An evaluation of the implementation of tuberculosis policies at a regional hospital in the Limpopo Province

Correspondence address: Professor M. Davhana-Maselesele NWU (Mafikeng Campus) P/Bag X2046 Mmabatho 2735 Thé current rate of tuberculosis infections as a result of new infections, as well as re­ infections of patients is of concern to the disease control and policy-making bodies of South Africa. Questions regarding the effectiveness of tuberculosis policies and programmes emerge all the time. This study intended to evaluate the extent to which tuberculosis policies are implemented in a regional hospital in the Vhembe district in the Limpopo Province.

Thé current rate o f tuberculosis infections as a result of new infections, as well as re infections o f patients is o f concern to the disease control and policy-making bodies of South Africa.Questions regarding the effectiveness of tuberculosis policies and programmes emerge all the time.This study intended to evaluate the extent to which tuberculosis policies are implemented in a regional hospital in the Vhembe district in the Limpopo Province.
The study was conducted using a qualitative, descriptive, exploratory and contextual design.A purposive sample o f professional nurses who work in medical wards was selected, and voluntary participation was ensured.Data was collected through individual interviews, which were audiotaped and then transcribed verbatim.The researcher used an observation checklist to find out which policies were available and accessible that dealt with the management o f tuberculosis.
Findings revealed that tuberculosis policies were not available in the medical wards and not accessible on shelves.Participants expressed lack of knowledge about the existing tuberculosis policies.Lack of information was attributed to insufficient policy information dissemination associated with lack of in-service training and reporting mechanisms after workshops.Shortage of treatment was also indicated as a deterrent to effective policy implementation.The conclusion was reached, based on the findings o f the research, that unless there was ongoing monitoring and evaluation o f tuberculosis policies at local clinic level, including hospital level, tuberculosis policies would continue to be talked about at a broader (global) level without the focus on implementation at grassroots level.Strategies should be put in place to encourage professional nurses' ownership o f policies.

Introduction
Tuberculosis (TB) is a communicable, potentially deadly disease that usually affects the lungs, but can also affect other parts o f the body.It spreads through droplet infection when a person with active TB breathes out bacilli, which are then in h aled by an o th er person.Tuberculosis is treatable and usually curable, although new drug-resistant strains are appearing that are difficult to treat.It is vital that TB patients follow their treatment regimen faithfully and take all medication as directed, for as long as directed, or the disease can recur in a drug-resistant form (DOH, 2003:3).
Tuberculosis remains one of the leading infectious diseases and causes illness and death worldwide.Each year, about nine million people around the world succumb to TB infection.The World Health Organization (WHO) declared TB a global emergency in 1993 in recognition of the growing importance o f TB as a public health problem.In 2004, there were an estimated 8, 9 million new cases of TB, o f which approximately 3.9 million cases were sputum -sm ear positive, the most infections form o f the disease.Tuberculosis alone is responsible for close to 2 m illion deaths per year worldwide.Most of the TB burden occurs among the low-income countries o f the world, particularly those in South-East Asia and Sub-Saharan Africa, where TB is o ften asso ciated w ith Hum an immunodeficiency virus (HIV) infection (DOH, 2003:2).
Initially there were specialised TB hospitals, such as the South African National TB Association (SANTA).In a recent study conducted by Heunis, Van R ensburg and M eulem as (2007:4) regarding patients' experience of SANTA versus public hospitals in the Free State; it was found that patients preferred public hospitals.Some of the reasons stated had to do w ith the long periods o f hospitalization at SANTA, having little privacy and limited opportunity to either express th eir cu lture or engage in re cre atio n during long m onths o f incarceration.It was therefore clear from the study that public hospitals and professional nurses would remain the core contact between TB patients and their treatment.There are several w ell-docum ented factors fuelling the outbreak, including: high treatm ent interruption rates o f drugs-sensitive TB and consequent low cure rates, to g eth er w ith the HIV ep id em ic, lack o f aw areness and education amongst people with regard to TB, have contributed to the emergency of multi-drug resistant (MDR-TB) and extrem e-drug resistant tuberculosis (XDR-TB).MDR-TB is tuberculosis that is resistant to at least two of the most commonly p rescrib ed m ed icatio n s, nam ely, rifampcin and isonized (Mvusi, 2007:4).This emergence could have served as an opportunity for people to learn more about this aspect of TB.Unfortunately, this was not given serious attention it deserved.It was only in 2006 with reports on the emergence of XDR-TB that people began to take interest Mvusi (2007:4).XDR-TB is MDR-TB plus resistance to at least three o f the six classes of secondline agents (Mvusi, 2007:4).
Recently MDR-TB and XDR-TB have been posing new threats to regional and global public health.The situation has been further exacerbated by reports that XDR-TB was now considered endemic in KwaZulu Natal (KZN), as it has been re p o rted in at least 39 hospitals throughout the province.Thirty new cases of XDR-TB are reportedly detected each month in KZN alone (Singh, Upshur & Padayatchi, 2007:116).In September 2006, WHO announced that a deadly new stream o f extreme (XDR-TB) had been detected in Tugela Ferry a rural town in the province of KZN.According to the study conducted by Singh et al (2007:115) of the 544 patients studied in the area in 2005, 221 had MDR-TB.O f these 221 cases, 53 were identified as XDR-TB, This reportedly represents almost one sixth of all known XDR-TB cases reported worldwide.In fact, it could be said that the em ergence o f X DR-TB is the evidence o f the systemic failure o f the global community to tackle a curable disease (Singh et al., 2007:116).
At the centre of TB management are nurses working either in hospitals or in primary health-care settings who should implement policies that are aimed at addressing TB.While efforts to move towards an integrated approach were highlighted and reinforced by National TB Control Policy (NTCP,) guidelines, the process did not tackle the question of how to re-orientate a system based on specialised TB hospitals to an integrated approach w here nurses in g eneral hospitals would be responsible for the care of TB patients.The process sidelined the role o f hospital nurses and rather put emphasis on the role of the district health system.It is therefore necessary to include nurses in the evaluation o f TB policies im plem entation.This study sought to evaluate the extent to which TB p o lic ie s are im plem ented by professional nurses at a regional hospital in the Vhembe district of the Limpopo Province.Although the NTCP, MDR-TB and XDR-TB policies are available in South Africa (SA), there is very little co n tex tu al evalu atio n o f its implementation.This study provides evidence o f the extent to which the policies are implemented from the point o f view o f the professional nurses in medical wards o f a regional hospital.

