Providing person-centred TB care: a participatory study with healthcare workers in Nairobi, Kenya

Abstract

Background

Policies promote patient-centred tuberculosis (TB) care in Kenya, a high-burden TB country, but implementation remains limited. This study sought to understand the experiences of TB healthcare workers in implementing patient-centred TB services in primary health facilities in Nairobi and explore how the challenges they face can be addressed.

Methods

Using collaborative research design, we recruited healthcare workers (n=29) from primary health facilities across three densely populated subcounties in Nairobi and TB stakeholders (n=24) including policymakers and managers. From March to April 2024, we collected data through three workshops with nurses (n=19) and clinical officers/doctors (n=10) and a joint workshop with stakeholders. Participants engaged in group discussions and participatory visual methods to define person-centred care, document practices, identify challenges and develop solutions. Our data analysis applied a framework approach drawing on the social–ecological, TB care cascade and health systems building blocks models.

Results

Healthcare workers identified practices for differentiated TB care across age groups, genders, occupations and comorbidities. Implementation faced multiple challenges including structural, health system, community and patient’s individual constraints. Shortages of funding, workforce and capacity affected close-to-community TB screening (Theme 1). Insufficient testing capacity at lower-level facilities led to diagnostic delays (Theme 2). Inflexible clinic hours and medication stockouts requiring frequent facility visits undermined TB treatment and adherence among working populations (Theme 3). Weak collaboration and referral systems limited support for people facing homelessness, substance use or poverty. Healthcare workers proposed enhanced TB training, increased TB workforce, flexible medication delivery, integrated TB services and strengthened intersectoral collaboration with education, labour and social protection sectors (Theme 4).

Conclusions

Healthcare workers demonstrate willingness and capacity to deliver patient-centred TB care but require strengthened health systems, ongoing training and sustainable intersectoral partnerships. Scaling up identified practices and innovative tools while addressing systemic barriers could improve TB care delivery and outcomes for underserved populations.

STRENGTH AND LIMITATIONS OF THIS STUDY.

• Researcher-led collaborative qualitative study to understand experiences and challenges faced by tuberculosis (TB) healthcare workers in implementing patient-centred TB services in primary healthcare facilities in Nairobi.

• Participatory methods used in the workshops with healthcare workers facilitated collective learning and exchange among nurses, clinical officers and doctors.

• Participatory workshops with healthcare workers, healthcare managers and policymakers enabled to identify concrete action for change.

• Although the study engaged different healthcare worker cadres, the views of close-to-community health cadres, laboratory staff and social workers, and people with TB were under-represented.

• The research was not equipped to evaluate implementation and effectiveness of proposed strategies and action plans.

Introduction

Despite patient-centred tuberculosis (TB) care being recommended, strategies to tailor care to people’s circumstances and needs are not widely implemented, including in Kenya.¹ The East African country is considered by the WHO as one of 30 high-burden countries for TB and HIV-associated TB.² In Kenya, close to 124 000 people—over 71 000 men, about 35 000 women and nearly 18 000 children—developed TB in 2023² but only about 97 000 people were diagnosed and notified, and about 85 000 completed treatment.³ Many dropped out of care, and TB programmes missed nearly one in four people with active TB in need of care.³

Although anyone can develop TB, social marginalisation, poverty, low education levels, malnutrition, overcrowded living conditions, occupational hazards and displacement among others increase vulnerability to TB and create barriers to prevention and care. Gender norms and responsibilities complicate pathways to TB care, including among men.⁴ TB can worsen existing inequalities and discrimination.

Kenya adopted integrated, patient-centred TB care and prevention to align with its 2012–2030 Health Policy and to meet the WHO End TB Strategy goals.⁵ People with increased exposure of TB due to living conditions, biological or behavioural factors and people with limited access to quality services were identified as TB key populations.⁶ The 2019–2023 National Strategic Plan for TB, at the time when this study was developed, outlined strategies to better reach these populations.⁶ These included patient-centred health education; community-based TB screening and prevention; healthcare worker training on clinical, nutritional and psychosocial care for TB; differentiated TB services based on clinical characteristics; and decentralisation to make TB services available at most health facilities and reduce transport costs for people with TB.

Despite patient-centred TB care policies and strategies, implementation is lagging globally.⁷ In Kenya, people with TB receive uniform services as attempts to distinguish care according to people’s circumstances remain limited.¹ This study sought to understand the experiences of TB healthcare workers in implementing patient-centred TB services in primary healthcare facilities in Nairobi and explore how the challenges they face can be addressed. As the current National Strategic Plan retains commitments to patient-centred TB care,⁸ lessons from this study will help close the implementation gap.

