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Provider perspectives of the introduction and implementation of care for drug-resistant tuberculosis patients in district-level facilities in South Africa: a qualitative study.

ABSTRACT: OBJECTIVES:Drug-resistant tuberculosis (DR-TB) is a growing concern in many low-income and middle-income countries. Facing rising numbers of DR-TB patients, South Africa (SA) introduced a decentralised model of care for DR-TB in 2011. We aimed to document the introduction and implementation of the new models of care for patients with DR-TB in four provinces (Northern Cape, KwaZulu-Natal, Eastern Cape and Gauteng) in 2015 using mixed methods, including interviews, register reviews and clinical audits. This paper reports on the qualitative component of the study. DESIGN:This is a qualitative interview study. SETTING:Data were collected in 22 decentralised DR-TB sites, primary healthcare facilities and district hospitals and one provincial central DR-TB hospital. PARTICIPANTS:58 healthcare workers (HCWs), facility staff and provincial and district TB coordinators were included in qualitative interviews. RESULTS:HCWs felt that the introduction of DR-TB care in their facility came with little warning or engagement, creating fear and anxiety. They expressed a need for support from the district and province to guide them through the changes but this support was often lacking. In addition, many respondents expressed feeling isolated and not supported by other healthcare providers which they feel impacts on the quality of the care they provide. CONCLUSION:Introduction of a new service such as DR-TB care can be difficult and does not always result in the intended outcomes. Improved engagement with front-line providers and addressing the fear and anxiety that may be raised by changes in daily practices should be addressed to ensure successful implementation and prevent negative consequences that can hamper quality of care for patients. Attention should be paid to how the decentralised DR-TB unit can be supported by district management and other healthcare providers.

SUBMITTER: Vanleeuw L

PROVIDER: S-EPMC7044892 | biostudies-literature | 2020 Feb

REPOSITORIES: biostudies-literature

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Provider perspectives of the introduction and implementation of care for drug-resistant tuberculosis patients in district-level facilities in South Africa: a qualitative study.

Vanleeuw Lieve L Atkins Salla S Zembe-Mkabile Wanga W Loveday Marian M

BMJ open 20200203 2

<h4>Objectives</h4>Drug-resistant tuberculosis (DR-TB) is a growing concern in many low-income and middle-income countries. Facing rising numbers of DR-TB patients, South Africa (SA) introduced a decentralised model of care for DR-TB in 2011. We aimed to document the introduction and implementation of the new models of care for patients with DR-TB in four provinces (Northern Cape, KwaZulu-Natal, Eastern Cape and Gauteng) in 2015 using mixed methods, including interviews, register reviews and cli ...[more]

PMID: 32019816

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Project description:BACKGROUND:Healthcare providers' skills and attitudes are both barriers and facilitators of contraceptive uptake. In South Africa, migration of healthcare workers and the demands of the HIV epidemic have also contributed to inequitable access to sexual and reproductive health (SRH) care. Yet, the country has committed to achieving universal access to SRH services. We explored healthcare provider's opinions and attitudes on provision of contraceptive services in public facilities, their personal use of methods, and their thoughts on the recent integration of new contraceptive methods in their facilities. METHODS:We conducted a phenomenological, qualitative study in 2017 at an outpatient, public HIV treatment clinic and two primary healthcare clinics (PHCs) in Johannesburg, South Africa. We purposively selected providers who had worked at the facilities for at least six months and were seeing patients for HIV or SRH services. Trained study staff conducted semi-structured interviews. We conducted descriptive analyses for quantitative data, and used an iterative, thematic analysis approach for open-ended responses. RESULTS:We interviewed 14 healthcare providers (HIV clinic - 5; PHCs - 9). One respondent was a man; all were nurses. All respondents reported having ever personally used a contraceptive method; half (7/14) were currently using a method. Responses on service provision were conflicting. Respondents felt that their clinics currently met the contraceptive needs of their female patients through on-site services or referrals. However, they noted that staff shortages, lack of training, and a limited contraceptive offering meant that women did not always get the counselling or method they wanted. Respondents noted that the 'best' contraceptive methods for women were those that fit with a woman's lifestyle and medical needs; however, providers also felt strongly that injectables were best for all women. Recent introduction of the implant at one PHC and injectable contraceptives at the HIV clinic was not overly challenging, though there were concerns about staffing and demand creation for the new methods. CONCLUSIONS:Respondents' conflicting responses revealed challenges with current service delivery, particularly contraceptive counselling. Addressing staff workloads and providing refresher training on contraception would contribute to increased contraceptive service capacity and quality in this setting.

