Health workers compliance and practices with guidelines for clinical screening of pulmonary tuberculosis in Mufulira district, Zambia Africa.
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BACKGROUND: Tuberculosis (TB) has re-emerged as a major and global public health problem with a third of the world’s population infected with Mycobacterium tuberculosis, the causative agent. Approximately eight million new cases and two million deaths occur annually due to TB. Globally and indeed at country level the only effective way of enhancing quick recovery from TB in through prompt but effective treatment supported with early identification of cases. Early detection of pulmonary tuberculosis (PTB) cases is based on high index of suspicion and good clinical screening skills by health workers. OBJECTIVE: The global of the project was to determine the level of knowledge and practices of health workers in clinical screening of pulmonary tuberculosis in the out patient department and implement interventions to improve PTB clinical screening in mufulira district. RESEARCH QUESTION: What is the level of knowledge of health workers in clinical screening of OPD attendees for pulmonary tuberculosis (PTB) in mufulira? What is the degree of adherence of health workers to world health organizations PTB clinical screening guidelines? What practices are exhibited by health workers in clinical screening of OPD attendees for PTB? What interventions can improve clinical screening of OPD attendees for PTB? DESIGN: The study used a quasi-experimental design and the performance improvement approach was used throughout the study (Defining the institutional context, getting and maintaining the stakeholder agreement, performing a needs assessment, determining performance gaps, pilot testing of instruments, conducting a root cause analysis with all the stakeholders (phase one) and testing of theories (validating), designing and implementing interventions (phase two) and phase three being the monitoring and evaluating of the effects of the intervention. METHODS: The study used both quantitative and qualitative data collection methods. Tools for data collection included interviews with health providers and observations. STUDY POPULATION, SIZE AND SETTING: All clinicians at the two health facilities (clinic one and kamuchanga district hospital) were the study was conducted were included in the project. Fifteen health providers were monitored in the study. Six observations were conducted for the same staff before and after interventions. Compliance was calculated if health provider failed only once or not at all out of the six observations. This meant applying all the guidelines during a clinical screening session with an out-patient department (OPD) attendee. The level of knowledge in PTB clinical screening, practices and adherence to clinical screening guidelines were assessed pre and post intervention. Factors that contributed to low adherence to clinical screening guidelines for PTB were also identified. MAIN FINDINGS: The study showed that health providers had inadequate knowledge on clinical screening guidelines of OPD attendees for PTB, while adherence was as low as 6.6%. The practices in clinical screening of OPD attendees for PTB were below the required standard. Some of the factors leading to non-compliance to guidelines were lack of supervision (specifically for clinical screening), inadequate feedback on performance of clinicians, unavailability of guidelines and lack of orientation in clinical screening of PTB. The key result areas were that guidelines which were not available for clinical screening skills were developed and supportive supervision strategies formulated, supported by orienting individual clinicians and giving feedback on their performance, included but not limited to; o Increasing level of knowlwdge among health workers from 20% to 53% o Increasing level of adherence from 6.6% to 53.3% Improving practices in terms of communication between clients and providers Notwithstanding, individuals showed both an increase in knowledge and improvement in practices even though they did not attain the standards set in the study. MAIN CONCLUSIONS ANS RECOMMENDATIONS: This study shows that it is possible for provider performance to improve dramatically provided that they are given support and that management sustains the interventions. Quality assurance and performance improvement strategies are promising, but need to be integrated into the daily functioning of the health facility to ensure sustainability, and they need to be linked to facility-wide human resources management activities. Post data collection was delayed for almost a year due to providers demanding that they be paid allowances for being observed, centrally to research ethics. A detailed study may be required to find out ways of sustaining both higher knowledge levels and good practices over a long period of time in a district which perceives remuneration as a priority against skill development and quality of health care.