Workplace interventions to reduce HIV and TB stigma among health care workers - Where do we go from here?

"As a patient I do not belong to the clinic, I belong to the community": co-developing multi-level, person-centred tuberculosis stigma interventions in Cape Town, South Africa

Background

Anticipated, internal, and enacted stigma are major barriers to tuberculosis (TB) care engagement and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.

Methods

Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n = 87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed, and then further interpreted using the socio-ecological model and behaviour change wheel framework.

Results

Intervention components across socio-ecological levels shared common functions linked to effective behaviour change, namely education, training, enablement, persuasion, modelling, and environmental restructuring. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal and anticipated stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended to decrease enacted stigma. Participants discussed how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.

Conclusions

Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-led multi-level intervention components should be prioritised by TB programs, including integrated TB/HIV care services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44263-024-00084-z.

"As a patient I do not belong to the clinic, I belong to the community." Co-developing a multi-level, person-centred tuberculosis stigma intervention in Cape Town, South Africa

Background

Anticipated, internal, and enacted stigma are major barriers to TB care engagement, and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.

Methods

Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n=87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed and then further interpreted using the socio-ecological model.

Results

Intervention components across socio-ecological levels shared common behaviour change strategies, namely education, empowerment, engagement, and innovation. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended. Consideration of how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested to decrease anticipated and enacted stigma. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.

Conclusions

Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-informed intervention components should be prioritised by TB programs, including integrated TB/HIV care services.

Changes in the rate of bacillus tuberculosis infection in health workers in the first year of the COVID-19 epidemic in Kashan- Iran

Objective

This cohort study aimed to determine the prevalence and risk factors of latent tuberculosis infection among healthcare workers during the COVID-19 pandemic.

Methods

A one-year cohort study was conducted in a referral hospital in Kashan, involving 176 medical, educational, and cleaning personnel. Initial evaluations and tuberculin skin tests were performed, followed by a one-year follow-up period. Data were analyzed using SPSS version 26 software.

Results

Among the participants, 26.1% (46 individuals) tested positive for latent tuberculosis infection. Age was a significant risk factor, with a 3.6% increase in latent tuberculosis infection risk with each advancing year. Men had 2.19 times (1.10-4.35) the chance of having a latent infection compared to women. Hospital staff were 3.7 times more at risk of tuberculosis infection than students. Among the hospital job categories, nursing assistants had the highest chance of tuberculosis infection, 6.77 times higher than medical students, followed by cleaning staff and nurses. The ICU, General, and Obstetrics and Gynecology departments had an infection chance of 2.46 (1.11-5.46) compared to other departments. No new positive cases were detected during the follow-up period.

Conclusion

This study contributes to the understanding of latent tuberculosis infection prevalence and its risk factors among healthcare workers during the COVID-19 pandemic. The findings highlight the importance of infection control measures and targeted interventions to protect healthcare workers from occupational tuberculosis exposure.

Psychiatrists’ occupational stigma conceptualization, measurement, and intervention: A literature review

Psychiatrists require frequent contact with and treatment of patients with mental illnesses. Due to the influence of associative stigma, psychiatrists may also be targets of stigma. Occupational stigma warrants special consideration because it significantly affects psychiatrists' career advancement, well-being, and their patients’ health. Given that there is no complete summary of this issue, this study reviewed the existing literature on psychiatrists' occupational stigma to clearly synthesize its concepts, measurement tools, and intervention strategies. Herein, we emphasize that psychiatrists’ occupational stigma is a multifaceted concept that simultaneously encompasses physically, socially, and morally tainted aspects. Currently, standardized methods to specifically measure psychiatrists’ occupational stigma are lacking. Interventions for psychiatrists’ occupational stigma may consider the use of protest, contact, education, comprehensive and systematic methods, as well as the use of psychotherapeutic approaches. This review provides a theoretical basis for the development of relevant measurement tools and intervention practices. Overall, this review seeks to raise public awareness of psychiatrists' occupational stigma, thereby promoting psychiatric professionalism and reducing its stigma.

