility where the contact was initially registered, leading to improper documentation on contact follow-up or the inability to trace the contact.

“Difficult to co-manage with other facilities; no communication on compliance to treatment or loss to follow up.” (Clinic staff, nurse)

“We try to contact them (contacts) via phone and send the TBIS-10 D form (reporting form for case or contact who can’t be reached to the district health inspector for further action, who will investigate and provide feedback to the clinic about the person. Some of the TB contacts might either have been transferred to another facility for follow up, go back to their hometown or are unable to be traced.” (Clinic staff, medical assistant)

4. Patient and contact related factors.

Factors that can be influenced at the client level identified through qualitative analysis were the client’s cooperation and commitment to TB contact investigation and preventive therapy. Staff interviews reported that contacts frequently failed to attend appointments, which some interpreted as “uncooperative” behaviour.

“A common problem in any clinic is the contact person not following instructions to come to the clinic for routine screening.” (Clinic staff, medical assistant)

“The contacts are not cooperative. They will always give many different excuses for not attending.” (Clinic staff, nurse)

Furthermore, the cooperation of clients is also closely linked with their commitment to attend their clinic appointment and subsequent follow up.

“Contact refused to attend screening as they “feel well” despite having explained the need for investigation.” (Health inspector)

“Contact did not attend follow up appointments.” (Clinic staff)

5. Guardian related factors.

Guardian’s acceptability in providing preventive therapy to their children was highly influenced by their cooperation, commitment, knowledge, and misconception towards TPT.

Cooperation and commitment. One of the main reasons affecting the guardian’s participation in TPT was the child’s condition at the time of screening. Parents of healthy children aged under one year appeared to be more likely to decline TPT when offered.

“Oh, the parents usually refuse. Because they’re afraid they’re unable to complete the six months of treatment as their children are still young.” (Clinic staff, nurse)

“It’s normal for some parents to refuse to start their child on the treatment because they’re afraid of side effects of the medication if it’s started on a very young child.” (Clinic staff, nurse)

On the contrary, parents who agreed to the treatment mostly showed good commitment to completing TPT.

“If the medication is for prevention, I will not refuse. We should take this disease seriously.” (Guardian of a child eligible for TPT)

“I will make sure my kids complete the treatment because I want them to be healthy." (Parent of children eligible for TPT)

Knowledge. Many staff identified a lack of knowledge about TPT and the need for preventive therapy as a factor affecting acceptability of the treatment among parents and guardians.

“Lack of knowledge is always the first problem for them to accept TPT.” (Clinic staff, nurse)

“Parents who do not know the importance of TPT will indeed feel hesitant to start this child’s treatment.” (Clinic staff, medical assistant)

Misconception. Misconceptions about the disease and TPT were also implicated as contributing to the acceptability of preventive therapy among guardians.

“This disease is like a hereditary disease.” (Parent of a child eligible for TPT)

“There are parents who say that this preventive treatment is not lifelong and it doesn’t protect their child from TB forever.” (Clinic staff, nurse)

6. Treatment related factors.

Parents and guardians whose children were initiated on TPT indicated that access to the child-friendly form of medication facilitated completion.

“The medicine is sweet, my child likes it.” (Parent of a child eligible for TPT)

“The medication is in syrup form. This helps me to give the medication to my kids easily.” (Parent of a child eligible for TPT)

Nevertheless, the duration of the treatment (6 months) posed a challenge for TPT completion for some parents.

“The parents usually refuse because they’re afraid of side effects of the medication if they’re unable to complete the 6 months of treatment.” (Clinic staff, nurse)

“If the medicine needs to be consumed over a long period, I am not sure whether I can finish it or not.” (Parent of a child eligible for TPT)

Most of the staff cited adverse effects of the medication as a barrier to TPT completion. At the same time, parents highlighted concerns about the potential for adverse effects as a determining factor in their decision to accept TPT.

“The next reason is that their child cannot tolerate the medication given. Some of them are allergic after taking the drug. Some of them suffer from diarrhea and vomiting.” (Clinic staff, nurse)

“Not sure yet. I will consider it first if there are adverse side effects. I will stop taking the medication if any adverse effects occur. It’s hard to talk about this for now because I haven’t seen any effects yet.” (Parent of a child eligible for TPT)