Healthcare worker knowledge, attitudes, and beliefs regarding tuberculosis preventive therapy in rural South Africa: A content analysis using the consolidated framework for implementation research

Background: South African national tuberculosis (TB) guidelines, in accordance with the World Health Organization, recommend conducting routine household TB contact investigation with provision of TB preventive therapy (TPT) for those who qualify. However, implementation of TPT has been suboptimal in rural South Africa. We sought to identify barriers and facilitators to TB contact investigations and TPT management in rural Eastern Cape, South Africa to inform the development of an implementation strategy to launch a comprehensive TB program. Methods: We collected qualitative data through individual semi-structured interviews with 19 healthcare workers at a district hospital and four surrounding primary-care clinics referring to the hospital. The consolidated framework for implementation research (CFIR) was used to develop interview questions as well as guide deductive content analysis to determine potential drivers of implementation success or failure. Results: A total of 19 healthcare workers were interviewed. Identified common barriers included lack of provider knowledge regarding efficacy of TPT, lack of TPT documentation workflows for clinicians, and widespread community resource constraints. Facilitators identified included healthcare workers high interest to learn more about the effectiveness of TPT, interest in problem-solving logistical barriers in provision of comprehensive TB care (including TPT), and desire for clinic and nurse-led TB prevention efforts. Conclusion: The use of the CFIR, a validated implementation determinants framework, provided a systematic approach to identify barriers and facilitators to TB household contact investigation, specifically the provision and management of TPT in this rural, high TB burden setting. Specific resources – time, trainings, and evidence – are necessary to ensure healthcare providers feel knowledgeable and competent about TPT prior to prescribing it more broadly. Tangible resources such as improved data systems coupled with political coordination and funding for TPT programming are essential for sustainability.


Introduction
To provide tuberculosis preventive therapy (TPT) to high-risk individuals, health systems -and healthcare workers (HCWs) -must effectively screen individuals to rule out disease and if appropriate, initiate TPT. Systematically screening individuals from high-risk groups is often challenging in lowresource settings. However, once disease is ruled out, TPT is 60-90% effective. [1][2][3][4] Currently, little is known about HCWs knowledge, attitudes, and beliefs regarding TPT to asymptomatic household contacts in low-resource, high TB incidence settings, such as South Africa. 5,6 Perceptions of HCWs implementing interventions is critical to its success. Poor HCW adoption leads to limited maintenance of interventions, making them more likely to fail. 7 Therefore, before implementing a comprehensive TB program in rural South Africa, we sought to understand the knowledge, attitudes, and beliefs of HCWs on factors in uencing TPT provision and drivers of implementation success or failure.

Setting
This study took place in the King Sabata Dalindyebo (KSD) sub-district, Eastern Cape (Fig. 1). The district hospital serves nearly 130,000 people and supports surrounding clinics. Since 2014, TPT has been routinely recommended for people living with HIV and children under ve who are household contacts of patients with TB per South African policy. 8

Study design
This was a baseline qualitative study inform the implementation of a forthcoming, comprehensive TB program. The Consolidated Framework for Implementation Research (CFIR) was used to guide interview development. 9 Standards for Reporting Qualitative Research (SRQR) was used to adhere to reporting guidelines. 10

Sampling and Recruitment
Purposive sampling was used to recruit HCWs directly involved with the TB program. Participants included doctors, professional and enrolled nurses, radiographers, pharmacists/pharmacy technicians, and TB data managers. All participants were over 18 years (Table 1).

Data collection
Interviews took place at the hospital and four referral clinics. Data were collected, con dentially in private o ces, via individual semi-structured interviews lasting 30 to 60 minutes. Interview guide included (Supplement I). Interviews were conducted in English and audio-recorded. Written informed consent was obtained prior to participation. No compensation was provided. Transcription was completed by Lain Transcription and uploaded into Dedoose for coding. 11 Data analysis A deductive content analytic approach was used to code descriptive quotes identi ed through analysis.
The CFIR codebook, including pre-speci ed domains and constructs, was used to guide analysis. Illustrative quotes were subsequently mapped onto the CFIR framework (Fig. 2). Data were reviewed and coded by BvdW and MW. To ensure inter-coder reliability, 20% (n = 4) of interviews were double coded.
Coders discussed discrepancies until consensus was achieved and coders agreed on to which construct a code (or quote) mapped. Subsequent interviews were coded independently. Coders went through codes, by construct, synthesizing barriers and facilitators to implementation ( Tables 2 and 3).