The development and validation of a novel COVID19 stigma scale among healthcare workers (COVISS-HCWs)

BACKGROUND AND AIM

Fear of coronavirus disease 2019 (COVID-19) and its complications may result in stigmatization of individuals who may carry the virus. This is of special concern to healthcare workers who tolerate additional physical and emotional stress at times of pandemic. The aims of this study are to (1) develop and validate the COVID-19 Stigma Scale (COVISS-HCWs) survey; and (2) investigate the experience of stigma among healthcare workers possibly dealing with COVID-19 patients in five major public hospitals in Damascus, Syria.

METHODS

We divided the sample into two parts and then underwent EFA on the first 350 participants, dividing the 14 questions into two dimensions. Furthermore, CFA was conducted on the other 350 participants to confirm how correctly a hypothesized model matched the factor structure by EFA, as described above. Moreover, the coefficient of determination (R2) and item-scale correlations (standardized factor loading) were estimated to establish the acceptability of the final structure of the COVISS-HCWs. Through a cross-sectional study, a convenience sample of 700 healthcare workers participated in a self-administered questionnaire containing a section for demographic variables and another for newly designed COVISS-HCWs. The scale comprises 14 adapted and novel items that measure two subscales: feelings of perceived harm and inferiority, and avoidance. Descriptive statistics, reliability, and validity were evaluated.

RESULTS

The 14 COVISS-HCWs items were reduced to 11 items with a high Cronbach's α of 0.909. A significant correlation was observed between the responses to each COVISS-HCWs item and the corresponding subscale, and between each subscale and the overall scale. Feeling stigmatized was reported by 9.86% of the participants. Younger age, low socioeconomic status, and higher intensity of contact with COVID-19 patients significantly correlated with higher stigmatization.

CONCLUSIONS

The novel COVISS-HCWs is a reliable and valid tool to evaluate stigma among healthcare workers during the COVID-19 pandemic. The Stigma prevalence among healthcare workers was 9.86%. Therefore, this must be addressed to prevent possible psychosocial and public health repercussions.

Analysing interventions designed to reduce tuberculosis-related stigma: A scoping review

Stigma is a critical barrier for TB care delivery; yet data on stigma reduction interventions is limited. This review maps the available literature on TB stigma reduction interventions, using the Health Stigma and Discrimination framework and an implementation analysis to identify research gaps and inform intervention design. Using search terms for TB and stigma, we systematically searched PubMed, EMBASE and Web of Science. Two independent reviewers screened all abstracts, full-texts, extracted data, conducted a quality assessment, and assessed implementation. Results were categorized by socio-ecological level, then sub-categorized by the stigma driver or manifestation targeted. After screening 1865 articles, we extracted data from nine. Three studies were implemented at the individual and interpersonal level using a combination of TB clubs and interpersonal support to target internal and anticipated stigma among persons with TB. Two studies were implemented at the interpersonal level using counselling or a video based informational tool delivered to households to reduce stigma drivers and manifestations. Three studies were implemented at the organizational level, targeting drivers of stigma among healthcare workers (HW) and enacted stigma among HWs. One study was implemented at the community level using an educational campaign for community members. Stakeholder consultation emphasized the importance of policy level interventions and education on the universality of risk to destigmatize TB. Review findings suggest that internal and anticipated TB stigma may be addressed effectively with interventions targeted towards individuals using counselling or support groups. In contrast, enacted TB stigma may be better addressed with information-based interventions implemented at the organizational or community level. Policy level interventions were absent but identified as critical by stakeholders. Implementation barriers included the lack of high-quality training and integration with mental health services. Three key gaps must be addressed in future research: consistent stigma definitions, standardized stigma measurement, and measurement of implementation outcomes.

Adapting and pilot testing an HIV and intersectional stigma reducing intervention for Dominican Republic healthcare contexts: Protocol for translational research

Background

This protocol details the adaptation and pilot testing of the Finding Respect and Ending Stigma around HIV (FRESH) intervention in Dominican Republic. FRESH is a healthcare setting stigma-reduction intervention designed to reduce stigmas affecting people living with HIV (PLHIV), focusing on HIV and intersectional stigmas experienced by sexual and gender minority (SGM) people living with HIV. After the successful adaptation of the FRESH intervention, it will be pilot-tested through the conduct of a pilot stepped wedge cluster randomized controlled trial.

