Perceived Feasibility of stool-based Tuberculosis diagnostics in children and adults with HIV in Uganda and Eswatini: Healthcare workers’ perspectives

Abstract Background Tuberculosis (TB) is the leading infectious killer. Diagnosis in people with HIV and children is limited due to the paucibacillary nature of the disease; respiratory specimen collection and diagnosis in these groups can be difficult, often requiring semi-invasive methods for sampling. This study explored the feasibility of stool-based TB diagnostics for tuberculosis as an alternative to sputum in Uganda and Eswatini, focusing on healthcare workers' (HCWs) perceptions. Methods In this qualitative study, researchers used semi-structured interviews in Uganda and In-depth Interviews and one focus group discussion in Eswatini to explore HCWs’ perceptions of stool-based TB diagnostics. This study was conducted at TB clinics in Uganda (Kampala) and Eswatini (Hhohho and Manzini). HCWs were selected using purposive and convenience sampling. The researchers analysed the transcribed interviews using deductive content analysis guided by Bowen’s feasibility framework to identify key themes related to the feasibility of stool-based TB diagnostics. Results Interviews with 21 HCWs in Uganda and Eswatini revealed perceived high acceptability of stool-based TB diagnostics, primarily due to their non-invasive nature and being favourable for children, particularly when sputum collection is challenging. HCWs reported high demand when standard sample collection kits were unavailable. However, implementation faces significant barriers: reluctance among adults, often resulting from cultural beliefs and aversion to stool, logistical challenges such as difficulty providing samples promptly and travel costs to return with the stool sample to the health facility, and the need for new resources, infrastructure upgrades in terms of sanitation facilities, public sensitisation and staff training to overcome resistance and ensure successful roll-out. Conclusions According to HCWs, stool-based TB diagnostics are highly acceptable and favourable for children. Integration of stool-based diagnostics will require a comprehensive approach, including securing external support, upgrading facilities, training staff and sensitising the public. Trial registration: This study is part of the Stool4TB study, registered on 2021-09-08 at ClinicalTrials.gov under ID NCT05047315(1).