Availability of tuberculosis infection control plans at rural hospitals of Vhembe district, Limpopo Province of South Africa

Abstract Background In Limpopo province the rate of new tuberculosis (TB) cases increase daily. The Infection Control (IC) plan is one of the essential actions for TB IC. This study aimed to establish the availability of these plans at health care facilities. Objectives The objectives were to explore and describe the awareness and knowledge of health care workers (HCWs) of the availability and content of TB IC plan; and to identity the role of infection control committees from the perspective of HCWs. Method A qualitative approach using a cross-sectional descriptive design was adopted. The target population was all HCWs from the seven hospitals of Vhembe district. A purposive sampling approach was used to select 57 participants. The approval to conduct this study was obtained from the relevant authorities and participants. Data was collected through seven focus group discussions comprising five to 10 members. An unstructured discussion guide was used to collect data, and an open-coding method was used to analyse the data. Lincoln and Guba's criteria ensured trustworthiness of the study findings. Results Findings revealed that HCWs were not aware of the availability and the information contained in the TB IC plans. No person was designated as TB IC officer at hospital level. There was lack of a TB IC Committee and teams as well as ineffective utilisation of those that did exist. Conclusions It was concluded that if the TB IC plans are not available at health care facilities, then the TB IC practices implemented by HCWs vary, resulting in TB nosocomial infection transmission. It was recommended that the World Health Organisation's TB IC plans be adopted and implemented in Vhembe district.


Introduction
In 2005, tuberculosis (TB) was declared an emergency by all Health Ministers from the African region who were gathered in Maputo attending the World Health Organization Regional Office for Africa (WHO/Afro) committee meeting. Every member state, including South Africa, was then asked to develop and implement a TB plan that would help to improve TB detection and the treatment success rate and reduce TB patients' defaulter rates. 1 Since time immemorial, TB has affected many lives and has resulted in the death of millions. In 2011, 8.7 million new cases of TB were reported. Of these, about 1.4 million people succumbed to the disease and died. 2 It was discovered then by the World Health Organization (WHO) that tuberculosis is one of the top killers of women. 2 Nationally, the average death rate in 2010 was at 6.5%. In Limpopo Province, the death rate was higher than the national average and was at 8.5% in 2010. 3 Limpopo province was the second highest province, with a death rate of 8.5%, as discussed at the third South African TB conference in 2012. 4 One of the goals of the National Strategic Plan of South Africa (NSPSA) for 2012-2016, the Millennium Development Goal (MDG) number 6 and the Stop TB partnership targets of WHO, is to reduce by 500 the number of new TB infections as well as deaths due to TB by 2015. 2 The reduction of new infections and deaths due to TB can only be possible if facilities could avail themselves of and implement the proposed TB Infection Control (TB IC) plans. 4 The Indian Ministry of Health and Family welfare 5 states that TB IC plans serve to establish visible commitment of the facility to prevent infection transmission. The TB IC plans articulate clear policies and procedures to ensure proper implementation and make staff roles and responsibilities clear. 6 According to the WHO 6 , the development of an Infection Control (IC) plan is one of the essential actions for effective TB infection control.
The WHO 7 believes that TB IC plans set aims and goals, compliance requirements, roles, responsibilities, policies, and procedures to administer and manage a TB infection control programme. According to the WHO, 7 the TB IC plan identifies TB transmission risk settings in a facility and makes TB information available to health care workers (HCWs) and patients. The TB IC plan prescribes the measures to be implemented in a given facility to control TB infection. The WHO 8 also emphasises that TB IC plans sets out standards for early recognition, adoption and initiation of airborne precautions to be implemented in either suspected or confirmed TB patients. According to the WHO, 9,10 the TB IC plan formalises the establishment of TB IC committees as well as the appointment of one individual per facility who is assigned the duty and authority to ensure that the prescribed infection control measures are adhered to.
According to the WHO, 6,11 every health care facility which renders TB services to suspected or confirmed TB patients should develop and implement a TB IC plan. The plan outlines standards for early recognition, adoption and initiation of airborne precautions implemented in suspected or confirmed TB cases. 12,13 Problem statement Despite the wide coverage and adoption of the Directly Observed Treatment Short course (DOTS), which has saved millions from the scourge of TB worldwide, the TB case load in the Limpopo province has been increasing from 11 897 in 2005 to 22 158 in 2011. 14 The number of TB cases in Vhembe district for the year 2009 was 2194. Of these, 750 cases were women of child-bearing age (aged 15-44 years). About 20 were children from 0-4 years of age. 15 Pakenham-Walsh and Bukachi 16 associate the lack of TB IC plans with lack of access to the basic, practical information and direction needed to ensure safe and effective TB care . There is currently no information that describes the availability of TB IC plans in South Africa as a whole, and Limpopo province and Vhembe district, more specifically for this study. It is not clear whether such plans are available or not in rural hospitals. This study, therefore, was conducted in order to investigate the availability of TB IC plans at the rural hospital of Vhembe district in order to; • explore and describe the awareness of health care providers regarding the availability of TB IC in the hospital • assess the knowledge of health care providers on the content of the TB IC plan • identify the role of infection control committees from the perspective of health care providers.
The results will serve as baseline information upon which the Department of Health (Limpopo province and Vhembe district) will plan and conduct workshops in order to empower TB managers and TB teams with information regarding how to develop TB IC plans and determine their contents.