Methods

Three aims are included in this study; Aim 1 includes exploratory qualitative assessment, specifically the conduct four focus groups with men who have sex with men (MSM) living with HIV (n = 24-32) and in-depth interviews with transgender women living with HIV to explore their experiences with stigma in clinics (n = 9-12). In-depth interviews will also be held with HIV healthcare workers to elucidate their perceptions and behaviors towards their SGM clients (n = 9-12). In Aim 2, informed by Aim 1 data, we will use the sequential phases of the ADAPT-ITT framework to iteratively adapt the FRESH intervention for the Dominican Republic. In Aim 3, the adapted intervention will be pilot-tested via a cluster stepped wedge randomized controlled trial to assess feasibility and acceptability of the intervention and study protocols.

Conclusions

If this pilot trial is successful, next steps will include testing the adapted intervention across Dominican Republic or in similar Spanish-speaking Caribbean nations in a larger trial to assess effectiveness in reducing stigma in clinical settings towards PLHIV.

Reducing HIV- and TB-Stigma among healthcare co-workers in South Africa: Results of a cluster randomised trial

RATIONALE

The HIV and TB co-epidemic has a severe impact on the South African healthcare workforce and health system. HIV- and TB- stigma directed from healthcare workers (HCWs) towards colleagues not only has a negative impact on the mental health and well-being of the HCWs, but has been identified as a barrier to their own health-seeking behaviour. It also increases the strain on the health system due to absenteeism.

OBJECTIVE

This cluster-randomised trial tested an intervention to reduce HIV- and TB-stigma among HCWs. The intervention, based on the theory of Diffusion of Innovations consisted of training healthcare workers as change agents in a Social and Behavioural Change Communication workshop to help them change stigmatising attitudes in the workplace. This was supported by a social marketing campaign.

METHODS

Eight hospitals in the Free State province were randomised into intervention and control group in a stratified study design. 652 respondents randomly drawn from the hospitals were surveyed on aspects of HIV and TB stigma once in 2016 and again in 2018. Since the study only used four hospitals per intervention arm, cluster-based summaries were compared when analysing the intervention effect, using the nonparametric Mann-Whitney test. To explore how the intervention worked, 24 qualitative focus groups were conducted following the intervention.

RESULTS

The quantitative test did not show a significant intervention effect on stigma between intervention and control groups. Qualitative evidence reported new awareness and changed behaviour related to HIV- and TB-stigma among individual HCWs, but a combination of factors including strong social hierarchies in the workplace and the down-scaling of the original version of the intervention seemed to reduce the impact. Conclusion The findings did not indicate a significant intervention effect, but show the potential of using HCWs as change agents to reduce HIV and TB stigma in their local communities.

Perceived Health System Barriers to Tuberculosis Control Among Health Workers in South Africa

Background

The healthcare workforce in high tuberculosis burden countries such as South Africa is at elevated risk of tuberculosis infection and disease with adverse consequences for their well-being and productivity. Despite the availability of international guidelines on protection of health workers from tuberculosis, research globally has focused on proximal deficiencies in practice rather than on health system barriers.

Objective

This study sought to elicit perceptions of informed persons within the health system regarding health system barriers to protecting health workers from tuberculosis.

Methods

Semi-structured interviews were conducted with 18 informants active in spheres related to workplace tuberculosis prevention and management in South Africa. Interviews were audio recorded and transcribed verbatim, validated and analysed to derive emergent themes. Responses were analysed using the World Health Organization building blocks as core elements of a health system bearing on protection of its health workforce.

Findings

The following health system barriers were identified by informants: leadership and governance were "top-down" and fragmented; lack of funding was a major barrier; there were insufficient numbers of staff trained in infection prevention and control and occupational health; occupational health services were not comprehensively available and the ability to sustain protective technologies was questioned. A cross-cutting barrier was lack of priority afforded to workforce occupational health associated with lack of accurate information on cases of TB among health workers.

Conclusions

We conclude that deficiencies in implementation of recommended infection control and tuberculosis management practices are unlikely to be corrected until health system barriers are addressed. More committed leadership from senior health system management and greater funding are needed. The process could be assisted by the development of indicators to characterise such barriers and monitor progress.

