Health worker experiences of implementing TB infection prevention and control: A qualitative evidence synthesis to inform implementation recommendations

Epidemiology of Latent Tuberculosis in Moroccan Healthcare Workers: Prevalence Patterns and Predisposing Factors

BACKGROUND

Among occupational hazards in healthcare settings, latent tuberculosis infection (LTBI) ranks as a major concern, particularly threatening healthcare workers (HCWs) in nations grappling with intermediate to high tuberculosis (TB) rates. Our study was conducted in Morocco, a country characterized by widespread Bacillus Calmette-Guérin (BCG) vaccination and a moderate TB burden of 93 cases per 100,000 inhabitants in 2022. We examined both the prevalence of LTBI among Moroccan HCWs and its various risk factors.

METHODS

A cross-sectional study was conducted from August 2022 to October 2024 in two Moroccan hospitals. One hundred forty-seven HCWs were recruited and screened for LTBI using the QuantiFERON-TB Gold In-Tube (QFT-GIT) test. Data on demographics, occupational characteristics, and potential risk factors were collected through standardized questionnaires. Statistical analysis included univariate and multivariate logistic regression to identify factors associated with LTBI.

RESULTS

The overall prevalence of LTBI was 32.65% (48/147). Multivariate analysis identified several independent risk factors: male gender (OR: 2.84; 95% CI: 1.54-5.22; p<0.001), age above 50 years (OR: 4.58; 95% CI: 1.50-13.90; p=0.007), smoking status (OR: 4.07; 95% CI: 1.63-10.14; p=0.003), and family history of TB (OR: 4.71; 95% CI: 1.33-16.65; p=0.016). Notably, neither specific work areas nor job categories were identified as significant risk factors in the final multivariate model.

CONCLUSIONS

The observed LTBI prevalence among HCWs in Morocco demonstrates concordance with epidemiological data from comparable intermediate-burden nations. The elucidation of predisposing factors, with particular emphasis on non-occupational determinants, underscores the imperative for implementing systematic surveillance protocols and World Health Organization (WHO)-sanctioned infection prevention measures within healthcare facilities. These epidemiological findings provide an empirical foundation for the formulation and optimization of TB control strategies specifically tailored to the occupational health needs of Morocco's healthcare workforce.

Stigma relating to tuberculosis infection prevention and control implementation in rural health facilities in South Africa - a qualitative study outlining opportunities for mitigation

BACKGROUND

Tuberculosis (TB) is a stigmatised disease with intersectional associations with poverty, HIV, transmission risk and mortality. The use of visible TB infection prevention and control (IPC) measures, such as masks or isolation, can contribute to stigma.

METHODS

To explore stigma in this condition, we conducted in-depth individual interviews with 18 health workers and 15 patients in the rural Eastern Cape of South Africa using a semi-structured interview guide and narrative approach. We used reflexive thematic analysis guided by line-by-line coding. We then interpreted these key findings using Link and Phelan's theoretical model of stigma, related this to stigma mitigation recommendations from participants and identified levels of intervention with the Health Stigma and Discrimination Framework.

RESULTS

Participants shared narratives of how TB IPC measures can contribute to stigma, with some describing feeling 'less than human'. We found TB IPC measures sometimes exacerbated stigma, for example through introducing physical isolation that became prolonged or through a mask marking the person out as being ill with TB. In this context, stigma emerged from the narrow definition of what mask-wearing symbolises, in contrast with broader uses of masks as a preventative measure. Patient and health workers had contrasting perspectives on the implications of TB IPC-related stigma, with patients focussing on communal benefit, while health workers focussed on the negative impact on the health worker-patient relationship. Participant recommendations to mitigate TB IPC-related stigma included comprehensive information on TB IPC measures, respectful communication between health workers and patients, shifting the focus of TB IPC messages to communal safety (which could draw on ubuntu, a humanist framework) and using universal IPC precautions instead of measures targeted at someone with infectious TB.

CONCLUSIONS

Health facilities may unwittingly perpetuate stigma through TB IPC implementation, but they also have the potential to reduce it. Evoking 'ubuntu' as an African humanist conceptual framework could provide a novel perspective to guide future TB IPC stigma mitigation interventions, including policy changes to universal IPC precautions.

