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SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIE!'ICES 
UNIVERSITY OF GHANA 
ASSESSMENT OF IMPLEMENT AT ION OF TUBERCULOSIS INFECTION 
CONTROL MEASURES AMONG HEALTH CARE WORKERS AT THE 
GREA TER ACCRA REGIONAL HOSPITAL 
BY 
PORTIA DZIVENU 
(10279244) 
THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, 
LEG ON IN PARTIAL FULFILLMENT FOR THE AWARD OF MASTER OF 
PUBLIC HEALTH DEGREE 
JULY. 2017 
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DECLARATION 
I, Portia Dzivenu. do hereby declare that with the exception of references made to other 
people's work and textbooks which have been duly acknowledged, this dissertation is my 
original work. I affirm that this work has neither been published in whole or part to any 
institution for any academic award . 
....... ~ ..... Date: .. ~ ~:-. ~ :7.~~~ 
Portia Dzivenu 
(Student) 
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DEDICATION 
This piece of work is dedicated to the Almighty God for His sustenance and provision, 
Nana Kwame Koranteng and Dr. & Mrs. Steele-Dadzie for their unwavering support. 
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ACKNOWLEDGEMENT 
"Now thank we all our God ... With countless gifts of love, and still is ours today." 
My heartfelt appreciation goes to my academic supervisor, Dr. Patricia Akweongo, who 
offered her time, knowledge and experience towards the successful completion of this 
research. Doc., I am truly grateful for the times when you had to bum the midnight candle 
just to ensure this piece of work comes out perfectly. 
I am highly indebted to the NIH Fogarty International Centre for the Scholarship to pursue 
this program. My gratitude further goes to my mentors; Prof. Richard Adanu, Prof. 
Margaret Lartey. Prof. Awewura Kwaara, Prof. Andrew Adjei and Dr. Ruben Esena for 
their guidance. support and constructive criticisms which made this work possible. 
Special thanks to the Management and Staff of the Greater Accra Regional Hospital 
especially Mad. Helena Ntoah-Boadi. Mr. John Blankson and Mad. Scholastica Dery for 
their great help and participation in this study. A big thank you to Dr. Matilda Asante, Dr. 
Benjamin Arko-Boham. Prof. Eric Ofori, Mr. Noah Tetteh. Mr. David Nana Adjei, Mr. 
Samuel Dery. Mr. Chris Guure. Mr. Tony Godzi, Peter Dotsevia. Gadeka Dormenyo, 
Bridget Tawiah. Mavis Narh Tsaako and the entire faculty and staff of the School of Public 
Health for your diverse contributions. 
Finally. I am super grateful to the Dzivenu and Nkumsah-Riverson family for unflinchingly 
standing by me throughout this project. Thank you for the love, prayers, support and well 
wishes. Guess what, it worked! To all who contributed to make this possible. mere; 
beaueoup.' Love you all. 
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ABSTRACT 
Background: Tuberculosis has become a global burden and of public health importance. 
Health care workers in developing countries are highly susceptible to workplace associated 
TB infection due to the long hours spent with patients who have undiagnosed or untreated 
TB cases, poor infection control measures and poor isolation of TB cases in health care 
facilities. 
Objective: To assess the implementation of tuberculosis infection control measures among 
health care workers at the Greater Accra Regional Hospital. 
Methods: Descriptive cross-sectional study design using both quantitative and qualitative 
approach was employed in this study. One hundred and thirty seven (137) Health Care 
Workers (HCWs) and seven (7) Key Informants participated in the study. The HCWs were 
proportionally selected from each job category using simple random sampling technique. 
Quantitative data were obtained using semi-structured questionnaires, and triangulated 
with direct observation and Key Informant Interviews. Descriptive analysis, univariate and 
multivariate logistic regression were carried out using STATA version 14.0. Qualitative 
data were transcribed verbatim and analyzed using thematic analysis. 
Results: More than half, 88 (64.2%) of the HCWs exhibited good knowledge, while a 
similar proportion 83 (60.6%) also exhibited good practice. Being female (COR= 2.06, 
95% CI: 1.00-4.22) and married (AOR= 3.19, 95% CI: 1.11-9.13) were significantly 
associated with knowledge. Having good knowledge (AOR = 5.83, 95% CI: 2.07-16.43) 
and being a Doctor (AOR= 7.91, 95% CI: 1.73-36.18) were significantly associated with 
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good practice. Qualitative data showed that HCWs perceived screening of patients as the 
main promoter of effective implementation of Tuberculosis Infection Control (TBIC), 
while inadequate Personal Protective Equipment (PPEs), absence of staff screening. small 
waiting area and improper ventilation were the major inhibitors. 
Conclusion: The overall level of knowledge and practice was good among HCWs. 
Knowledge and job category were the main significant predictors of TBIC practice. 
Sustained TBIC practice was perceived to be largely promoted by availability of screening 
of suspected TB patients, while inadequate PPEs and absence of staff screening for TB 
were perceived to be the major inhibitors. Hence, facility management should work closely 
with the TB Coordinator to ensure periodic staff screening exercise and provision of needed 
logistics. 
