The four organizing themes that were identified after data analysis process included the following:
- Health workers personal safety
- Infection prevention practices
- Health workers working environment
- Health promotion
Organizing Theme 1: Health workers personal safety
When asked about professional practices that subjected health workers to the risk of contracting tuberculosis whilst caring-out their duties, four participants acknowledged that majority of nurses who were in frequent contact with tuberculosis patients at the hospital were not wearing face masks because of existing tradition and culture. They admitted that the practice compromised their personal safety and exposed them to tuberculosis infection:
“...when it comes to attending to these patients, there are those disposable face masks but because of our tradition…most of them do not wear those masks. Very few put on those masks as they are examining those patients, that’s one thing I have seen…” [Senior Nursing Officer]
The quotation above significantly showed the relationship between tuberculosis control measures and cultural norms. According to the nurses, wearing face masks when attending to tuberculosis patients was against the local culture and tradition. Additionally, patients and community members felt discriminated against when doctors and nurses wore face masks.
Despite six participants confirming the use of disposable gloves during their professional practice, other nurses highlighted that it was not all the times they wore disposable gloves when attending to tuberculosis patients at the hospital. They felt that the tendency of not always wearing disposable gloves when handling and examining tuberculosis patients made them vulnerable to contracting tuberculosis:
“...health workers do not always put-on disposable gloves when they are attending to tuberculosis patients…” [Registered Nurse]
According to the above quotation, all health workers who were not frequently wearing disposable gloves were at high risk of contracting tuberculosis while discharging their duties. Nevertheless, few nurses had some awareness on tuberculosis transmission and described it to be very infectious and contagious. Furthermore, they also described the risk of contracting tuberculosis at the hospital to be very high:
“The risks are there…we know that people who have tuberculosis are infectious, very contagious, so the risk is very high” [Registered Specialist Nurse]
The above quotation reaffirms the significance of health workers wearing complete protective equipment when attending to tuberculosis patients and other highly infectious conditions in order to prevent transmission within the hospital setting. Participants were scared of people with tuberculosis; this resulted in social exclusion and discrimination. Furthermore, one participant echoed that tuberculosis was highly infectious and that it was not only found at the hospital but also in public places and communities:
“...because even in taxi, mini-buses you can get it, so hmmm, I think we need very serious measures on how to protect health workers and the general public” [Registered Specialist Nurse]
It is with such evidence that participants felt the need of providing adequate ventilation system not only in public service vehicles but also in dwelling houses and congested places in order to reduce the risk of tuberculosis transmission from an infected person to a healthy individual. Furthermore, two participants responded in a similar way when asked to describe the personal safety of health workers at the hospital:
“I describe personal safety not to be adequate at our hospital…when you put-on uniform, you can move from one ward to another and yet putting-on the same uniform…” [Registered Nurse]
The above quotation highlighted on the importance of health workers adherence to personal safety procedures especially when attending to patients with highly infectious condition. According to the participants, adherence to personal safety procedures within the hospital setting reduces the risks of transmission of infectious diseases from patients to health workers and communities.
