Investigating socio-ecological factors influencing implementation of tuberculosis infection prevention and control in rural Papua New Guinea.

BACKGROUND: Tuberculosis (TB) is a highly transmissible infectious disease killing millions of people yearly, particularly in low-income countries. TB is most likely to be transmitted in healthcare settings with poor infection control practices. Implementing TB infection prevention and control (TB-IPC) is pivotal to preventing TB transmission in healthcare settings. This study investigated diverse stakeholders' perspectives relating to barriers and strategies for TB-IPC in rural hospitals in Papua New Guinea. METHODS: Multiple qualitative case studies were conducted with 32 key stakeholders with experience in TB services. Data collection drew on three primary sources to triangulate data: semi-structured interviews, document reviews and field notes. The data were analyzed using hybrid deductive-inductive thematic analysis. RESULTS: Our results reveal that key stakeholders perceive multiple interdependent factors that affect TB-IPC practice. The key emerging themes include strategic planning for and prioritizing TB-IPC guidelines; governance, leadership and accountability at the provincial level; community attitudes towards TB control; institutional capacity to deliver TB care, healthcare workers' safety, and long-term partnership and integration of TB-IPC programmes into the broad IPC programme. CONCLUSIONS: The evidence suggests that a multi-perspective approach is crucial for TB-IPC guidelines in healthcare institutions. Interventions focusing on addressing health systems strengthening may improve the implementation of TB-IPC guidelines.

What tuberculosis infection control measures are effective in resource-constrained primary healthcare facilities? A systematic review of the literature.

INTRODUCTION: Tuberculosis (TB) remains a major global health challenge, killing millions of people, despite the availability of preventive TB medication. The majority of these infections and deaths occur in low-income countries. Therefore, practical public health strategies are required to reduce the global TB burden in these countries effectively. The purpose of this review was to examine the current evidence of tuberculosis infection control (TBIC) measures in reducing TB transmission and explore the barriers and enablers of TBIC measures in resource-constrained primary healthcare settings. METHODS: The PRISMA framework was adopted to identify studies that report on the evidence and barriers and facilitators of administrative, environmental and respiratory control measures at healthcare settings in low- and middle-income countries (LMICs). ProQuest, Scopus, ScienceDirect, Embase and PubMed were searched for English language peer-reviewed studies published since the introduction of TBIC guidelines. Studies not relevant to the topic, were not on TBIC measures or were reviews or commentary-style papers were excluded. Included articles were evaluated based on their aim, study design, geography and health settings interventions (TBIC measures), economic setting (ie LMICs) and main findings. RESULTS: Our review of the 15 included studies identified a cough officer screening system, isolation of TB patients, modification of consultation rooms, and opening windows and doors as effective TB prevention measures. Lack of patient education, unsupportive workplace culture, inadequate supply of particulate respirators, insufficient isolation facilities and poor physical infrastructures were identified as barriers to TBIC practices. Triaging TB patients, maintenance of health infrastructure, appropriate use of personal protective equipment (PPE) and healthcare workers (HCWs) training on the correct use of PPE were reported as facilitators of TBIC in primary healthcare facilities. CONCLUSION: Our review provides consistent evidence of TBIC measures in reducing TB transmission in resource-constrained primary healthcare settings. This review has demonstrated that TB transmission can be successfully controlled using multiple and simple low-cost TBIC measures including administrative, environmental and respiratory controls. Effective implementation of triaging patients with suspected TB alongside maintenance of health infrastructure, appropriate use of PPE and robust HCWs training on TBIC could improve implementation of TBIC measures in primary healthcare settings. Healthcare management should address these areas particularly in rural and remote locations to improve the implementation of TBIC measures in primary healthcare facilities in LMICs.

Barriers and facilitators to effective tuberculosis infection control practices in Madang Province, PNG - a qualitative study.