Results
Nineteen participants were interviewed. Interviewees included ten hospital-and nine clinic-based individuals with a total of eight nurses, six doctors, two radiographers, two pharmacists, and one TB data clerk (Table 1). Ages ranged from 20 years to mid 50s.

Results by CFIR Domains and Constructs
Intervention characteristics Design quality and packaging of the intervention: Looking at the 'big picture' and patient-centered design Participants described many topics around design quality and packaging the program well, speci cally having innovative, novel interventions re ecting the needs of patients and providers. Quality documentation for TPT also arose. Currently there are no systems in place to ensure follow up and treatment for individuals on TPT (Line 38) (Supplement 2). Conceptualizing a comprehensive data management system that remains simple and algorithmic is important to overall design of the intervention. This system could be incrementally introduced, until the program is functioning at full capacity (Line 49, 52, 54, 55).
Participants also discussed the need for interventions to be patient-centered. First, to increase adherence, some HCWs recommended providing patients with the full length of treatment upon initiation rather than monthly re lls (Line 50). Also, having the intervention clinic-based rather than hospital-based was suggested as improving success. This would improve feasibility and sustainability as clinics are embedded within communities, closer to patients' homes and provide ongoing patient management (Line 63).
Complexity: Improving capacity at the clinic and community level Similar to design quality and packaging, the complexity of providing TPT and reaching patients at the household-level came up often. For example, access to household contacts is di cult because the burden rests on patients (passive case nding) or strains the health system (Line 13). Once household contacts are identi ed, having a sensitive and speci c algorithm for ruling out TB disease among different populations complicates screening and examinations of contacts. Participants felt it was important to understand who should do certain tasks (i.e. community health workers, nurses, doctors) for program success. Once patients initiate TPT, multifaceted challenges remain. In particular, ensuring patients stay engaged with care and adhere to TPT can be di cult (Line 16). The duration of the intervention (i.e. following each family for at least 12 months), and deciding which clinics and patients to prioritize, were additional complexities discussed (Line 26).

Outer setting
Needs and Resources of those served by the organization: High community needs and few resources Many participants discussed the signi cant needs of the community pertaining to this TB program (Line 166). Some HCWs described the importance of providing community-based education via a TPT campaign ensuring community members understand what TPT is and why it is important (Line 165). Lack of transportation and prohibitive costs of transport was consistently mentioned (167, 168, 169). Additionally, getting TB-exposed community members to clinics was perceived as di cult for many HCWs. (Line 174, 176) Another theme within this domain was the discussion of perceived acceptability of patient engagement. For example, participants felt adolescents and men were hard groups to reach; however, elderly individuals may be easier to engage. Therefore, elders could be enablers and support other family members (Line 177). Other participants felt women and children would be easier to reach than men for TPT (Line 181).
Documentation for TPT was also noted as a resource barrier at both hospital and clinics (Line 183). Participants, especially doctors and pharmacists, noted stock outs of medications were commonespecially in clinics and another barrier to implementation success (Line 186). Implementation climate -relative priority: Survival mode versus sustained momentum Individuals described TB screening programs often lose priority because of the day-to-day " res" many clinicians metaphorically put out (Line 98, 106, 108). Participants mentioned they often function in "survival mode" and adding another program may be too much (Line 99). A TPT program is seen as important until something like COVID comes along and derails momentum (Line 100). Also, some participants noted screening for TB can be overwhelming because it is too big of a problem to tackle (Line 104).
Additionally, the need to shift HCWs perspective on preventing drug-sensitive TB was a theme among some respondents. HIV is taken seriously and seen as a disease to prevent and treat, while TB is less clear. However, some HCWs viewed screening and close follow-up for TPT as feasible and especially urgent for drug-resistant TB (Line 112, 114).
Nevertheless, for the apathy some participants reported, multiple participants brought up the central role nurses should play in TPT delivery. Nurses were thought to be better suited to screen patients for TB than doctors (Line 83) and nurses could improve TB care through TPT if they were motivated, provided with appropriate training, had support from colleagues, and given time to provide patient education (Lines 234, 236, 238).
Readiness for Implementation -Access to knowledge and information: Improved access to information is desperately needed Access to knowledge and information about TPT and how to incorporate it into daily work ows was lacking for many HCWs. They discussed rarely learning about TPT in university, and feeling unprepared to teach others about TPT when they had poor understanding themselves (Line 199,198,200

