An interdisciplinary case study of infection prevention and control for tuberculosis in a rural district of South Africa

Tuberculosis (TB) remains one of the leading infectious disease causes of death at a global level, only surpassed in 2020-21 by COVID-19. Airborne infection prevention and control (IPC) measures in health facilities play an important role to reduce the spread of TB and make health care facilities safer for patients and health workers. My overall aim with the programme of research was to explore health worker and patient experiences of using TB IPC measures in healthcare facilities from an interdisciplinary perspective. I conducted a systematic review and qualitative evidence synthesis to better understand the existing academic literature on TB IPC implementation and develop implementation considerations that could support TB IPC guideline implementation. I found that health workers often focussed their TB IPC efforts on patients who are known with TB and are already on treatment, who only pose a small risk of infection. Existing research also highlighted stigma as an important impediment to TB IPC implementation, with sparse evidence about how this could be mitigated. I responded to these evidence gaps by including this as focus areas for my fieldwork. I looked at how a district hospital refined where it focussed it TB IPC efforts and aimed to explore ways in which the stigma associated with TB IPC measures could be better understood and potentially mitigated. Using the rural Eastern Cape in South Africa as setting for in-person data collection, I draw on in-depth individual interviews with 18 health workers and 15 patients conducted between 2019 and 2020 as well as fieldnotes and document reviews. During 2021 I conducted 11 remote follow-up interviews during the COVID-19 pandemic. My analysis makes an original contribution to understanding the complexity involved in using TB IPC measures in health facilities through exploring a positive deviant organisational case study. My main findings are that TB IPC use can be understood as a process of organisational sensemaking, where what was ‘necessary’ and ‘effective’ TB IPC are contested and negotiated between health workers. In my study context, I found that TB IPC measures both reflected and contributed to the stigma that patients with TB experience. I recommend viewing TB IPC implementation in health facilities through the perspective of the broader cultural setting and adapting IPC campaigns based on contextual factors such as local explanatory models of illnesses. Using a pragmatist philosophical approach, I focus on how these findings could be used to support TB IPC implementation and relate to the clinical context. The position I develop in this thesis is to view TB IPC implementation as an example of a social practice: with reciprocal interactions between broader societal social structures, norms in healthcare organisations, health worker and patient knowledge, beliefs and values, and the social meanings and material properties of TB IPC technologies. Viewing TB IPC implementation as a social practice offers new ways of understanding why TB IPC has been difficult to implement and presents novel possibilities for an interdisciplinary approach to support TB IPC implementation.