Gladys Kigozi

Accuracy of Tuberculosis Routine Data and Nurses' Views of the TB-HIV Information System in the Free State, South Africa

Christo Heunis, PhD, is an Associate Professor, Centre for Health Systems ResearchD and Research Associate, Centre for Health Systems Research & Development, University of the Free State, Bloemfontein. Gladys Kigozi, MSc, is a Junior Researcher and Doctoral Student, Centre for Health Systems Research & Development, University of the Free State, Bloemfontein. Michelle Engelbrecht, PhD, is a Senior Researcher, Centre for Health Systems Research&Development, University of the Free State, Bloemfontein. Yolisa Tsibolane, BA Cur, is a Senior Manager, TB Management Programme, Free State Department of Health, Bloemfontein. Sonja van der Merwe, B Soc Sc, is an Assistant Director, TB Programme Surveillance, Free State Department of Health, Bloemfontein. Seipati Motlhanke, BA Cur, is an Assistant Director, TB-HIV/AIDS Programme Integration, Free State Department of Health, Bloemfontein. Reliable data are a prerequisite for evidence-based decision making in health care policy (AbouZahr & Boerma, 2005). Accurate measurement is crucial in evaluating epidemic trends, as well as in planning and monitoring disease-specific service provision. On the basis of a systematic review of descriptive and comparative studies and previous reviews of health information technologies, Chaudhry et al. (2006) demonstrated the efficacy of information gathered using health information technologies, such as electronic health records, to improve both quality and efficiency of health care. Sound data are especially vital for the success of large-scale public sector health programs in developing countries where limited human and financial resources require their optimal use (Fraser et al., 2005). Lippeveld (in AbouZahr & Boerma, 2005) defined a health information system (HIS) as an “integrated effort to collect, process, report and use health information and knowledge to influence policy-making, programme action and research” (p. 579). HISs are especially important when responses need to be urgent, as in the case of epidemic diseases such as

TB/HIV-related training, knowledge and attitudes of community health workers in the Free State province, South Africa.

With its emphasis on task shifting and multi-trained and skilled outreach teams the primary healthcare (PHC) re-engineering strategy in South Africa depends on the training, knowledge and attitudes of community health workers (CHWs) to provide a variety of TB/HIV services. The aim of this exploratory research was to assess TB/ HIV-related training, knowledge and attitudes of CHWs. Interviews were conducted with 206 CHWs at 28 clinics in 1 urban and 2 rural sub-districts in the Free State province. Descriptive and bivariate analyses were performed using chi-square, Kruskal–Wallis (H) and Mann–Whitney (U) tests for non-parametric data. More than half (54.9%) had not received basic training in HIV counselling and testing; almost one-third (31.1%) had not received basic training in TB/directly observed treatment (DOT) support. Furthermore, most CHWs had not received any follow-up training in HIV counselling and testing and in TB/DOT support. Significant associations (0.01 < p < 0.05) between the types of CHWs and their sub-district location, and their TB/HIV-related training, knowledge and attitudes were observed. In respect of the TB/HIV knowledge items assessed, a large majority (>95%) were knowledgeable, with only a few being ignorant about important facts related to TB/HIV. Lay counsellors were significantly more knowledgeable about TB/HIV than TB/DOT supporters and other CHWs were. Most CHWs disagreed with stigmatising statements about people with TB/HIV. The sub-district location of CHWs was significantly associated with their attitudes towards people with TB/HIV. CHWs in the two rural sub-districts were more likely to agree with stigmatising statements. In the context of PHC re-engineering, this exploratory research suggests that CHW TB/HIV training, knowledge and attitudes can and need to be improved if integrated TB/HIV services are to be successfully task-shifted to them in line with policy recommendations.

Voices from the frontline: barriers and strategies to improve tuberculosis infection control in primary health care facilities in South Africa

