ABSTRACT

Objective

To describe health care workers' practical recommendations for strengthening adherence to Mycobacterium tuberculosis infection control practices in their health institutions and elsewhere across the Dominican Republic.

Methods

In this qualitative study, 10 focus groups, with a total of 40 clinicians (24 physicians, 16 nurses), were conducted in 2016 at two tertiary-level institutions in the Dominican Republic. Grounded theory guided the analysis to expand on health care workers' recommendations for empowering clinicians to adhere to M. tuberculosis infection control practices. To ensure reliability and validity, the authors analyzed data and incorporated both peer debriefing with qualitative experts and participant feedback or validation on the final themes.

Results

Six emerging themes were described: 1) education and training; 2) administrative policy; 3) infrastructure policy; 4) economic allocations; 5) research; and 6) public health policy.

Conclusions

Future efforts may combine the health care workers' recommendations with evidence-based strategies in M. tuberculosis infection control in low-resource settings. This could pave the way for interventions that empower health care workers in their application of M. tuberculosis infection control measures in clinical practice.

Keywords
Focus groups; grounded theory; health personnel; infection control; disease transmission; infectious; Mycobacterium tuberculosis; occupational exposure; Dominican Republic

RESUMEN

Objetivo

Definir las recomendaciones prácticas de los trabajadores de salud para consolidar la adhesión a las prácticas de control de la infección por Mycobacterium tuberculosis en instituciones de salud y otros lugares de la República Dominicana.

Métodos

En este estudio cualitativo, se organizaron 10 grupos de debate, con un total de 40 trabajadores clínicos (24 médicos, 16 enfermeras), en dos instituciones de nivel terciario de la República Dominicana en el 2016. El análisis para ampliar las recomendaciones de los trabajadores de salud a fin de estimular a los trabajadores clínicos a adherirse a las prácticas de control de la infección por M. tuberculosis se basó en teoría fundamentada. Para garantizar la fiabilidad y validez de los resultados, los autores analizaron los datos e incorporaron el asesoramiento sobre el diseño y el análisis del estudio a cargo de expertos cualitativos y la verificación de la información con los participantes sobre los temas finales.

Resultados

Se encontraron seis temas emergentes: 1) educación y capacitación; 2) política administrativa; 3) política de infraestructura; 4) asignaciones económicas; 5) investigación; y 6) política de salud pública.

Conclusiones

En iniciativas futuras para el control de la infección por M. tuberculosis en entornos de escasos recursos, se pueden combinar las recomendaciones de los trabajadores de salud con estrategias basadas en evidencia. De esta forma se podría allanar el camino para llevar a cabo intervenciones que ayuden a los trabajadores de salud a aplicar las medidas de control de la infección por M. tuberculosis en la práctica clínica.

Palabras clave
Grupos focales; teoría fundamentada; personal de salud; control de infecciones; transmisión de enfermedad infecciosa; Mycobacterium tuberculosis; exposición ocupacional; República Dominicana

RESUMO

Objetivo

Descrever as recomendações dos profissionais da saúde para reforçar a adesão às práticas de controle de infecção por Mycobacterium tuberculosis nas instituições de saúde e outros locais na República Dominicana.

Métodos

Estudo qualitativo realizado com 10 grupos de discussão, ao todo 40 profissionais da área clínica (24 médicos, 16 enfermeiros), em duas instituições de nível terciário na República Dominicana em 2016. A análise foi baseada em teoria fundamentada para expandir as recomendações dos profissionais da saúde a fim de habilitar o pessoal da área clínica a aderir às práticas de controle da infecção por M. tuberculosis. Para assegurar a confiabilidade e a validade dos dados, os autores analisaram as informações e incluíram um processo de revisão com especialistas em pesquisa qualitativa (peer debriefing) e observações ou validação dos participantes sobre os temas finais.

