Rodney Ehrlich’s research while affiliated with University of Cape Town and other places

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Publications (13)


Fig. 1 Summary of participant recommendations for multi-level, TB IPC stigma intervention targets
Table 2 (continued)
Stigma relating to tuberculosis infection prevention and control implementation in rural health facilities in South Africa — a qualitative study outlining opportunities for mitigation
  • Article
  • Full-text available

October 2024

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7 Reads

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2 Citations

BMC Global and Public Health

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Rodney Ehrlich

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Ncumisa Somdyala

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[...]

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Chris C. Butler

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.

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Key milestones in TB IPC organisational sensemaking.
Airborne infection prevention and control implementation: A positive deviant organisational case study of tuberculosis and COVID-19 at a South African rural district hospital

July 2024

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8 Reads

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.


Table 1
Stigma relating to tuberculosis infection prevention and control implementation in rural health facilities in South Africa – a theoretical analysis with opportunities for mitigation

November 2023

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40 Reads

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2 Citations

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.


PRISMA flow diagram
of five key themes identified through thematic synthesis
of ten key findings of qualitative evidence synthesis with CERQual assessment
Contextualising and evaluating TB IPC implementation considerations identified through this qualitative evidence synthesis
Recommendations for translating the ten key findings of this qualitative evidence synthesis to TB IPC implementation plans
Health worker experiences of implementing TB infection prevention and control: A qualitative evidence synthesis to inform implementation recommendations

July 2022

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101 Reads

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13 Citations

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 plans. We undertook a qualitative evidence synthesis of studies that used qualitative methods to explore the experiences of health workers implementing TB IPC in health facilities. We searched eight databases in November 2021, complemented by citation tracking. Two reviewers screened titles and abstracts and reviewed full texts of potentially eligible papers. We used the Critical Appraisals Skills Programme checklist for quality appraisal, thematic synthesis to identify key findings and the GRADE-CERQual method to appraise the certainty of review findings. The review protocol was pre-registered on PROSPERO, ID CRD42020165314. We screened 1062 titles and abstracts and reviewed 102 full texts, with 37 studies included in the synthesis. We developed 10 key findings, five of which we had high confidence in. We describe several components of TB IPC as a complex intervention. Health workers were influenced by their personal occupational TB risk perceptions when deciding whether to implement TB IPC and neglected the contribution of TB IPC to patient safety. Health workers and researchers expressed multiple uncertainties (for example the duration of infectiousness of people with TB), assumptions and misconceptions about what constitutes effective TB IPC, including focussing TB IPC on patients known with TB on treatment who pose a small risk of transmission. Instead, TB IPC resources should target high risk areas for transmission (crowded, poorly ventilated spaces). Furthermore, TB IPC implementation plans should support health workers to translate TB IPC guidelines to local contexts, including how to navigate unintended stigma caused by IPC, and using limited IPC resources effectively.


Triage criteria for routing of claims to one of three panels, February 2020–October 2020
Flow of triaged claims through the panel system
Reforming the workers’ compensation process for occupational lung disease among miners in South Africa: an efficiency study of claims assessment

May 2022

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56 Reads

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5 Citations

International Archives of Occupational and Environmental Health

Purpose The large burden of silicosis and tuberculosis (TB) in the South African mining industry, coupled with an under-resourcing of the compensation agencies responsible for certifying occupational lung disease, have resulted in serious backlogs. This work aimed to measure the efficiency gains from triaging occupational lung disease claims using claim type, years of mining exposure and computer aided detection (CAD) to save on scarce medical adjudicators. Methods During 2020, the compensation authority started to triage claims for TB and those of miners with < 10 years of service to two-person panels instead of the four-person panel plus radiologist used previously. Efficiency gain was calculated in medical person-units saved and reduction in delays. Different service thresholds predictive of silicosis were simulated, as well as the impact of pre-classification of chest X-rays with CAD using different combinations of sensitivity and specificity. Results The new triage system saved 20.3% in person-time units and reduced delays by 10–20 days. Without CAD the greatest efficiency gain (28%) was projected from dispensing with a mining service threshold and routing all non-TB claims to the small panels at the outset. Simulation of four different CAD sensitivity/specificity combinations yielded efficiency gains of 18.2–36.1%, with 31.1% judged the most realistic. Use of sensitivity of close to 100% would not be feasible because of the very low resulting specificity. Conclusion Pre-adjudication triage of claims at the compensation agency is capable of saving a substantial proportion of adjudicator time and reducing certification delays. Additional efficiency gains are achievable by referring all claims to small panels to begin with and improvement of CAD performance for this ex-miner population.