Coping efforts made: Psychological burden of people living with tuberculosis due to social stigma in society. A qualitative phenomenology study

The psychological burden is greatly felt by people living with tuberculosis because the characteristics of the disease are very visible and very contagious, and the obligation to take the right dose of medication with long treatment. This is what makes tuberculosis a very stigmatic disease. The aim of this research is to explore the psychological burden felt by people living with tuberculosis due to social stigma by society and how coping efforts are made. This research uses a qualitative phenomenological design through in-depth face-to-face interviews which take place in a semi-structured manner with the hope of obtaining complete data. The purposive sampling method was used in this research with Participatory Interpretative Phenomenology analysis involving 25 participants consisting of 16 men and 9 women. This research produced several themes, including 1) "The Perception of stigma limiting space and time", 2) "The Opportunities for interpersonal interaction become narrow", 3) "The mental stress as a challenging emotion", and 4) " Expanding coping efforts". The psychological burden is felt by people living with tuberculosis because society's treatment is felt to be very discriminatory due to the social stigma that has developed in society so they lose the opportunity to interact with society. For that reason, they tried to explore some of the personal and environmental resources used to modify adaptive coping in resolving perceived psychological burdens. Given the possibility of ongoing stigma and discrimination during tuberculosis treatment programs, it is important to consider the psychological burden in this context, both on the general population and on groups affected by stigma.

Exploring the Role of Healthcare Personnel in Designing Tuberculosis Infection Prevention and Control Measures in Healthcare Settings: A Scoping Review

Background: Healthcare personnel (HCP) in high TB-burdened countries continue to be at high risk of occupational TB due to inadequate implementation of Tuberculosis Infection Prevention and Control (TB-IPC) measures and a lack of understanding of the context and relevance to local settings. Such transmission in the healthcare workplace has prompted the development and dissemination of numerous guidelines for strengthening TB-IPC for use in settings globally. However, a lack of involvement of healthcare personnel in the conceptualisation and development of guidelines and programmes seeking to improve TB-IPC in high-burden countries generally has been observed. Objectives: The aim of this review was to explore the inclusion of HCP in decision-making when designing the TB-IPC guidelines, in healthcare settings. Methods: A scoping review methodology was selected for this study to gain insight into the relevant research evidence, identifying and mapping key elements in the TB-IPC measures in relation to HCP as implementors. Results: Studies in this review refer to factors related to HCP's knowledge of TB-IPC, perception regarding occupational risks and behaviours, their role against a background of structural resource constraints, and guidelines' adherence. They report several challenges in TB-IPC implementation and adherence, particularly eliciting recommendations from HCP for improved TB-IPC practices. Conclusions: This review highlights a lack of participation in decision-making by the implementers of the policies and guidelines, yet adherence to TB-IPC measures is anticipated. Future research needs to focus more on consultations with users to understand the preferences from both within individual healthcare facilities and the communities. There is an urgent need for research on the participation of the implementers in the decision-making when developing TB-IPC policies and guidelines.

Airborne infection prevention and control implementation: A positive deviant organisational case study of tuberculosis and COVID-19 at a South African rural district hospital

There are many examples of poor TB infection prevention and control (IPC) implementation in the academic literature, describing a high-risk environment for nosocomial spread of airborne diseases to patients and health workers. We developed a positive deviant organisational case study drawing on Weick's theory of organisational sensemaking. We focused on a district hospital in the rural Eastern Cape, South Africa and used four primary care clinics as comparator sites. We interviewed 18 health workers to understand TB IPC implementation over time. We included follow-up interviews on interactions between TB and COVID-19 IPC. We found that TB IPC implementation at the district hospital was strengthened by continually adapting strategies based on synergistic interventions (e.g. TB triage and staff health services), changes in what value health workers attached to TB IPC and establishing organisational TB IPC norms. The COVID-19 pandemic severely tested organisational resilience and COVID-19 IPC measures competed instead of acted synergistically with TB. Yet there is the opportunity for applying COVID-19 IPC organisational narratives to TB IPC to support its use. Based on this positive deviant case we recommend viewing TB IPC implementation as a social process where health workers contribute to how evidence is interpreted and applied.