Problem statement
WHO report (2007) states that SA has the third highest TB epidemic on the continent for 2005 after Nigeria, Ethiopia, India and China.South Africa reports more than 100 000 TB cases yearly.This is an incidence rate of more than 500/100 000 population.

Purpose of the study
The p u rp o se o f this study was to evaluate the extent to which TB policies are implemented by Professional Nurses in a medical ward in a regional hospital in the Vhembe District o f the Limpopo Province.

Objectives
The objectives o f this study were to: • assess the availability, accessibility and utilisation of TB policies in the medical wards; • explore the extent to which TB policies are implemented from the point o f view of the professional nurses working in medical wards.

Design
The n atu re o f the research was qualitative, explorative, descriptive and contextual (Polit & Hungler, 1996:175,640 & 651).The study was explorative in that it intended to scrutinize and explore the in-depth richness and complexity, o f the extent o f implementation of TB policies by professional nurses working in the medical wards.The study was conducted within the context o f a public hospital's general medical ward.

Population and sampling
The sample hospital was selected from am ong the to tal num ber o f seven hospitals in Vhembe District.Purposive sampling was applied.All community hospitals transfer patients to a regional hospital for further management.The selected hospital is the only regional hospital within Vhembe District.More than ten professional nurses in each medical ward fitted the criteria.However, only those who volunteered to participate in the study actu a lly p articip ated .P rofessional nurses w ho had been working in medical wards for more than a year were chosen.
The sample size was determined by data saturation (Polit & Hungler, 1996:238), that is to the point where no new information was obtained and redundancy o f inform ation w as achieved.Data saturation was reached after having interviewed 12 participants.In addition, those wards that had professional nurses participating in the study also provided the setting in which an observational checklist was used to answer some of the research questions and to validate some responses that participants had given.

Data collection
Data collection was done through the use of individual interviews, field notes and a checklist.(M orse & Field 1996:913, Wilson, 1993:222).