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TABLE OF CONTENTS 
DECLARATION ................................................................................................................. i 
DEDIC A TION .................................................................................................................... ii 
ACKNOWLEDGEMENT ................................................................................................. iii 
ABSTRACT ...................................................................................................................... iv 
TABLE OF CONTENTS .................................................................................................. vi 
LIST OF TABLES .... ..... ...... . ............................................................................................ x 
LIST OF FIGURES ........................................................................................................... xi 
LIST OF ABBREVIATIONS ........................................................................................... xii 
OPERATIONAL DEFINITION OF TERMS ................................................................. xiv 
CHAPTER ONE ............................................................................................................... I 
INTRODUCTION. ............................................................................................................ I 
1.0 Background .......... .......................... . .................................................................. 1 
1.1 Problem Statement ............................................................................................ ~. 3 
1.2 Conceptual Framework on Implementation ofTBIC .......................................... 5 
1.3 Justification .......................................................................................................... 9 
1.4 Research Questions .............................................................................................. 9 
1.5 Objectives of the Study ..................................................................................... 10 
1.5.1 General Objective ....................................................................................... 10 
1.5.2 Specific Objectives ..................................................................................... 10 
CHAPTER TWO ............................................................................................................ II 
LITERATURE REVIEW .............................................................................................. II 
2.0 Introduction ... . ................... 11 
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2.1 Tuberculosis Epidemiology ................................................................................ II 
2.2 Tuberculosis Infection in the Health Care Settings ............................................ 12 
2.3 Infection Prevention Control in Health Care Settings ........................................ 13 
2.4 Tuberculosis Infection, Prevention and Control Measures ................................ 14 
2.4.1 Administrative measures ............................................................................. 15 
2.4.2 Environmental measures ............................................................................. 16 
2.4.3 Personal Respiratory Protection Measures ................................................. 16 
2.5 Health Care Workers' Knowledge and Practices towards the implementation of 
TBIC Measures ............................................................................................................. 17 
2.6 Factors Influencing the Implementation ofTBIC Measures .............................. 19 
2.7 Measurement of Levels of Knowledge and Practice of HCWs on TBIC .......... 22 
2.8 Summary of Literature Review ............................................................................... 23 
CHAFfER THREE ........................................................................................................ 24 
METHODS ...................................................................................................................... 24 
3.0 Introduction ................. . . ........................................................................ 24 
3.1 Study Design ..................................................................................................... 24 
3.2 Study Area ......................................................................................................... 24 
3.3 Study Population ................................................................................................ 26 
3.3.1 Inclusion Criteria ........................................................................................ 27 
3.3.2 Exclusion Criteria ...................................................................................... 27 
3.4 Study Variables ................................................................................................. 28 
3.5 Sampling and Sampling Procedure .................................................................... 31 
3.5.1 Sample Size Determination ........................................................................ 31 
3.5.2 Sampling Procedure ................................................................................... 31 
3.5.3 Data Collection Instruments ...................................................................... 33 
3.5.4 Key Informant Interviews ........................................................................... 34 
3.5.5 Direct Observation of Health Care Workers' Practice ............................... 34 
3.6 Quality Control .................................................................................................. 35 
3.6.1 Data Handling ........................................................................................... 35 
3.6.2 Data Storage I Data Protection .................................................................... 35 
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3.6.3 Data Validation ........................................................................................... 35 
3.6.4 Pre-testing of Tools ................. ·. .............. ·············"" ................................... 35 
3.7 Data Analysis ..................................................................................................... 36 
3.8 Limitations ............................................................................................................. 37 
3.9 Ethical Issues ........................................................................................................... 37 
3.9.1 Privacy and Confidentiality .............................................................................. 37 
3.9.2 Voluntary Participation and Withdrawal .......................................................... 38 
3.9.3 Benefits ........ ........................................................................................ 38 
3.9.4 CostlCompensation ..................................................................................... 38 
3.9.5 Declaration of Conflict of Interest .................................................................... 38 
3.9.6 Research Funding ........................................................................................ 38 
CHAPTER FOUR ........................................................................................................... 39 
RESULTS ........................................................................................................................ 39 
4.0 Introduction ........................................................................................................ 39 
4.1 Socio-Demographic Characteristics of Participants ........................................... 39 
4.2 Level of Knowledge of HCWs on TB and TBIC ............................................... 43 
4.3 Relationship between Level of Knowledge and Demographic Characteristics of 
HCWs ............................................................................................................................ 45 
4.4 Health Care Worker Factors Associated with Level ofTB and TBIC Knowledge 
............................................................................................ .48 
4.5 Level of Practice of Health Care Workers (HCWs) ofTB Infection Control.. .. 50 
4.6 Relationship between Level of Practice and Demographic characteristics of 
