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Implementation of TB infection prevention and control (IPC) measures in health facilities is frequently inadequate, despite nosocomial TB transmission to patients and health workers causing harm. We aimed to review qualitative evidence of the complexity associated with implementing TB IPC, to help guide the development of TB IPC implementation plan...
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Background
Acute HIV infection during pregnancy and in the postpartum period increases the risk of vertical transmission. The World Health Organization (WHO) has recommended preexposure prophylaxis for pregnant and postpartum women at risk of acquiring HIV. However, there are significant gaps between the actual practice and the ideal goal of preexp...
Citations
... Transmission of TB through the air when a sufferer coughs or sneezes will increase the risk of transmission to people around them. Toddlers who are around sufferers will be more susceptible to infection if they do not wear masks, so awareness is needed for both parents of toddlers and TB sufferers to prevent transmission by using masks [37]. ...
The incidence of children suffering from Tuberculosis (TB) is increasing. A history of contact between adult TB patients and children is an important factor in the transmission of Tuberculosis to children. This research aims to determine tuberculosis's prevalence and determinants in children under five in household contacts in the Banyumas District, Central Java. The design of this research is quantitative with a cross-sectional approach. The sample of this study was children under 5 years of age (toddlers) in Banyumas Regency (District of South Purwokerto and Sumbang) in whose homes there were positive patient of tuberculosis and were willing to undergo a Mantoux test as many as 48 toddlers. Data collection was carried out using the Mantoux test and questionnaires. Data analysis using univariate, bivariate, and multivariate analysis. The prevalence of Tuberculosis among children under five is 270/1000. The most influential variable on the incidence of tuberculosis is health conditions (lumps in glands) with a p-value of 0.009 OR = 83.204 and sleeping in the same room with TB patients ( p-value of 0.035 OR = 14.246). The results concluded that the risk factor of toddler tuberculosis in Banyumas Regency is health condition (lumps in glands) and sleeping in the same room.
... [17]. Several factors intervene in this process like infection control measures: (1) administrative controls (presence vs absence of TB screening programs, patient isolation protocols, staff training programs), (2) environmental controls (ventilation systems, UV irradiation, negative pressure rooms), and (3) personal protective equipment (N95 mask availability and usage, compliance with protocols, training adequacy) [30]. ...
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.
... Despite receiving prominence in the policy and academic literature, there has been little progress in finding ways in which TB IPC-related stigma can be mitigated [6,10,11]. Instead, avoiding the stigma related to mask wearing by people with TB is sometimes cited as a reason for abandoning the use of masks in health facilities [12]. This contributes to the ongoing spread of TB to health workers, patients and visitors -affecting those with underlying health conditions more severely. ...
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.
Supplementary Information
The online version contains supplementary material available at 10.1186/s44263-024-00097-8.
... However, several studies have reported that some people living with tuberculosis still have the opportunity to interact with officers. when seeking treatment [83,84] and with family at home [30], but cross-infection must be watched out for when interacting with them because tuberculosis is transmitted through droplet infection, where direct contact is very facilitative for the transmission of tuberculosis germs [85][86][87]. This interaction problem may have contributed to the psychological burden felt, because they had difficulty expressing their feelings due to the social distance that limited them, considering that several participants expressed the protective nature of previous experiences of perceived stigma. ...
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.
... This hazard is extensive: in South Africa TB has been the leading cause of death, with health workers falling ill with TB disease at a three times increased rate compared to the general population (Department of Statistics South Africa, 2020; Uden et al., 2017). During the COVID-19 pandemic, as airborne precautions became an increasingly important part of the pandemic response, there was an opportunity to consider airborne infection prevention and control (IPC) implementation as a multi-disease intervention combining the emergency COVID-19 response and 'routine' care for diseases such as TB (van der Westhuizen et al., 2022). Implementation of TB IPC across health facilities in South Africa and in other high TB burden countries is generally described to be poor Engelbrecht et al., 2018;Farley et al., 2012;O'Hara et al., 2017). ...
... This includes administrative controls (triage and the use of isolation and respiratory hygiene for people with TB symptoms or disease, as well as prompt initiation of effective treatment), environmental controls (ventilation and upper-room germicidal ultraviolet systems) and use of personal protective equipment (World Health Organization, 2019). These components interact to influence the risk of nosocomial airborne disease transmission making this a complex intervention (van der Westhuizen et al., 2022). ...
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.
... Views of the implementers on the possibility of them deciding how TB-IPC measures may be tailored to accommodate different settings have not been examined [19]. The aim of this review was to explore the inclusion of the implementers, healthcare personnel, in decision-making when designing the TB-IPC guidelines in healthcare settings. ...
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.