Resultados

Seis temas emergentes foram descritos: 1) educação e capacitação, 2) política administrativa, 3) política de infraestrutura, 4) alocações financeiras, 5) pesquisa e 6) política de saúde pública.

Conclusões

Iniciativas futuras podem combinar as recomendações dos profissionais da saúde com estratégias baseadas em evidências para o controle de infecção por M. tuberculosis em locais com poucos recursos. Isso poderia abrir o caminho para intervenções que habilitam os profissionais da saúde a empregar medidas de controle de infecção por M. tuberculosis na prática clínica.

Palavras-chave
Grupos focais; teoria fundamentada; pessoal de saúde; controle de infecções; transmissão de doença infecciosa; Mycobacterium tuberculosis; exposição ocupacional; República Dominicana

Health care workers (HCWs) have an increased risk of Mycobacterium tuberculosis infection in their clinical workplace. For HCWs, when compared to the general population, the estimated annual incidence rate ratios range from 1.4 to 5.4 in tuberculosis (TB) incidence regions with low TB incidence (< 50 cases/100 000 population), intermediate TB incidence (50–100/100 000 population), and high TB incidence (> 100/100 000 population) (¹1. Baussano I, Nunn P, Williams B, Pivetta E, Bugiani M, Scano F. Tuberculosis among health care workers. Emerg Infect Dis. 2011;17(3):488–94.). The provision of clinical care to TB patients, including those undiagnosed or noncompliant to recommended treatment, coupled with inadequate infection control practices in the health institution, can increase HCWs' occupational risk of M. tuberculosis infection or disease (²2. von Delft A, Dramowski A, Khosa C, Kotze K, Lederer P, Mosidi T, et al. Why healthcare workers are sick of TB. Int J Infect Dis. 2015;32:147–51., ³3. Menzies D, Joshi R, Pai M. Risk of tuberculosis infection and disease associated with work in health care settings. Int J Tuberc Lung Dis. 2007;11(6):593–605.). In order to safeguard the health and well-being of front-line HCWs in their clinical practice, the existence and application of robust M. tuberculosis infection control policies are essential to reduce risk of nosocomial TB transmission among HCWs or patients. Furthermore, it is important to understand HCWs' perceived risk of susceptibility, knowledge about M. tuberculosis epidemiology and burden on population health, and routine application of infection control measures in clinical practice (²2. von Delft A, Dramowski A, Khosa C, Kotze K, Lederer P, Mosidi T, et al. Why healthcare workers are sick of TB. Int J Infect Dis. 2015;32:147–51., ⁴4. Jensen PA, Lambert LA, Iademarco MF, Ridzon R, CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005;54(RR-17):1–141.).

With more than 90% of TB deaths occurring in low- and middle-income countries, many health systems are challenged to implement international guidelines in TB prevention and control published by the World Health Organization and the United States Centers for Disease Control and Prevention (⁵5. World Health Organization. Guidelines for the prevention of tuberculosis in health care facilities in resource limited settings. Geneva: WHO; 1999., ⁶6. TB CARE I. International standards for tuberculosis care. 3rd ed. The Hague: TB CARE I; 2014.). HCWs may be unable to consistently adhere to these hierarchy-level practices in health care service delivery (⁵5. World Health Organization. Guidelines for the prevention of tuberculosis in health care facilities in resource limited settings. Geneva: WHO; 1999.–⁷7. Pai M, Kalantri S, Aggarwal AN, Menzies D, Blumberg HM. Nosocomial tuberculosis in India. Emerg Infect Dis. 2006;12(9):1311–8.). These practices include: 1) administrative controls (e.g., implementing TB infection control plan; completing TB risk assessments); 2) environmental controls (e.g., controlling airflow in rooms; ensuring appropriate ventilation to remove contaminated air); and 3) respiratory protection (e.g., using protective masks for HCWs and patients; training patients about proper cough etiquette). These inconsistencies in applying scientific knowledge to clinical practice in infection control, sometimes described as the “knowledge–action gap,” may stem from barriers within the health provider or health system, and may impact service delivery (⁸8. Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bull World Health Organ. 2004;82(10):724–32.), requiring significant attention in TB prevention and control initiatives.