Health Care Workers ..................................................................................................... 53 
4.7 Work-related Factors Associated with Level of Practice of Health Care Workers 
on Tuberculosis Infection Control ................................................................................ 56 
4.8 Service Factors Influencing Implementation ofTBIC at the Greater Accra 
Regional Hospital .......................................................................................................... 60 
4.9 Environmental Factors Influencing TB Infection Control at the Greater Accra 
Regional Hospital .......................................................................................................... 66 
CHAPTER FIVE ............................................................................................................ 70 
DISCUSSION .................................................................................................................. 70 
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5.0 Introduction ..............................................................•..•...................................... 70 
5.1 Level of Knowledge of Health Care Workers (HCWs) on TB and TBIC ......... 70 
5.2 Level of Practice of HCWs on TB and TBIC .................................................... 72 
5.3 Service Factors Influencing Sustained Implementation ofTBIC ...................... 75 
5.4 Environmental Factors Influencing Sustained Implementation ofTBIC ........... 76 
CHAPTER SIX ............................................................................................................... 78 
CONCLUSION AND RECOMMENDAn ON ............................................................ 78 
6.1 Conclusion .......................................................................................................... 78 
6.2 Recommendations ............................................. .. ............................................. 78 
REFERENCES ................................................................................................................ 79 
APPENDICES ................................................................................................................. 83 
Appendix I: Participant Information Sheet and Consent Form ..................................... 83 
Appendix II: Semi-Structured Questionnaire for Health Care Workers (HCWs) ........ 86 
Appendix Ill: Key Informant Interview guide .............................................................. 94 
Appendix IV: Direct Observation Checklist ................................................................. 96 
Appendix V: Ghana Health Service Ethical ApprovaL ............................................... 98 
Appendix VI: Approval for Use of Study Site .............................................................. 99 
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LIST OF TABLES 
Table 3.1: List of Independent Variables ......................................... ···· ............................ 28 
Table 3.2: HCWs Distribution from Each Job Category .................................................. 32 
Table 4.la: Socio-Demographic Characteristics of Health Care Workers (HCWs) ......... 40 
Table 4.1 b: Work-related Demographics of Health Care Workers .................................. 42 
Table 4.2: Knowledge of Health Care Workers on TB and TBIC .................................... 44 
Table 4.3: Relationship between Level of Knowledge and Demographic Characteristics 
ofHCWs ........................................................................................................................... 47 
Table 4.4: Odds Ratio ofSocio-demographic and Work-related Factors Associated with 
Level of Knowledge of Health Care Workers on TB and TBIC ...................................... 49 
Table 4.5: Practice of HCWs regarding TB Infection Control at the Greater Accra 
Regional Hospital .............................................................................................................. 52 
Table 4.6a: Relationship between Level of Practice and Socio-demographic 
Characteristics ofHCWs ................................................................................................... 55 
Table 4.6b: Relationship between Level of Practice and Socio-demographic 
Characteristics ................................................................................................................... 56 
Table 4.7: Odds Ratio ofSocio-demographic and Work-related Factors Associated with 
Level of TBIC Practice ..................................................................................................... 59 
Table 4.8: Service Factors Influencing Implementation ofTBIC at the Greater Accra 
Regional Hospital.............. .. ......................................................................................... 65 
Table 4.9: Environmental Factors Influencing Implementation ofTBIC at the Greater 
Accra Regional Hospital ................................................................................................... 68 
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LIST OF FIGURES 
Figure 1.1: Conceptual Framework on Tuberculosis Infection Control ............................. 8 
Figure 3.2: Map showing the location of the Greater Accra Regional HospitaL ............ 26 
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LIST OF ABBREVIATIONS 
AIDS Acquired Immune Deficiency Syndrome 
AMA Accra Metropolitan Assembly 
AOR Adjusted Odds Ratio 
ART Antiretroviral Treatment 
COC Center for Disease Control 
COR Crude Odds Ratio 
DOTS Directly Observed Treatment Short Course 
ERe Ethical Review Committee 
FFP2 An oil and non-oil aerosol mask or respirator with 
94% filter efficiency that protects from inhaling 
infectious droplet nuclei 
GARH Greater Accra Regional Hospital 
GHS Ghana Health Service 
GSS Ghana Statistical Service 
HCWs Health Care Workers 
HIV Human Immune Virus 
MDGs Millennium Development Goals 
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MOH Ministry of Health 
NTP National Tuberculosis Programme 
N95 A non-oil close fitted mask with 95% filter 
efficiency that protects from inhaling droplet uclei 
OPD Out Patient Department 
PPE Personal Protective Equipment 
KlIs Key Informant Interviews 
SOOs Sustainable Development Goals 
TB Tuberculosis 
TBIC Tuberculosis Infection Control 
UNO United Nations Organization 
UVGI Ultraviolet Germicidal Irradiation 
WHO World Health Organization 
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OPERA TIONAL DEFINITION OF TERMS 
Knowledge: Information and understanding of health care workers concerning TB and 
its control measures. 
Practices: Attitudes and activities of health care workers towards controlling TB 
transmission at the Greater Accra Regional Hospital. 
Tuberculosis Infection Control: The necessary actions or precautionary measures put in 
place to reduce the spread of Mycobacterium tuberculosis from one person to another. 
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CHAYfERONE 
INTRODUCTION 
1.0 Background 
In health care settings, TB spreads from patients to health care workers and other users of 
the facility (Sissolak, Marais, & Mehtar, 20(1). The World Health Organization in 2016 
reported a global TB incidence of lOA million (5.9 million men, 3.5 million women and I 
million children) with an incidence rate of 142 per 100,000 populations in 2015. Africa 
recorded an incidence of 2. 7 million \\ ith an incidence rate of275 per 100,000 populations. 
This was the highest incidence rate amongst all the six WHO regions. Ghana, however, 
recorded an incidence of 44,000 with an incidence rate of 160 per 100,000 populations 
(WHO,2016). 
The global mortality of TB was 1.4 million with a mortality rate of 19 deaths per 100,000 
populations. In Africa, 450,000 deaths were recorded with a mortality rate of 45 per 
100,000 populations. Again, Africa had the highest rate amongst all the six WHO regions. 
Ghana recorded 10,000 deaths with mortality rate of 37 per 100,000 popUlations (WHO, 
2016). 
In 2015, an incidence of 9,977 was recorded among Health Care Workers (HCWs) in 67 
countries. of \\hich South Africa emerged as the second highest, recording 2,095 cases 
(WHO. 2016). A report by Ghana's National Tuberculosis Programme in 2011 revealed 
that about three hundred health care workers (HCWs) in Ghana were infected with 
tuberculosis (NTP, 2011, unpublished data). 
