Macro-level barriers and facilitators.

Lack of consideration of IPC in HIV and TB integration. The study from Uganda conducted in 51 health care facilities noted that the work flow of their hospital neglected to take into account the need to separate TB patients from HIV patients [17]:

“…the worst thing is that these HIV patients are seated together with TB patients and some of them are suspects and not yet on treatment.”

Ineffective occupational health policies as part of TBIPC. Poor screening of healthcare workers for TB and HIV was reported in the studies from South Africa and the Dominican Republic [8, 27]. The nationwide study from Romania reported an underdeveloped system for reporting TB amongst healthcare workers [13]. None of the hospitals had developed a way to discreetly reassign immunocompromised healthcare workers to lower risk environments as this risked exposing their HIV status. In South Africa, this led to healthcare workers avoiding TB screening [22, 26]. In TB specialist hospitals, staff felt there was no point in screening as there were no safer designations available within the facility [26]. One study in KwaZulu-Natal, South Africa, conducted across three district hospitals purposefully selected because they had MDR-TB wards, found that occupational health nurses were unable to guarantee reassignment for healthcare workers with HIV. The hospital had made employees sign forms declaring that they understood the risks and chose to work in a high-risk environment [25]. This study also found that occupational health nurses lacked training specific to their role relative to IPC nurses [25]. Using open-ended structured questionnaires, this study found that the occupational health nurses felt they did not have the authority to implement changes, whilst IPC nurses felt they had the authority to implement changes that they thought appropriate to protect the healthcare workers. Despite recognising the value of integrating TBIPC and occupational health, this was not carried out as they were often run by separate departments [23]. Occupational health nurses also reported that the lack of a health and safety officer was a barrier to investigating safety issues. A government official from South Africa explained that due to limited resources, the health of patients was prioritized over that of healthcare workers [23]:

“…because there are not enough resources, they would rather channel resources to serving the public than those people assisting the public”

Shortages of funding and resources. Poor funding and insufficient resources were the theme by far most frequently mentioned across all studies. Healthcare workers cited poor infrastructure, such as a lack of isolation space [17,24], poor clinic layout [28], windows opening in the wrong direction [29], and being unable to maintain equipment such as extractor fans as barriers to implementing isolation or environmental measures [17, 19, 26, 27, 30]. Because of insufficient funding to hire more staff, overstretched healthcare workers viewed cough screening, isolation and patient education as additional, non-essential tasks [14, 17, 19, 22, 30, 31]. Some interviewees in a Nigerian study felt that this was compounded by the fact that TB services in their hospitals were free and hence did not generate revenue for the centre. As a result, managers would prioritise available funding to other areas of the hospital [18].

Meso-level barriers and facilitators.

Transition from policy to programme. Some facility managers in South Africa found it difficult to understand the written policy and hence felt ill-equipped to train their staff or clarify misconceptions [8]. A study conducted in two rural district hospitals in South Africa reported an absence of any formal policy within the health care facility, despite a national policy being available [32]. One of the healthcare workers from a study conducted in South Africa cited a contradiction between the Ideal Clinic Initiative and the National Core Standard [8]:

“…the Ideal Clinic says you must not have a separate TB room, that TB falls under chronic patients. The National Core Standard says you must have a TB cubicle…” Although the Ideal Clinic Initiative is aimed at improving the standard of care in primary health care facilities in general, it includes standards concerning TBIPC which are not harmonized with the National Core Standard. A lack of healthcare worker involvement in governance was identified as a barrier in implementation of policies. Interviewees in a South African study cited the example that human resource departments were often tasked with implementing protective and supportive measures to prevent the acquisition of occupational TB [23]. However, they often lacked the necessary clinical understanding to implement these programmes:

“There is no direct access to the decision makers around TB implementation policy in SA.”

Both studies from Romania and Tajikistan trained TBIPC managers to adapt TBIPC programmes to suit their facilities [13, 14]. The study in Tajikistan conducted a feedback session to evaluate the utility of such training. They reported an increased uptake of administrative controls, such as an increase in the organization of TBIPC activities within their facilities (from 37% before training to 73% after training), staff and patient education, and policies changes within their facility. The study in Romania reported a 77.7% use of their TBIPC template by participants who were TBIPC coordinators from individual facilities or counties. However, it is worth noting that only 18 of the 42 participants responded to the questionnaire, placing the results at risk of a responder bias.