Organizing Theme 2: Infection prevention practices
When asked about the professional practices that contributed to the risks of contracting tuberculosis from patients at the hospital, four participants acknowledged that nurses did not frequently wash their hands after attending to tuberculosis patients:
“...not taking frequent hand washing and sometimes you find that nurses are consuming food just in the ward where they are attending to tuberculosis patients” [Registered Nurse]
Participants recognized hand washing as a universal personal hygiene practice and best infection prevention strategy that could reduce transmission of infectious diseases within the hospital setting and communities. Furthermore, participants confirmed that the hospital had no isolation ward for admission of confirmed tuberculosis patients; instead tuberculosis patients were admitted together with patients with different medical conditions in the same ward:
“The risks are there because we do not have an isolation ward, we just combine them in the main ward, so I would just say that the risk is 100%, it is just by the grace of God that we are not infected” [Enrolled Nurse]
The above quotation revealed that there were compromised infection prevention practices at the hospital. Furthermore, inadequate staffing was such a big issue that one participant linked it to compromised infection prevention practices by health workers at the hospital:
“We do not have nurses specifically for tuberculosis ward, so the practice has been that if the emergency happens, you do not even take-off what you have been using in the tuberculosis ward or rather the uniform or whatever gear you have been putting-on and- go straight to the other wards. That is actually what has compromised infection - prevention, its inadequate staffing…” [Registered Nurse]
Additionally, two participants responded in a similar way when asked to describe the risk behavior of health workers after attending to tuberculosis patients at the hospital:
“...you go with your clothes back home, it’s not like in western countries were you will have a locker of uniforms and coats but here you go with them home, if you have carried the bacterium home, even the children will get it, so those I think can be risk behaviors” [Registered Specialist Nurse]
The above quotation showed how tuberculosis could be transmitted from the hospital setting to communities and participants suggested that key tuberculosis preventive health messages should not only be disseminated to health workers but also to the general population. In addition, when asked what came into their mind when attending to tuberculosis patients at the hospital, one participant linked tuberculosis to HIV/AIDS infection:
“What comes to my mind hmmm, [Laughs], obviously it’s hmmm HIV comes there, looking at the way they are related…” [Enrolled Nurse]
The above quotation clearly showed how health workers and community members stigmatize patients with tuberculosis. According to majority of participant’s views, people with tuberculosis infection were perceived to be very dangerous and socially excluded. Furthermore, participants linked health workers fear of tuberculosis patients to health inequalities observed in health facilities and communities. In addition, one participant confirmed that health workers at the hospital took tuberculosis patients like any other patient without considering infection prevention interventions hence, exposing themselves to the risks of contracting tuberculosis infection while on duty:
“A lot of people come with cough but you just take it to be a normal cough…” [Registered Specialist Nurse]
Furthermore, another participant confirmed that storage of tuberculosis infectious wastes within the wards at the hospital was not according to the recommended standards due to limited waste bins hence, resulted in non-segregation of infectious wastes:
“We just throw them in the bin and there is only one bin which we use to keep wastes from all patients. Hmmm, there are no bins specifically meant for tuberculosis wastes” [Registered Nurse]
The quotation above significantly indicated that there was compromised health care waste management at the hospital thereby, contributing to the risks of health workers contracting infectious diseases including tuberculosis during their professional practice. Therefore, participants felt the need of providing adequate waste bins and segregation of infectious wastes in the wards in order to prevent the risks of contracting infectious diseases at the hospital.
Organizing Theme 3: Health workers working environment
According to three participant’s views, the working environment at the hospital was not conducive and that it favoured transmission of tuberculosis infection:
“Hmmm, I would say yes because when you look at the conditions we are working-in, it favours transmission of tuberculosis infection” [Registered Nurse]
Additionally, another participant acknowledged the importance of working in a clean and conducive environment and that it helps reduce transmission of infectious diseases. She also mentioned that it would be quiet difficult for mycobacterium tuberculosis to flourish in a clean hospital setting:
“...then also even the environment where you are treating those patients, it has to be very clean, it has to be dump dusted, it has to be cleaned, so that the chances of the bacterium to be in the environment is reduced hence, even reducing the chances of transmission” [Registered Specialist Nurse]
Majority of participants acknowledged that the working environment at the hospital facilitated transmission of tuberculosis from patients to health workers and eventually to other community members. Furthermore, when asked to describe their experiences regarding ventilation in the wards where tuberculosis patients were admitted, five participants gave a similar response:
“...there is no much space for adequate ventilation, the rooms are small and not well ventilated in short” [Nurse]
Participants confirmed that the rooms where tuberculosis patients were admitted were too small and poorly ventilated. In addition, five participants gave a similar response when asked to explain whether tuberculosis patients were overcrowded in the admission wards:
“...as I speak now when you go to female ward you will find that the ward is fully packed and what if there is one who is being investigated for tuberculosis, then they are crowded, that’s already the risk to the patients even to the health workers who are there” [Registered Specialist Nurse]
Furthermore, another participant acknowledged that there were many people visiting the wards where tuberculosis patients were being admitted at the hospital:
“My experience has been that hmmm, in our setting there has been no restriction whatsoever of people visiting, so traffic to these wards has not been controlled, so it is very easy for people to catch infections” [Registered Nurse]
Many participants felt that congestion and overcrowding in the wards where tuberculosis patients were admitted was caused by small space and weak access control measures for visitors.
