Healthcare workers’ perspectives on the implementation of tuberculosis infection prevention and control policy in rural Papua New Guinea

Introduction

Before the SARS-CoV-2 pandemic (COVID-19), infection with Mycobacterium tuberculosis was the leading cause of death from a single infectious disease worldwide (Falzon et al. 2023). Although Papua New Guinea (PNG) has transitioned out of the 30 countries with a high tuberculosis (TB)/HIV burden, there was an extremely high TB incidence of 432 per 100,000 in 2023, and the case fatality rate among HIV-negative people with TB was 27 per 100,000 (World Health Organization 2023). Among nationally reported TB cases, it was estimated that 3.4% of new TB patients and 26% of previously treated cases had multidrug-resistant TB (MDR TB) in 2020, reducing the positive treatment outcomes of the national TB control efforts (Diefenbach-Elstob et al. 2019). A study of MDR-TB in rural Western Province, PNG from 2014 to 2017 found that of the 1548 people registered for TB medications, 1208 (78%) had drug-susceptible TB, and 333 (21.5%) had MDR-TB (Morris et al. 2019). Similarly, a cross-sectional study conducted in four PNG provinces (Madang, Morobe, National Capital District and Western Province) from 2012 to 2014 found that among 1182 TB patients enrolled in the study, 20 new cases (2.7%) and 24 post-treatment cases (19.1%) were diagnosed with MDR-TB (Aia et al. 2016).

In the context of these complex realities, the necessity of effectively implementing TB infection prevention and control (TB-IPC) measures in resource-constrained primary healthcare (PHC) institutions is clear (Bozzani et al. 2022). Although TB transmission is more prevalent outside health facilities, TB infections in PHC settings present a considerable and, in principle, preventable cause of TB incidence. Therefore, designing relevant TB-IPC strategies is essential to prevent TB transmission within PHC settings.

TB-IPC measures have emerged as an effective preventive public health platform to prevent TB transmission in often overcrowded healthcare settings (Reid et al. 2012). Effective TB-IPC measures are critical to the quality of healthcare service delivery to achieve people-centred, integrated, universal health coverage. The WHO TB-IPC guidelines are among the most widely used, and are a mainstay of public health practice to address the prevalence of infectious diseases, such as TB (World Health Organization 2019). These measures are commonly composed of three main pillars: administrative controls – triaging individuals with signs and symptoms of TB, isolating suspected TB cases and initiation of correct medications, developing appropriate health facilities infrastructure to act promptly and appropriately to patients diagnosed with TB in the health facilities; environmental controls – improving the ventilation systems and quality of fresh air in a healthcare setting to minimise TB transmission to health workers; and personal protective control measures – using face masks and respirators appropriately to reduce TB transmission to health workers and individuals seeking medical care in clinical settings. The WHO recommends that healthcare institutions, including PHC facilities that manage TB cases, apply these measures to minimise TB transmission among susceptible individuals in healthcare settings and prevent spread into the wider community.

Despite these crucial recommendations, health system challenges, such as a deficit in basic healthcare infrastructure, insufficient financing of TB-IPC activities and lack of sustained IPC standards, have restricted implementation in resource-constrained PHC in low-income countries (Zwama et al. 2021). Even though TB-IPC measures are suitable for PHC facilities, the extent to which they are effectively implemented is highly dependent on the context of the healthcare system. There is limited understanding of the perceived barriers and strategies of primary health settings and HCWs’ understanding and experience of relevant strategies to address the implementation barriers.

The literature on TB-IPC recommends an increasingly consistent set of strategies for effectively implementing TB-IPC in tertiary healthcare institutions (Zwama et al. 2021). However, there is limited information on strategies related to PHC settings. Zinatsa et al. (2018) provide an excellent overview of some of the strategies relevant to PHC facilities in urban areas of South Africa. These strategies include HCWs training on TB-IPC, improved patient education and awareness of TB-IPC, HCWs as TB-IPC champions, improved social support, and clarity on TB-IPC guidelines. An investigation into PHC settings from a rural area perspective may enhance our understanding of specific strategies required for effective TB-IPC practice (Paleckyte et al. 2021). In some countries, such as PNG, with a high rural population of >85% and a reliance on a distributed PHC system where individuals in need can easily access health care at their location, understanding the key public health policies and prioritised implementation remains under-researched. In PNG, the administration of PHC services was decentralised to the provinces after it gained independence in 1975. The PHC encompassed 1800 aid posts located in the community, 800 health centres and >25 district or rural hospitals. Secondary healthcare services are provided by 23 provincial hospitals and one national referral hospital (Wiltshire et al. 2020). This study aimed to prioritise relevant strategies, and demonstrate their significance in making TB-IPC work better in resource-constrained PHC settings in PNG.