Stigma in health facilities: why it matters and how we can change it

Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health. This correspondence article seeks to assess how developments over the past 5 years have contributed to the state of programmatic knowledge-both approaches and methods-regarding interventions to reduce stigma in health facilities, and explores the potential to concurrently address multiple health condition stigmas. It is supported by findings from a systematic review of published articles indexed in PubMed, Psychinfo and Web of Science, and in the United States Agency for International Development's Development Experience Clearinghouse, which was conducted in February 2018 and restricted to the past 5 years. Forty-two studies met inclusion criteria and provided insight on interventions to reduce HIV, mental illness, or substance abuse stigma. Multiple common approaches to address stigma in health facilities emerged, which were implemented in a variety of ways. The literature search identified key gaps including a dearth of stigma reduction interventions in health facilities that focus on tuberculosis, diabetes, leprosy, or cancer; target multiple cadres of staff or multiple ecological levels; leverage interactive technology; or address stigma experienced by health workers. Preliminary results from ongoing innovative responses to these gaps are also described.The current evidence base of stigma reduction in health facilities provides a solid foundation to develop and implement interventions. However, gaps exist and merit further work. Future investment in health facility stigma reduction should prioritize the involvement of clients living with the stigmatized condition or behavior and health workers living with stigmatized conditions and should address both individual and structural level stigma.

The Impact of Quality Assurance Initiatives and Workplace Policies and Procedures on HIV/AIDS-Related Stigma Experienced by Patients and Nurses in Regions with High Prevalence of HIV/AIDS

Stigma is commonly experienced by people living with HIV/AIDS and by those providing care to HIV/AIDS patients. Few intervention studies have explored the impact of workplace policies and/or quality improvement on stigma. We examine the contribution of health care workplace policies, procedures and quality assurance initiatives, and self- and peer-assessed individual nurse practices, to nurse-reported HIV/AIDS-stigma practices toward patients living with HIV/AIDS and nurses in health care settings. Our sample of survey respondents (n = 1157) included managers (n = 392) and registered/enrolled nurses (n = 765) from 29 facilities in 4 countries (South Africa, Uganda, Jamaica, Kenya). This is one of the first studies in LMIC countries to use hierarchical linear modeling to examine the contributions of organizational and individual factors to HIV/AIDS stigma. Based on our results, we argue that organizational interventions explicitly targeting HIV/AIDS stigma are required to reduce the incidence, prevalence and morbidity of HIV/AIDS.

Towards a health-enabling working environment - developing and testing interventions to decrease HIV and TB stigma among healthcare workers in the Free State, South Africa: study protocol for a randomised controlled trial

Background

Occupational exposure to tuberculosis (TB) constitutes a major health risk for healthcare workers (HCWs). The HIV epidemic equally affects the workforce because of the mutually reinforcing epidemiology of HIV and TB. Stigmas associated with HIV and TB have become so intricately entangled that they stop some HCWs from seeking care in a context where serious shortages in human resources for health besiege public health facilities. It is thus imperative to research, as well as attempt to tackle, HIV and TB stigma among HCWs. But little has been done internationally—and nationally, only our own exploratory studies. Our project aims to address this by (1) scientifically assessing the extent and sources of HIV and TB-related stigma among HCWs and (2) developing and testing evidence-based, stigma-reduction interventions in public hospitals in the Free State Province of South Africa.

Methods/design

The research follows a stratified cluster randomised controlled trial (RCT) design. Pre intervention, a self-administered questionnaire with the pilot study’s validated stigma scales is used to measure stigma and other key variables among randomly selected HCWs in eight hospitals—stratified by size and district and then randomly allocated to four intervention and four control sites. Interventions comprise HIV- and TB-stigma reduction activities—mainly Social and Behavioural Change Communication (SBCC) interventions—at three social-ecology levels (individual, community, and socio-structural). An outside assessor will appraise the trial mid-way through implementation. Post intervention, all baseline respondents will be followed up to complete the baseline questionnaire with additional items on interventions. Qualitative data will be collected to better understand HIV and TB stigma and explore if, and how, interventions impact stigma levels in the workplace.