Ethical considerations
The Limpopo Provincial Department of Health approved the study, and ethical clearance was issued by the University of Venda, Research Ethics Committee. Permission to access the seven hospitals was obtained from each hospital manager. The participants signed informed consent, and anonymity and confidentiality were observed throughout the study.

Research method and design Study approach and design
This study adopted a qualitative approach using a crosssectional descriptive design. 17,18 A case study method of inquiry was used. 17

The study setting
The study was conducted in the district of Vhembe, in the Limpopo province of South Africa. Vhembe district is situated in the far-northern side of South Africa, bordered by Zimbabwe and Mozambique, and consists of four subdistricts, namely, Thulamela, Makhado, Mutale and Musina. This district has seven hospitals, 112 clinics and eight health centres. The study was conducted at the seven hospitals of Vhembe district.

The target population
The target population of this study was all types of HCWs in the participating hospitals. The study hospitals differed in size in terms of number of beds and the number of wards. Some hospitals had only three wards, whereas others had a maximum of nine. The researchers were satisfied to welcome one representative from each of the wards per study hospital.
As a result, 57 HCWs participated in this study, as described in Table 1.

Data collection methods
Data for this study was collected through focus group discussions (FGDs), with HCWs serving as focus group members. There was only one focus group per study hospital, making seven focus groups in seven hospitals, each comprising five to 12 participants, depending on the size of the hospital in terms of the number of wards.

Data collection tool
One unstructured question, namely, 'Could you please describe what is contained in the TB IC plan implemented in this hospital?' was used to collect data from the participants. This question was followed by probing questions that needed clarity regarding the availability of the TB IC plan, IC officer and IC Committee or team, as well as what the TB IC plan of the hospital covered. Each focus group session lasted between one hour thirty minutes and two hours to enable the researcher to obtain the necessary information until theoretical saturation of each category was reached. 18

Data collection process
The researcher set the date and time for the FGDs and communicated these to the hospital managers, requesting help regarding the arrangement of the venue and delegation of representatives. On the set date and time, the researcher found the participants assembled in venues arranged by the managers. The participants comprised representatives from each unit of the hospital. The researcher facilitated FGDs of between five to 12 participants. Permission to use the voice recorder to capture the information accurately was negotiated with the participants. Only one FGD session per participating hospital was facilitated.

Data analysis
Analysis of the data was guided by Tesch's eight-step open-coding method as discussed in Cresswell, 19 where the researcher read through all of the field notes (from the FGDs) and interpreted them carefully in order to get a sense of the entire notes. The interpretations were written as themes and similar themes were clustered together and arranged finally into one major theme and four subthemes. The tape-recorded information served as a back-up.

Trustworthiness
Trustworthiness was ensured through the use of Lincoln and Guba's criteria 20,21 as outlined in Creswell, 19 namely, credibility, transferability, confirmability and dependability. Credibility was ensured by prolonged engagement of the participants in FGDs lasting from one-and-a-half to two hours. Triangulation of data capturing was performed through the use of the voice recorder during FGDs and the writing of field notes. Referential adequacy using a voice recorder to capture the interviews provided a suitable authentic record. 22,23 Tape recordings as well as field notes taken during FGDs increased the confirmability of the research. Transferability was ensured by a complete description of research method and interpretation of the research findings in the study report.

Results
In the field notes, the seven hospitals were given codes in the form of letters of alphabet (A-G) to ensure their privacy and anonymity. The main theme and four sub-themes that emerged during data analysis are presented in Table 2.

Infection control plans at rural hospitals
The tuberculosis IC plans establish goals, compliance requirements, roles, responsibilities, policies, and procedures to administer and manage a TB IC programme. 24,25 The TB IC plan further identifies high risk areas for TB transmission in a facility and provides TB information to HCWs and patients. TB IC policies, procedures and plans are measures to be implemented in a given facility to control TB infection. According to the WHO, 26 one individual in a facility should be assigned the responsibility and accorded the authority to monitor the implementation of the TB IC plan. In this study, empirical data collected through FGDs revealed the subthemes as displayed in Table 2. Each subtheme is discussed individually below.

No awareness of infection control plans
The participants indicated that clients who present with TB symptoms are managed according to different protocols that are available in each of the health care facilities, and said that they were not aware of the WHO TB IC plans. They indicated that they were not aware that a TB IC plan existed at their hospitals, and the next paragraphs show what some of the participants said during the FGDs.