Project description:BackgroundTranslating health policy into effective implementation is a core priority for responding effectively to the tuberculosis (TB) crisis. The national TB Recovery Plan was developed in response to the negative impact that the COVID-19 pandemic had on TB care in South Africa. We aimed to explore the implementation of the TB Recovery Plan and develop recommendations for strengthening accountability for policy implementation for this and future TB policies.MethodsWe interviewed 24 participants working on or impacted by TB policy implementation in South Africa. This included perspectives from national, provincial, and local health department representatives, civil society, and community representatives. In-depth interviews were conducted in English and isiXhosa and we drew on reflexive thematic methods for analysis.ResultsParticipants felt that there was potential for COVID-19 innovations and urgency to influence TB policy development and implementation, including the use of data dashboards. Implementation of the TB Recovery Plan predominantly used a top-down approach to implementation (cascading from national policy to local implementers) but experienced bottlenecks at provincial level. Recommendations for closing the TB policy-implementation gap included using phased implementation and enhancing provincial-level accountability. Civil society organisations were concerned about the lack of provincial implementation data which impeded advocacy for improved accountability and inadequate resourcing for implementation. Community health workers were viewed as key to implementation but were not engaged in the policy development process and were often not aware of new TB policies. At local level, there were also opportunities to strengthen community engagement in policy implementation including through community-led monitoring. Participants recommended broader multi-stakeholder engagement that includes community and community health worker representatives in the development and implementation phases of new TB policies.ConclusionsCommunities affected by TB, with the support of civil society organisations, could play a bigger role in monitoring policy implementation at local level and need to be capacitated to do this. This bottom-up approach could complement existing top-down strategies and contribute to greater accountability for TB policy implementation.Supplementary informationThe online version contains supplementary material available at 10.1186/s44263-024-00077-y.

Project description:South Africa has implemented a community-based HIV programme (CBHP) in its primary healthcare (PHC) re-engineering strategy that aims to improve public healthcare delivery. This CBHP is delivered by ward-based outreach teams (WBOTs); provision of community HIV services comprises an important component of this programme. We conducted an exploratory study to determine the facilitators and barriers to successful implementation of this CBHP in rural Mopani District, South Africa. Focus group discussions were conducted with the community health workers (CHWs) and PHC nurses; participant interviews were conducted with community members who access these health services, community leaders, and social workers. We conducted a thematic content analysis and based on the key themes reported, we identified the Consolidated Framework for Implementation Research, consisting of five domains, as the most appropriate model to interpret our findings. First, in terms of intervention characteristics, community members generally valued the HIV services provided, but the variable needs impacted on programme implementation. Outer setting challenges include inability to meet the need of patients as a result of stigma, non-disclosure of HIV status and social factors. In terms of the inner setting, CHWs were grateful for the equipment and training received but expressed the need for better support of management and the provision of additional resources. With regard to characteristics of the implementers, the CHWs expressed the desire for further training despite reporting having sufficient knowledge to conduct their HIV work. Finally, in terms of the implementation process, the importance of relationship building between CHWs and community members was emphasised. In conclusion, these data underline the positive receipt and potential of the CBHP in this rural district and identify areas to further strengthen the programme. The success and sustainability of the CBHP requires ongoing commitment of resources, training, supervision, and organisational support in order to operate effectively and efficiently.