In 2016, the Dominican Republic Ministry of Health (MoH) documented intermediate TB incidence (60/100 000), multidrug resistance (2.9% in new cases; 34% in previously treated cases), and TB-HIV coinfection incidence (14/100 000) (⁹9. World Health Organization. Tuberculosis country profile: Dominican Republic, 2016. Geneva: WHO; 2017.). Like in other low- and middle-income countries, in the Dominican Republic, health leaders face challenges that sustain hospital and community TB transmission. These challenges include social stigma that propagates myths, financial burdens for TB patients and families (¹⁰10. Mauch V, Melgen R, Marcelino B, Acosta I, Klinkenberg E, Suarez P. Tuberculosis patients in the Dominican Republic face severe direct and indirect costs and need social protection. Rev Panam Salud Publica. 2013;33(5):332–9.), overcrowded living conditions in urban areas and in rural settings saturated by sugarcane plantation (batey) communities of Haitian immigrants or persons of Haitian descent (¹¹11. Suiter SV. Community health needs assessment and action planning in seven Dominican bateyes. Eval Program Plann. 2017;60:103–11.), and high levels of multidrug resistance and TB-HIV coinfection (⁹9. World Health Organization. Tuberculosis country profile: Dominican Republic, 2016. Geneva: WHO; 2017.). However, the annual TB budget was US$ 15 million in 2017, with 65% from domestic funds, 19% from international sources, and 17% as unfunded (⁹9. World Health Organization. Tuberculosis country profile: Dominican Republic, 2016. Geneva: WHO; 2017.). This budget provides support for the National Tuberculosis Program (NTP) initiatives at local and national levels, such as health educational campaigns (e.g., school programs, community events), social programs (e.g., nutrition supplements, financial subsidies), and directly observed treatment, short-course (DOTS) management.

To date, three studies have reported on the occupational risk of M. tuberculosis in tertiary-level health institutions in the Dominican Republic. One descriptive study, by the Dominican NTP, documented the scope of TB disease in 111 HCWs (39 nurses, 20 janitorial staff, 13 physicians, 7 laboratory personnel, 6 maintenance staff, 4 administrators, 1 dentist, and 21 persons of unknown job category) employed at 49 tertiary-level health institutions between 2005 and 2012 (¹²12. Genao M, Rodríguez A. Prevalencia de enfermedad tuberculosa en trabajadores de salud a nivel nacional, República Dominicana, 2005–2012. In: Ministerio de Salud Pública y Asistencia Social. Programa National de Tuberculosis. Investigación operativa en tuberculosis, 2011–2013: dossier de investigaciones. Santo Domingo: MISPAS; 2013:195–205.). Subsequently, two published qualitative studies examined adherence to M. tuberculosis infection control practices among HCWs in two tertiary-level health institutions in the Dominican Republic (¹³13. Chapman HJ, Veras-Estévez BA, Pomeranz JL, Pérez-Then EN, Marcelino B, Lauzardo M. Perceived barriers to adherence to tuberculosis infection control measures among health care workers in the Dominican Republic. MEDICC Rev. 2017;19(1):16–22., ¹⁴14. Chapman HJ, Veras-Estévez BA, Pomeranz JL, Pérez-Then EN, Marcelino B, Lauzardo M. The role of powerlessness among health care workers in tuberculosis infection control. Qual Health Res. 2017;27(14):2116–27.). The authors of the latter two studies employed a grounded theory approach to first identify barriers to HCWs' consistent use of recommended M. tuberculosis infection control practices. Using semi-structured interviews with HCWs, the authors identified five barriers, which were categorized as either intrinsic factors (sense of invincibility of HCWs, personal beliefs of HCWs related to direct patient communication) or extrinsic factors (low provider-to-patient ratio at institutions, absence of TB isolation units for patients within institutions, limited availability of protective masks for HCWs). Then, the authors facilitated focus group discussions with HCWs to further explore how each identified barrier influenced the HCWs' decision-making process in M. tuberculosis infection control practices, resulting in the development of a theoretical model.