... (5,8,11) Avoiding the stigma related to mask-wearing by people with TB is sometimes cited as a reason for abandoning the use of masks in health facilities. (12) This contributes to the ongoing spread of TB to health workers, patients and visitors -affecting those with underlying health conditions more severely. ...
Background
Tuberculosis (TB) is a stigmatised disease due to its 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 and applied Link and Phelan’s theoretical model of stigma.
Results
Participants shared poignant narratives of TB stigma, often entailing TB IPC, with some 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. In this way, the health facility itself was shown to play an important role in generating and perpetuating IPC related stigma. We applied ‘ubuntu’ as African humanist conceptual framework to develop recommendations of how TB IPC implementation could be destigmatised.
Conclusion
Health facilities may unwittingly perpetuate stigma, but they also have the potential to reduce it. Ubuntu emphases shared humanity and collective wellbeing and could engage with some of the deep-rooted contributors to TB stigma. An ubuntu-informed approach could underpin a local policy change to universal masking, thereby destigmatising an important IPC practice.
... 1 This misperception of risk location has been noted by others, including access to TB-IPC training and respiratory personal protective equipment being preferentially offered to staff providing TB testing and treatment 21 ; also administrative, domestic, and community health workers being denied access to these resources. 21 We undertook a TB prevalence survey enrolling 2055 adults attending two primary healthcare clinics in rural KwaZulu-Natal. 22 Most participants with Mtb cultured from sputum were attending routine appointments for HIV care. ...
... Our observation that thermal comfort places limits on the levels of natural ventilation that can be achieved has also been noted by others. 21,47 South Africa experiences both hot summers and, in places, cold winters. We are currently using airflow modeling to investigate approaches to improving natural ventilation while maintaining thermal comfort. ...
... 20 Similar observations have been made in other settings. 21 We used a participatory System Dynamics Modeling approach, to explore health systems constraints that prevent various TB-IPC interventions from being implemented. 53 As part of the process, key stakeholders suggested changes that might overcome these constraints. ...
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.
... The strong recommendation from study participants was that the quality of services offered be improved. Participants' suggestions for improvements are in line with the stipulations of UNAIDS [27,28] and WHO [42][43][44][45]. These organizations urge sub-Saharan countries to make the best use of their limited resources rather than use lack of resources as a justification for poorly integrated TB and HIV control programs. ...
... HIV-TB services refer to screening, diagnosis, and treatment services provided for both diseases at the same clinic, by the same clinic team, on the same visit day, according to the World Health Organization. Similar studies elsewhere have reported that an integrated therapy of both HIV and TB based on the current evidence of studies from both diseases has been shown to be feasible and efficient in controlling the diseases and yields better survival in various clinical settings [2,19,32,43,45]. This study was conducted in a district that is mainly influenced by the high rate of poverty and overburdened by co-infection [33], owing to the size of the study; our results can only be representative of the O.R. Tambo District Municipality. ...
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.
... Studies elsewhere have observed that issues of stigma are very important in the battle against HIV/AIDS especially in Africa since it may affect patient attendance at healthcare centres for obtaining antiretroviral (ARV) medications and regular medical check-ups [ 42] . Stigmatization creates an unnecessary culture of secrecy and silence based on ignorance and fear of victimization [42,43,44]. These findings are aligned with those of WHO, [45,46] in 'HIV-Associated Tuberculosis factsheet' that about 80% of respondents still faced challenges of being stigmatised and discrimination in our health care facilities, this makes TB and HIV services inaccessible especially deprived communities. ...
... Infection Prevention and control (IPC) can reduce the risk of TB transmission even in settings with limited resources [11]. Studies published elsewhere, had similar findings in their studies, whereby the facilities have only infection control guidelines but official appointment of infection control nurse is not available because of limited budget [14,43]. The lack of awareness about National TB cotrol program among by patients was indicated by study. ...
Tuberculosis (TB) and human immunodeficiency virus (HIV) epidemics in South Africa have been closely related and persistent, posing a significant burden for healthcare provision. We explored the patients perspectives on challenges and barriers of scaling up TB and HIV integrated services. A descriptive cross-sectional study applying a qualitive research approach was used. Through focus group discusssions (FGDs), we interviewed 29 patients accessing TB and HIV services at the study sites which were selected at primary health care (PHC) clinics in the O.R Tambo district in Eastern Cape, South Africa. Anonymised data was analysed using both content and thematic analysis technique. Challenges and barriers identified included a lack of health education about TB and HIV; an inadequate counselling for antiretroviral drugs (ARVs) and HIV; a lack of awareness of the National TB control program; and poor quality of services provided by the health care facilities. These findings suggest that the O.R. Tambo district needs to strengthen its TB-HIV integration immediately. Keywords: TB-HIV integration; Challenges and barriers; Patients; O.R Tambo District; Eastern Cape; South Africa