Methods

Data collection procedure

Data were collected between October 2022 and March 2023. The researchers contacted the relevant course lead to seek permission to conduct the group discussion with the participants, and following permission and consent, participants were invited to attend the discussion. After the selection of the most important barriers and strategies using coloured dots, using the NGT (Laenen 2015), experienced HCWs employed in TB-IPC programs were engaged in group discussions to reach a consensus on the selected barriers and strategies to improve TB-IPC measures in rural PHC facilities in PNG. The five stages of the NGT used for this research are summarised in Figs 1 and 2.

Fig. 1.

The four stages of the nominal group technique used with the inclusion of the fifth step by the authors. Adapted from Ronto et al. (2016).

Fig. 2.

Steps in using the nominal group technique.

Results

Discussion

TB-IPC guidelines have emerged as a potential preventive public health strategy to support TB control efforts. However, applying relevant TB-IPC measures to improve TB control efforts in resource-constrained PHC settings is limited and poorly understood. This study explored HCWs’ perspectives on the most important strategies to strengthen the implementation of TB-IPC policy in rural PHC settings in PNG. Despite the diversity in types of workers involved in this study, nearly all participants thought that HCWs capacity building on TB-IPC guidelines, adequate PHC infrastructure and community awareness of TB were the most important strategies for good TB-IPC practices in PHC facilities.

Comprehensive and sustained implementation of TB-IPC guidelines by HCWs is critical to reducing the risk of nosocomial transmission of TB in PHC settings and spreading it into the community. HCWs perceive this as best achieved through training and upskilling HCWs with skills and knowledge of relevant TB-IPC guidelines and standards. This finding aligns with the WHO’s recommendations that promote the significance of healthcare staff training and the practical application of TB-IPC standards (World Health Organization 2019). Although many participants prioritised HCWs’ training as an important strategy for TB-IPC, differences were noted between the responses from policymakers and healthcare providers in the field. Most policymakers (M = 0.73, s.d. = 0.47) tend to prioritise HCWs’ capacity building as the most important strategy compared with health service providers (M = 0.56, s.d. = 0.45; P ≤ 0.71). Although the variations are statistically insignificant, they demonstrate the level of knowledge among the different HCWs and the level of exposure to the TB-IPC guidelines. These findings suggest that HCWs prefer many different priorities and strategies to strengthen the TB burden other than training and skills development for HCWs. This finding aligns with Shrestha et al. (2017), who suggested that the differences in HCWs’ knowledge of TB-IPC guidelines can be addressed through systematic training programs for HCWs. They revealed that HCWs’ knowledge of TB-IPC guidelines was significantly associated with education level and TB training. This implies that periodic in-service training and continuous education can enhance and maintain primary HCWs’ knowledge and skills.

Moreover, Zinatsa et al. (2018) found that a lack of HCWs’ training and conflicting guidelines was responsible for inadequate TB-IPC practices in the South African healthcare system. They maintained that comprehensive training for all HCWs and clarity on TB-IPC guidelines were significant for TB eradication and prevention efforts in South Africa (Zinatsa et al. 2018). Similarly, our study found that key stakeholders perceived the training of HCWs as the highest priority for delivering quality TB care in PHC settings. However, many participants indicated that the lack of capacity building for HCWs, such as training, remains the most significant barrier to effective TB prevention efforts, and contributes to the poor quality of healthcare services in PNG. Participants expressed that the lack of training challenges primary healthcare providers’ abilities to plan and coordinate healthcare services that address the health needs of communities and individuals with chronic health conditions. This further suggests that knowledge can be perceived as a decision-making tool for HCWs to govern their clinical practice, and establish the process through which they are held accountable for continually improving the quality of their health services and safeguarding a high standard of care. Therefore, effective infection control measures, including regular skill-based training and orientation for all categories of HCWs, can improve infection control practices in PHC facilities.

Many HCWs prioritised improving and maintaining PHC setting infrastructure as the second most important strategy for TB-IPC guidelines. The results of this study indicate that most participants were aware of the poor PHC infrastructure in PNG, and how it influences TB care and healthcare services more broadly. This research found minimum differences in the HCWs’ perspectives, indicating that improving healthcare infrastructure, such as diagnostic facilities, TB wards and isolation units, can significantly prevent TB transmission and infection. Most participants concur that periodic maintenance and improvement of PHC facilities are essential to manage diseases, such as TB. This finding is consistent with that of Baumgarten et al. (2018), who indicated that high-quality TB control is associated with some aspects of the primary healthcare infrastructure, including a sound supply system, adequate physical infrastructure and community outreach programs. This is also supported by Luxon (2015), who maintains that infrastructure is a crucial pillar of high-quality healthcare and promotes improved patient care and wellbeing. Therefore, investing in healthcare infrastructure promotes a resilient healthcare system, and ensures that PNG can effectively prevent and respond to current and emerging infectious diseases.