Empowering HCWs to adhere to M. tuberculosis infection control measures in clinical practice and establish intersectoral collaborations with primary-, secondary-, and tertiary-level health institutions is indispensable to maximize TB prevention and control efforts and end TB transmission in high-risk population groups. In this qualitative study, we describe HCWs' practical recommendations for improving adherence to M. tuberculosis infection control practices in their health institutions and across other entities in the Dominican Republic.

METHODS

Setting and sample

During May 2016, a qualitative study was conducted to examine HCWs' recommendations for strengthening HCWs' adherence to M. tuberculosis infection control practices in their health institutions and elsewhere across the Dominican Republic. Two tertiary-level health institutions, in the cities of San Pedro de Macorís (Hospital A) and Santiago de los Caballeros (Hospital B), were selected, based on the MoH's report of high TB caseloads and established medical training programs in primary care and emergency medicine. In these two institutions, a purposive sample of 40 clinicians (24 physicians, 16 nurses) in emergency, family, and internal medicine specialties participated in 10 focus group discussions, of the same sex and occupation to minimize potential power dynamics (¹⁵15. Barbour RS. Making sense of focus groups. Med Educ. 2005;39(7):742–50.). Inclusion criteria were clinicians with full-time employment and who had completed at least one year of postgraduate medical specialty (physicians) or nursing training (nurses).

Procedure

Using a semi-structured interview guide, the first author (HJC) employed 13 questions to elaborate on five barriers identified from previously published studies (¹³13. Chapman HJ, Veras-Estévez BA, Pomeranz JL, Pérez-Then EN, Marcelino B, Lauzardo M. Perceived barriers to adherence to tuberculosis infection control measures among health care workers in the Dominican Republic. MEDICC Rev. 2017;19(1):16–22., ¹⁴14. Chapman HJ, Veras-Estévez BA, Pomeranz JL, Pérez-Then EN, Marcelino B, Lauzardo M. The role of powerlessness among health care workers in tuberculosis infection control. Qual Health Res. 2017;27(14):2116–27.), eliciting the clinicians' practical recommendations for improving adherence to M. tuberculosis infection control practices. Interview probes were used to clarify responses (¹⁶16. Bernard HR. Research methods in anthropology: qualitative and quantitative approaches. 5th ed. Lanham, Maryland: AltaMira Press; 2011.). The first author directed each focus group discussion, which was digitally recorded. Ranging in length from 45 to 60 minutes, the gatherings were held in a vacant conference room within the institution. These sessions allowed participants to reflect on the phenomenon (e.g., M. tuberculosis infection control measures) and discuss similar or conflicting viewpoints (¹⁷17. Krueger RA. Focus groups: a practical guide for applied research. Beverly Hills, California: Sage; 1988.), based on recommendations to strengthen M. tuberculosis infection control practices. With their respective medical or nursing training, participants shared similar experiences yet exhibited sufficient diversity to facilitate group interactions (¹⁷17. Krueger RA. Focus groups: a practical guide for applied research. Beverly Hills, California: Sage; 1988., ¹⁸18. Kidd PS, Parshall MB. Getting the focus and the group: enhancing analytical rigor in focus group research. Qual Health Res. 2000;10(3):293–308.). After each session, the first author prepared field notes from jottings about interactions with HCWs and daily logs of institutional activities (¹⁶16. Bernard HR. Research methods in anthropology: qualitative and quantitative approaches. 5th ed. Lanham, Maryland: AltaMira Press; 2011.). To compensate them for their time, participants were provided a small assortment of office supplies. When no new information emerged from data collection, saturation was reached and data collection ceased (¹⁹19. Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. Los Angeles: Sage; 2006.).