Characteristics of the individual
Knowledge and beliefs about the Innovation: Give us knowledge and we will disseminate Participants positive attitudes toward, and value placed on, this innovation was commonly discussed. Speci cally, many found it important to educate patients about TB, differentiate between TB infection and disease, and explain why TPT is crucial even when patients are not demonstrably sick (Line 160). Healthcare workers were keen to learn more about TPT and if given su cient training and resources agreed that a systematic implementation approach is needed for success (Line 130, 133,135, 139, 142, 146).
Self-e cacy: In order not to make a mistake, let's not do anything Self-e cacy, or an individual's beliefs in their own capabilities to execute courses of action to achieve implementation goals, 9 varied between different types of HCWs. Some interviews centered around providers -mostly nurses -not wanting to "do anything wrong" and therefore, defaulted to doing very little regarding TPT (Line 272, 274, 275).
Disempowerment and lack of clear TB and TPT policies have often led to suboptimal implementation (Line 277). Despite the lack of self-e cacy discussed, many participants stated nurses and clinics are better suited to lead TPT program implementation because nurses spend more time with patients than doctors, nurses are knowledgeable on current TPT regimens, and they are often more adherent to guidelines than other clinical cadres. Structurally, clinics (staffed by nurses) are also more accessible to patients (Line 281, 280, 279). Currently, nurses seem to be doing the bulk of work around TPT, so providing nurses leadership roles and resources necessary to lead TPT programs could improve its effectiveness (Line 284, 281).

Process
Champions: necessary in the clinic and the community Having champions -both HCW champions as well as community champions (i.e. grandmothers, elders, chiefs) -was discussed as an important puzzle piece to support TPT implementation. One individual said: "nurses are far better at screening than doctors and I know the way our system works here, an intentional TB screen is supposed to happen for every patient. And I think it does happen actually quite well because it's part of the triage process [in the outpatient department at the hospital]." (Doctor, Male, Line 83) The description of nurses being well trained to follow and implement guidelines-when given the resources to do so, being respected and knowledgeable, (Line 191) and having a program that is integrated into a triage process, helps ensure that it gets completed without adding too much additional strain to individuals or the organization. In addition to nurses as being potential champions to successfully launch a TPT program, elders were also thought to be potential champions.

Discussion
Improving HCW knowledge regarding e cacy of TPT is necessary prior to effective implementation of a TPT program. An identi ed enabler was that HCWs have positive attitudes towards learning about TPT effectiveness and how to rule out TB. Providing systematic support through simple and clinically relevant documentation work ows could also enable successful program implementation. Therefore, providing education with high engagement, that is free to access repeatedly, and available at the point-of-care is ideal. 12,13 Finally, ensuring the TB program is nurse-led and clinic-based is important for feasibility, cost, and scalability. 14,15 In summary, participants were enthusiastic, but felt the need for more knowledge, clear guidelines, speci c work ows, and continuous momentum. Table 4 describes next steps for program implementation.  19 Ensuring the program is patient-centered and aligns with the WHO's End TB Strategy Pillar One, which "puts patients at the heart of service delivery" is also important. 20 Guaranteeing patient voices are heard and involved in the design of the program and provided options for TPT (when possible) is an important next step in this context.
Additionally, the availability and need for resources and competing priorities were common barriers discussed. Research in TB and primary care shows that nurses and non-physician clinicians are excellent at following clinical guidelines and they provide quality care in resource constrained settings. 12,[21][22][23][24] The development of algorithms for high-risk individuals, utilizing cascade analyses, have been proven di cult to measure in this setting, which participants discussed as potential barriers. 16-18 However, cascade indicators are being routinely used in TB care, though less in preventive therapy; potentially due to lack of quality reporting mechanisms. [25][26][27][28] Ultimately, shifting the priority from a treatment-focused approach to prevention -in nursing and medical education, and in point-of-care algorithms and documentation systems -is necessary to transform comprehensive TB care. This is especially critical as South Africa has recently released updated guidelines greatly expanding TPT eligibility. 29

Limitations
Interviews were conducted with a limited range of HCWs and limited scope of differing experiences. It would be prudent to further these data with community member and past or current patients with TB input. Finally, reliance on a pre-determined CFIR coding scheme could have led to authors missing pertinent data.

Conclusion
Healthcare workers need increased knowledge regarding TPT prior to implementing a comprehensive TB program; despite positive attitudes and beliefs about TPT. Furthermore, additional resources -time, trainings, and contextualized evidence -to prescribe TPT more broadly. Tangible resources such as suitable documentation systems and funding to administer TPT programming are also critical to sustainability.