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 treat patients with TB. In healthcare facilities, the key areas of risk of infection include settings where people with undiagnosed TB, including multidrug-resistant TB, congregate, such as outpatient waiting areas, pathology waiting areas, radiology departments and pharmacies, and wards where untreated patients await investigation results. With high levels of TB in the community, and symptoms 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 was to explore rural health workers' perspectives of barriers and facilitators to effective TBIC practices in rural health facilities in Madang Province, Papua New Guinea (PNG). The conceptual framework was adopted from WHO policy on TBIC in healthcare facilities, congregate settings and households as a benchmark to guide the study. Qualitative individual and group interviews (with an average time of 30 minutes) and field notes were conducted with 12 key informants comprising 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. They include issues related to inadequacies in the healthcare systems, access to personal protective equipment, separation procedures, sputum status, monitoring and control, training, and health services as TB 'hot spots'. CONCLUSIONS The study found evidence that health system factors do impact on the capacity to implement TBIC. Further, factors beyond TBIC such as sociocultural factors have an important influence on the way TBIC is implemented. The results of this study are useful for clinicians, health administrators and policymakers 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 the findings cannot automatically be generalised 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.