Ethical considerations
Permission to conduct the study was sought and obtained from the Research E thics C om m ittee o f the Lim popo Provincial Department o f Health and Social Development, Vhembe district Health Department and the regional hospital.The rights of the participants were protected and confidentiality and privacy were maintained (Bums & Grove, 1993:99).The names o f the participating professional nurses were not recorded during interviews.Each professional nurse who completed the consent form was informed about the aims and the processes of the study.Permission was sought to record the interv iew s.P articip atio n was v o lu n tary and co n fid en tial and the nu rses w ere informed about their freedom to withdraw from participation at any time.They were also informed that the information gained from the study was purely for research purposes and that it would not be used against them.The checklist and the broad interview question were provided so that they could evaluate whether it would be in their interests to participate (Polit & Hungler, 1997:137).

Data analysis
The researcher analysed data using Tesch's method (Creswell, 1994:154) of open coding, while constant comparison was employed to analyse the checklist data.Topics were abbreviated as codes and these were w ritten next to the appropriate segments of the text.Related topics were grouped together to reduce the list o f sub-themes.The identified m ajor themes and sub-them es were coded and ca teg o rised (C resw ell, 1994:154).A final decision was then taken regarding the wording for each theme.D ata belonging to each them e was assem bled as presented in the table (Creswell, 1994:154).
Four themes emerged from the data collected by the various means, i.e. observational checklist, interviews and field notes.Items from the checklist were compared with those of the other sources o f data to establish common themes.Table 1 gives an outline o f the themes that emerged.

Policy utilisation
Judgment regarding TB policy utilisation by professional nurses in the medical wards was made against the criteria of availability, accessibility, and knowledge o f professional nurses regarding and what is contained in the current TB policy documents and where they are to be found, and the presence of monitoring and evaluation mechanism.These are discussed as follows: Unavailability and inaccessibility of TB p o licies leading to in su fficien t information regarding existing TB policies in the medical wards.Upon visiting the wards, the researcher noticed that in most of the medical wards, there were no TB policies available.However, professional nurses appeared to know about the existence o f such policies, but admitted that they never really read them or seen them except at a workshop or seminar.These are some of the responses by p artic ip a n ts that evidenced the unavailability o f TB policies in the ward: "There is no TB policy.Maybe it is in the deputy manager s office "I have not seen it before but I heard about it when I attended the TB workshop." Another p artic ip a n t: "Is only those who underwent TB training who have access to TB policies and information on how to implement the policies." "I only know the N a tio n a l Tuberculosis C ontrol Programme." Participants also raised their concern about insufficient information related to existing TB policies.What seems to be the trend in the ward is an itemised protocol or standing orders for TB p atien ts that p rofessional nurses followed while taking care of the patients.These practices did not really encourage them to seek to understand and refer to the actual policy.It appeared that professional nurses who participated in the study relied on those standing orders or TB protocol and also on what they gathered from a workshop or seminar about TB.The unavailability o f TB policies on shelves and the response of participants led one to conclude that TB policy documents were inaccessible in the medical wards where TB patients were usually admitted.This raised the question o f whether it could be trusted that professional nurses had enough knowledge at their disposal regarding the TB policies, its rationale, processes and what it set out to achieve or address.The following quotations revealed a worrying practice: As one participant said, "It is assumed that we know about these policies, but there is no policy, I have not seen the actual policy.." Another participant said, "The policies sh o u ld be fa m ilia r is e d to every professional nurses; newly appointed nurses must be oriented." According to Maher (2003:2), NTCP in most countries have concentrated on promoting access to effective TB care.It should be easily accessible to the staff members who are managing TB patients for reference purposes as the policy acts as a guideline when executing duties.In this regard, one would therefore start questioning the im plementation o f a p olicy that is u n av a ila b le and inaccessible to the user.The other theme that emerged entailed problems relating to lack of knowledge o f the existing TB policies regarding TB management which shall now be discussed.Andi (2005:3) indicates that one of the challenges in SA is inaccurate recording and lack of sharing of TB notification data.This statement implies in essence that there is poor reporting, not only in this hospital but to such extent that is a recognised problem in the country.