Methods

This research was conducted by the African Institute for Development Policy (AFIDEP), Respiratory Society of Kenya and the Liverpool School of Tropical Medicine (LSTM) as part of the Leaving no-one behind: Transforming gendered pathways to health for TB (LIGHT) Consortium (https://light.lstmed.ac.uk/). LIGHT, a 6-year cross-disciplinary global health research programme, aims to generate new evidence on gender and TB in urban contexts supporting better development outcomes.

Study design

We applied a researcher-led collaborative study design⁹ to conduct participatory workshops with healthcare workers, healthcare managers and policymakers. We selected workshops for their potential to discuss views in greater depth compared with key informant interviews or focus group discussion; to facilitate learning between the different stakeholders; and to aid consensus on practical action.

Conceptual framework

Our study considered TB services along the care cascade,^{10 11} from health education to TB screening, testing, treatment and post-TB care. We applied a gender-sensitive, person-centred care perspective that goes beyond disease-specific, medication-focussed care for TB offering holistic services focused on health needs and expectations of people and communities.¹² Person-centred, like patient-centred, care requires that people affected by TB are engaged as partners and supported to overcome the social, economic, cultural, legal and psychological difficulties that can affect their care and recovery.¹³ We adapted a social–ecological model^{14 15} to explore factors that shaped healthcare workers’ experiences and challenges of providing TB care considering individual, family, school, work, community, health system and structural levels. To be able to expand factors related to the health system, we drew on the WHO health system building blocks model¹⁶ considering health leadership/governance, financing, workforce, services, information systems and medical products/technologies.

Study site and population

The study was conducted in Nairobi County, Kenya’s capital city, where TB burden is high and health-seeking is low.¹⁷ Nairobi’s primary and TB healthcare is coordinated by 12 subcounty health management teams and 23 TB care zones with designated TB coordinators. We purposely selected Embakasi, Kibra/Langata and Ruaraka subcounties where densely populated and underprivileged settlements are located. The study focused on TB services delivered at primary health levels—dispensaries (level 2) and health centres (level 3)—offering health promotion, disease prevention, outpatient, emergency inpatient and referral services.¹⁸ We selected health facilities, with guidance from county and subcounty TB coordinators, to include public (n=19), faith-based (n=6) and private (n=4) providers.

TB healthcare workers were the primary participants, considering different cadres offering various professional experiences in a health facility. These included nurses who are often involved in triage, administering medication and management of follow-up; clinical officers who are the first point of patient examination, testing and interpretation of the results and prescribe treatment; and doctors who offer consultation, often to the more complex conditions that are referred to them by clinical officers and nurses who run the TB clinic’s day-to-day operations. At a minimum, nurses and clinical officers have completed a 3-year non-degree course, doctors a 6-year degree-course.

Research team and reflexivity

Our interdisciplinary team (table 1) included a senior policy analyst (LHA), a communication expert (ES), a clinical officer and early career researcher (RPK), a programme manager (CO) and a freelance research assistant (VM), all from Kenya, alongside a social scientist (BR). Senior team members in Kenya (BM), Malawi (EMZ) and the UK (KM, RT) provided advice and oversight.

Table 1. Research team.

Domain	Data collection and analysis	Oversight and supervision
Initials	BR, ES, CO, LHA, RPK, VM	BM, EMZ, KM, RT
Backgrounds
Gender	5 Women (BR, ES, LHA, RPK, VM) 1 Man (CO)	3 Women (BM, KM, RT) 1 Man (EMZ)
Education	2 Bachelor (ES, VM) 2 Master (CO, RPK) 2 PhD (BR, LHA)	4 PhD (BM, EMZ, KM, RT)
Nationality (main)	5 Kenya (CO, ES, LHA, RPK, VM) 1 Germany (BR)	1 Kenya (BM) 1 Malawi (EMZ) 2 UK (KM, RT)
Residence	5 Kenya (CO, ES, LHA, RPK, VM) 1 Uganda (BR)	1 Kenya (BM) 1 Malawi (EMZ) 2 UK (KM, RT)
Relevant research experience	Qualitative research: 6 (BR, CO, ES, LHA, RPK, VM) Participatory research: 2 (BR, VM) Research uptake: 2 (ES, LHA)	Qualitative research: 2 (EMZ, RT) Participatory research: 1 (RT) Research uptake: 4 (BM, EMZ, KM, RT)

Characteristics at the time of data collection.