Project description:BackgroundEffective pharmaceutical inventory management is essential for optimizing healthcare outcomes and supply chain performance. However, challenges such as stockouts, overstocking, and wastage can hinder this process. This study examines the interrelationships between overstocking, stockouts, and wastage in eight healthcare facilities in Northern KwaZulu-Natal, South Africa. It also explores the extent of these challenges and investigates the use of medicine redistribution as a strategy to address inventory management issues.MethodsA retrospective quantitative analysis was conducted using pharmacy inventory records from public healthcare facilities. Eight facilities, including hospitals and a community healthcare center in King Cetshwayo District, were purposively sampled. Linear regression analysis was used to examine the association between medicine redistribution as the outcome and the predictors - stockouts, overstocking, and wastage. Pearson's correlation was utilized to evaluate associations between the predictors. Descriptive statistics were employed to quantify the levels and extent of overstocking, stockouts, and wastage related to expiry.ResultsThe study included eight healthcare facilities with pharmacy warehouses managed by pharmacists. A total of 392 medicines were analyzed (49 per facility). Stockouts affected 85.6% of medicines, while overstocking and expiry-related wastage impacted 50.6% and 15.2% of medicines, respectively. The most common stock-out medicines were salbutamol 200mcg inhalant (4.0%), paracetamol 500 mg tablets (3.5%), and azithromycin 500 mg tablets (3.3%). Overstocking, stock with short-dated expiry, and expired medicines explained 68% of redistribution transactions to other facilities (r² = 0.68). A moderate, statistically significant correlation was observed between overstocking and expiry-related wastage (r² = 0.47, p-value = 0.020). Stockouts had a weak correlation with redistribution, accounting for only 4.5% (p-value < 0.01). A weak correlation was found between stockouts and overstocking (r = 0.10), as well as between stockouts and expired medicines (r = -0.20).ConclusionThis study highlights significant challenges in inventory management, particularly regarding stockouts, overstocking, and expiry-related wastage in the evaluated healthcare facilities. Medicine redistribution emerged as a viable strategy to address these challenges. Improving inventory management practices and implementing targeted interventions are crucial for optimizing pharmaceutical supply chain performance and enhancing healthcare delivery outcomes in this setting.

Project description:BackgroundInadequate neonatal facilities in rural areas is one of the challenges affecting the management of preterm infants. In low income countries with limited resources, over 90% of preterm babies die within few days of life.PurposeThe purpose of this study was to describe the challenges encountered by midwives when providing care to preterm infants at resource limited health facilities in Limpopo Province, South Africa.MethodsQualitative research approach, using exploratory and descriptive design was used. Non-probability purposive sampling was used to select twenty three midwives who had an experience of two or more years in maternity. Data was collected using unstructured individual interviews, which were voice recorded and transcribed and data analysed qualitatively through the open-coding method.FindingsRevealed one theme, preterm condition and expected care; with sub-themes namely; perceived causes of preterm complications and deaths, preterm babies experience several difficulties which need specialised care, the need for constant individualised care and monitoring of preterm infants by midwives, functional relevant equipment needed for care of preterm infants, a need for constant training for midwives regarding care of preterm infants, and importance for a proper structure to house preterm infants which will lead to quality care provision.ConclusionPreterm babies need simple essential care such as warmth, feeding support, safe oxygen use and prevention of infection. Lack of adequate resources and limited skills from midwives could contribute to morbidity and mortality. Health facility managers need to create opportunities for basic and advanced preterm care to equip the skills of midwives by sending them to special trainings such as Limpopo Initiative Neonatal Care (LINC), Helping Baby Breath (HHB) and Neonatal Intensive Care Unit (NICU). Operational managers should be involved in the identification, procurement and supply of required equipment. Continuous health education should be provided on the mothers about kangaroo mother care (KMC) and measures to prevent infections in the neonatal unit.

Project description:BackgroundA pragmatic three-tiered approach to monitor the world's largest antiretroviral treatment (ART) programme was adopted by the South African National Department of Health in 2010. With the rapid expansion of the programme, the limitations of the paper-based register (tier 1) were the catalyst for implementation of the stand-alone electronic register (tier 2), which offers simple digitisation of the paper-based register. This article engages with theory on implementation to identify and contextualise enabling and constraining factors for implementation of the electronic register, to describe experiences and use of the register, and to make recommendations for implementation in similar settings where standardisation of ART monitoring and evaluation has not been achieved.MethodsWe conducted a qualitative evaluation of the roll-out of the register. This comprised twenty in-depth interviews with a diverse sample of stakeholders at facility, sub-district, and district levels of the health system. Facility-level participants were selected across five sub-districts, including one facility per sub-district. Responses were coded and analysed using a thematic approach. An implementation science framework guided interpretation of the data.Results & discussionWe identified the following seven themes: 1) ease of implementation, 2) perceived value of an electronic M&E system, 3) importance of stakeholder engagement, 4) influence of a data champion, 5) operational and logistical factors, 6) workload and role clarity, and 7) importance of integrating the electronic register with routine facility monitoring and evaluation. Interpreting our findings through an implementation theory enabled us to construct the scaffolding for implementation across the five facility-settings. This approach illustrated that implementation was not a linear process but occurred at two nodes: at the adoption of the register for roll-out, and at implementation at facility-level.ConclusionIn this study we found that relative advantage of an intervention and stakeholder engagement are critical to implementation. We suggest that without these aspects of implementation, formative and summative outcomes of implementation at both the adoption and coalface stages of implementation would be negatively affected.