BackgroundTuberculosis (TB) infection control at primary healthcare (PHC) level remains problematic, especially in South Africa. Improvements are significantly dependent on healthcare workers’ (HCWs) behaviours, underwriting an urgent need for behaviour change. This study sought to 1) identify factors influencing TB infection control behaviour at PHC level within a high TB burden district and 2) in a participatory manner elicit recommendations from HCWs for improved TB infection control.MethodA qualitative case study was employed. TB nurses and facility managers in the Mangaung Metropolitan District, South Africa, participated in five focus group and nominal group discussions. Data was thematically analysed.ResultsUtilising the Information Motivation and Behaviour (IMB) Model, major barriers to TB infection control information included poor training and conflicting policy guidelines. Low levels of motivation were observed among participants, linked to feelings of powerlessness, negative attitudes of HCWs, poor district health support, and general health system challenges. With a few exceptions, most behaviours necessary to achieve TB risk-reduction, were generally regarded as easy to accomplish.ConclusionsStrategies for improved TB infection control included: training for comprehensive TB infection control for all HCWs; clarity on TB infection control policy guidelines; improved patient education and awareness of TB infection control measures; emphasis on the active role HCWs can play in infection control as change agents; improved social support; practical, hands-on training or role playing to improve behavioural skills; and the destigmatisation of TB/HIV among HCWs and patients.

Fighting stigma, promoting care: a study on the use of occupationally-based HIV services in the Free State Province of South Africa

ABSTRACT Fear of breaches in confidentiality and HIV-related stigma in the workplace have been shown to be primary concerns and potential barriers to uptake of HIV testing and treatment by health care workers (HCWs) at the Occupational Health Unit (OHU). In a context of human resource shortages, it is essential to investigate potential ways of reducing HIV-related stigma and promoting confidentially in the workplace. Using Structural Equation Modelling (SEM), baseline data of the “HIV and TB Stigma among Health Care Workers Study” (HaTSaH Study) for 818 respondents has been analysed to investigate (1) whether bottom-up stigma-reduction activities already occur; and (2) whether such grassroots actions can reduce the fear of breaches in confidentiality and HIV-related stigma – and thus indirectly stimulate the uptake of HIV services at the OHU. Results (aim 1) illustrate the occurrence of existing activities aiming to reduce HIV-related stigma, such as HCWs giving extra support to HIV positive co-workers and educating co-workers who stigmatise HIV. Furthermore, results of the SEM analysis (aim 2) show that the Fighting-stigma factor has a significant negative effect on HIV-related stigma and a significant positive effect on Confidentiality. Results show that the latent fighting-stigma factor has a significant positive total indirect effect on the use of HIV testing, CD4 cell count and HIV-treatment at the OHU. The findings reveal that the fear of breaches in confidentiality and HIV-related stigma can be potential barriers to the uptake of occupationally-based HIV services. However, results also show that a bottom-up climate of fighting HIV-related stigma can stimulate confidentiality in the workplace and diminish the negative effect of HIV-related stigma – resulting in an overall positive effect on the reported willingness to access occupationally-based HIV services.

Factors influencing treatment default among tuberculosis patients in a high burden province of South Africa

OBJECTIVE To determine and describe the factors influencing treatment default of tuberculosis (TB) patients in the Free State Province of South Africa. METHODS A retrospective records review of pulmonary TB cases captured in the ETR.Net electronic TB register between 2003 and 2012 was performed. Subjects were >15 years of age and had a recorded pre-treatment smear result. The demographic and clinical characteristics of defaulters were described. Multivariate logistic regression analysis was used to determine factors associated with treatment default. The odds ratios (OR) together with their corresponding 95% confidence intervals (CI) were estimated. Statistical significance was considered at 0.05. RESULTS A total of 7980 out of 110 349 (7.2%) cases defaulted treatment. Significantly higher proportions of cases were male (8.3% vs. female: 5.8%; p<0.001), <25 years old (9.1% vs. 25-34 years: 8.7%; 35-44 years: 7.0%; 45-54 years: 5.2%; 55-64 years: 4.4%; >64 years: 3.9%; p<0.001), undergoing TB retreatment (11.0% vs. new cases: 6.3%; p<0.001), had a negative pre-treatment sputum smear result (7.8% vs. positive smear results: 7.1%; p<0.001), were in the first 2 months of treatment (95.5% vs. >2 months: 4.8%; p<0.001), and had unknown HIV status (7.8% vs. HIV-positive: 7.0% and HIV-negative: 5.7%; p<0.001). After controlling for potential confounders, multivariate analysis revealed a two-fold increased risk of defaulting treatment when being retreated compared to being treated for the first time for TB (adjusted OR (AOR) 2.0, 95% CI 1.85-2.25). Female cases were 40% less likely to default treatment compared to their male counterparts (AOR 0.6, 95% CI 0.51-0.71). Treatment default was less likely among cases >24 years old compared to younger cases (25-34 years: AOR 0.8, 95% CI 0.77-0.87; 35-44 years: AOR 0.6, 95% CI 0.50-0.64; 45-54 years: AOR 0.4, 95% CI 0.32-0.49; 55-64 years: AOR 0.3, 95% CI 0.21-0.43; >64 years: AOR 0.3, 95% CI 0.19-0.35). Co-infected cases receiving antiretroviral therapy (ART) were 40% less likely to default TB treatment relative to those whose ART status was unknown (AOR 0.6, 95% CI 0.46-0.57). CONCLUSIONS Salient factors influence TB patient treatment default in the Free State Province. Therefore, the strengthening of clinical and programmatic interventions for patients at high risk of treatment default is recommended. In particular, ART provision to co-infected cases facilitates TB treatment adherence and outcomes.

