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

Abstract

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

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

“…Occupational health programmes should be prioritized, maintained and rigorously evaluated, with an emphasis on computerized data collection to facilitate operational monitoring and evaluation 61 . We advocate that occupation should be added to facility TB patient registers and recorded by national TB programmes so that the epidemiology of occupational TB can be better understood and enable the prioritization of target interventions 39 .…”

“…Access to rapid molecular diagnostic tests such as Xpert MTB/RIF for active TB diagnosis 65 must be ensured so that healthcare professionals can be promptly tested if they experience any symptoms of TB and start effective therapy based on drug susceptibility testing 28 . Confidentiality should be ensured as far as possible with regards to the outcome of tests, to overcome this barrier to getting tested 61 , although it is important that this should not preclude contact screening. Building robust occupational health systems will be an important component for overall TB elimination efforts 42 .…”

Records in tuberculosis detection: perception of health professionals

“…Thus, health records have the essential information to assist in the coordination of assistance to the respiratory symptom, providing the professional with the necessary assistance to monitor the actions performed, and the planning and organization of individual and collective assistance. [5][6][7][8][9][10][16][17][18] In the results of this study, the LRSR was pointed out as the adjuvant instrument in care of person with respiratory symptoms of tuberculosis, providing a consolidated data on the assistance performed. Corroborating with the understanding of nurses interviewed in a study carried out in the municipality of Natal, between the years of 2013 and 2014, who considered that the records related to tuberculosis are instruments that allow access to information for all professionals, being important for the identification of the person with respiratory symptoms of tuberculosis, and the effectiveness of the diagnosis of the disease.…”

“…2 However, operational research on the topic of tuberculosis has shown weaknesses in the use of these instruments. [6][7][8][9][10] Studies developed in municipalities of Rio Grande do Sul 7 , of Rio Grande do Norte 8 and in the metropolitan region of Belém/PA 6 identified the absence of LRSR in the health services, the non-use of the book by professionals as the main instrument of monitoring, the incompleteness of data, the lack of readability and even the lack of information.…”

Effectiveness of control measures to prevent occupational tuberculosis infection in health care workers: a systematic review

“…However, even before-after studies are logistically demanding, requiring establishment of an accurate baseline rate of conversion, proper implementation of the intervention, and subsequent follow up periods of measurement. Sustained and accurate record-keeping [ 44 ], consistency of testing practice, assessment of co-intervention and confounding over this period all increase the resource and staffing requirements of such research.…”