Project description:Progress has been made to improve access to family planning services and contraceptive methods, yet many women still struggle to access contraception, increasing their risk for unintended pregnancy. This is also true for South Africa, where over fifty per cent of pregnancies are reported as unintended, even though contraception is freely available. There is also stagnation in the fertility rate indicators and contraceptive use data, indicating that there may be challenges to accessing contraception. This paper explores the evaluation of access to contraception from community and health care provider perspectives. This qualitative study explored factors affecting the uptake and use of contraception through focus group discussions (n = 14), in-depth interviews (n = 8), and drawings. Participants included male and female community members (n = 103) between 15 and 49 years of age, health care providers (n = 16), and key stakeholder informants (n = 8), with a total number of 127 participants. Thematic content analysis was used to explore the data using NVivo 10. Emergent themes were elucidated and thematically categorised. The results were categorised according to a priori access components. Overall, the results showed that the greatest obstacle to accessing contraception was the accommodation component. This included the effects of integrated care, long waiting times, and limited operational hours-all of which contributed to the discontinuation of contraception. Community members reported being satisfied with the accessibility and affordability components but less satisfied with the availability of trained providers and a variety of contraceptive methods. The accessibility and affordability themes also revealed the important role that individual agency and choice in service provider plays in accessing contraception. Data from the illustrations showed that adolescent males experienced the most geographic barriers. This study illustrated the importance of examining access as a holistic concept and to assess each component's influence on contraceptive uptake and use.

Project description:BackgroundThe past decade has seen substantial global reduction in malaria morbidity and mortality due to increased international funding and decisive steps by the international malaria community to fight malaria. South Africa has been declared ready to institute malaria elimination. However, research on the factors that would affect this policy implementation is inadequate.ObjectiveTo investigate the stakeholders' understanding of the malaria elimination policy in South Africa, including their perceived barriers and facilitators to effective policy implementation.MethodsThe study followed a constructivist epistemological approach which manifests in phenomenological study design. Twelve purposively selected key informants from malaria researchers, provincial and national malaria programmes were interviewed using semi-structured interviews. Interview questions elicited interviewees' knowledge of the policy and its achievability, including any perceived barriers and facilitating factors to effective implementation. The hybrid approach was used to perform thematic data analysis.ResultsThe dominant view was that malaria remains a problem in South Africa, exacerbated by staff attitudes and poor capacity, lack of resources, lack of new effective intervention tools, lack of intra- and inter-departmental collaboration, poor cross-border collaboration and weak stakeholder collaboration. Informants were concerned about the target year (2018) for elimination, and about the process followed in developing the policy, including the perceived malaria epidemiology shortfalls, regulatory issues and political context of the policy.ConclusionsAchievability of malaria elimination remains a subject of intense debate for a variety of reasons. These include the sporadic nature of malaria resurgence, raising questions about the contributions of malaria control interventions and climate to the transmission trends in South Africa. The shortage of resources, inadequate staff capacity, lack of any new effective intervention tools, and gaps in malaria epidemiology were key concerns, as was the superficially participative nature of the consultation process followed in developing the policy.

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Provider perspectives of the introduction and implementation of care for drug-resistant tuberculosis patients in district-level facilities in South Africa: a qualitative study.

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Provider perspectives of the introduction and implementation of care for drug-resistant tuberculosis patients in district-level facilities in South Africa: a qualitative study.

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