INTRODUCTION: Tuberculosis (TB) remains a major public health problem in many countries. There is a greater threat of exposure to TB in congregate settings including healthcare facilities, prisons and households where health workers treat patients with TB. In healthcare facilities, the key areas of risk of infection include settings where people with undiagnosed TB, including multidrug-resistant TB, congregate, such as outpatient waiting areas, pathology waiting areas, radiology departments and pharmacies, and wards where untreated patients await investigation results. With high levels of TB in the community, and symptoms leading people to seek treatment, health services can be TB 'hot spots', and in the absence of good TB infection control (TBIC) a clinical service may actually promote the spread of TB, rather than contain it. Practical and relevant control measures are, therefore, necessary to monitor the spread of TB. METHODS: The purpose of this hermeneutic phenomenological research was to explore rural health workers' perspectives of barriers and facilitators to effective TBIC practices in rural health facilities in Madang Province, Papua New Guinea (PNG). The conceptual framework was adopted from WHO policy on TBIC in healthcare facilities, congregate settings and households as a benchmark to guide the study. Qualitative individual and group interviews (with an average time of 30 minutes) and field notes were conducted with 12 key informants comprising clinicians (n=9) and support staff (n=3) from the health facilities. Trustworthy steps were taken during the semi-structured interview to ensure data validity through member check and repeating participants' narratives to ensure accurate representation of participants' experiences. All interviews and field notes were analysed using standard phenomenological methods. RESULTS: The findings showed that numerous interconnected factors have influenced the implementation of TBIC measures in the rural health facilities in Madang Province. They include issues related to inadequacies in the healthcare systems, access to personal protective equipment, separation procedures, sputum status, monitoring and control, training, and health services as TB 'hot spots'. CONCLUSIONS: The study found evidence that health system factors do impact on the capacity to implement TBIC. Further, factors beyond TBIC such as sociocultural factors have an important influence on the way TBIC is implemented. The results of this study are useful for clinicians, health administrators and policymakers to improve the interventions and application of TBIC procedures at the rural health facilities in PNG. The study is limited to health services in Madang Province, and therefore the findings cannot automatically be generalised to other district hospitals and health centres in other parts of PNG. However, the WHO TBIC is a standardised policy and the results of the findings may be useful for other health facilities that manage TB patients in PNG and for future health systems researchers to help improve the generalisability of the findings. Further research is needed to explore health workers' experiences of conditions, actions and everyday practical issues affecting the application of TBIC measures in the rural health facilities of PNG.

Tuberculosis infection prevention and control in rural Papua New Guinea: an evaluation using the infection prevention and control assessment framework.

BACKGROUND: Papua New Guinea (PNG) is one of the 14 countries categorised as having a triple burden of tuberculosis (TB), multidrug-resistant TB (MDR TB), and TB-human immunodeficiency virus (HIV) co-infections. TB infection prevention and control (TB-IPC) guidelines were introduced in 2011 by the National Health Department of PNG. This study assesses the implementation of this policy in a sample of district hospitals in two regions of PNG. METHODS: The implementation of TB-IPC policy was assessed using a survey method based on the World Health Organization (WHO) IPC assessment framework (IPCAF) to implement the WHO's IPC core components. The study included facility assessment at ten district hospitals and validation observations of TB-IPC practices. RESULTS: Overall, implementation of IPC and TB-IPC guidelines was inadequate in participating facilities. Though 80% of facilities had an IPC program, many needed more clearly defined IPC objectives, budget allocation, and yearly work plans. In addition, they did not include senior facility managers in the IPC committee. 80% (n = 8 of 10) of hospitals had no IPC training and education; 90% had no IPC committee to support the IPC team; 70% had no surveillance protocols to monitor infections, and only 20% used multimodal strategies for IPC activities. Similarly, 70% of facilities had a TB-IPC program without a proper budget and did not include facility managers in the TB-IPC team; 80% indicated that patient flow poses a risk of TB transmission; 70% had poor ventilation systems; 90% had inadequate isolation rooms; and though 80% have personal protective equipment available, frequent shortages were reported. CONCLUSIONS: The WHO-recommended TB-IPC policy is not effectively implemented in most of the participating district hospitals. Improvements in implementing and disseminating TB-IPC guidelines, monitoring TB-IPC practices, and systematic healthcare worker training are essential to improve TB-IPC guidelines' operationalisation in health settings to reduce TB prevalence in PNG.