Organizing Theme 4: Health promotion
Five participants responded in a similar way when asked whether tuberculosis awareness among health workers was adequate or not:
“Hmmm, I can say it is somehow inadequate because hmmm, those messages for awareness of tuberculosis are kept in the book, they are not really disseminated to everyone…” [Medical Doctor]
Additionally, one participant said that due to inadequate tuberculosis awareness, two nurses had already contracted tuberculosis from patients and were admitted and receiving treatment at the same hospital:
“...we even have members of staff on the ward who have contracted tuberculosis and are on treatment, two nurses actually. That shows that there is a problem” [Senior Nursing Officer]
Furthermore, one participant revealed that lack of health education sessions to relatives of patients admitted at the hospital was another profession practice that contributed to the risks of tuberculosis transmission from patients to health workers:
“Sometimes hmmm, no proper health education is given to bedsiders or relatives to the patients…” [Registered Nurse]
In addition, another participant highlighted that there was inadequate tuberculosis prevention materials distributed to health workers, relatives to the patients and the general population:
“Hmmm, they should provide them with enough health education materials to use when they are teaching tuberculosis patients on how to cough and also on the principles of infection prevention” [Nurse]
Again, one participant felt the need of having children vaccinated against tuberculosis:
“...so I would educate these patients on the need of having their children vaccinated against tuberculosis…” [Enrolled Nurse]
Furthermore, two participants revealed that there were no refreshers training on tuberculosis held at the hospital especially for the newly recruited health workers:
“...there have been no tuberculosis refresher training for health workers, hmmm there have been no new skills on prevention of tuberculosis especially to the health workers who have just started working…” [Registered Nurse]
Additionally, another participant felt the need of extending health promotion on the coughing techniques to patients and advise them to properly cover their mouth when coughing as a way of preventing tuberculosis transmission to health workers and the general public:
“Hmmm, the first thing, I think is to educate patients that hmmm, on how they should handle their cough, I mean covering their mouth whenever they are coughing…because these tuberculosis patients just cough and spit anyhow” [Enrolled Nurse]
Furthermore, one participant echoed the significance of having effective health promotion strategies on tuberculosis prevention and noted that he would like to see a health promoter conduct tuberculosis training workshop to health workers and also within communities:
“Hmmm, mostly like doing tuberculosis workshop, I would like to see someone come to teach more about tuberculosis and educate health workers so that they become aware hmmm, workshops, sensitization even in the communities so that communities can be aware that tuberculosis is there, it’s real, it’s curable and preventable” [Tuberculosis Coordinator]
In addition, one participant felt that it would be more effective for health promoters to raise tuberculosis awareness to health workers and the general public during world tuberculosis day commemoration because the disease affected everyone indirectly or directly:
“I think during world tuberculosis day commemoration, they should involve much of health workers but also ordinary individuals because you find that, like the current situation, the hospital is not involved much in the tuberculosis awareness programmes…so it makes them to be vulnerable to tuberculosis infection…” [Senior Nursing Officer]
Furthermore, one participant suggested effective method of disseminating key tuberculosis awareness messages to both health workers and patients:
“...so they need to be reminded, you can even put pictures because with pictures it is very easy for someone to pick the message and not to forget, then it will remain in their mind and people will continue spreading the message in that way” [Medical Doctor]
According to the above quotation, participants felt that disseminating tuberculosis awareness messages to the targeted audience through pictures was more effective because the messages would remain in their mind.