Doctors’ Extended Shifts as Risk to Practitioner and Patient: South Africa as a Case Study

August 2020

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77 Reads

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4 Citations

Extended shifts are common in medical practice. This is when doctors are required to work continuously for more than 16 hours, with little or no rest, often without a maximum limit. These shifts have been a part of medical practice for more than a century. Research on the impact of fatigue presents compelling evidence that extended shifts increase the risk of harm to patients and practitioners. However, where the number of doctors is limited and their workloads are not easily reduced, there are numerous barriers to reform. Some of these include a perceived lack of safer alternatives, concerns about continuity of care, trainee education, and doctors’ preferences. As such, working hour reorganisation has been contentious globally. South Africa, a middle-income country where extended shifts are unregulated for most doctors, offers a useful case study of reform efforts. The South African Safe Working Hours campaign has promoted working hour reorganization through multi-level advocacy efforts, although extended shifts remain common. We propose that extended shifts should be regarded as an occupational hazard under health and safety legislation. We suggest options for managing the risks of extended shifts by adapting the hierarchy of controls for occupational hazards. Despite the challenges reform pose, the practice of unregulated extended shifts should not continue.


Workers’ compensation claims for occupational tuberculosis in South African health workers: Outcomes and workers’ experiences

April 2020

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655 Reads

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5 Citations

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde

Background: Given the elevated risk of tuberculosis (TB), including drug-resistant disease, experienced by health workers in South Africa (SA), effective workers' compensation for occupational TB is a legal right and an essential social benefit. Objectives: To investigate the experience of the workers' compensation system among health workers who suffered from TB while working in public service facilities in Western Cape Province, SA. Methods: In this case series with a qualitative component, 300 claims for occupational TB in health workers were sampled from the provincial health department database of claims submitted. Claim status for each case was ascertained. An attempt was made to contact each health worker for a telephonic interview consisting of both closed- and open-ended (qualitative) questions. Fifty-one interviews were completed. Results: In nearly half of the cases, there was no record of claim status on the state Compensation Fund website. Of the 51 interviewees, only one had received all the compensation benefits for their particular claim circumstances. Health workers' experience of having their cases reported for compensation purposes was marred by perception of poor communication and administration. The experience of contracting TB was further characterised by surprise, perceptions of stigma, financial burden and ongoing ill-health. Conclusions: Affected health workers' experience of the workers' compensation system was mostly negative, adding to the burden of being ill with TB. Education of management and clinicians, improvement in communication, and timeous and regular checking of claim status and of payment of applicable compensation are required at the provincial level. Dedicated facility-based occupational health units are needed, with a staff complement of knowledgeable persons trusted by their colleagues. However, the effectiveness of the system is ultimately dependent on the ability of the Compensation Fund to register and display claims timeously and administer compensation expeditiously.


Computer-aided detection for tuberculosis and silicosis in chest radiographs of gold miners of South Africa

April 2020

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71 Reads

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23 Citations

The International Journal of Tuberculosis and Lung Disease

BACKGROUND: For over one hundred years, the gold mining sector has been a considerable source of tuberculosis (TB) and silicosis disease burden across Southern Africa. Reading chest radiographs (CXRs) is an expert and time-intensive process necessary for the screening and diagnosis of lung disease and the provision of evidence for compensation claims. Our study explores the use of computer-aided detection (CAD) of TB and silicosis in CXRs of a population with a high incidence of both diseases. METHODS: A set of 330 CXRs with human expert-determined classifications of silicosis, TB, silcotuberculosis and normal were provided to four health technology companies. The ability of each of their respective CAD systems to predict disease was assessed using receiver operating characteristic curve analysis of the under the curve metric. RESULTS: Three of the four systems differentiated accurately between TB and normal images, while two differentiated accurately between silicosis and normal images. Inclusion of silicotuberculosis images reduced each system's ability to detect either disease. In differentiating between any abnormal from normal CXR, the most accurate system achieved both a sensitivity and specificity of 98.2%. CONCLUSION: The current ability of CAD to differentiate between TB and silicosis is limited, but its use as a mass screening tool for both diseases shows considerable promise.


Fig. 2. Incorporating person-centred principles in TB IPC implementation.
The high-quality health system ‘revolution’: Re-imagining tuberculosis infection prevention and control

August 2019

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101 Reads

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23 Citations

Journal of Clinical Tuberculosis and Other Mycobacterial Diseases

The Lancet Commission on High-Quality Health Systems called for a 'revolution' in the quality of care provided in low- and middle-income countries. We argue that this provides a helpful framework to demonstrate how effective tuberculosis infection prevention and control (TB IPC) implementation should be linked with health system strengthening, moving it from the silo of the national TB programmes. Using this framework, we identify and discuss links between TB IPC implementation and patient safety, human resources for health, prioritising person-centred care, building trust in health systems and refining the tools used to measure TB IPC implementation. Prioritising patient experience has been a recent addition to the definition of high-quality care. In high TB burden settings, the encounter with TB IPC measures may be a TB patient's initial contact with the healthcare system and may cause feelings of stigmatisation. We advocate for re-imagining the way we implement TB IPC, by drawing on the principles of person-centred care through incorporating the experiences of people using healthcare services. Health workers who developed occupational TB also offer a unique perspective: they have both experienced TB IPC and have played a role in implementing it in their workplace. They can be powerful advocates for person-centred TB IPC implementation. Through framing TB IPC as part of health system strengthening and consciously including person-centred perspectives in TB IPC design, measurement and guidelines, we hope to influence future TB IPC research and practice.