Discussion

The study regards as HCWs all staff, working in all different types of jobs, at all levels in the hospitals. Thus, the research addresses HIV and TB stigma across the whole workforce and the entire workplace. In doing so it will (1) generate essential information on stigma among HCWs and (2) implement stigma-reduction interventions that are innovative yet replicable, and potentially beneficial in addressing a pernicious human-rights-based issue.

Trial registration

South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2713-5) contains supplementary material, which is available to authorized users.

Fighting stigma, promoting care: a study on the use of occupationally-based HIV services in the Free State Province of South Africa

Fear of breaches in confidentiality and HIV-related stigma in the workplace have been shown to be primary concerns and potential barriers to uptake of HIV testing and treatment by health care workers (HCWs) at the Occupational Health Unit (OHU). In a context of human resource shortages, it is essential to investigate potential ways of reducing HIV-related stigma and promoting confidentially in the workplace. Using Structural Equation Modelling (SEM), baseline data of the "HIV and TB Stigma among Health Care Workers Study" (HaTSaH Study) for 818 respondents has been analysed to investigate (1) whether bottom-up stigma-reduction activities already occur; and (2) whether such grassroots actions can reduce the fear of breaches in confidentiality and HIV-related stigma - and thus indirectly stimulate the uptake of HIV services at the OHU. Results (aim 1) illustrate the occurrence of existing activities aiming to reduce HIV-related stigma, such as HCWs giving extra support to HIV positive co-workers and educating co-workers who stigmatise HIV. Furthermore, results of the SEM analysis (aim 2) show that the Fighting-stigma factor has a significant negative effect on HIV-related stigma and a significant positive effect on Confidentiality. Results show that the latent fighting-stigma factor has a significant positive total indirect effect on the use of HIV testing, CD4 cell count and HIV-treatment at the OHU. The findings reveal that the fear of breaches in confidentiality and HIV-related stigma can be potential barriers to the uptake of occupationally-based HIV services. However, results also show that a bottom-up climate of fighting HIV-related stigma can stimulate confidentiality in the workplace and diminish the negative effect of HIV-related stigma - resulting in an overall positive effect on the reported willingness to access occupationally-based HIV services.

High rates of exposure to tuberculosis patients among HIV-infected health care workers in Botswana

OBJECTIVE

To compare daily exposure to tuberculosis (TB) patients between HIV-infected and non-HIV-infected health care workers (HCWs), and examine the uptake of antiretroviral therapy (ART) and isoniazid preventive therapy (IPT) among HIV-infected HCWs in Botswana.

DESIGN

We conducted a cross-sectional study among HCWs in 30 hospitals and clinics. We determined self-reported exposure frequency to TB patients and HIV status through in-person interviews. HCWs with unknown or negative HIV status were offered rapid HIV testing. Multivariable Poisson regression modeling with robust variance was used to estimate the association between HIV status and daily exposure to TB patients.

RESULTS

Of 1877 participants enrolled, 1388 (73.9%) with complete data were included in this study. Among 277 (20.0%) HIV-infected participants, 14.3% were newly diagnosed, 57.8% were on ART, and 34.3% reported previously receiving IPT. Daily exposure to TB patients was reported by respectively 48.4% and 52.9% of HIV-infected and non-infected participants. After adjusting for sex, age, occupation, and department, the rates of daily TB exposure remained similar between HIV-infected and non-HIV-infected participants (prevalence ratio 0.96, 95%CI 0.85-1.08).

CONCLUSIONS

We found similar rates of exposure to TB patients between HIV-infected and non-HIV-infected HCWs. Improved efforts are needed to reduce nosocomial exposure to TB among HIV-infected HCWs.

African and Caribbean Nurses' Decisions about HIV Testing: A Mixed Methods Study

Nurses in Jamaica, Kenya, South Africa, and Uganda are at risk for occupational exposure to HIV. Little is known about the experiences and policy supports related to nurses having themselves tested for the virus. This article reports a mixed-methods study about contextual influences on nurses' decision-making about HIV testing. Individual and focus group interviews, as well as a questionnaire on workplace polices and quality assurance and a human resource management assessment tool provided data. Fear of a positive diagnosis and stigma and lack of confidentiality along with gaps in the policy environment contributed to indecision about testing. There were significant differences in policy supports among countries. Institutional support must be addressed if improvements in HIV testing for health care workers are going to be effectively implemented. Future work is required to better understand how HRM policies intersect to create conditions of perceived vulnerability for HIV positive staff.

