Enablers and barriers to stool sample collection for TB diagnosis: insights from caregivers and adult patients in three high TB/HIV burden countries in Sub-Saharan Africa (Eswatini, Mozambique, and Uganda)
8 affiliations
- 1Centro de Investigação em Saúde de Manhiça (CISM)
- 2Department of Medical Microbiology and Makerere University Lung Institute, Makerere University
- 3Baylor College of Medicine Children’s Foundation-Eswatini
- 4University of Eswatini
- 5Barcelona Institute for Global Health (ISGlobal)
- 6Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam UMC, Location University of Amsterdam
- 7Global Tuberculosis Program, Baylor College of Medicine and Texas Children’s Hospital
- 8Eswatini Health Laboratory Services
Abstract
New stool-based TB diagnostics, such as Xpert Ultra, have shown promise in improving TB diagnosis in children and people living with HIV. However, limited research has explored the acceptability of stool collection among these target groups. This study aimed to assess the barriers and enablers influencing the willingness of caregivers of minor patients and adults to provide stool samples for TB diagnosis. We employed a generic qualitative study design that integrated different data collection approaches, including exit-, in-depth, and semi-structured interviews. This study was conducted in Eswatini, Mozambique, and Uganda between February 2022 and October 2024. A total of 102 participants, comprising 79 caregivers and 23 adult living with HIV, were recruited. Most participants reported no prior experience with stool sample collection. Nonetheless, they reported minimal difficulties in collecting stool samples and expressed a high willingness to provide stool samples. Factors influencing this willingness included the desire to recover from illness, trust in the healthcare system, and the non-invasive nature of the procedure. Refusals were rare, reported in 2 out of 102 participants. These were mainly attributed to challenges in obtaining stool samples at the required time and discomfort with handling the samples. Additionally, factors such as transportation costs to the health facility, direct association between sputum and cough, local beliefs surrounding stool were identified as potential barriers that may reduce willingness and shape patients’ preference for sputum-based methods over stool-based approaches, even among those otherwise open to providing stool samples. Our findings revealed that, despite high willingness among our participants to provide stool samples, several barriers could influence the acceptability of Sb-TBD and preference for alternative TB diagnostic procedures. These challenges should be addressed through strategies such as providing clear instructions for stool sample collection with collection kits, alongside community-based interventions to improve awareness and understanding of Sb-TBD.
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BibTeX
@article{lima2026enablers,
title = {{Enablers and barriers to stool sample collection for TB diagnosis: insights from caregivers and adult patients in three high TB/HIV burden countries in Sub-Saharan Africa (Eswatini, Mozambique, and Uganda)}},
author = {Agostinho Viana Lima and Joachim Nsubuga Kikoyo and Babongile Nkala and Faith Dlamini and Fortunate Shabalala and Lucia Carratala-Castro and Joanna Ehrlich and Sabine Hermans and Alexander Kay and Willy Ssengooba and Anna Mandalakas and Christoph Lange and Sozinho Acácio and Khátia Munguambe and Hermínio Cossa and Alberto L. Garcia-Basteiro and the Stool4TB Global Partnership},
journal = {BMC Infectious Diseases},
year = {2026},
month = aug,
doi = {10.1186/s12879-026-14154-0},
url = {https://doi.org/10.1186/s12879-026-14154-0},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Enablers and barriers to stool sample collection for TB diagnosis: insights from caregivers and adult patients in three high TB/HIV burden countries in Sub-Saharan Africa (Eswatini, Mozambique, and Uganda)
AU - Agostinho Viana Lima
AU - Joachim Nsubuga Kikoyo
AU - Babongile Nkala
AU - Faith Dlamini
AU - Fortunate Shabalala
AU - Lucia Carratala-Castro
AU - Joanna Ehrlich
AU - Sabine Hermans
AU - Alexander Kay
AU - Willy Ssengooba
AU - Anna Mandalakas
AU - Christoph Lange
AU - Sozinho Acácio
AU - Khátia Munguambe
AU - Hermínio Cossa
AU - Alberto L. Garcia-Basteiro
AU - the Stool4TB Global Partnership
PY - 2026
DA - 2026/08/01
JO - BMC Infectious Diseases
DO - 10.1186/s12879-026-14154-0
UR - https://doi.org/10.1186/s12879-026-14154-0
AB - New stool-based TB diagnostics, such as Xpert Ultra, have shown promise in improving TB diagnosis in children and people living with HIV. However, limited research has explored the acceptability of stool collection among these target groups. This study aimed to assess the barriers and enablers influencing the willingness of caregivers of minor patients and adults to provide stool samples for TB diagnosis. We employed a generic qualitative study design that integrated different data collection approaches, including exit-, in-depth, and semi-structured interviews. This study was conducted in Eswatini, Mozambique, and Uganda between February 2022 and October 2024. A total of 102 participants, comprising 79 caregivers and 23 adult living with HIV, were recruited. Most participants reported no prior experience with stool sample collection. Nonetheless, they reported minimal difficulties in collecting stool samples and expressed a high willingness to provide stool samples. Factors influencing this willingness included the desire to recover from illness, trust in the healthcare system, and the non-invasive nature of the procedure. Refusals were rare, reported in 2 out of 102 participants. These were mainly attributed to challenges in obtaining stool samples at the required time and discomfort with handling the samples. Additionally, factors such as transportation costs to the health facility, direct association between sputum and cough, local beliefs surrounding stool were identified as potential barriers that may reduce willingness and shape patients’ preference for sputum-based methods over stool-based approaches, even among those otherwise open to providing stool samples. Our findings revealed that, despite high willingness among our participants to provide stool samples, several barriers could influence the acceptability of Sb-TBD and preference for alternative TB diagnostic procedures. These challenges should be addressed through strategies such as providing clear instructions for stool sample collection with collection kits, alongside community-based interventions to improve awareness and understanding of Sb-TBD.
SN - 1471-2334
ER -