Most team members were outsiders with regards to TB disease, TB care and study locations in densely populated urban settlements, except for RPK and BM who had several years of professional experience in TB care and programmes in Kenya. BM, KM and RT had several years of TB focused research experience. The research idea did not stem from personal experience but our shared interest in improving care and outcomes for people with TB and believe that person-centred TB care would help increase TB care access and quality. We approached the topic from different disciplinary perspectives, motivated to support respiratory health professionals (CO, RPK) and strengthen capacity for evidence-informed decision-making (ES, EMZ, LHA), participatory health research (BR, RT) and research uptake (KM, RT). Further details are provided in a structured reflexivity statement (online supplemental file S1).

Kenyan team members knew most TB stakeholders and a few healthcare workers before the study, which facilitated study inception and recruitment. Building on previous studies,^{19 20 21} we selected a participatory group-based approach for its potential to enable ownership and trustworthiness of the research process and findings as well as learning and collaboration among healthcare practitioners, policymakers and researchers. Curiosity and questions about the research design that was novel in this context may have motivated participation, while power imbalance and group dynamics could have limited information and dialogue. We drew on our diverse experiences from clinical practice (RPK), participatory research (BR, VM) and policy engagement (ES, LHA) to design and conduct the workshops encouraging dialogue and mitigating limitations. We combined theoretical and practice-based lenses to analyse data, including to understand the structural and social determinants that shape individual behaviour, interpret findings and state recommendations.

Sample and recruitment

Overall, 53 TB healthcare workers and stakeholders participated in the study. We used a stratified purposive sampling strategy to recruit nurses, clinical officers and doctors at selected health facilities with at least 6 months of professional experience in TB screening, diagnosis and/or treatment. LA invited potential participants via email that explained research purpose and activities, and participant’s rights, benefits and risks. Of the 30 healthcare workers invited, 29 participated in the participatory data collection workshops (19 nurses, 8 clinical officers, 2 doctors); 1 could not attend due to other commitments. We recruited more women (n=20) than men (n=9), reflecting the gender composition of Kenya’s health workforce.²² Table 2 describes characteristics of participants including various professional training and experience, and roles; levels and types of health facilities; and subcounties.

Table 2. Characteristics of primary participants.

Domain	Workshop 1 (n=12)	Workshop 2 (n=7)	Workshop 3 (n=10)	All (n=29)
Gender
Female	8	5	7	20
Male	4	2	3	9
Profession
Clinical officer	–	–	8	8
Doctor	–	–	2	2
Nurse	12	7		19
Professional education
Diploma	6	5	4	15
Bachelor	3	2	3	8
Prefer not to say	3	–	3	6
Years of professional experience (years)
Median (IQR)	15 (5, 32)	9 (8, 17)	9 (7, 13)	10 (8, 19)
Type of health facility
Faith-based	3	2	1	6
Private	1	–	3	4
Public	8	5	6	19
Health service level of facility
Level 2 dispensaries	1	4	3	8
Level 3 health centres	11	3	7	21
Department of main role
TB clinic	9	4	1	14
Outpatient departments	2	2	7	11
Comprehensive care clinic	1	1	2	4
Subcounty
Embakasi	4	1	3	8
Kibra/Langata	4	3	3	10
Ruaraka	4	3	4	11
Participation
One workshop	2	3	–	5
Both workshops	10	4	10	24

TB, tuberculosis.

Additionally, we used key informant sampling to identify TB stakeholders who design and/or coordinate TB policies and programmes drawing on in-country stakeholder lists generated by the wider consortium and research.²³ LHA invited potential participants via email that explained research purpose and activities, and participant’s rights, benefits and risks. In total, 24 TB stakeholders participated in the study, including women (n=15) and men (n=9), representing the National Tuberculosis, Leprosy and Lung Disease Programme (n=1), Nairobi County Health Management Team (n=18), selected Sub-County Health Management Teams (n=4) and non-governmental organisations (n=1).

Data collection

Data were collected through participatory workshops in March and April 2024. First, three data collection workshops were conducted, two with nurses and one with clinical officers and doctors. As shown in table 2, participants for each workshop were drawn from different subcounties, health facilities to ensure diversity of views and promote exchange. We used group discussion and participatory methods including power walk²⁴ to define person-centred TB care; spider diagrams²⁵ to document good practice and understand challenges; and stepping stones method²⁶ to explore potential solutions that would enable healthcare workers to provide care that better meets the needs of people with TB. Second, we engaged the healthcare workers (24 of 29 attended; 5 did not attend due to annual leave (n=1) and undisclosed reasons (n=4)) and the other TB stakeholders in a joint workshop. Healthcare worker participants presented their workshop results as researchers discussed cross-cutting findings. All participants evaluated and prioritised issues presented in randomly assigned round-table discussions. Afterwards, healthcare workers and stakeholders agreed sub-county action plans.