The Development and Piloting of Parallel Scales Measuring External and Internal HIV and Tuberculosis Stigma Among Healthcare Workers in the Free State Province, South Africa

BACKGROUND

The dual burden of tuberculosis and human immunodeficiency virus (HIV) is severely impacting the South African healthcare workforce. However, the use of on-site occupational health services is hampered by stigma among the healthcare workforce. The success of stigma-reduction interventions is difficult to evaluate because of a dearth of appropriate scientific tools to measure stigma in this specific professional setting.

METHODS

The current pilot study aimed to develop and test a range of scales measuring different aspects of stigma-internal and external stigma toward tuberculosis as well as HIV-in a South African healthcare setting. The study employed data of a sample of 200 staff members of a large hospital in Bloemfontein, South Africa.

RESULTS

Confirmatory factor analysis produced 7 scales, displaying internal construct validity: (1) colleagues' external HIV stigma, (2) colleagues' actions against external HIV stigma, (3) respondent's external HIV stigma, (4) respondent's internal HIV stigma, (5) colleagues' external tuberculosis stigma, (6) respondent's external tuberculosis stigma, and (7) respondent's internal tuberculosis stigma. Subsequent analyses (reliability analysis, structural equation modeling) demonstrated that the scales displayed good psychometric properties in terms of reliability and external construct validity.

CONCLUSIONS

The study outcomes support the use of the developed scales as a valid and reliable means to measure levels of tuberculosis- and HIV-related stigma among the healthcare workforce in a resource-limited context. Future studies should build on these findings to fine-tune the instruments and apply them to larger study populations across a range of different resource-limited healthcare settings with high HIV and tuberculosis prevalence.

Strengthening Human Immunodeficiency Virus and Tuberculosis Prevention Capacity among South African Healthcare Workers: A Mixed Methods Study of a Collaborative Occupational Health Program

Background

Insufficient training in infection control and occupational health among healthcare workers (HCWs) in countries with high human immunodeficiency virus (HIV) and tuberculosis (TB) burdens requires attention. We examined the effectiveness of a 1-year Certificate Program in Occupational Health and Infection Control conducted in Free State Province, South Africa in an international partnership to empower HCWs to become change agents to promote workplace-based HIV and TB prevention.

Methods

Questionnaires assessing reactions to the program and Knowledge, Attitudes, Skills, and Practices were collected pre-, mid-, and postprogram. Individual interviews, group project evaluations, and participant observation were also conducted. Quantitative data were analyzed using Wilcoxon signed-rank test. Qualitative data were thematically coded and analyzed using the Kirkpatrick framework.

Results

Participants recruited (n = 32) were mostly female (81%) and nurses (56%). Pre-to-post-program mean scores improved in knowledge (+12%, p = 0.002) and skills/practices (+14%, p = 0.002). Pre-program attitude scores were high but did not change. Participants felt empowered and demonstrated attitudinal improvements regarding HIV, TB, infection control, and occupational health. Successful projects were indeed implemented. However, participants encountered considerable difficulties in trying to sustain improvement, due largely to lack of pre-existing knowledge and experience, combined with inadequate staffing and insufficient management support.

Conclusion

Training is essential to strengthen HCWs' occupational health and infection control knowledge, attitudes, skills, and practices, and workplace-based training programs such as this can yield impressive results. However, the considerable mentorship resources required for such programs and the substantial infrastructural supports needed for implementation and sustainability of improvements in settings without pre-existing experience in such endeavors should not be underestimated.

The neglected burden of tuberculosis disease among health workers: a decade-long cohort study in South Africa

Background

Health workers (HWs) in resource-limited settings are at high-risk of exposure to tuberculosis (TB) at work. The aim of this study was to estimate the rate of TB disease among HWs in the Free State Province of South Africa between 2002 and 2012 and to compare demographic and clinical characteristics between HWs and the general population with TB. This study also explores the effect of occupational variables on risk of TB among HWs.

Methods

Probabilistic record linkage was utilized to identify HWs who were also registered as TB patients. This historical prospective cohort study calculated incidence rate ratios (IRR) for TB disease among HWs in Free State from 2002 to 2012. Generalized linear mixed-effects regression was used to model the association between sex, race, facility type, occupation, duration of employment, and the rate of TB.