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A Meta-analysis revealed that health care workers have three times (3x) average annual 
risk of tuberculosis infection than the general population across all settings (Baussano et 
aI., 2012). In three districts in Kwazulu-Natal, South Africa. 112 TB cases were detected 
among 1,313 health care workers studied (Tudor et aI., 2014). A study in Kigali, Rwanda 
showed that out of every three health care worker, almost two were infected with 
nosocomial TB infection (Rutanga et aI., 2015). 
The spread of Mycobacterium tuberculosis in health facilities to both patients and health 
care workers may be due to poor infection control practices within the facilities. 
Additionally, the long waiting time spent by patients in various health facilities is a 
contributory factor to the high rate of tuberculosis in health care settings (Escombe et aI., 
2010). This is because patients with undiagnosed or untreated TB mingle with other 
patients and health care workers thereby increasing their risk of infection. 
Implementation of infection control measures as an essential component of health care 
provides the basis for TB risk reduction among health care workers, patients and other 
facility users. The WHO, in a bid to achieve this, established an implementation guideline, 
which was updated in 2009 to curb TB infection in health care settings. The objective of 
the program was to ensure prompt detection of infectious patients, airborne precautions 
and treatment of people with suspected or confirmed TB (WHO, 2009). 
The policy covers managerial/administrative, environmental and personal protective 
measures. The managerial and administrative measures are the first and most important 
level in TB infection prevention and control (Chen et aI., 2016). It focuses on reducing the 
droplets of Mycobacterium tuberculosis in health care settings by eliminating its generation 
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and risk of exposure. Environmental measures seek to provide an infection free 
environment for both health care workers and users by preventing spread as well as 
reducing the concentration of the TB bacterium in the air. The third level, which is the 
personal protective measures. involves the use of respirators to protect users from inhaling 
the Mycobacterium tuberculosis. It serves as the last line of defense in the event of failed 
manageriaVadministrative and environmental protective measures (WHO, 2009). The 
implementation of Tuberculosis Infection Control (TBIC) is largely dependent on health 
care workers because of their role as front liners in health service delivery. However, 
studies have confirmed that such a function has greatly been limited in many health 
facilities due to poor knowledge, poor training of health care workers on the 
implementation of TBIC and insufficient provision of personal protective equipment 
amongst others (Baussano et aI., 2012). 
This study therefore sought to assess the implementation of Tuberculosis Infection Control 
measures among health care workers at the Greater Accra Regional Hospital using both 
quantitative and qualitative research approach. 
1.1 Problem Statement 
In Ghana, about 300 health care workers (HCWs) were infected with tuberculosis in 2011 
(NTP. 2011. unpublished data). It has been identified that poor ventilation and air 
recirculation alongside poor infection control and isolation practices are often contributory 
factors to TB transmission in health care setting (Castel a, Silva, Ferreira, & Nienhaus, 
20 II). Long waiting time of patients with undiagnosed and untreated TB cases at health 
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facilities also increases health care workers' susceptibility to TB infection (HeyseIl, 
Shenoi, Thomas & Friedland, 2011). 
Infection control is regarded as a critical preventive measure in TB care. In 2009, the WHO 
revised the guidelines for the implementation of TB Infection Control (TBIC) in health 
facilities to protect other patients and to reduce TB risk among health care workers (WHO, 
2009). Ghana's Ministry of Health (MOH) also adopted and implemented the WHO TBIC 
policy due to the heightened concerns about unacceptable infection control practices 
throughout the country (MOH, 2009). 
[he implementation of the Tuberculosis Infection Control (TBIC) is largely dependent on 
health care workers' knowledge, attitudes and practices. Unfortunately, many health care 
workers perceive it as a burden due to work overload and the use of personal protective 
measures as uncomfortable thereby posing challenges to implementing TBIC (Efstathiou, 
Papastavrou, Raftopoulos, & Merkouris, 201 I). 
A national survey in Ghana by Amo-Adjei (2013) revealed that health system factors such 
as poor funding, poor infrastructure, friction between clinicians and public health 
professionals. weak monitoring and evaluation practices were some of the barriers to 
effective implementation ofTBlC. A study at the Tema General Hospital by Codjoe (20 12) 
also showed lack of wards for isolating TB patients, lack of protective equipment and 
overcrowding of patients at Out Patient Department (OPD) and inadequate training as 
factors hindering implementation ofTBIC in the facility. Another study in Urban Takoradi 
Ghana reported that isolation ofTB wards in addition to "excessive" use of PPEs (gloves) 
by health professionals when attending to TB patients served as basis for stigmatizing 
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against the patient (Dodor & Kelly, 2010). As such, isolation of TB patients was not 
effectively practiced. The quality of environmental factors and service factors (frequency 
of screening. availability of TBIC materials, availability of TB laboratory for testing and 
reporting) influencing the implementation ofTBIC are however unknown. 
Thus, this study sought to assess the practices of Health Care Workers (HCWs) on 
Tuberculosis Infection Control (TBIC), and explore service factors and environmental 
factors influencing its implementation at the Greater Accra Regional Hospital using a 
mixed method approach. 
1.2 Conceptual Framework on Implementation of TBIC 
Figure I below shows the relationship between the various aspects of implementation of 
Tuberculosis Infection Control (TBIC) among health care workers. These factors include 
facility-level managerial activities alongside administrative, environmental and personal 
protection measures. 
Facility-level managerial activities comprise the systems in place to ensure appropriate set 
up and implementation of the three aforementioned TBIC measures at the facility level. It 
includes leadership, planning. coordinating activities and groups, monitoring and 
evaluation, development of policies and procedures, facility assessment, and participating 
in research works in line with the national TB agenda. It is usually fused into the 
administrative measures. 
