Table 4.

Challenges to delivery of TEC

Challenges	Quote
Competing time demands and human resource shortages	‘In my opinion… we are not economically stable in terms of income…the doctor or health worker is teaching and you as a patient have been promised some money and are expecting money from someone; …you are expectant. …you are likely to tell the health worker that today, I will not be able to attend the education. Can I just get the medication and go? So that I can access the money promised, because, we need the money to cater for our needs.’ (Male TB patient, TB FGD 1) ‘If you are being taught and your thoughts are on something else, you do not gain much.’ (Male TB patient, TB FGD 1) ‘… we come very early in the morning [to the TB clinic], but I do not know whether health workers are few…’ (Male TB-HIV patient, TB FGD 7). ‘…so, you find someone sitting the whole day and they get tired and go away, that means we will not be able to track whether they were here or not and that means they will have inadequate counselling… and their adherence will be poor.’ (TB clinic HCW, HCW FGD) ‘… part of the challenge is like unlike in the HIV clinic where we have counsellors who are dedicated to provide information and give time to these patients in the TB units all over Uganda we do not have counsellors… one nurse cannot provide adequate counselling when he or she is going to attend to fifty patients so in the end the patients do not benefit so much in the counselling.’ (TB clinic HCW, HCW FGD 1) ‘Yeah, so in most cases I want to be honest… when the patients are beginning their treatment, they really get comprehensive counselling. Only the other times when they come for refill, and you don’t have the time to go over things repeatedly, then you just do chap, chap [quickly].’ (TB clinic HCW, HCW FGD 4)
Limited space in the TB unit	‘…there is no waiting area…, Yes, the issue is space.’ (TB clinic HCW, HCW FGD 1)
Lack of integration of TB-HIV care	‘…I don’t know whether they do not have the information because I do not see them counsel HIV positive clients. Me, I do not have information on TB… So likewise, even me I would not counsel some[one] with TB, so, we are the same. You need to educate them on HIV and TB together because they are taking a whole package together… [especially], when they come back for review.’ (HIV clinic HCW, HCW FGD 1) ‘… At the end of it when they have completed 6 months of anti-TBs then we discover that they have not been taking ARVs. They say that you see the side effects of efavirenz, you see this and this just because they are not reviewed [for adherence to both TB medications and ARVs] on each visit so you find that they are not taking.’ (HIV clinic HCW, HCW FGD 1)
Lack of interpreter services	‘… but the challenge I have is that sometimes there is a language barrier. I use English, but in most [patients] complain, we don’t know English, so after using English I try and interpret in Luganda, I use a little Luganda, I was suggesting if we can have someone to translate, we can do it.’ (TB clinic HCW, HCW FGD 4)

Abbreviations: CHW, community health worker; FGD, focus group discussion; HCW, health care worker; TB, tuberculosis; TEC, TB education and counselling.