Results

There were 2677 cases of TB diagnosed among HWs from 2002 to 2012 and 1280 cases were expected. The overall TB incidence rate in HWs during the study period was 1496·32 per 100,000 compared to an incidence rate of 719·37 per 100,000 in the general population during the same time period. IRR ranged from 1·14 in 2012 to 3·12 in 2005. HWs who were male, black, coloured and employed less than 20 years had higher risk of TB. Facility type and occupation were not associated with increased risk of TB when adjusted for other covariates.

Conclusion

HWs in South Africa have higher rates of TB than the general population. Improved infection prevention and control measures are necessary in all high-burden TB healthcare settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2659-3) contains supplementary material, which is available to authorized users.

Agents of change: The role of healthcare workers in the prevention of nosocomial and occupational tuberculosis

Healthcare workers (HCWs) play a central role in global tuberculosis (TB) elimination efforts but their contributions are undermined by occupational TB. HCWs have higher rates of latent and active TB than the general population due to persistent occupational TB exposure, particularly in settings where there is a high prevalence of undiagnosed TB in healthcare facilities and TB infection control (TB-IC) programmes are absent or poorly implemented. Occupational health programmes in high TB burden settings are often weak or non-existent and thus data that record the extent of the increased risk of occupational TB globally are scarce. HCWs represent a limited resource in high TB burden settings and occupational TB can lead to workforce attrition. Stigma plays a role in delayed diagnosis, poor treatment outcomes and impaired well-being in HCWs who develop TB. Ensuring the prioritization and implementation of TB-IC interventions and occupational health programmes, which include robust monitoring and evaluation, is critical to reduce nosocomial TB transmission to patients and HCWs. The provision of preventive therapy for HCWs with latent TB infection (LTBI) can also prevent progression to active TB. Unlike other patient groups, HCWs are in a unique position to serve as agents of change to raise awareness, advocate for necessary resource allocation and implement TB-IC interventions, with appropriate support from dedicated TB-IC officers at the facility and national TB programme level. Students and community health workers (CHWs) must be engaged and involved in these efforts. Nosocomial TB transmission is an urgent public health problem and adopting rights-based approaches can be helpful. However, these efforts cannot succeed without increased political will, supportive legal frameworks and financial investments to support HCWs in efforts to decrease TB transmission.

Who Should We Target? The Impact of Individual and Family Characteristics on the Expressed Need for Community-Based Treatment Support in HIV Patients in South Africa

Reviews of impact evaluations of community-based health workers and peer support groups highlight the considerable variability in the effectiveness of such support in improving antiretroviral treatment (ART) outcomes. Evidence indicates that community-based support interventions targeting patients known to be at risk will probably display better results than generic interventions aimed at the entire population of people living with HIV. It is however difficult to identify these at-risk populations, rendering knowledge on the characteristics of patients groups who are in need of community-based support a clear research priority. The current study aims to address the knowledge gap by exploring the predictors of the willingness to (1) receive the support from a community-based health worker or (2) to participate in a support group in public sector ART programme of the Free State Province of South Africa. Based on the Individual-Family-Community framework for HIV research, the study employs a comprehensive approach by not only testing classical individual-level but also family-level predictors of the willingness to receive community-based support. In addition to individual-level predictors—such as age, health status and coping styles—our analysis demonstrated the importance of family characteristics. The results indicated that discrepancies in the family’s changeability level were an important predictor of the demand for community-based support services. Conversely, the findings indicated that patients living in a family more flexible than deemed ideal are more likely to require the support of a community health worker. The current study expands theory by indicating the need to acknowledge all social ecological levels in the study of chronic HIV care. The detection of both individual level and family level determinants of the expressed need for community-based support can inform health policy to devise strategies to target scarce resources to those vulnerable patients who report the greatest need for this support. In this way, the study results are a first step in an attempt to move away from generic, broad based community-based interventions towards community support that is tailored to the patient needs at both the individual and family level.