Administrative Measures is the first line of defense for the implementation of TBIC 
(Menon. 2013). It focuses on preventing droplet nuclei containing mycobacterium 
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tuberculosis from being generated in the facility thereby reducing exposure of patients and 
health care workers to TH. It therefore requires prompt identification of TB suspects 
(triaging), separation and treatment of people with TB symptoms, and minimizing time 
spent in health care facilities. These measures tend to influence both the environmental and 
personal protection measures. 
Administrative and managerial factors can be grouped into two; service factors, and 
human resource and leadership factors. Service factors are factors directly linked with TB 
care. These include availability ofTBIC materials, availability ofTB laboratory for testing 
and reporting, frequency of TB screening, and availability of an isolation ward for 
separation of infectious patients. Availability of TBIC materials such as TBIC plan, 
policies and procedures, PPEs and Information, Education, Communication (IEC) 
materials may enhance sustained implementation of TB Infection Control among HCWs. 
They know what is expected of them and how to go about it in order to reduce TB infection 
in the health care facilities. 
The human resource and leadership factors are factors that indirectly affect the quality of 
the implementation ofTBIC measures among health care workers. These include training 
of HCWs on TBIC, education of patient on cough etiquettes and respiratory hygiene, and 
~upervisory activities. These factors reduce TB transmission in health care settings by 
making health care workers conscious of TB related issues and the appropriate ways to 
handle them Yo hile proper supervision ensures effective implementation ofTBIC Measures. 
Environmental Measures include ways of reducing the concentration of Mycobacterium 
TB droplet nuclei in the air and controlling the direction of the infectious air (WHO, 2009). 
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It is largely tailored towards ensuring quality ventilation system, which in turns reduces 
TB infection in health facilities. An effective administrative and facility-level managerial 
activity is key to ensuring proper environmental measures since the administrative and 
managerial activities are responsible for the provision of the ventilation equipment. 
Personal Protective Measures involves the use of Personal Protective Equipment (PPEs), 
like particulate respirators and masks. to protect HCWs from TB infection. It is used 
together with the administrative measures and facility-level managerial activities, and 
environmental measures where there is an increased risk of transmission (WHO. 2009). 
Adequate provision of personal protection equipment as well as training on its appropriate 
use may encourage usage among health care workers (WHO, 2009). It has been shown that 
many HeWs are unclear about the use of respiratory protection in terms of when, how and 
which type is needed in specific situation (Peterson, Novak, Stradtman. Wilson, & 
Couzens. 2015). Effective supervision may also reduce the rate of non -compliance to the 
use of personal protection equipment among HCWs. 
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CONCEPTUAL FRAMEWORK OF TUBERCULOSIS INFECTION CONTROL 
EDviroaaeotal Measures 
Admiaistratk-f Measures ud faclliCy- . Availability of Adequate 
Level.faJllleria1 Activities . VeDtilation Availability ofWeU-Ventilated 
Sputum Booths 
1 1 
H1IIII0 Service factors 
Resource 01: 
Leadership • Availability of 
Factors TBIC Materials 
• Availability of 
• Training TB Laboratory 
• Education for Testing 
• Supervision • Isolation of 
and Infectious 
CoorcliDation Patients 
• Frequent 
Screening for TB 
• Intervention 
Packages 
1 1 
Practice or Healtb Care Workers TB INFECTION CONTROL 
Figure 1.1: Conceptual Framework on Tuberculosis Infection Control 
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1.3 Justification 
Improved infection control measures have been shown to be effective in preventing 
tuberculosis transmission within health care settings. Thus, this study will provide 
quantitative and qualitative data on the implementation of Tuberculosis Infection Control 
(TBIC) measures among health care workers at the Greater Accra Regional Hospital, 
Ghana. This would inform policies on tuberculosis infection control as the challenges 
health care workers face in implementing TBIC would be unearthed. It would also provide 
recommendations to health facility heads on health service delivery factors needed to 
support health care workers in implementing TBIC. This study would also unearth the 
practices of health care workers in implementing the tuberculosis infection control 
measures, which may enable facility heads to undertake effective monitoring and 
evaluation to reduce nosocomial TB transmission among health care workers, patients and 
relatives. 
1.4 Research Questions 
I. What is the level of knowledge and practice of health care workers on TB 
infection control? 
2. What service factors are influencing the implementation ofTBIC among health 
care workers? 
3. What are the environmental factors influencing the implementation of TBIC 
among health care workers? 
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1.5 Objectives of the Study 
This section outlines the general and specific objectives of the study. 
1.5.1 General Objective 
To assess the implementation of Tuberculosis Infection Control (TBIC) measures among 
Health Care Workers at the Greater Accra Regional Hospital. 
1.5.2 Specific Objectives 
I. To assess the level of knowledge and practice of health care workers on TB 
infection control 
2. To explore the service factors influencing the implementation ofTBIC 
3. To describe the environmental factors influencing the implementation ofTBIC 
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CHAPTER TWO 
LITERATURE REVIEW 
2.0 Introduction 
This chapter provides an overview of previous research on Tuberculosis (TS) and 
Tuberculosis Infection Control (TSIC) measures. It highlights the following themes 
tuberculosis epidemiology, TS infection in the health care settings, TS infection, 
prevention and control strategies, Health Care Workers' (HCWs) practices of TSIC 
policies and measures, and Challenges faced by HCWs in the implementation of TSIC 
measures. 
2.1 Tuberculosis Epidemiology 
Tuberculosis is a major global health problem and of public health concern. According to 
the World Health Organization, in 2015, TS ranked (above HIV/AIDS) among the top ten 
causes of death worldwide (WHO, 2016). Despite the numerous measures employed to 
militate against this infectious disease, in 2015, the new cases ofTS recorded globally were 
about 10.4 million, comprising 5.9 million men, 3.5 million women, and 1.0 million 
children (WHO, 2016). The global incidence rate was 142 per every 100,000 populations. 