All workshops were held in hotels in Nairobi’s central business district and facilitated by BR, CO, ES, LHA and RPK in English language. Each workshop included lunch, refreshments and transport refund (2000 KSH/US$14–15). They lasted for 5–5.5 hours. Plenary discussions were audiorecorded with participants’ permission, group work documented on flipcharts and VM took notes.

Data analysis

VM transcribed audiorecordings, typed notes and flipcharts and compiled workshop reports. A framework approach²⁷ was used to analyse data, combining deductive and inductive methods. Familiarising: BM, LHA and VM read all transcripts and reports, identified recurrent ideas and structured them in a coding frame drawing on the TB care cascade, social–ecological and health system building blocks models. Themes were identified deductively building on the milestones according to the TB care cascade¹¹ and the related tasks expected of healthcare workers. A fourth theme was identified inductively from the data to focus on non-clinical services that required multisectoral collaboration. A social–ecological model¹⁵ was adapted to categorise factors that shaped healthcare workers’ experiences and challenges of providing TB care considering factors outlined above, using the WHO Health Systems Building Blocks framework¹⁶ to unpack factors related to the health system. Indexing: BR and VM indexed data manually, copying and pasting appropriate text from the transcript into a shared MS Word document.²⁸ Charting: BR charted and summarised data by theme and subtheme, using MS Word tables. Synthesising: we held virtual meetings with the entire research team to discuss descriptive summaries and themes, reflect on the main ideas and refine and name the themes. The manuscript followed qualitative research reporting criteria (online supplemental S2).

Written informed consent was obtained from TB healthcare workers and stakeholders before data collection. We ensured participants understood that confidentiality could not be guaranteed in workshops and encouraged them to respect everyone’s privacy. Separate workshops and break-out discussions catered for peer discussion and presentation of collective rather than individual views. We pseudonymised transcripts and removed person identifying information. We debriefed regularly for collective learning and analysis.

Results

Healthcare workers identified examples of person-centred TB care in their health facilities and the challenges they faced in tailoring care to the needs of their patients. Issues ranged from structural failings and health system weaknesses to challenges emerging from characteristics of communities and people. We structured research findings along the TB care cascade—screening (Theme 1), testing (Theme 2) and treatment (Theme 3)—and collaboration with other sectors (Theme 4) for an effective TB response.

Theme 1: Close-to-community TB screening

TB education and screening are entry points to TB care. Healthcare workers stressed the importance of close-to-community TB screening and the role of close-to-community providers, like community health promoters, TB assistants, cough monitors and peer educators, among others, for timely TB diagnosis. Often, only selected health facility departments conducted TB screening. TB healthcare workers and policymakers worried about missed TB screening opportunities within and outside facilities.

TB screening in children

Across workshops, healthcare workers highlighted individual and health system factors driving delays in TB diagnosis among children. TB healthcare workers understood that TB presents differently in children compared with adults but relied on referrals from other departments, like child health and outpatient departments, where TB screening was not systematically incorporated into clinical algorithms for child health, specific training was lacking and awareness and capacity to diagnose were limited, contributing to misdiagnosis and low TB detection rate among children. Paediatric TB screening strategies were limited; a few health facilities delivered TB education and screening in schools. Healthcare workers and managers from Kibra/Langata subcounty planned during the joint workshop to prioritise paediatric TB screening and establish dedicated quality improvement teams coordinating continuous medical education for colleagues, TB screening of all children in all healthcare departments, outreaches targeting schools, daycare centres and churches and robust referral systems.

[W]e need to give on job trainings to our health care workers, to our community health promoters and everyone who will usually work with children there at our place so that they can be equipped with the knowledge…[so] that they can be able to diagnose more children. (Nurse, female, W4)

They lobbied for additional funding for diagnostics and continuous medical education on paediatric TB care to advance systematic screening for early diagnosis of TB in children.

Youth-friendly TB screening

Only a few health facilities offered youth-specific TB screening, for example, through football matches and skills-building programmes.

I will talk about the facility I come from. It’s a donor funded facility, offering youth friendly services…youths are encouraged to come and train in different things like computer packages, dancing, and karate, and other skills. So, during that time is when we have health talk to youths about their health issues…when we arrange for screening and they come to the clinic. (Nurse, male, W1)

Healthcare workers and policymakers admired such interventions and recommended developing more age-specific and gender-specific initiatives for different youth populations.

TB screening among adults

In the underprivileged urban settlements, access to TB education and screening during clinic hours were restricted by work schedules among men and combined work and childcare obligations among women.