Data analysis

All interview data and field notes were transcribed verbatim in Spanish, de-identified for confidentiality, and confirmed by the second author (BAVE), a bilingual Dominican physician. QSR International's NVivo 11 qualitative data analysis software (QSR International Inc., Burlington, Massachusetts, United States of America) facilitated data management of transcripts during the coding process. We used grounded theory and dimensional analysis techniques to guide the analysis process (¹⁹19. Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. Los Angeles: Sage; 2006., ²⁰20. Schatzman L. Dimensional analysis: notes on an alternative approach to the grounding of theory in qualitative research. In: Maines DR, ed. Social organization and social process. New York: Aldine De Gruyter; 1991;303–14.).

Prior to data collection, the first two authors (HJC and BAVE), who were knowledgeable about TB control and the five described barriers, created general coding categories. The two authors independently coded data transcripts and then met to discuss discrepancies in the analysis and to settle on emerging themes. Memo writing was used to further examine the phenomenon throughout the analysis process (²¹21. Birks M, Chapman Y, Francis K. Memoing in qualitative research: probing data and processes. J Res Nurs. 2008;13(1):68–75.). The two authors used open coding to identify categories from data, axial coding to identify relationships between categories, and selective coding to develop the principal themes of the theoretical framework (²²22. Corbin JM, Strauss A. Grounded theory research: procedures, canons, and evaluative criteria. Qual Sociol. 1990;13(1):3–21.). In order to improve scientific validity and rigor, they used techniques such as comparative analyses to compare and contrast categories in theory development (²²22. Corbin JM, Strauss A. Grounded theory research: procedures, canons, and evaluative criteria. Qual Sociol. 1990;13(1):3–21.), card sorting to examine relationships in emerging themes (²³23. Ryan GW, Bernard HR. Techniques to identify themes. Field Methods. 2003;15(1):85–109.), and audit trails to record the data collection process (²⁴24. Guba EG. Criteria for assessing the trustworthiness of naturalistic inquiries. Educ Commun Tech. 1981;29:75–91.). They also incorporated participant checking (²⁵25. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.), for study participants to provide feedback or validation on the final themes and interpretations, as well as peer debriefing (²⁶26. Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park, California: Sage; 1985.), with qualitative research experts of the University of Florida Qualitative Research Colloquium offering advice on study design and analysis.

Ethical considerations

This study was authorized by the institutional review boards of the University of Florida (Gainesville, Florida, United States) and O&M Medical School (O&Med) (Santo Domingo, Dominican Republic). The protocol was approved by the Dominican Republic NTP, the Department of Academics of Hospital A, and the institutional review board of Hospital B. All participants signed written informed consent for study participation. Measures to maintain confidentiality of participants and their responses were strictly maintained, using standard survey codes (e.g., A) or standard focus group codes (e.g., FG-01).

RESULTS

A total of 10 focus group discussions were conducted with 40 participants (24 physicians, 16 nurses). Of the 24 physicians, 4 were trained in internal medicine, 6 in family medicine, and 14 in emergency medicine. Eight physicians were second-year medical residents, and 16 were third-year medical residents. Of the 16 nurses, 4 were employed in the department of internal medicine, and 12 worked in the department of emergency medicine. Four nurses had one year of nursing training (e.g., certificate level), two had two years of nursing training (e.g., associate level), and 10 had four years of nursing training (e.g., bachelor level).

Five emerging themes were described at the institutional level: 1) education and training; 2) administrative policy; 3) infrastructure policy; 4) economic allocations; and 5) research. A sixth theme (public health policy) emerged only at the national level. Table 1 displays six emerging themes described at the national level. Table 2 presents six categories of proposed recommendations described by HCWs.