The WHO South-East Asia Region recorded an estimated incidence of 4, 740,000 TS cases, 
\\ ith an incidence rate of 246 per 100,000 populations. The WHO African Region, with 
total incidence of 2,720,000 cases, recorded the highest incidence rate of 275 per every 
100,000 populations (WHO, 2016).The incidence in Ghana was 44,000 cases with an 
incidence rate of 160 per every 100,000 popUlations. 
In terms of mortality, an estimated 1.4 million TB deaths were recorded in 2015 globally. 
Sixty percent (60%) of these deaths were recorded in six (6) countries only: India, 
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Indonesia, China, Nigeria, Pakistan and South Africa. The global mortality rate was 19 
deaths per 100,000 populations. The WHO African Region alongside WHO South-East 
Asia recorded the highest total deaths in 2015 (an estimated 450,000 and 710,000 deaths 
respectively). In terms of mortality rate, the African Region recorded the highest rate of 4S 
per every 100.000 populations followed by the South-East Asia Region with a rate of 37 
deaths per e.very 100,000 populations. Ghana recorded about 10,000 deaths with a mortality 
rate of 37 deaths per 100,000 populations (WHO, 2016). This makes TB a poverty-related 
disease. mainly affecting the poorest regions in the world. 
2.2 Tuberculosis Infection in tbe Healtb Care Settings 
The risk of contracting the Mycobacterium tuberculosis increases with the frequency of 
contact with people infected with the disease. This makes health care settings one of the 
most common locations for TB transmission. The risk of exposure to TB in health care 
facilities increases as health-care facilities become overcrowded with undiagnosed and 
infectious TB patients who spend long hours waiting to receive medical care. Improper 
environmental infection control due to poor ventilation, and poorly enforced TB infection 
prevention and control measures are among the contributory factors to health care setting 
TB infection (Grobler et aI., 2016). 
In 2009. the WHO reported that the TB incidence rate of people working in health care 
settings was higher than that of the general population (WHO. 2009). In a bid to mitigate 
this. the WHO also came out with a policy on TB infection control in health-care facilities, 
congregated settings and household. The objective of the policy is to "provide Member 
States with guidance on how to reduce the risk ofrB transmission in healthcarefacilities. 
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congregate settings and households. and how to prioritize TB infection control measures" 
(WHO, 2009). In 2015, an incidence of 9,977 cases among health-care workers were 
reported from 67 countries, with China and South Africa accounting for 31 % and 21 % of 
these cases respectively (WHO, 2016). A research by Adams and colleagues reported that 
generally, health care facilities in South Africa have less adequate or inappropriate 
infection prevention and control measures established to protect their employees (Adams 
et ai., 2013), despite the international policy recommendations to mitigate TB in such 
settings (WHO, 2010). In Ghana, however, about 300 health care workers were infected 
with tuberculosis in 2011 (NTP, 2011 Unpublished data). 
2.3 Infection Prevention Control in Health Care Settings 
Nosocomial infections, also known as "healthcare-associated infections," are the infections 
that occur due to prolonged patient stay in health facilities (Brusaferro et ai., 2015). These 
infections could be picked from other patients, equipment and even through the air. It can 
increase the length of stay of patients in hospital thereby increasing hospital cost and 
prolonging recovery. 
Infection Prevention Control (lPC) has been shown to be of utmost importance in health 
care settings and in healthcare because of its potential benefit in reducing the burden of 
disease on patients, facilities and the nation at large. Thus, health care organizations are 
taking pragmatic steps to improve the prevention and control of nosocomial infections. 
In, 2009, the Ministry of Health in Ghana revised its IPC policy with focus on improving 
environmental health and other hygienic measures in health care settings. It recommended 
that a\l facility based infection prevention control programmes should be fused with other 
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important programmes such as TB programmes, quality assurance, environmental and 
occupational health, communicable disease control among others (MOH, 2009). Previous 
study has shown that isolation precautions are essential in reducing transmission of 
infectious agents within health care settings (Raka, 2010). 
2.4 Tuberculosis Infection, Prevention and Control Measures 
Tuberculosis is a leading cause of morbidity and mortality globally, especially amongst 
developing countries (Zaman, 2010). Due to TB's global impact, various measures and 
policies have been developed over the years to fight it. The quest to end epidemics 
including TB is now a prominent part of strategies developed by global bodies, including 
the United Nations Organization (UNO) and the World Health organization (UNO, 2015; 
WHO. 2016). 
The Directly-Observed Therapy Short course (DOTS) has been a leap forward in 
controlling tuberculosis. It has become the basis for treating TB in many countries. 
From the year 2000 to 2015, two major global measures were implemented to reduce the 
burden ofTB: the Millennium Development Goals (MDGs) (2000 - 2015) that sought to 
"halt and reverse" TB incidence by 2015 (MDG 6, Target 8), and the Stop TB Strategy 
(2006-2015) by focusing on halving TB prevalence and TB mortality by 2015 compared 
with their levels in 1990, in addition to achieving the MDG target. According to WHO, the 
MOO target was achieved on a world-wide basis. Further, there was a 47% fall in global 
TB death rate between 1990 and 2015, with most improvement occurring after 2000. It 
also indicated that the prevalence rate fell by 42% between the same periods (WHO, 2016). 