Remember, we are also dealing with the working community…the mothers, who normally go to the marketplace, what time do they go for to the market? At 4 am. Then they come back, they take lunch to the children, and they go back to the market. And what time do they close the, the kibanda (stall)? At 10 pm. I look at the industry… that man woke up at what time? By seven [am], they're reporting. Then by evening, at what time [do] they go home? (Stakeholder, female, W4)

Some health facilities conducted health camps in marketplaces to reach women and outreaches in workplaces and social venues to engage men. However, community and health system factors limited close-to-community TB screening for adults. Insufficient funding, staff shortages and security concerns constrained community-based screening. A few health facilities partnered with Savings and Credit Cooperative Organisations (SACCOs), main employers in the transport sector, to extend TB screening, testing and treatment to matatu drivers and touts, most of whom were men.

We were focusing more on matatu drivers and touts. We do health education at the various stages where the Community Health Promoters go and do health education…[W]hen they are doing screening, they collect the samples…[and] brings the sample to the clinic. (Clinician, female, W3)

Healthcare workers and policymakers felt partnerships with SACCOs operating along the Langata–Nairobi routes could be scaled up to other transport corridors and sectors to reach more men (Theme 4).

Screening people with chronic health conditions for TB

Routine TB screening was widely integrated into Comprehensive Care Centres serving people with HIV. Medication delivery through treatment supporters could aid access and adherence to treatment among people with long-term conditions (like diabetes or HIV) but reduced patients’ contact time with healthcare workers. Lack of TB screening protocols for these patients contributed to TB screening gaps.

One of the challenges was treatment support where the family takes the medicine on behalf of the patient. It’s a challenge because you can’t actively screen [for TB] …[W]e can call the patients via phone, [so] we can achieve the active case finding. (Clinician, female, W3)

Healthcare workers proposed protocols and tools to administer TB screening through treatment supporters, over the phone or a mobile application.

Theme 2: TB testing at lower-level facilities

Individual, family, community, health system and structural factors shaped the delivery of person-centred TB testing at primary health centres. Most of them offered TB testing at the facility, rarely in the community.

Testing children

Healthcare workers fast-tracked students, who presented to the health facility wearing their school uniform, to ensure timely and continuous care for school-going children. Numerous challenges made the diagnosis of TB in children difficult for healthcare workers. They relied on adults to bring children to the facility and to support the healthcare offered to them. Some parents were reported to not accept their child’s TB test result but move from clinic to clinic or disappear from care altogether.

We have mothers who have financial constraints. So, when they bring in their children, and they are told they could have TB, they disappear thinking that it could be a cold or because of the industries that we live around. (Nurse, male, W1)

Since many children struggled to produce sputum for testing, healthcare workers employed paediatric testing algorithms, including x-ray of the lungs and Gene Xpert testing of stool samples. While policymakers praised these services to be free of charge, healthcare workers raised concerns about their availability only at higher-level facilities. Distance to x-ray sites created significant barriers for low-income households, especially when a donor-funded paediatric TB programme closed ending transport refund to referral sites.

…chest x-ray is not accessible. Sending a mother to St Mary (faith-based, level-5 hospital), they have free services because of a donor, but for a mother to get there, she needs 200 shillings (~1.40 US$). So, most of the time we do fundraiser for her to get there. (Nurse, female, W1)

Healthcare workers lobbied for funds to expand diagnostic capacity at lower-level, high-volume facilities and refund transport to referral sites so that all children with symptoms presumptive of TB were tested.

Testing men

Factors across all levels hindered early TB diagnosis in men who often reached health facilities only when symptoms were severe.

Men usually come to seek treatment when they are very sick…Men they will buy medicine at the pharmacy, and when they are very sick, that’s when the wife will bring them to the hospital. (Nurse, male, W1)

According to healthcare workers, TB misconceptions, myths and stigma discouraged health seeking and testing. Restricted clinic days and opening hours disadvantaged men, especially those in casual, informal or insecure employment, who could not take time off work without risking loss of daily income or employment. Staff shortages and inflexible work conditions in public health facilities prevented healthcare workers from running services outside work hours, more common in faith-based and private facilities.

Healthcare workers relied on short turn-around times of test results to avoid unnecessary clinic visits. Delays, due to shortages of laboratory staff and commodities caused by inconsistent data entry or supply chains, were common.

About human resource; even if you want more clients, in the lab, you have to have results from the lab, but there’s usually a delay in getting the results. So, if we have more human resource, we will be able to get the results faster. (Nurse, female, W1)

Such diagnostic delays undermined continuation of care for the working men, while women in insecure employment, like market vendors and sex workers, could be affected alike. Having observed the power of coordinated activism around other conditions like HIV, healthcare workers believed collective advocacy together with TB survivors could compel the government and donors to step up funding for close-to-community TB testing and commodities.

