Healthcare workers’ perspectives on barriers to and facilitators of the implementation of national tuberculosis programme guidelines for management of pre-treatment loss to follow-up in Ekurhuleni district, South Africa

Abstract

Introduction: Tuberculosis (TB) control in South Africa is sub-optimal despite the comprehensive National TB Programme. One factor contributing to poor control is the pool of pre-treatment lost to follow up (LTFU) patients. While a plan for managing these LTFU patients is laid out in the Tracing and Retention in Care Standard Operating Procedure (TRIC SOP), pre-treatment LTFU rates remain high. This study aimed to explore healthcare workers’ perspectives on barriers to and facilitators of the implementation of this guideline in clinics in the Ekurhuleni District. Furthermore, the differences and similarities between under-performing and well-performing clinics were explored. Methods: A qualitative study was conducted at three study sites. One was well-performing and two were under-performing clinics with regard to pre-treatment LTFU in Ekurhuleni District. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. In-depth interviews were conducted. Fourteen healthcare workers involved in implementation of the TRIC SOP were interviewed. After transcription and de-identification of data, coding was done using MAXQDA software. Both inductive and deductive coding were used, and framework analysis was conducted. The themes were grouped according to the CFIR domains. Results: The healthcare workers experienced barriers relating to the guideline itself, poor accessibility of the facilities, patient-related socio-economic challenges, safety issues as well as internal facility-related factors. In the domain of Intervention characteristics (aspects of the intervention itself that could affect its implementation), the guidelines were viewed as not being comprehensive enough. In the Outer setting (social, economic, political and physical environment in which the clinics function), poor clinic accessibility, poor patient socio-economic circumstances, stigma and lack of safety were barriers . In the Inner setting (characteristics of the clinics implementing the interventions) barriers included staff constraints and lack of transport, while use of electronic registers and devices were facilitators in this domain. Under the domain of Individuals involved (characteristics of 0703998N Tasanya Nomaliso Chinsamy Abstract people involved in implementation of the intervention), lack of adequate training and a lack of acknowledgement of healthcare workers’ efforts were barriers to healthcare workers being able to implement the interventions effectively. Under the domain of Implementation process (the steps of planning, engaging with relevant stakeholders, executing the interventions, reflection and evaluation), a barrier that emerged was the lack of involvement of facility-level healthcare workers in guideline development and implementation planning. The facilitating factors experienced by the healthcare workers included Outer Setting factors such as support from partner organisations and the HIV, AIDS, STI and TB (HAST) Team and Inner Setting factors such as the use of electronic data systems and use of electronic devices by community health workers. Common barriers experienced across the facilities were challenges caused by patient socio economic circumstances, stigma and the resulting negative attitude to healthcare workers, as well as safety concerns. Both well-performing and under-performing clinics had challenges with lack of transport, staff and training. Common facilitators across all the clinics were external support from partner organisations and the HAST team, understanding patients’ counselling needs and the use of electronic data systems. The differences that emerged were that the well-performing clinic was more easily accessible and had additional resources including generators and electronic devices such as smartphones for use by community health workers. Conclusion: The healthcare workers perceptions of the barriers faced in returning LTFU patients to care included barriers such as patient-related and socio-economic factors which may be beyond the immediate control of the healthcare system. However, some areas of improvement that are within the control of the facilities implementing the TRIC SOP were identified. The study has also suggested facilitators that can be maximized upon to reduce pre-treatment LTFU.