Citations (11)


... Some of the common symptoms related to TB that influence an individual diagnosed with TB's ability to return to work are low physical endurance, loss of motivation, and a loss of self-esteem [6]. Other psychosocial factors include the stigma that society has towards individuals with TB due to the fear of becoming infected by them [7]. The worker roles of individuals diagnosed with TB are affected, as they often struggle to complete work tasks due to their symptoms of low physical endurance [5]. ...

Reference:

The Development of a Vocational Rehabilitation Program to Assist Individuals With MDRTB and TB in Returning to Work
Stigma relating to tuberculosis infection prevention and control implementation in rural health facilities in South Africa — a qualitative study outlining opportunities for mitigation

BMC Global and Public Health

... The World Health Organization (WHO) developed a strategy to end the global pulmonary TB epidemic by 2035 by reducing the incidence and mortality rates by 90% and 95%, respectively [11]. DOTS strategy recommendations (Directly Observed Treatment Shortcourse) from WHO as an effort to control Lung TB have not had a positive impact, and its success is still low [12]. especially the transmission of Lung TB in the Sumenep community is still very high [13]. ...

Stigma relating to tuberculosis infection prevention and control implementation in rural health facilities in South Africa – a theoretical analysis with opportunities for mitigation

... 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]. ...

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

... The demonstration that at least one CAD system is capable of detecting silicosis in a population with a high background prevalence of prior TB is particularly noteworthy. The next stage is to use CAD in practice for this population, and to monitor and evaluate its impact on system efficiency [38], on satisfaction of clinicians and medical adjudicators, and on ethical practice [39]. ...

Reforming the workers’ compensation process for occupational lung disease among miners in South Africa: an efficiency study of claims assessment

International Archives of Occupational and Environmental Health

... Доказано канцерогенное 7 и аутоиммунное воздействие кремнезёма с развитием злокачественных новообразований различной локализации и целого ряда системных заболеваний [11]. ...

Silica-a Multisystem Hazard
  • Citing Article
  • February 2021

International Journal of Epidemiology

... The disadvantages of private healthcare are that it is expensive, there are fewer facilities, and patients are responsible for paying for healthcare visits, pharmaceuticals, and additional resources such as wheelchairs. On the other hand, a study by[24] highlighted doctors' extended shifts as a risk to practitioner and patient. It was indicated in this study that getting access to more specialized levels of service depended on referrals. ...

Doctors’ Extended Shifts as Risk to Practitioner and Patient: South Africa as a Case Study

... Characteristics are identified as an important factor to accidental underreporting including the feeling of being healthy, apprehension of harassment, small-business employment, and administrative obstacles, especially inadequate access to existing healthcare sevices. 10 Thani, and Phuket. ...

Workers’ compensation claims for occupational tuberculosis in South African health workers: Outcomes and workers’ experiences

South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde

... Examples of other studies include COVID-19 forecast models in Iran [40] and India [41], Ebola forecast models for Africa [42], and automated malaria diagnostic models in Uganda [43]. Various tuberculosis prediction studies in Brazil [44], South Africa [45], and Peru [46] have also been conducted. And despite the mixed performance of an AI COVID CT diagnosis tool in Ecuador, it remained in use due to the absence of alternatives [47]. ...

Computer-aided detection for tuberculosis and silicosis in chest radiographs of gold miners of South Africa
  • Citing Article
  • April 2020

The International Journal of Tuberculosis and Lung Disease

... Por otro lado, factores relacionados con la cultura institucional y las actitudes del personal sanitario juegan un papel importante en la efectividad de las medidas de prevención. El estigma asociado a la tuberculosis y la falta de priorización de esta enfermedad en la agenda hospitalaria limitan la adopción de medidas efectivas de control(Liboon et al., 2023;Van Der Westhuizen et al., 2019).En resumen, los factores que inciden en la transmisión nosocomial de tuberculosis incluyen principalmente la falta de aislamiento adecuado, la infraestructura hospitalaria deficiente, el diagnóstico tardío, y la falta de medidas efectivas de prevención y control de infecciones. Por otro lado, la mejora de la ventilación en salas hospitalarias, la capacitación continua del personal de salud, y la implementación oportuna de medidas de control de infecciones han demostrado ser cruciales para prevenir la propagación de esta enfermedad dentro de los ...

The high-quality health system ‘revolution’: Re-imagining tuberculosis infection prevention and control

Journal of Clinical Tuberculosis and Other Mycobacterial Diseases

... We have previously argued that the worker-centred lens is needed for improved protection of health workers against occupational TB [77] and have called for greater integration of IPC and occupational health and safety (OHS) [77][78][79]. Besides the core components of IPC, the OHS approach includes an emphasis on worker screening, treatment, and disability management; confidential occupational health services; and education about occupational risks and rights [78]. ...

Diverse approaches to preventing occupational tuberculosis in health workers: cross-disciplinary or cross purposes?
  • Citing Article
  • March 2019

Public Health Action