Towards a health-enabling working environment - developing and testing interventions to decrease HIV and TB stigma among healthcare workers in the Free State, South Africa: study protocol for a randomised controlled trial

BackgroundOccupational exposure to tuberculosis (TB) constitutes a major health risk for healthcare workers (HCWs). The HIV epidemic equally affects the workforce because of the mutually reinforcing epidemiology of HIV and TB. Stigmas associated with HIV and TB have become so intricately entangled that they stop some HCWs from seeking care in a context where serious shortages in human resources for health besiege public health facilities. It is thus imperative to research, as well as attempt to tackle, HIV and TB stigma among HCWs. But little has been done internationally—and nationally, only our own exploratory studies. Our project aims to address this by (1) scientifically assessing the extent and sources of HIV and TB-related stigma among HCWs and (2) developing and testing evidence-based, stigma-reduction interventions in public hospitals in the Free State Province of South Africa.Methods/designThe research follows a stratified cluster randomised controlled trial (RCT) design. Pre intervention, a self-administered questionnaire with the pilot study’s validated stigma scales is used to measure stigma and other key variables among randomly selected HCWs in eight hospitals—stratified by size and district and then randomly allocated to four intervention and four control sites. Interventions comprise HIV- and TB-stigma reduction activities—mainly Social and Behavioural Change Communication (SBCC) interventions—at three social-ecology levels (individual, community, and socio-structural). An outside assessor will appraise the trial mid-way through implementation. Post intervention, all baseline respondents will be followed up to complete the baseline questionnaire with additional items on interventions. Qualitative data will be collected to better understand HIV and TB stigma and explore if, and how, interventions impact stigma levels in the workplace.DiscussionThe study regards as HCWs all staff, working in all different types of jobs, at all levels in the hospitals. Thus, the research addresses HIV and TB stigma across the whole workforce and the entire workplace. In doing so it will (1) generate essential information on stigma among HCWs and (2) implement stigma-reduction interventions that are innovative yet replicable, and potentially beneficial in addressing a pernicious human-rights-based issue.Trial registrationSouth African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.

Tuberculosis prevention knowledge, attitudes, and practices of primary health care nurses: Nurses’ TB prevention knowledge, attitudes and practices

AIM Tuberculosis (TB) continues to challenge global health systems, especially in South Africa. Nurses are especially vulnerable to TB exposure, because of their prolonged front-line contact with infected patients-especially in primary health care (PHC) clinics. Their infection control practices, influenced by key factors such as knowledge and attitudes towards TB prevention, become an important consideration. The aim of the study was to (1) describe the TB prevention knowledge, attitudes, and practices of PHC nurses in a South African district and (2) explore moderating factors on TB prevention practices. METHODS A cross-sectional survey was undertaken at all 41 PHC facilities in Mangaung Metropolitan district, Free State province, South Africa, using self-administered questionnaires. Captured data were analysed to yield descriptive and multivariate statistics. RESULTS Results suggest several instances of inadequate TB prevention knowledge, attitudes, and practices. Good TB practice was predicted by TB attitudes and knowledge, and the relationship between TB prevention knowledge and practices was not moderated by training, attitudes, or nurse category. CONCLUSION Results echo previous indications that nurses often do not exhibit the desired knowledge, attitudes, and practices required to adequately protect themselves and others against TB and suggest further exploration towards understanding the influences on TB prevention practice among nurses.