Education and training

Participants described the need to educate, train, and empower HCWs and patients in their institutions, including in terms of understanding TB disease and preventive measures, dispelling myths about transmission, and reducing TB-associated stigma or discrimination. One family physician suggested that preemployment training seminars that incorporate scientific and social aspects of TB pathology and infection control would be ideal for HCWs: “Orientation workshops can be conducted when [health care workers] start their employment … . If there is any stigma or bias, then it can be eliminated … They can be reminded of appropriate biosecurity measures, review pathology, and then they will be prepared to work.”

One family physician mentioned that daily health campaigns would reduce misconceptions regarding the importance for TB infection control and adherence to medications: “When TB patients are admitted to the hospital, we can go in teams to educate them with proper facts …. This can raise awareness with patients and families.” Also, participants highlighted that nonclinical HCWs, such as administrators or janitors, are frequently overlooked in educational programs. One internal medicine physician said that regardless of their previous training, HCWs are employed in a workplace where they may have close daily interactions with TB patients: “Mandatory workshops should be offered for every employee [in the health institution].” Participants also described the importance of HCWs' comprehension of the current TB health burden in the Dominican Republic and their regular contemplation of their role in delivering preventive health care services.

Administrative policy

Participants emphasized that administrative policies should be strengthened to promote the intertwined factors in TB infection control and patient management that are essential for reducing disease propagation in hospitals and communities. Many described the need for health institutions to recognize multiple workplace hazards, and, in effect, prioritize health and well-being of HCWs through stricter policies. One emergency physician suggested that daily workplace stressors can affect HCWs' physical and mental health, and called for periodic assessments: “There should be biannual medical evaluations for all health care workers … . We evaluate patients, but they do not evaluate us.” Participants acknowledged stressors related to heavy work schedules, reasoning that having more HCWs in clinical areas could reduce their individual workloads. Another emergency physician proposed decreasing cumulative work hours per HCW as a way to cut the risk of workplace hazards: “Reduce work schedule hours for health care workers, since the longer the time spent in clinical areas, the greater the risk of infection.” Finally, several participants said that M. tuberculosis infection control strategies should be compulsory, and that clinical staff should be monitored for adherence to those guidelines. One emergency physician suggested that HCWs sign an employee contract laying out graded punishments, with a maximum of three offenses allowed before removal from the institution: “An employee has a first offense, and they would deduct three pesos from the salary. On the second offense, they would deduct a greater amount from the salary. On the third offense, the employee would be fired.”

Infrastructure policy

The participants believed that health institutions should improve the physical infrastructure, such as by having adequate ventilation in exam rooms and TB isolation wards and reducing patient overcrowding. These changes would cut the risk of nosocomial M. tuberculosis transmission among HCWs and patients. One internal medicine physician said that TB isolation wards are essential “as a specific area for patients with respiratory symptoms, under clinical evaluation for tuberculosis,” to separate out and assess patients with TB or suspected of having active TB from susceptible patients. Participants stated that separate wards—without additional stigma or shame—would be appropriate and fair for TB patients, since TB is a curable disease. Another internal medicine physician said that modifications in infrastructure should be in line with the number of admissions and external consultations: “I would create an [isolation] area that matches the size of the health center.”

Economic allocations

Participants described the critical need to identify available funding to maintain adequate supplies of disposable materials and other equipment and to sustain overall health expenditures for TB control. One emergency physician stated that this challenge could be resolved by modifying administrative staff responsibilities, rather than clinical staff duties: “Administrative personnel can be selected and assigned to seek solutions for this challenge.” Participants mentioned that the evaluation of institutional budgets, compared to proposed and actual health expenditures, could support financial requests to the country's MoH. An emergency physician emphasized that institutions with increased health expenditures (due to substantial annual patient admissions, external consultations, and emergency visits) should have increased funding to meet the demand for services: “This hospital receives larger numbers of patients than other health institutions … . The supply of disposable materials should be three times greater than any other hospital because of the large number [of patients].” Another emergency physician suggested that additional fund-raising could reduce at least one financial burden on the institution: “Health campaigns can raise funds to buy protective masks.”