No infection control officer
The majority of the hospitals in Vhembe district did not have a person designated as a TB IC officer. Other participants indicated that quality assurance nurses and occupational health and safety nurses were delegated the roles of TB IC officers. The following statements from the participants have been cited to support the findings.
A radiographer from hospital G said: The situation was the same in hospital C, as stated by a nurse who works in the female medical ward: 'The Occupational Health and Safety nurse has been assigned the responsibility of managing infection control in the hospital'. (P14, Female, 53)

Ineffective utilisation of available structures
Of the seven participating hospitals, only four indicated that their hospitals have infection control committees. However, functions of these committees were different amongst the hospitals. It was further discovered during the FGDs that the available committees were not utilised effectively. The general perception was that the committee would only focus on ordering protective clothing. Furthermore, it was determined that the terms 'team' and 'committee' were used interchangeably to mean a structure responsible for infection control in the hospital. The quotations in the following paragraphs are presented in support of the lack of and/ or ineffective utilisation of TB IC committees ('team' and 'committee' used interchangeably). In contrast, the nurse who was working in the male medical ward in hospital C said: 'What I know is that the hospital does have an infection control committee, which is not functional, because I don't know what their role is'. (P16, Male, 53) The Deputy Manager from hospital F was also of the opinion that the committee is available but not utilised effectively, saying: 'There is an infection control committee in this hospital, which is responsible for ordering and distributing protective clothing such as masks, gowns, gloves, goggles, boots and plastic aprons'. (P17, Female, 16) The nurse working at the ARV clinic at hospital F said: 'The infection control team is responsible for ordering and distributing protective clothing such as masks, gowns, gloves, goggles, boots and plastic aprons'. (P18, Female, 38)

Discussion
The findings of this study indicated that not one of the hospitals in Vhembe district had a TB IC plan. The findings are supported by Sissolack, Marais and Mehtar 27 in a study that was conducted to investigate factors influencing TB prevention and control practices from the perspective of nurses at Tygerberg Hospital in Cape Town, South Africa, which identified lack of a TB IC plan as being one of the factors associated with the risk of TB transmission in health care facilities. A similar study conducted by Luhalima, Netshandama and Davhana-Maselesele, 28 to evaluate the implementation of tuberculosis policies at a regional hospital in the Limpopo province, revealed that a TB IC plan was not available in the wards and participants expressed lack of knowledge of such a plan.
Furthermore, the findings of this study concur with Pakenham-Walsh and Bukachi, 28 who discovered that members of the health care team in developing countries continue to be deprived of basic, practical information, which would enable them to render safe and effective TB care. Pakenham-Walsh and Bukachi 16 argue that gross deficiency of basic information on how to manage common diseases is often associated with substandard, often dangerous, health care practices and mismanagement of a lot of diseases. The analogy example to this is documented in Oluwole, 29 where lack of information was found to be a barrier to breast self-examination in a study conducted to determine the level of awareness, knowledge and practices of breast self-examination in Nigeria. Similarly, another study cited in Oluwole 29 stated that the prevention of suicide has not been adequately addressed worldwide due to a basic lack of information about suicide as a major problem. The WHO 9 emphasises that lack of TB IC plans could lead to TB infection control through trial and error methods resulting from different perceptions to various practices of TB IC.

Practical implications
In order to ensure effective TB IC, every health care facility must develop and implement a TB IC plan. The TB IC plan should direct the path and practices of members of the health team in a health care setting, when dealing with suspected cases of TB. The TB IC committee should oversee TB infection control issues in a hospital setting, and the TB IC officer should monitor the implementation of the TB IC plan in this setting. When the TB IC plan is implemented effectively, contribution to the achievement of MDG Goal number 6 will be realised.

Limitations
The study was only conducted at hospitals in Vhembe district, and the findings are therefore not transferable to all hospitals in the entire Limpopo province. However, these findings can serve as a basis upon which a decision can be made with regard to conducting a similar study on a wider scope such as the entire Limpopo province or South Africa as a whole.

Conclusions
It was concluded that if the TB Infection Control plans are not available at the hospitals in Vhembe district, TB IC practices implemented by HCWs will vary greatly. As a result, TB infection transmission will not be reduced, which could theoretically be extrapolated as leading to the failure of the country as a whole with regard to the control of TB infection.

Recommendations
The following recommendations were meant to address each of the study findings: • The Department of Health, Vhembe district should, in collaboration with the University of Venda, organise a seminar or workshops where TB managers and their teams would be empowered on how to develop TB IC plans and their contents. Thereafter, each health care facility would be obliged to develop its own TB IC plan. • Each hospital should then organise a follow-up workshop targeting all HCWs responsible for TB management in the hospital where the contents of the TB IC plans will be presented. • Each hospital should, in response to the stipulations of the plan, appoint a TB IC committee as well as one or more TB IC officers. • The TB IC officer should be assigned the responsibility of ensuring that the developed TB IC plan is implemented correctly.

The possible future direction of the study
A follow-up study should be conducted to assess the impact of developing and implementing TB IC plans on TB infection transmission at hospitals of Vhembe district.