Staff training. Healthcare workers in the Dominican Republic supported the use of health education programmes to improve adherence to TBIPC measures [27]. Various barriers were brought up regarding training. Two studies from South Africa reported that healthcare facilities provided no training at all [8, 22]. A study conducted in Ethiopia across four hospitals, including 326 healthcare workers, found that only 18.8% of respondents were trained in TBIPC. Studies in Ethiopia and South Africa found selective training of staff who worked in TB-specific roles, such as facility managers [32], TB nurses or managers [19, 30], while the Dominican Republic study found that staff were prioritized for training based on their educational attainments [27]. Prioritizing staff for TBIPC training seemed to promote an attitude that TBIPC is solely the responsibility of staff who receive training [30]. In the study conducted in Georgia, only 30% of 240 respondents in the National TB programme were able to correctly identify high risk TB groups [21].

Micro-level barriers and facilitators.

Shortage of respirators. The absence or shortage of N95 respirators was a commonly raised obstacle [8, 18, 19, 26, 30, 31]. This is especially detrimental to the prevention of nosocomial transmission among healthcare workers in low-resource settings where often, due to the failure of administrative and environmental protection measures, there is an over-reliance on the use of personal respiratory protection [26]. In Ethiopia, N95 respirators were reserved only for healthcare workers in contact with people with MDR-TB [19]. In Georgia, only 36% of healthcare workers from the National TB Programme reported frequent use of respirators when working with patients being investigated for or known to have active TB [21]. In Nigeria, 13.4% of DOTS centres within both primary and secondary health facilities reported to have N95 respirators available for staff use. However, on direct observation of hospital practices, the use of N95 respirators by staff was observed in less than 10% of centres.

A continued lack of respirators was found to lead to an indifference towards use, as healthcare workers in Mozambique reported growing accustomed to not wearing them [30]. Staff in the Dominican Republic felt undervalued, questioning why something as basic as respirators were not readily available [31]. The study conducted in Georgia through the National TB Programme found that the only reliable predictor of respirator use was their availability [21].

Lack of authority to implement TBIPC programme. Most guidelines recommend that a TBIPC manager is appointed within a facility to disseminate the healthcare facility’s policy and conduct surveillance on TBIPC implementation within the facility. There were facilities in South Africa and Ethiopia with absent [16, 19] plans and missing standard operating procedures [22]. In South Africa, some healthcare workers were unaware of their health care facility’s TBIPC policy and others were unfamiliar with its content [8, 33]. The document in Lesotho found that 22% of healthcare workers were unable to access a copy of the facility’s TBIPC plan, some reported a single copy kept in the office of the TBIPC manager [33]. In Nigeria, it was found that of 112 DOTS centres, only 21.4% had a TBIPC plan and only 58% had a designated TBIPC officer [18].

A study from South Africa suggested the TBIPC officer did not have the authority to implement the guidelines:

“Nurses do not wear N95 masks because they say they are uncomfortable. So what is a hospital manager supposed to do?”

[26]

This was also brought up as one of the broader challenges by facility level TBIPC managers in the Romanian study [13].

TBIPC administrators who visited wards and offered verbal encouragement to healthcare workers in Russia were viewed as supportive [34]. Similarly, visits from district officials in South Africa to reassure facility managers that their TBIPC programme was robust was a motivating factor for the staff and managers [8].

Work culture. The studies in Uganda, Russia and Mozambique found that poor adherence to TBIPC measures, if not rectified, becomes entrenched in the work culture [17, 30, 34].

“…we have worked here for years treating TB patients and none of us has ever got TB. Why the fuss now?”

[17] (Uganda)

Poor adherence was also found to be passed from a senior to junior level in a different study of healthcare worker students in Uganda [35]. 66% of health Science students in a South African study feared possible academic consequences if they went against their seniors by adhering to TBIPC measures [12].

A South African Study reported a sense of powerless to change the way things are done [26].

“This is such longstanding problems in the primary healthcare that even if you tell me it will change [by] December I will think it’s a big joke!’