• Lack of interest and commitment
The participants indicated that there was lack o f interest and commitment on the part of some of the professional nurses concerning the implementation o f TB policies.In each medical ward there were nurses who attended TB workshops and they w ere the ones to carry all the responsibility o f TB patients in the medical wards, but they were not doing so.The following statement evidenced this: "Patients referred to the hospital fo r collection o f treatmentfrom the clinic are also returned or lodged in the ward without treatment because the TB nurses were not around.They will be given treatment on the following day when the so-called "TB nurses " will be around, this was done by the professional who attended the workshop but never knows anything about the TB regimen." "I think maybe it is because TB is infectious; that is why some nurses are not interested." Participants recommended that it was necessary to check the interest of staff members before sending them for a workshop.
A ccording to A chm at and R oberts (2005:20), the 2004, South African Health Review suggests some o f the things that contributed to failure to implement NTCP as "lack o f TB management capacity, p o o r TB m anagem ent system s and inadequately trained and motivated staff at district level".

Shortage of TB drugs which contributed to poor compliance
Participants reported concern regarding the shortage of TB drugs at the clinics and sometimes in the hospital setting, as w ell as lack o f D irectly O bserved T reatm ent S hort course (D O TS) supporters.One cannot address lack of TB treatment and separate it from the DOTS supporters.It was indicated that som etim es p atien ts d efau lted on treatment due to shortage o f TB drugs in the clinic setting.The DOTS supporters could assist p atien ts to follow up treatm ent before it was com pletely finished.Participants indicated that patients were coming back to the hospital to collect treatment instead of collecting it at the clinics.The following statement evidenced this: "Shortage ofTB drugs is the main problem that makes patients to default treatment." "Patients still come back to the hospital, fo r collection o f treatment which is something we do not expect.This is so because patients explain to nurses at the hospital that there is no treatment at the clinic." "Patients from several areas reported that when they w a n ted to co llec t treatment in their local clinics there were no TB treatment." In the study conducted by Achmat and Roberts (2005:11) it was also stated that the South African TB control programme was hindered by a rigid implementation o f the TB g u idelines, and also by inadequate TB facilities.The health-care facilities were ill equipped to implement the NTCP properly.
According to Collins, Andrew and Newell (2002:7) and Nhiwatiwa and Sepitla (2004:298), when drug supplies are interrupted, patients are likely to default or take only some of the drugs required for cure.This leads to recurrence o f the disease and possible drug resistance with wider implications.It is further indicated that poor provision o f drugs has been the great weakness o f TB program m es.Again there is central procurement, which is often poor, and distribution to the periphery, which is weak.
DOTS is practised in the belief that by directly observing the patient consume all required medication, a full treatment regimen will be ensured, thereby reducing the risk o f treatment failure (Nazar-Stewart and Nolan, 1992:58).
The DOTS strategy has proved to be more cost effective than conventionally delivered treatment for the treatment of new cases of TB in adults in SA (RSA, 2003(RSA, /2004)) Since the participants indicated that TB smear-positive patients were admitted at the ward for a short period and then further said that patients were nursed in the com m unity, taking treatm ent supervised by the DOTS supporters, therefore there is a need for DOTS supporters to be trained in large numbers.
Lack o f m onitoring and evaluation m echanism s associated w ith overcrowded and busy medical wards as opposed to specialized care in a TB ward When visiting the ward, the researcher asked questions regarding the monitoring and evaluation strategy.It was ev id en t from the response o f participants that no m onitoring and ev a lu a tio n plans w ere in place.Participants indicated that there were no p erio d ic review s on TB policy implementation except statistics, as the patients were defaulting on treatment.Interestingly, participants' response also assum ed that the responsibility for monitoring and evaluation was that of either the government or management.This raised question of policy ownership betw een policy m akers and policy implementers.
Some o f the statements from participants were: " Up to now evaluation is not done.The government must also revise their policies and must make sure that policies are evaluated in the hospitals.They must notjust write the policies and leave them as they are.When policies are in place they should be reviewed.'' "It seems as i f in my knowledge there is nobody who is responsible f o r TB policies im plementation evaluation.They must do something fo r TB.When we were having TB wards they were being monitored very well." In addition some participants felt that monitoring and evaluation was not done according to policy because TB patients were nursed with any other patients.The follow ing quotations evidence this: "Medical wards are full.One is supposed to attend to patients suffering from diabetes mellitus, heartfailure and other medical conditions, maybe that is why there is lack o f m onitoring and evaluation." "Patients who are suffering from TB are s till p la c e d with p a tien ts who are suffering from diabetes mellitus whose im m unity is low ered and other conditions with low ered resistance.These patients may easily get infected with TB." Participants further stated that, "in the medical wards where nurses are ca rin g f o r p a tie n ts with d iffe ren t diagnoses, they are unable to concentrate on TB patients only." It is important to have a separate TB ward fo r only TB patients unlike combining TB p a tien ts with D iabetic, cardiac conditions and Hypertensive patients "The issue o f phasing out TB wards crea ted p ro b lem s.This sh o u ld be revisited again ".
One o f the participants said: "I think the government should ensure that there is a TB ward specifically fo r TB patients and special nurses who are trained to deal with TB.Then it will be easier to monitor TB policies implementation ", A ccording to De Villiers and Toms (2004:213), policies, guidelines, indicators and monitoring mechanisms are in place, but are inconsistently applied.However the hospital should have in place review mechanisms and have some ownership of policy implementation.This would promote quality patient care, when there is programme ownership at grassroots level, involvement o f staff at grassroots will be o f great value as nurses are re sp o n sib le in im plem enting the programme.
The monitoring system is supposed to be district based according to WHO and then send quarterly reports up to the central programme (WHO 2001:9;WHO: 2004;Schneider, Lush & Ogden 2003:18).Bamford, Loveday and Verkuijl (2002) indicated that there are po licies, guidelines, indicators and monitoring tools that are in place, but are inconsistently applied.It was further stated that th ere w as also lack o f continuous monitoring of policies; these findings correspond with the research result that was done at the Mumbai, policy analysis and TB (Rangan & Porter, 2003: 6).In addition the study conducted by (Andi 2005: 3) revealed that there was lack of capacity at central level to monitor and supervise district programs.
Participants indicated that TB patients are not nursed accordingly as there is absence o f dedicated staff to deal with TB and therefore, policy implementation and monitoring will not be possible.

