A Morning with Three Health Professionals Working on the Stool4TB Tuberculosis Study

Three women are largely responsible for the success of a study in Mozambique to validate a diagnostic test for tuberculosis.

Farida, a medical technician and Jorcelina, a nurse, get up between 4.30 and 5 am to organise their day and get their children ready for school before they leave for work. They live at quite a distance from the town of Manhiça in southern Mozambique where they both work. The two women have to take two chapas (minibuses that ply established routes) to get to the city before their working day starts at 7.30 am at the Manhiça Health Research Center (CISM). Benilde, another nurse, and also a mother, does not have to be up quite so early because she lives closer to the city, but it is understood that she will be the first one to arrive, so whenever there is a task that has to start at 7.30 sharp it falls to her to take care of it.

These three health professionals are working on the Stool4TB study, a project we have set up in the Manhiça district to validate a new molecular test that can diagnose tuberculosis with a single stool sample. If the study is successful, the diagnosis of tuberculosis will be simpler and more accessible. However, for now, the job is to compare this new test with the methods currently in use: sputum samples in adolescents and adults, and induced sputum or gastric aspirate in children. To be successful, the Stool4TB study requires a great deal of collaboration from its participants: they have to understand the study concept and want to be involved. Securing their cooperation is not easy, even when there is a clinical indication for carrying out certain procedures. For this reason, the work that Farida, Jorcelina and Benilde do every day, and that of the whole Stool4TB team at the clinic, is key to earning and maintaining the trust of every participant.

Team meeting in the CISM "palhota". Lucía on the left; Farida, Benilde and Jorcelina on the right.

7.30 am Benilde heads out to visit several participants

Today, as often happens, it is Benilde who is going out to visit the participants due for follow-up visits who could not be reached by phone. She hopes everything will go well and that she can make about four visits this morning. To find the participants she uses a GPS localisation system designed by CISM's demographics department. But, if the participant is not at home, her trip may have been in vain.

8.00 am Jorcelina explains the study to a new participant and asks her to sign an informed consent form

At 7.30 am Jorcelina opens her door to the first candidate of the day, a woman with suspected tuberculosis. First she gives the woman a detailed explanation of the study and then she asks her to sign the informed consent form. At this point, Jorcelina realises that the woman does not know how to read so she explains that she will call in an impartial witness who will confirm that what is written in the form is what has been explained in detail during the visit. When a participant is happy that the form is correct, they indicate their consent with a fingerprint and the witness writes the name of the future participant on the form. However, in this case, as sometimes happens, the woman is reluctant to sign with a fingerprint because she feels that this would imply that she cannot write her own name, which she can even though she cannot read. Jorcelina manages the situation as delicately as possible, making an effort to put herself in the shoes of the other woman.

8.30 am Farida suspects that a child has tuberculosis

At the same time, Farida is visiting another participant; a boy who has come in for a follow-up visit after taking a one-week course of antibiotics. There are signs that the boy’s condition has not responded to treatment so Farida studies the radiograph from the first visit, which she thinks is highly suggestive of tuberculosis. Although she does not have bacteriological confirmation, she feels that the boy will most likely have to be started on treatment for tuberculosis because of the high suspicion that the disease is present. In fact, only around 25% of children who start treatment have a diagnosis of tuberculosis confirmed by a laboratory test. Nonetheless, even though she is sure she should start treatment, Farida wants to be cautious and she discusses the case with her colleagues at the national tuberculosis programme. They are responsible for the care of these patients and it is essential to collaborate with them and to ensure that they are involved. 

Shilzia (laboratory), Katia (project assistant), Farida, Benilde, Jorcelina. 

Clinical research in tuberculosis—the sum of small and large efforts

As we can see, every small contribution counts. Every detail is important, from how the work is organised to achieve the greatest efficiency to ensuring the involvement of patients and other health professionals. Benilde, Farida and Jorcelina are, to a large extent, the three people responsible for the success of this study. They are women, they are mothers and, in some cases, the only person responsible for maintaining a family; but above all, they are great people, an essential characteristic if they are to succeed in this job.

Clinical research involves the study of human beings, and as such it requires a particular ethical framework and entails specific challenges that go beyond those common to research in general. This means that one of the keys to the success of a study of this kind is the relationship the professionals involved can build between themselves and the study participants.