[8]

In South Africa, feeling undervalued and unsupported were attributed to reasons such not receiving danger pay when working with DR-TB, being unable to claim compensation despite acquiring TB nosocomially [26], management failing to implement new safety regulations when colleagues contract TB and blaming the healthcare workers for negligence when they contract TB [8]. Healthcare workers in a study from the Dominican Republic felt that other health goals such as maternal and child health [27] were prioritised over TB, while healthcare workers in another study in South Africa felt that HIV was prioritized over TB [22].

Difficulty in educating and sensitizing patients. healthcare workers in Zambia and Botswana brought up patient cooperation as a barrier to implementing TBIPC [24]. A study in South Africa reported that patients would refuse surgical masks distributed by healthcare workers [8]. When nurses and patients originated from different backgrounds or cultures, they faced a communication barrier when attempting to educate patients on TBIPC [22].

Stigma. Out of concern for the impact a TB diagnosis may have on how the community perceives a patient, healthcare workers were found to selectively implement TBIPC measures. The study from Mozambique reported a regression in the practice of isolating TB patients.

“…more recently this practice [isolation] was considered discriminatory, he or she is a patient like any other patient and then we started to mix them with the others”

[30]

Another study in Uganda found that the reason healthcare workers did not screen for TB symptoms in the waiting area was because they felt that the questions were too sensitive and should be asked in private during the consultation. In patients where a diagnosis was suspected but not confirmed, healthcare workers were uncomfortable informing the patient [17].

In attempt to build a closer patient-healthcare provider relationship, healthcare workers in Mozambique were found to forego the use of respirators [30]. Studies from both Mozambique and the Dominican Republic reported that healthcare workers perceive masks as both a physical barrier, preventing effective provider-patient dialogue, and an emotional distancing mechanism, displaying a lack of empathy [30, 31].

The stigma surrounding TB and HIV also impacted the decisions healthcare workers made regarding their own health. Two studies from South Africa found that healthcare workers were uncomfortable with attending occupational health screening for TB or HIV for fear of their colleagues breaching confidentiality [16, 26], and of being redeployed to a low-risk working environment, inadvertently exposing their HIV status. By contrast, one study in Ethiopia reported 84.8% and 87.5% of healthcare workers were comfortable with requesting their HIV and TB status respectively [19].

Healthcare workers perceived risks towards others. healthcare workers in Russia and Mozambique were motivated to adhere to TBIPC measures to avoid putting their family members at risk of acquiring TB [30, 34], whilst healthcare workers from studies in South Africa and the Dominican Republic feared spreading TB within the facility to other patients [22, 27] and other hospital staff [27].

The two studies from the Dominican Republic found that a strong sense of duty of care felt by healthcare workers towards their patients manifested itself in two contrasting schools of thought. While some felt a moral obligation to adhere to TBIPC measures to protect their patients, whom they felt were powerless to protect themselves [27], others prioritised empathy and building patient rapport over wearing respirators. They justified their actions by taking other precautions, such as keeping a distance from patients when speaking to them [31].

Healthcare workers perceived risks towards themselves. A desensitization to the risks of acquiring nosocomial TB was common. The study from Russia found that healthcare workers perception of their risk seemed to diminish with time [34], while the two studies from the Dominican Republic found that healthcare workers developed of a sense of invincibility [27, 31]. Other participants from these studies believed that most healthcare workers had already contracted TB [31, 34] or, in the case of South Africa, MDR-TB [8] and exposure was inevitable, hence TBIPC would be futile. Some believed that divine intervention was protective [8, 31].

The study conducted in Mozambique cited that healthcare workers felt empowered by knowledge. They argued that knowledge allowed them to manage the risks by taking precautionary measures with TBIPC [30]. Similarly, one study argued that the under-reporting of TB cases would dangerously underestimate the extent of nosocomial transmission within a facility and hence reduce awareness amongst healthcare workers of their risk [23]. In three studies from South Africa, healthcare workers reported that witnessing fellow colleagues contract MDR- and extensively drug-resistant TB (XDR-TB) initially served as a motivating factor [8, 22, 32], but this was quickly attenuated when no changes were made to improve working conditions.

A study conducted in Georgia [21] based on the health belief model found that healthcare workers were more like to refuse treatment for latent TB infection if they worked in TB facilities. They rationalised that they would shortly reacquire latent TB infection on completion of treatment, and hence this short-lived benefit outweighed the inconvenience of being on treatment. The study also found that those who perceived latent TB infection to be more serious were more willing to receive treatment.