Theme 3: TB treatment and adherence support

Free TB treatment alongside effective client–healthcare worker communication and trust were critical for seamless TB treatment and care, including for key populations who were reported to value and follow health and treatment education.

[B]ecause of poverty some people in the slum don’t have information. When you explain the treatment to them, they take the treatment positively, they trust you. (Nurse, male, W2)

Additional support like peer groups, nutrition support and transport refund incentivised retention in TB care and treatment but were only available to people with multidrug-resistant TB. In addition, health system and structural factors affected treatment and adherence support for people with TB.

Retaining working men and women in TB treatment

Good practices to support adherence were notably limited. Several health facilities offered TB medication delivery or flexible collection dates for working people, especially men, who were not allowed paid sick leave and struggled to take time off work. Overall, many healthcare workers in public health facilities lacked support and flexibility to dispense TB medication outside work hours. Challenges included inflexible working hours, absence of overtime premium and lack of funds for calls and transport. Drug shortages exacerbated challenges. For example, in 2023, supplies were insufficient for healthcare workers to stock separate, full TB medication dosage for each person enrolled in treatment. They had to ask patients to come more frequently for refills—at times daily.

So, this (drug stock outs) brought strain to our clients, especially to those who are casual labourers who are unable to get frequent sick leaves from the employers…[W]hen we are having these stock outs, they will be forced to come several times back to the facilities. (Clinician, female, W4)

Healthcare workers recommended scaling up the flexible TB treatment collection and delivery models and collaborations with main employers within catchment areas to ensure continuous treatment and employment for working populations with TB. Serving many factory workers and day labourers, healthcare workers and managers from Embakasi subcounty planned collaborations between health facilities that would enable working people enrolled at (public) TB clinics with limited opening hours to receive TB care and medication from nearby (private or not-for-profit) 24-hour health facilities. To make this model work, facilities need to exchange TB medication and patient information in real time.

Managing TB treatment for people with other health conditions

Healthcare workers felt disease-specific organisation of health services complicated the care for people with multiple health conditions. Some healthcare teams collaborated across departments to combine services for all health conditions in one clinic or on the same day. Strict follow-up schedules during the intensive TB treatment phase and shortage of staff or capacity hindered healthcare team’s efforts towards one-stop multi-morbidity care.

[W]e ensure TB clients with other co-morbidities are attended the same day in collaboration with the staff from other departments…[but] we don’t have enough personnel to cater for this. (Nurse, female, W2)

Healthcare workers were eager to better manage multi-morbidity but required more staff and training, and better equipment and coordination at facilities.

Addressing alcohol and drug use among men

Men with TB who used alcohol or substances needed additional support; they could easily forget their medication or lose it altogether. Community insecurity and men’s mobility complicated treatment follow-up and completion further. Despite the pervasive challenge of adherence, some good practices were identified among a few not-for-profit health facilities such as employing directly observed treatment, organising support groups and collaborating with chang’aa (liqueur) den owners to ensure these men were supported to complete TB treatment. A group of healthcare workers, who discussed adherence support for this population, felt public health facilities should take up these initiatives for better treatment outcomes in this population.

The first thing is working with the chang’aa den owners…to enforce adherence, because the clients go there every day. Before they take the chang’aa, the client has taken medication…And then also offering rehabs for alcoholic clients to help prevent dropouts, because one of the bigger reasons for dropout is alcoholism. The other part is group therapy to help the men in coping. (Nurse, male, W1)

Expanding collaborations with other clinics and sectors would enable healthcare workers to link more men to male-specific group therapy, stress management, and treatment for drug use disorders.

Mitigate effects of homelessness

Health facilities in Ruaraka subcounty, near Nairobi’s main dumpsite Dandora, served people who were homeless, comprising mainly young men known as street families, more often than those elsewhere. Healthcare teams ensured street families could access their premises and services and were not sent away by security or health personnel.

[A] majority of them (street families) don’t have a mobile phone. So, accessing them is hard…There’s a language barrier, they use slang. When you give a health talk, it’s hard to communicate with them…The other thing is discrimination; they come to the hospital with work clothes, which are usually dirty, and you see even at the gate some watchmen will not allow them in. (Clinician, male, W3)

Street families lacked secure housing and other basic needs, struggled to store TB medication and often preferred directly observed treatment. Healthcare workers relied on social support among street families to administer TB medication at the facility and on treatment supporters to deliver medication at street family work or social places. While some engaged mental health teams to address alcohol and substance use disorders, many wished they could offer additional incentives (like breakfast, transport and clothes) to alleviate the impact of poverty and homelessness on TB treatment and health among street families.