After 2015, the UN initiated the Sustainable Development Goals (SDGs) - from 2016 to 
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2030 _ and the WHO is implementing the End TB Strategies (2016-2035). Target 3.3 of 
the Sustainable Development Goal 3, focuses on ending epidemics - including tuberculosis 
_ by 2030 (UN, 2015). The WHO End TB Strategy also seeks to reduce 18 deaths by 95% 
and TB incidence by 90% from 20 I 5 to 2035. The overall goal is to reduce incidence to 10 
new cases per 100,000 populations (WHO, 2016). 
Tuberculosis infection control involves employing diverse "measures aimed at minimizing 
the risk ofTB infection transmission within populations" (WHO, 2009). It involves early 
and rapid diagnosis, and proper management of TB patients. As part of the WHO's Stop 
TB Strategy, a policy for the implementation of sound TB infection control, with focus on 
control in health-care facilities and congregated settings and households, was introduced 
in 2009 and adopted by Ghana's Ministry of Health. The policy covers three main levels 
of controls: Administrative Measures, Environmental Measures, and Personal Respiratory 
Protection. It also covers managerial activities that facilitate the implementation of these 
controls. 
2.4.1 Administrative measures 
Administrative Measures is the first line of defense for the implementation ofTBIC in any 
setting regardless of available resources (Menon, 2013). They are the most effective and 
least expensive intervention (Nardell & Dharrnadhikari, 2010). It focuses on preventing 
droplet nuclei containing mycobacterium tuberculosis from being generated in the facility 
thereby reducing exposure of patients and health care workers to TB. It therefore requires 
prompt identification, separation of infectious patients, control of spread of pathogens, and 
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treatment of people with TB symptoms, while minimizing time spent in health care 
facilities (WHO, 2009). 
2.4.2 Environmental measures 
Environmental Measures aim to reduce the concentration of TB droplet nuclei in the air 
and ways to control the direction of infectious air (WHO, 2009). It usually starts with 
construction of buildings, renovations and maintenance works. thereby reducing the risk 
of nosocomial TB infections that result from over-crowded wards in high-burden settings. 
Environmental measures could be natural or mechanical I artificial ventilation system. 
Simple natural ventilation is achieved by proper window sizes, and locating them on 
opposing walls (WHO, 2009). It is considered as a low maintenance, low cost and the most 
effective airborne infection control measure. As such, it is recommended in low-resourced 
settings in warm climates (Escombe et aI., 2007; Shenoi, Escombe, & Friedland, 2010). 
Mechanical ventilation in the form offans could also be employed when natural ventilation 
alone is not sufficient. Besides, ultraviolet germicidal irradiation (UVGI) fixtures may be 
used (WHO, 2009). The UGVI is climate independent, and as such addresses the limitation 
of natural ventilation (Shenoi et aI., 2010). However, it requires skilled architects for its 
proper installation (Nardell & Dharmadhikari, 2010). Environmental Measures is largely 
innuenced by resource availability making its effective implementation challenging in 
many low- resourced settings. However, proper staff training on the correct use of these 
measures and proper maintenance is shown to be beneficial. 
2.4.3 Personal Respiratory Protection Measures 
Personal Protection Measures involves the use of personal protective equipment in 
instances .... hen there is increased risk of transmission (Jensen, Lambert, Iadermarco, & 
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Ridzon, 2005). This may be in the fonn of particulate respirators or surgical masks. The 
respirators are recommended for health care workers directly involved in TB care as well 
as other facility users who encounter TB patients, while patients or people suspected to be 
infected with TB are advised to use surgical masks for proper coughing etiquettes. The 
WHO recommends particulate respirators that has standards equivalent to or exceeding 
N95 standard or FFP2 standard for US and Europe respectively (WHO, 2009). The 
personal protective measures complement HCWs level of protection after the 
administrative and environmental measures have been implemented. Constant provision of 
quality Personal Protective Equipment (PPE) coupled with adequate training for its use 
highly influences implementation ofTBIC measures. However, previous literature reports 
that tit-testing ofPPEs is neglected (Nardell & Dhannadhikari, 2010). 
2.5 Healtb Care Workers' Knowledge and Practices towards tbe implementation 
ofTBIC Measures 
Health Care Workers (HCWs) playa very important role in the success or failure ofTBIC 
measures due to their frontline functions. An effective tuberculosis infection control will 
require that HeWs properly implement the various TBIC measures, and also educate TB 
patients and the community about basic control measures like adequate ventilation, cough 
h) giene. etc. As such, it is very necessary that they have adequate awareness and level of 
knowledge of the TBIC measures. A study in Northwest Ethiopia from August 2010 to 
January 20 II indicated that health professionals with good knowledge were ten (10) times 
more likely to practice TBIC compared to those with poor knowledge (Temesgen & 
Demissie, 2014). According to Demissie Gizaw. Aderaw Alemu, & Kibret (2015), 
tuberculosis training and work experiences are major contributory factors to knowledge, 
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while TB related training and experiences are significant pointers to practice. A study in 
Russia showed that knowledge level of health care workers could influence the prevalence 
ofTB infection (Woith, Volchenkov, & Larson, 2012). 
Nonetheless, previous researchers have found that HCWs often lack adequate knowledge 
about TBIC. According to the study of selected health care workers in northwest Ethiopia 
by Temesgen and Demissie. "though the majority of the participants had good TBIC 
knowledge and practice, a considerable proportion of health professionals were not trained 
on TBIC" (Temesgen & Demissie, 2014). In 2013, a study by Minnery and his colleagues 
on the knowledge and attitudes offront-line TB personnel in Lima, Peru, also showed that 
there were major knowledge gaps in areas related to TB treatment and diagnosis, which 
retlected other previous findings in TB endemic areas throughout the world (Minnery et 
al..2013). 
