Press release
First qualitative study of its kind in The Gambia fills a critical evidence gap, showing the WHO-recommended diagnostic method is workable, but only if health systems address transport, training and age-specific concern.
A new study published in BMJ Open provides critical real-world evidence on how families and healthcare workers in West Africa experience stool-based testing for childhood tuberculosis (TB). While the method is a World Health Organisation (WHO)-recommended alternative to invasive sputum collection, the research reveals that its success depends heavily on addressing age-specific concerns and logistical hurdles.
Tuberculosis remains a leading infectious killer of children, with an estimated 174,000 deaths in 2024. Roughly 96% of children who die from TB are never diagnosed, largely because young children cannot easily produce the sputum (coughed-up mucus) required for traditional tests. While the WHO has recommended less invasive stool testing since 2021, most research has focused on diagnostic accuracy rather than the “human side” of how patients and providers feel about the method.
Dr Sheila Owusu, study leadand WANETAM-TALENT PhD Fellow at MRCG at LSHTM, stated that, “While the diagnostic accuracy of any test for TB in children is crucial, it is also important to consider end users’ perspectives in the early phases of rolling out a new diagnostic test.”
This study was conducted in partnership with The Gambia National Leprosy and Tuberculosis Control Programme (NLTP). Using in-depth, semi-structured interviews analysed through established qualitative frameworks, researchers explored the perspectives of different stakeholders including caregivers, adolescents, healthcare workers, and NLTP officials. All participants had direct experience with stool sampling through the multi-country childhood TB research project in West Africa, i.e. the CHIRWA-2 study.
The study finds thatmost caregivers were willing to provide stool samples for their children, motivated by the desire for a diagnosis, even if they were initially surprised that stool could be used for a respiratory disease. However, they reported practical obstacles, including the stigma and hygiene concerns of transporting stool on public transport.
In contrast to caregivers, adolescents expressed embarrassment and anxiety regarding stool sampling, citing a lack of privacy in clinical settings. Some even stated they would prefer more invasive sputum collection over the awkwardness of providing a stool sample.
Most importantly, healthcare workers strongly supported the method because it avoids distressing procedures like gastric lavage. While officials confirmed the method is feasible using existing equipment, they warned that success requires a reliable supply of test cartridges and regular staff training to manage high turnover.
“Diagnostic tools can only work if the people being asked to use them are willing and able to do so,” Professor Toyin Togun, the study’s senior author and Principal Investigator of the CHIRWA-2 study noted. “Our findings show that technical accuracy alone won’t close the childhood TB diagnostic gap – caregivers, healthcare workers and adolescents each experience stool-based testing differently, and adolescents in particular are at risk of being left behind by a ‘one-size-fits-all’ approach. Successful national rollout will depend on sustained supply chains, staff training, community campaigns to familiarise the public with the method, improved privacy and age-appropriate counselling, as much as on the test itself.”
The Gambia has already adopted stool-based TB testing nationally. This research provides a roadmap for a successful rollout, emphasizing the need for sustainable supply chains and further research into children’s own perspectives.