Learning from a cluster randomized controlled trial to improve healthcare workers' access to prevention and care for tuberculosis and HIV in Free State, South Africa: the pivotal role of information systems

Background

Occupational tuberculosis (TB) continues to plague the healthcare workforce in South Africa. A 2-year cluster randomized controlled trial was therefore launched in 27 public hospitals in Free State province, to better understand how a combined workforce and workplace program can improve health of the healthcare workforce.

Objective

This mid-term evaluation aimed to analyze how well the intervention was being implemented, seek evidence of impact or harm, and draw lessons.

Methods

Both intervention and comparison sites had been instructed to conduct bi-annual and issue-based infection control assessments (when healthcare workers [HCW] are diagnosed with TB) and offer HCWs confidential TB and HIV counseling and testing, TB treatment and prophylaxis for HIV-positive HCWs. Intervention sites were additionally instructed to conduct quarterly workplace assessments, and also offer HCWs HIV treatment at their occupational health units (OHUs). Trends in HCW mortality, sick-time, and turnover rates (2005–2014) were analyzed from the personnel salary database (‘PERSAL’). Data submitted by the OHUs were also analyzed. Open-ended questionnaires were then distributed to OHU HCWs and in-depth interviews conducted at 17 of the sites to investigate challenges encountered.

Results

OHUs reported identifying and treating 23 new HCW cases of TB amongst the 1,372 workers who used the OHU for HIV and/or TB services; 39 new cases of HIV were also identified and 108 known-HIV-positive HCWs serviced. Although intervention-site workforces used these services significantly more than comparison-site healthcare staff (p<0.001), the data recorded were incomplete for both the intervention and comparison OHUs. An overall significant decline in mortality and turnover rates was documented over this period, but no significant differences between intervention and comparison sites; sick-time data proved unreliable. Severe OHU workload as well as residual confidentiality concerns prevented the proper implementation of protocols, especially workplace assessments and data recording. Particularly, the failure to implement computerized data collection required OHU staff to duplicate their operational data collection duties by also entering research paper forms. The study was therefore halted pending the implementation of a computerized system.

Conclusions

The significant differences in OHU use documented cannot be attributable to the intervention due to incomplete data reporting; unreliable sick-time data further precluded ascertaining the benefit potentially attributable to the intervention. Computerized data collection is essential to facilitate operational monitoring while conducting real-world intervention research. The digital divide still requires the attention of researchers along with overall infrastructural constraints.

Protecting health workers from infectious disease transmission: an exploration of a Canadian-South African partnership of partnerships

BACKGROUND

Health workers are at high risk of acquiring infectious diseases at work, especially in low and middle-income countries (LMIC) with critical health human resource deficiencies and limited implementation of occupational health and infection control measures. Amidst increasing interest in international partnerships to address such issues, how best to develop such collaborations is being actively debated. In 2006, a partnership developed between occupational health and infection control experts in Canada and institutions in South Africa (including an institute with a national mandate to conduct research and provide guidance to protect health workers from infectious diseases and promote improved working conditions). This article describes the collaboration, analyzes the determinants of success and shares lessons learned.

METHODS

Synthesizing participant-observer experience from over 9 years of collaboration and 10 studies already published from this work, we applied a realist review analysis to describe the various achievements at global, national, provincial and hospital levels. Expectations of the various parties on developing new insights, providing training, and addressing service needs were examined through a micro-meso-macro lens, focusing on how each main partner organization contributed to and benefitted from working together.

RESULTS

A state-of-the-art occupational health and safety surveillance program was established in South Africa following successful technology transfer from a similar undertaking in Canada and training was conducted that synergistically benefitted Northern as well as Southern trainees. Integrated policies combining infection control and occupational health to prevent and control infectious disease transmission among health workers were also launched. Having a national (South-South) network reinforced by the international (North-south) partnership was pivotal in mitigating the challenges that emerged.

CONCLUSIONS

High-income country partnerships with experience in health system strengthening - particularly in much needed areas such as occupational health and infection control - can effectively work through strong collaborators in the Global South to build capacity. Partnerships are particularly well positioned to sustainably reinforce efforts at national and sub-national LMIC levels when they adopt a "communities of practice" model, characterized by multi-directional learning. The principles of effective collaboration learned in this "partnership of partnerships" to improve working conditions for health workers can be applied to other areas where health system strengthening is needed.