Theme 4: multisectoral response

Healthcare workers needed support from other sectors beyond health, like education, labour and nutrition, among others, to complement clinical care for TB. All workshops valued community leadership and social support from family members, peer groups, pastors and imams, among others.

Ensuring support and non-discrimination in schools

The education sector played a key role in supporting students with TB. Health facilities permitted whole-term dispensing of TB medication for students with TB attending boarding school, relying on school nurses to administer and monitor treatment. Not all schools were supportive; healthcare workers and stakeholders recalled head teachers who denied students access to school while on treatment.

We had one of the scenarios, the mother went [to school] and said, ‘my child is taking anti TB [medication]’. The teacher went and told the head teacher, and then the head teacher told the mother that let that child not come to school. (Stakeholder, female, W4)

Collaboration between health and education sectors must ensure non-discrimination and coordination of TB care between health facilities and schools.

Promoting healthcare and non-discrimination in the workplace

Stigma and discrimination against people with TB were common in workplaces, including loss of employment and income. Workplace-based TB prevention and care could help protect against discrimination and unemployment, as demonstrated by the collaboration with matatu owners (Theme 1).

There’s a facility in our group that had come up with a way they were engaging matatu drivers and touts through their SACCOs. They could be able to offer services to them, and they also reduce the stigma battle. Once you're diagnosed with TB, you're not fired…making sure you have an income. (Healthcare worker, male, W4)

Healthcare workers and stakeholders promoted the expansion of such collaborations to other sectors, noting the need to manage employee’s right to confidentiality in workplace-based health services.

Mitigating the impact of poverty

Poverty emerged as a key challenge driving exposure to TB and hindering access to TB care. Due to lack of lucrative employment and high cost of living, many people with TB could barely meet their basic needs and lacked access to information, nutrition, transport and healthcare among others.

Poverty has challenges. At first, we saw transport becomes a challenge for a patient to come to the facility. Congestion…most of them…live in a small room, maybe three to four people. Most of the houses in the slum area don’t even have windows…The issue of lack of food is a challenge…at times they don’t have money to buy food. Time is also a challenge; when they come to the clinic, most of them are in a hurry, because of the nature of work they do. Some have not asked for permission from work, so they are always in a hurry. (Nurse, male, W2)

Noting the absence of nutritionists in TB clinics across settings, healthcare workers lobbied to expand this cadre and their assignment to TB clinics. People affected by poverty needed food and other incentives to be able to benefit from the advice of nutritionists. Healthcare workers and managers from Ruaraka subcounty were concerned about high rates of TB treatment failure in their locality which they attributed to poverty-driven late diagnosis of TB. During the joint workshop, they planned intensifying systematic TB screening to reach and treat people with TB earlier.

Discussion

Our research shows that primary healthcare providers recognise the unique needs of various groups of people affected by TB, and are willing to tailor their care accordingly. They consider factors such as age, gender, socioeconomic status, occupation and comorbidities, among others. Some developed innovative TB care approaches to better reach and retain underserved populations. Good practice examples that this study identified may have previously been undocumented.¹ Healthcare providers require a supportive health system to bridge the barriers and challenges faced in offering integrated patient-centred care.

As in similar studies, TB healthcare workers aspired to expand close-to-community TB screening,²⁰ increase TB diagnostic capacity at lower-level facilities,²⁹ provide holistic TB treatment and adherence support³⁰ and draw on collaborations across multiple sectors.²³ Our study underscores that the realisation of differentiated care, envisioned in international and national policy documents like the Kenya TB National Strategic Plan, requires context-specific approaches responding to the specific populations that facilities serve. Availability of new tools like near point-of-care TB testing platforms, artificial intelligence enabled portable digital chest x-rays, paediatric TB screening and diagnostic algorithms and shorter medication regimens, among others have potential to enhance patient-centred care at primary healthcare facilities.31,33 Ultimately, healthcare workers need access and guidance for these tools to be able to use them to offer more flexible choices and models to different populations served.

Healthcare workers worried that unmet basic needs of people with TB outside healthcare facilities limited the impact of the care they could offer. In line with existing evidence demonstrating the positive impact of social protection and nutrition support on TB treatment adherence and clinical outcomes,34,36 most proposals to address basic needs through nutrition, transport and other forms of support in our study were geared towards achieving clinical targets.⁵ This trend resonates with a scoping review that found person-centred TB care models served an instrumental function for improving treatment adherence and completion among people with TB in various settings.⁷

While not explicitly stated, pressure to meet TB targets was ubiquitous across workshops as healthcare workers narrated the challenges they faced in providing care within the limits of the health system. Evidence from South Africa suggests the pressure of TB targets, risk of TB infection and stigma of working in TB clinics can affect mental well-being of TB healthcare workers.²⁹

The reported 2023 stockout crisis of TB medication and commodities³ served as a reminder that strong health systems are the basis for differentiated care. National TB programmes must recognise that the health system blocks must be available for healthcare workers to offer patient-centred care: well-equipped facilities; sufficient numbers of well-trained staff; ongoing training; fair compensation, including overtime pay and special clinic allowances; consistent supply of medical products; and diagnostic capabilities at lower-level facilities. These will allow for more individualised attention, facilitate efficient diagnosis and treatment and improve job satisfaction and retention.

