Table 1 Linking gaps in empiric data for behavioural analysis to intervention design (stages 1 and 2)
Summary of gaps identified in empiric data from our previous studies | COM-B | TDF constructs linked to COM-B | Relevance of the theoretical domain | Proposed intervention function from the BCW guide [36] |
|---|---|---|---|---|
Under-detection of TB in children, 60-70% thought to be missed (QUAN) Nearly 60% of all paediatric admissions met guideline criteria for suspected TB but < 3% got a diagnosis (QUAN) | Capability-psychological | Knowledge Behavioural regulation | Awareness of steps in diagnosing TB in children; of the available tests. Do they know what they should do and when and why? Self-monitoring; how to break a habit e.g. missed diagnosis. Anything in place to prompt them to make a diagnosis and to self-monitor? | Training: Imparting skills on how to correctly diagnose TB in children Modelling: Providing an example for people to aspire/imitate, e.g. via champions/clinical leaders Persuasion: Using communication to stimulate action, e.g. via audit and feedback |
Some reported that they did consider a TB differential diagnosis but sometimes forgot to document (QUAL) Some reported they do tests but forgot to document (QUAL) | Capability-psychological | Memory attention and decision processes Behavioural regulation | Ability to retain information, to consistently remember to document what is done Self-monitoring; how to break a habit, e.g. failure to document. Anything in place to prompt them to always document? | Environmental restructuring: Changing the physical context, e.g. availability of record forms for better documentation, job aides Persuasion: Using communication to induce positive or negative feelings or stimulate action, e.g. via audit & feedback; shared goals with peers |
Some health workers fear/are reluctant to make a diagnosis of TB in children sometimes due to stigma in caregivers of TB-HIV association (QUAL) | Capability-psychological Motivation-automatic | Knowledge Reinforcement Emotion | Awareness of steps in diagnosing TB in children; of the available tests. Do they know what they should do and when and why? Anything to motivate or demotivate them? Does it evoke an emotional response, e.g. some got uncomfortable when babies cried during specimen collection; some were reprimanded harshly by caregivers | Education: Increasing knowledge or understanding of TB in children Persuasion: Building communication skills to better counsel families Modelling: by the champions to demonstrate how best to de-stigmatise |
Underutilisation of TB diagnostic tests, 1% get Xpert done (QUAN) Health workers generally seem to have a challenge in collecting specimen for children (QUAL) | Capability-psychological Capability-physical Motivation-reflective Motivation-automatic | Knowledge Physical skills Beliefs about capability Reinforcement | Awareness of steps in diagnosing TB in children; of the available tests. Do they know what they should do, when and why? Are they physically able/proficient in diagnosing TB; collecting specimen; using diagnostic tests? Acquired through practice Are they confident diagnosing TB in children; collecting specimen? How difficult or easy? Increasing likelihood of TB tests being used appropriately | Training: Imparting skills to use available diagnostic tests and specimen collection Modelling: Champions/clinical leaders demonstrating correct procedures Environmental restructuring: identifying who is responsible for ensuring TB tests get done; job aides to serve as reminders of procedures |
Health workers report consistently negative Xpert test results (QUAL) | Capability-psychological Motivation-reflective | Knowledge Beliefs about consequences | Do they know how to respond to negative test results? How and when to make a clinical diagnosis? Do they believe doing it or not makes a difference? | Education: increasing understanding on making a clinical diagnosis and the epidemiology and natural course of TB in children Persuasion: communication to pass on the value of TB tests |
Some facilities had good teamwork and mentorship that helped model the correct way to diagnose TB in children (QUAL) | Opportunity-social Motivation-reflective | Social/professional role and identity Optimism | Do they think it is part of their job, e.g. to collect specimen (senior doctors struggled) Do they think it’s something that can be done? How confident are they of this? | Modelling and social environment restructuring: Providing an example for people to aspire/imitate and encouraging teamwork Persuasion: communication to pass on the value of diagnosing TB in children |
Most facilities had long and unclear processes that contributed to TB being missed in children (QUAL) Some reported frequent stock-outs of some reagents and XPert cartridges (QUAL) | Opportunity-physical | Environmental context and resources | Organisational processes and patient flows; resources like job aides, PPE, reagents. Aspects of the environment that influence whether or not they diagnose TB in children | Environmental restructuring: Changing the physical context to ensure better work flows and availability of equipment, reagents |
Lack of skilled human resource to interpret some test results like chest X-rays (QUAL) | Opportunity-physical Capability-psychological | Environmental context and resources Knowledge | Aspects of the environment that influence whether or not they diagnose TB in children Awareness of steps in diagnosing TB in children; of the available tests. How to make a clinical diagnosis? | Environmental restructuring: e.g. job aides to guide clinical diagnosis; remote decision-support for X-ray interpretation Training: Imparting skills of reading X-rays looking for TB-specific features; making a clinical diagnosis |
Some policies and directives including selection of participants for training disadvantaged front-line health workers (QUAL) | Opportunity-physical Motivation-automatic | Environmental context and resources Reinforcement | Aspects of the environment that influence whether or not they diagnose TB in children Anything to motivate or demotivate? (lack of training was a demotivator) | Education: increasing policy makers’ understanding of the need of rethinking how TB training is done Persuasion: Using communication to stimulate action, e.g. feedback to policy makers on the impact of training |
TB programme policy of doing quarterly audits and supervisory visits helped (QUAL) | Motivation-reflective | Intentions Goals | Feedback to enable health workers to make a conscious decision to improve case detection Visualise what they want to achieve | Persuasion: Using communication to stimulate action, e.g. via audit & feedback |