Recommendations
Discussion on recommendations focused on two areas; namely to improve practice and for further research.

Recommendations to improve practice
There should be policy files available in the w ards for re fere n ce purposes.Policies should be communicated to all staff.Since staff at grassroots level have to implement the policies immediately they become available, they should be familiarized with the existing policies, the content o f the policies and also how to im plem ent them .Initial orientation regarding TB policies and training of all health-care workers including students should be done and contin u in g d iscu ssio n s should take place.Professional nurses' skills should be continually updated through formal courses, workshops, in-service training conferences, seminars and symposia in order to improve their level of knowledge about TB policy management.Enough treatment drugs should be ordered from the drug suppliers.C om m unication between drug distributors and clinic/ hospital/provincial stores is essential.Each clin ic sh ould m aintain an uninterrupted supply o f essential TB drugs.To ensure continuity DOTS supporters should be trained in large numbers and given support at all times.The patient should be told about the in v olv em en t o f DOTS during h o sp ita lisa tio n , and that it should continue during the transfer period and into the community.
It is necessary that there should be evaluation mechanisms in place to assess the effectiveness o f every programme.However, when the mechanisms are in place the responsibility should be with the end-user together with the policy makers.Jointly they can determine the strengths and the weaknesses o f the policy and come up with strategies as to how best TB policies could be made more effective.
Inform ation dissem ination on policy implementation is required as it was clear that most o f the policies are written and on the other hand those who have to implement those policies are not informed about the application; therefore are not know n by th e h ealth w orkers at operational level.
Monitoring and evaluation tools should be developed and implemented at ward level.A w orking m onito rin g and evaluation co m m ittee should be established to ensure that this area of responsibility is allocated to a specific group of professional nurses who should be trained to do that effectively.These responsibilities could be rotated among different professional nurses to empower all staff members in this area

Recommendations for Research
Broader scientific research needs to be conducted, to identify other problems in connection w ith the TB policy im plementation at local level in the Limpopo province.It is also necessary that all policies that are related to patient's management need extensive scientific study to challenge their effectiveness and to monitor and evaluate th eir effectiv en ess.M ore research studies are required on policy analysis and utilization.

Table 1 Summary of themes and sub-themes regarding implementation of TB policies
the ward patients are turned back.So le t' s train more nurses or everybody must be trained."Whilein-service training and workshops were identified as the main mechanism for g o v ern m en t to share p olicy