Research

Participants stated that research studies are essential for analyzing and evaluating basic health indicators, identifying enablers and barriers in service delivery, and examining influences of stigma and social determinants of health on health outcomes. One nurse in the department of emergency medicine commented on the power of research findings to modify current clinical practices: “Research produces recommendations that can inform us about what is needed for proper use and management of TB pathology.” In addition, a nurse in the department of internal medicine said that the exchange of research findings is crucial for all countries, especially health systems that encounter similar challenges in service delivery and health outcomes: “Research can yield innovative approaches that can be directly applied from one country to another. This can facilitate change in infection control practices.”

DISCUSSION

This is the first known study to examine HCWs' practical recommendations for improved TB control in health institutions and the general community in the Dominican Republic. Increased capacity-building for clinicians was deemed fundamental for strengthening M. tuberculosis infection control practices and treatment adherence. Pilot capacity-building programs in TB infection control, epidemiology, and operations research applied in Latvia, Mexico, Nigeria, Russia, South Africa, and Vietnam have resulted in successful educational training (²⁷27. Laserson KF, Binkin NJ, Thorpe LE, Laing R, Iademarco MF, Bloom A, et al. Capacity building for international tuberculosis control through operations research training. Int J Turberc Lung Dis. 2005;9(2):145–50.) and improvements in M. tuberculosis infection control (²⁸28. Dokubo EK, Odume B, Lipke V, Muianga C, Onu E, Olutola A, et al. Building and strengthening infection control strategies to prevent tuberculosis – Nigeria, 2015. MMWR Morb Mortal Wkly Rep. 2016;65(10):263–6.). Hence, once physicians and nurses are trained in their designated pedagogical models, they can reinforce their new expertise in adherence to M. tuberculosis infection control measures. They can also gain insight on holistic and multidimensional TB care and develop health promotion activities that educate TB patients and families about available resources that support long-term TB management.

The study participants indicated that administrative policies can add more oversight to M. tuberculosis infection control practices, ranging from continued surveillance programs to annual periodic health evaluations for HCWs. These policy additions have four benefits. First, prevalence of latent and active TB among HCWs can be carefully recorded and documented, ensuring prompt diagnosis and management. Second, departmental records can quantify medications and supplies and confirm that stock meets institutional demands for best practices. Third, by increasing the number of HCWs per work shift and distributing responsibilities, overall job stress and burnout can be reduced (²⁹29. Seo H, Kim H, Hwang S, Hong S, Lee I. Predictors of job satisfaction and burnout among tuberculosis management nurses and physicians. Epidemiol Health. 2016;38:e2016008.). Fourth, monetary or legal sanctions for failed adherence to recommended infection control practices could underscore critical changes in the organizational culture within the health institution that prioritize HCWs' physical and mental health. These deterrents may also motivate HCWs to consistently use infection control practices.

Participants mentioned that institutional policies should focus on environmental controls for proper TB management in health institutions. Institutions with sufficient ventilation to control airflow in patient rooms can reduce biological threats of nosocomial M. tuberculosis transmission (⁴4. Jensen PA, Lambert LA, Iademarco MF, Ridzon R, CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005;54(RR-17):1–141.–⁶6. TB CARE I. International standards for tuberculosis care. 3rd ed. The Hague: TB CARE I; 2014.). However, with few existing isolation wards in the Dominican Republic, and national renovation of more than 50 hospitals since 2013, HCWs have the academic training and expertise to influence changes in institutional policies that promote M. tuberculosis infection control practices within their health institutions. With the national TB budget of US$ 15 million in 2017 (which is consistent with reported TB budgets of US$ 15–21 million since 2013) (⁹9. World Health Organization. Tuberculosis country profile: Dominican Republic, 2016. Geneva: WHO; 2017.), MoH leaders can consider hospital utilization rates and reevaluate the national budget designated for Dominican health institutions.

