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 keep patients with TB. In healthcare facilities, the key areas of risk of infection include settings where people with undiagnosed TB, including Multi Drug Resistant-TB (MDR-TB) congregate such as outpatient waiting areas, pathology waiting areas, radiology departments, and pharmacies, or wards where staff keep untreated patients awaiting investigation results. With high levels of TB in the community, illness 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 is to explore rural health workers’ perspectives of barriers and facilitators to effective TBIC practices in rural health facilities in Madang Province, PNG. The conceptual framework was adopted from World Health Organisation (WHO) policy on TBIC in healthcare facilities, congregate settings, and households as a benchmark to guide the study. Qualitative individual and group interviews (averaging 30 minutes) and field notes were conducted with twelve key informants consisting of twelve 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, PNG. They include issues related to inadequacies in the healthcare systems, access to personal protective equipment (PPE), separation procedures, sputum status, monitoring and control, training, and health services are TB hotspots.

Conclusions: The study found evidence that health system factors do impact on the capacity to implement TBIC.  Further, important finding beyond TBIC such as socio cultural factors have an important influence on the way TBIC is implemented. The results of this study are useful for clinicians, health administrators and policy makers 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 cannot automatically generalise the findings 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.