Time to change the way we think about tuberculosis infection prevention and control in health facilities: insights from recent research

In clinical settings where airborne pathogens, such as Mycobacterium tuberculosis, are prevalent, they constitute an important threat to health workers and people accessing healthcare. We report key insights from a 3-year project conducted in primary healthcare clinics in South Africa, alongside other recent tuberculosis infection prevention and control (TB-IPC) research. We discuss the fragmentation of TB-IPC policies and budgets; the characteristics of individuals attending clinics with prevalent pulmonary tuberculosis; clinic congestion and patient flow; clinic design and natural ventilation; and the facility-level determinants of the implementation (or not) of TB-IPC interventions. We present modeling studies that describe the contribution of M. tuberculosis transmission in clinics to the community tuberculosis burden and economic evaluations showing that TB-IPC interventions are highly cost-effective. We argue for a set of changes to TB-IPC, including better coordination of policymaking, clinic decongestion, changes to clinic design and building regulations, and budgeting for enablers to sustain implementation of TB-IPC interventions. Additional research is needed to find the most effective means of improving the implementation of TB-IPC interventions; to develop approaches to screening for prevalent pulmonary tuberculosis that do not rely on symptoms; and to identify groups of patients that can be seen in clinic less frequently.

Voices from the Patients: A Qualitative Study of the Integration of Tuberculosis, Human Immunodeficiency Virus and Primary Healthcare Services in O.R. Tambo District, Eastern Cape, South Africa

Tuberculosis (TB), a disease of poverty and inequality, is a leading cause of severe illness and death among people with human immunodeficiency virus (HIV). In South Africa, both TB and HIV epidemics have been closely related and persistent, posing a significant burden for healthcare provision. Studies have observed that TB-HIV integration reduces mortality. The operational implementation of integrated services is still challenging. This study aimed to describe patients' perceptions on barriers to scaling up of TB-HIV integration services at selected health facilities (study sites) in Oliver Reginald (O.R) Tambo Municipality, Eastern Cape province, South Africa. We purposely recruited twenty-nine (29) patients accessing TB and HIV services at the study sites. Data were analyzed using qualitative content analysis and presented as emerging themes. Barriers identified included a lack of health education about TB and HIV; an inadequate counselling for HIV and the antiretroviral drugs (ARVs); and poor quality of services provided by the healthcare facilities. These findings suggest that the O.R. Tambo district needs to strengthen its TB-HIV integration immediately.

Experience and Perception of Healthcare Workers on the Challenges of Follow-Up and Treatment of Tuberculosis Patients in Southern Ethiopia: An Exploratory-Descriptive Qualitative Study

Background

There is a scarcity of research evidence on TB follow-up and treatment challenges from a healthcare worker's perspective in Ethiopia. Therefore, this study aimed to explore and describe the experience and perception of healthcare workers on the challenges of follow-up and treatment of TB patients in Southern Ethiopia.

Material and Methods

A qualitative exploratory-descriptive study was employed among 26 purposely selected Healthcare Workers (HCWs) from Wolaita Sodo University-Comprehensive Specialized Hospital and Achura, Boloso Sore, and Tida Health Centers in December 2021 and January 2022. Initially, the maximum variation purposive sampling technique was employed, then based on the data requirement of the study it was enriched by a theoretical sampling method. The required data were collected through one-on-one face-to-face audio-taped in-depth interviews. Data analysis was conducted by using a qualitative data analysis framework for the applied research method. NVivo Software Version 11 was used to ease data organization and analysis. Detailed textual narration of subthemes, and themes was done using direct verbatim quotations in the respective headings and subheadings.

Results

In the current study, three major themes and eleven sub-themes emerged from the data. The three major themes include the experience of healthcare workers, perceived challenges, and suggestions for improvement of TB patients' follow-up and treatment. Healthcare worker's experience, compliance with infection prevention protocols, fear of contracting and/or spreading TB, public awareness of TB, socio-economic burdens, providers-related problems, shortage of medical supplies, unconducive physical work environment, provision of holistic support for the patients, provision of in or out of service training, and supportive supervision were the sub-themes.

Conclusion

This study explored the multidimensional challenges adjoining follow-up and treatment of TB patients. Regular monitoring and supportive supervision accompanied by appropriate and timely decisions and feedback are vital to ensure effective follow-up and treatment of TB patients in Ethiopia.