Our data suggest TB care and treatment were delivered in various settings. Health facilities involved lay healthcare workers and partnered with schools and businesses to reach people outside TB clinics. Overall, these diverse care models were geared towards treatment completion following standard TB treatment and follow-up regimens, involving the intensive and continuation phase. Further research could explore the effectiveness of giving healthcare workers greater flexibility to strike a balance between standard follow-up schedules and infection control on the one hand, and people’s clinical characteristics and economic and social demands on the other hand to further diversify person-centred care model.

Comorbidities are prevalent and a major contributor to TB incidence and mortality necessitating integrated service delivery models.³⁷ At facility level, colocation of services for TB and other conditions, mostly HIV, in the same clinic and/or by the same healthcare worker was common in our study. Service colocation has been shown to improve delivery of integrated services,^{38 39} improve diagnosis and treatment,⁴⁰ save time⁴¹ and reduce costs for patients.³⁸ Given the potential for synergies, integration of TB services in primary healthcare could be expanded beyond HIV.

Changing funding landscape threatens provision of essential TB prevention, diagnostic and treatment services.⁴² Our study preceded the 2025 funding cuts, but we anticipate that reduced international donor funding will affect patient-centred care. To mitigate this, countries, including Kenya, should increase their domestic financing and integrate TB care within primary healthcare and universal health coverage.⁴³ Multisectoral action and accountability is essential for addressing broader social determinants that influence susceptibility to TB transmission and disease and reducing the TB burden.⁴² Hub and spoke models have been adopted to establish primary healthcare networks in Kenya⁴⁴ and TB diagnostic networks across countries.⁴⁵ Diagnostic networks have been shown to improve timely TB diagnosis through effective transport of samples and results.⁴⁶ TB programmes should build on this concept to establish linkages with social, mental health, nutrition and social protection services, as shown in figure 1. Strong networks can ensure seamless coordination with other services, free time for healthcare workers to focus on clinical care and facilitate better care and health outcomes for people affected by TB.⁴⁷

Figure 1. TB care coordination model embedded within PHC networks. Adapted from Kenya Ministry of Health Guidelines.³⁸ PHC, Primary Health Care; TB, tuberculosis.

Study strengths and limitations

Research participants—healthcare workers, managers and policymakers—appreciated the study for its novel approach and interactive methods. We engaged healthcare workers collectively in data collection, analysis and dissemination. Healthcare workers valued the opportunity to learn through exchange with peers and to discuss good practice, gaps and recommendations with stakeholders. Our approach helped identify concrete action for change, hence could be beneficial to similar qualitative TB studies in the future.

Our study had several limitations. As a small study exploring a participatory approach, we engaged nurses, clinical officers and doctors considering trade-offs between diversity of views, power dynamics between cadres and budget and time constraints. Future research should include voices under-represented in this study like various close-to-community health cadres, laboratory staff and social workers, among others. Our study focused on experiences of providing TB care in densely populated urban areas in Nairobi and did not involve people affected by TB. While other studies by the Consortium explored experiences of care among people with or who had TB,^{19 20 48 49} additional research with end users of TB care could complement findings to understand where gaps are experienced or perceived and what kinds of people-centred care might be most useful and prioritised. Nonetheless, insights and recommendations generated by this study may be transferable to similar contexts while additional research may be needed to explore realities in settings that are fundamentally different from selected study sites. While we will monitor and support research uptake of this study, our research was not equipped to evaluate implementation and effectiveness of proposed strategies and action plans. Similar future studies should be equipped to incorporate an implementation research component.

Conclusions

Primary healthcare workers in Nairobi demonstrate willingness and capacity to deliver patient-centred TB care but require strengthened health systems, increased resources, ongoing training and sustainable intersectoral partnerships. Additionally, availability of innovative new screening and diagnostic tools have potential to improve patient-centred care at primary healthcare facilities. In the changing funding landscape, integrating TB care within primary healthcare and universal health coverage is integral in ensuring patient-centred care. Scaling up identified good practices while addressing systemic barriers could improve TB care delivery and outcomes for underserved populations affected by TB. Implementation research is needed to evaluate proposed strategies’ effectiveness.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.