State and non-state mental health service collaboration in a South African district: a mixed methods study

The Life Esidimeni tragedy in South Africa showed that, despite significant global gains in recognizing the salience of integrated public mental health care during the past decade, crucial gaps remain. State and non-state mental health service collaboration is a recognized strategy to increase access to care and optimal use of community resources, but little evidence exist about how it unfolds in low- to middle-income countries. South Africas Mental Health Policy Framework and Strategic Plan 2013-20 (MHPF) underlines the importance of collaborative public mental health care, though it is unclear how and to what extent this happens. The aim of the study was to explore the extent and nature of state and non-state mental health service collaboration in the Mangaung Metropolitan District, Free State, South Africa. The research involved an equal status, sequential mixed methods design, comprised of social network analysis (SNA) and semi-structured interviews. SNA-structured interviews were conducted with collaborating state and non-state mental health service providers. Semi-structured interviews were conducted with collaborating partners and key stake holders. Descriptive network analyses of the SNA data were performed with Gephi, and thematic analysis of the semi-structured interview data were performed in NVivo. SNA results suggested a fragmented, hospital centric network, with low average density and clustering, and high authority and influence of a specialist psychiatric hospital. Several different types of collaborative interactions emerged, of which housing and treatment adherence a key point of collaboration. Proportional interactions between state and non-state services were low. Qualitative data expanded on these findings, highlighting the range of available mental health services, and pointed to power dynamics as an important consideration in the mental health service network. The fostering of a well-integrated system of care as proposed in the MHPF requires inter-institutional arrangements that include both clinical and social facets of care, and improvements in local governance.

Tuberculosis infection control practices in a high-burden metro in South Africa: A perpetual bane for efficient primary health care service delivery

Background Tuberculosis (TB) prevention, including infection control, is a key element in the strategy to end the global TB epidemic. While effective infection control requires all health system components to function well, this is an area that has not received sufficient attention in South Africa despite the availability of policy and guidelines. Aim To describe the state of implementation of TB infection control measures in a high-burden metro in South Africa. Setting The research was undertaken in a high TB- and HIV-burdened metropolitan area of South Africa. More specifically, the study sites were primary health care facilities (PHC), that among other services also diagnosed TB. Methods A cross-sectional survey, focusing on the World Health Organization levels of infection control, which included structured interviews with nurses providing TB diagnosis and treatment services as well as observations, at all 41 PHC facilities in a high TB-burdened and HIV-burdened metro of South Africa. Results Tuberculosis infection control was poorly implemented, with few facilities scoring 80% and above on compliance with infection control measures. Facility controls: 26 facilities (63.4%) had an infection control committee and 12 (29.3%) had a written infection control plan. Administrative controls: 26 facilities (63.4%) reported separating coughing and non-coughing patients, while observations revealed that only 11 facilities (26.8%) had separate waiting areas for (presumptive) TB patients. Environmental controls: most facilities used open windows for ventilation (n = 30; 73.2%); however, on the day of the visit, only 12 facilities (30.3%) had open windows in consulting rooms. Personal protective equipment: 9 facilities (22%) did not have any disposable respirators in stock and only 9 respondents (22%) had undergone fit testing. The most frequently reported barrier to implementing good TB infection control practices was lack of equipment (n = 22; 40%) such as masks and disposable respirators, as well as the structure or layout of the PHC facilities. The main recommendation to improve TB infection control was education for patients and health care workers (n = 18; 33.3%). Conclusion All levels of the health care system should be engaged to address TB prevention and infection control in PHC facilities. Improved infection control will address the nosocomial spread of TB in health facilities and keep health care workers and patients safe from infection.

Stigma as a barrier to the use of occupational health units for tuberculosis services in South Africa

SETTING Tuberculosis (TB) is the leading cause of death in South Africa, and health care workers (HCWs) are disproportionally affected. The resulting absenteeism strains the already overburdened health system. Although hospital occupational health care units (OHUs) are cost-effective and of crucial importance in tackling the TB epidemic, the fear of being stigmatised by other colleagues might lead HCWs to avoid using OHUs. OBJECTIVE To investigate whether the perception of TB stigma among colleagues has a negative effect on the willingness to use OHUs for TB services. DESIGN In the Free State Province, South Africa, a representative sample of 804 HCWs from six hospitals were surveyed on workplace stigma as a predictor for the use of OHUs for TB services. Applying structural equation modelling, we also controlled for exogenous variables. RESULTS There was a significant negative relationship between the perception of stigmatising attitudes and behaviours among co-workers and the use of OHUs for TB screening (β -0.21, P = 0.000), treatment (β -0.16, P = 0.001) and isoniazid preventive therapy (β -0.17, P = 0.000). CONCLUSION The negative effect of TB stigma on OHU use among HCWs can impact upon their health and increase hospital costs. This needs to be addressed by interventions combating TB stigma among HCWs in the workplace.