Despite the recommendations that an effective TB-IPC program depends on adequate PHC infrastructure, almost half of the participants expressed concern that a deficit in basic PHC infrastructure remains a severe obstacle to the effective application of TB-IPC guidelines. These findings are consistent with a study in South Africa, which found that poor primary health facility infrastructure coupled with insufficient maintenance, and lack of resources and materials impedes effective TB-IPC implementation in primary healthcare settings (Zinatsa et al. 2018). Similar to our study, HCWs in the South African healthcare system agree that poor infrastructure was one of the most significant obstacles to good TB-IPC practices (Zinatsa et al. 2018). These findings suggest that, as the success of TB control efforts depends on health system factors, health managers and decision-makers need to seriously consider investment in health systems via health systems strengthening interventions, such as healthcare infrastructure, to curb the high TB burden in PNG.

HCWs recommended increasing TB education and awareness programs in rural communities as the third most important strategy for effective TB-IPC practice. Many participants stressed that health awareness educates individuals and communities about health risks and symptoms that may lead to serious health conditions. Jops et al. (2023) argue that decentralising TB care services to the local community can improve TB detection and strengthen public health delivery in PNG. This would mean that the Provincial Health Authorities responsible for primary health services at the subnational levels can ensure a more efficient allocation of healthcare resources, strengthen local resource mobilisation, and improve local governance and accountability (Farmer et al. 2018).

Moreover, the findings in the present study are consistent with the findings of Iribarren et al. (2014), who emphasise that capitalising on community capabilities and maximising established decentralised systems are important, and could mitigate some of the health system barriers preventing accessibility to primary healthcare services. Increasing community health awareness programs would provide opportunities for rural and disadvantaged individuals in PNG to access primary healthcare services in their catchment area, and increase their knowledge of TB, treatment outcomes and risk factors. Increasing primary healthcare services to communities will further reduce the financial burdens on rural inhabitants associated with the excessive travel cost to access TB care at district health centres (Maha et al. 2019; Lewis et al. 2022). The findings in this research have demonstrated that improving the knowledge of the community of TB through health education and health promotion through the decentralisation system was considered an essential strategy to empower individuals, families and communities to take charge of their health.

TB remains a significant public health challenge, particularly affecting economically disadvantaged populations. An essential next step for the national government is to enhance primary healthcare strategies, as detailed in the National Health Plan 2021–2030. This initiative seeks to foster healthier communities by encouraging active participation from local residents. Church health services in Papua New Guinea are pivotal in supporting the government’s primary healthcare initiatives through the Healthy Island Program. Therefore, the government should allocate resources to strengthen church health services, enabling effective implementation of the healthy island concept in local communities.

Strengths and limitations

A key strength of this study was that it considered the voices of the frontline HCWs engaged in the TB-IPC program to brainstorm ideas and to determine the most important strategies that may work in resource-constrained PHC settings. Although this study has contributed to a better understanding of healthcare experts’ perceptions of the essential strategy for good TB-IPC practice in PHC settings in PNG that could influence policy and practice, the study has some limitations that must be acknowledged. First, HCWs were presented with nine strategies for good TB-IPC practice in PHC institutions. There might be other strategies of TB-IPC measures that should have been included in the present study. However, all researchers conceptualised good TB control practices to identify TB control strategies based on the current literature. Second, HCWs were requested to choose only the three most important TB-IPC strategies that could improve TB-IPC standards in PHC institutions. Third, only one investigator (GM) coded the data, so a potential bias in identifying the codes may exist. To minimise this, the co-authors met regularly to review the codes and categories.

Conclusions

This study aimed to prioritise suitable TB-IPC strategies in PHC settings. The healthcare staff ranked HCWs’ training and education, adequate PHC infrastructure, and increasing community awareness and education as the most important for them to implement TB-IPC guidelines successfully in PHC settings to control the TB burden in PNG. The findings in this study suggest that primary health care enables health systems to strengthen individuals’ health needs, from the promotion of disease prevention to medication and rehabilitation. This approach also ensures that basic healthcare services are delivered in a way that is focused on the community’s needs and respects their health choices. As primary health care is a whole-of-society approach to effectively organise and support the national health system to direct health services closer to communities, the health sector should respond to the national health plan strategy on strengthening primary health systems, including investment in health workforce training, community health services and primary healthcare infrastructure.