Likewise, by highlighting the need for increased capacity in research, participants emphasized that epidemiologic and other baseline studies are essential to better understand TB transmission dynamics in the Dominican Republic. For example, regular hospital and community assessments can identify barriers that hinder treatment adherence among TB patients (³⁰30. Munro SA, Lewin SA, Smith HJ, Engel ME, Fretheim A, Volmink J. Patient adherence to tuberculosis treatment: a systematic review of qualitative research. PLoS Med. 2007;4(7):e238.). By identifying barriers specific to the Dominican Republic's population, HCWs can foster sustainable, ethical health care service delivery and minimize TB-associated stigma. In turn, this may encourage the MoH to develop stronger clinical and community measures and policies. A closer review of the national budget for each health institution and an emphasis on strengthening local and national health leadership could highlight limitations in the health system. Therefore, evidence-based public health policy should incorporate three domains in order to strengthen M. tuberculosis infection control practices in the Dominican Republic: 1) process (e.g., approaches linked with policy approval); 2) content (e.g., components considered effective); and 3) outcomes (e.g., documented effects of policy) (³¹31. Brownson RC, Chriqui JF, Stamatakis KA. Understanding evidence-based public health policy. Am J Public Health. 2009;99(9):1576–83.).

This exhaustive examination adds value to clinical practice by stressing potential modifications of infection control standards across health institutions in the Dominican Republic. Our study findings were presented to health officials at the Dominican NTP and selected hospitals for review prior to publication. However, there were some limitations in the study design and analysis. First, two authors analyzed the data for final themes, incorporating the techniques of participant checking for feedback on the final consensus of recommendations and peer debriefing with qualitative research experts for advice on study design and analysis. We acknowledge that that our data analysis could be interpreted in additional ways (³²32. Miles MB, Huberman AM, Saldaña J. Qualitative data analysis: a methods sourcebook. 3rd ed. Thousand Oaks, California: Sage Publications Inc.; 2014.). Second, the focus groups did not incorporate rank ordering of the six themes, based on the weighted contribution of importance to TB infection control measures. Adding rank ordering of the themes might have accentuated one theme over another, thus simplifying formal briefings to the country's MoH.

The observed “knowledge–action gap,” described as inconsistencies in HCWs' application of clinical knowledge to practice (⁸8. Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bull World Health Organ. 2004;82(10):724–32.), results in ineffective TB prevention and control in health institutions in the Dominican Republic. Direct consultation with front-line HCWs about their perceived limitations of M. tuberculosis infection control practices at the institutional and national levels can add value to their recommendations for enhanced TB control efforts. Likewise, these recommendations can serve as a framework for continued national dialogue with the Dominican MoH on policy reform. This is especially valuable since the Dominican Republic is a middle-income country with an established MoH national budget and political commitment to TB control. Hence, this study can serve as a model for other low and intermediate TB burden countries that share national priorities for strengthening HCWs' leadership in clinical practice, supporting TB elimination efforts, and improving population health.

Conclusions

The Dominican HCWs believe that M. tuberculosis infection control measures can be strengthened at the institutional and national levels by emphasizing their practical recommendations for education and training, administrative policy, infrastructure policy, economic allocations, research, and public health policy. Future efforts may combine these recommendations with evidence-based strategies in M. tuberculosis infection control, thus paving the way for interventions in specific target areas that empower HCWs as institutional and national health leaders in TB prevention.

Acknowledgments

The authors wish to thank the participants for giving their time to describe their unique viewpoints and experiences regarding TB infection control in their clinical practice. We acknowledge the research support from the Dominican Republic's NTP, O&M Medical School, and selected health institutions. We recognize the academic mentorship of Dr. Mary Ellen Young and peer debriefing provided by the University of Florida Qualitative Research Colloquium during the data design and analysis. We also acknowledge the logistical support from Dr. Guillermo Hernández, Mr. Saulo Rodríguez, and Mrs. Cristina Ventura.

REFERENCES

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