Tuberculosis Infection Control (TBIC) involves employing diverse measures aimed at 
minimizing the risk of TB transmission within populations (WHO, 2009). The WHO 
recommended a combination of measures - including administrative measures, 
environmental measures, and personal respiratory protection - to reduce TB infection 
(WHO. 2009). Effective TBIC implementation requires early identification, isolation of 
infected persons, and timely, effective treatment of persons with TB. Gaps in the 
implementation of TBIC predispose health care workers and patients to nosocomial TB 
transmission (Temesgen & Demissie, 2014). 
However, TBIC is rarely effectively implemented in most developing countries due to 
resource constraints. A study of two districts in Uganda showed that TBIC measures were 
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not being implemented. It identified factors like lack of staff, space and funds as barriers 
to the implementation of TBrC (Buregyeya, Mitchell, Rutebemberwa, Criel, & Kiguli, 
2013). 
According to Temesgen and Demissie, '"a rapid assessment done in 2008 revealed that most 
health care facilities in Ethiopia do not use TBIC practices," exposing both health care 
workers and patients to TB transmission. especially at facilities with high case load 
(Temesgen & Demissie, 2014). Another research shows that a significant portion ofHCWs 
had unsatisfactory practice on TBIC (Demissie Gizaw et aI., 2015). 
2.6 Facton Innuencing the Implementation ofTBIC Measures 
Tuberculosis. although a curable disease, remains a major health problem globally despite 
the various measures introduced by the World Health Organizations and other international 
bodies and groups (WHO, 2016). There are many challenges that many times beset the 
implementation of the tuberculosis infection control. These include clinical, institutional, 
and socio-cultural factors. Previous studies also identify other barriers such as delays in 
diagnosis, inadequate financial support, insufficient motivation. lack of clear guidelines, 
shortage of materials, inadequate qualified health professionals and inadequate health care 
worker training (Cramm, FinkenflUgel, M0l1er, & Nieboer, 20\0; Amo-Adjei, 20\3; 
Buregyeya et aI., 2013; Brouwer, Coelho, Das Dores Mosse, et aI., 2014; Wynne, Richter, 
Banura, & Kipp, 2014). 
Inadequac) of qualified health professionals coupled with poor training programs is a 
major hindrance to effective implementation ofTBIC. According to Wynne and colleagues 
(2014), health providers in Western Uganda are unable to effectively implement TB control 
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programs due to inadequate qualified health professionals and poor health care worker 
training. There were health facilities that had only one health professional with proper 
training on TB, and other workers relied on outdated materials from school. The 
inadequacy of knowledge results in extensive delays in diagnosing patients, and in some 
cases. failure to even identify the signs and symptoms to screen the patients (Wynne et aI., 
2014). Further, Buregyeya et al.. (2013) also identified lack of human resource 
(understaffing) as a limiting factor to effective implementation of TBIC. It was again 
reported that TBIC measures like screening for people with cough, timely sputum 
examination. and health education were perceived as extra workload for the already 
overstretched personnel (Tamir, Wasie, & Azage, 2016). As such, screening was not done 
at the point of arrival of the patients. 
In Mozambique, it was recorded that although some TB staff went through formal TB 
training. the auxiliary staff were not partaking in such trainings even though they often 
assisted with patient-related activities (Brouwer et aI., 2014). Other researchers showed 
that the practicality of some of the training programs also was inadequate. They revealed 
that training was not identified to have an influence on TBIC practice in many public health 
facilities in Ethiopia, indicating that it could be a result of much focus on the theoretical 
components of the training instead of the skill-based aspects (Temesgen & Demissie, 2014; 
Demissie Gizaw et aI., 2015). 
A study across 3 districts in South Africa revealed lack of training, poor compliance, 
absence of TBIC plan and committee, dire shortage of respirators as hindrances 
(Engelbrecht & Van Rensburg, 2013) . Also, implementation and practice of TBIC in 
facilities in Ikeja, Nigeria was poor due to barriers such as non-existence of TBIC plan. 
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lack of training, shortage of manpower, stigmatization and structural inadequacies (Kuyinu 
et aI., 2016). 
In adequate funding for TB control programs is also a challenge to effective implementation 
of TBIC by health care workers. In Uganda, it was recorded that lack of adequate and 
consistent funding meant that health care workers were also limited in undertaking 
community visits and effective follow ups on patients. Logistics and medication were also 
inadequate and a significant portion of the financial burden was transferred to the patients, 
who mostly are unable to follow up with the routine (including the regular visits to health 
care facilities) drawn for dealing with the disease (Wynne et aI., 2014). These factors, 
amongst others, frustrated health professionals' ability to implement the DOTS program. 
Amo-Adjei (2013) indicated that inadequacy offunding coupled with delays in accessing 
funds from donors and the government was a barrier to effective TBIC implementation by 
some institutions in Ghana. 
Another barrier to effective implementation of TBIC is the lack of adherence of patients. 
Patients were identified as not complying with cough etiquette and separation process 
(Buregyeya et aI., 2013). A common pattern realized by Wynne et aI., (2014) was the 
attempts of patients to engage in self-treatments for initial cough symptoms till infection is 
worsened before a visit is made to hospitals. These factors contribute to extensive delays 
in diagnosis and overcrowding in health care facilities, thereby increasing the risk of 
transmission. Brouwer and Collegues also identified that patients' daily routine was also a 
challenge faced by HCWs to effective implementation of TBIC measures. There were 
certain measures some patients could not adhere to due to their everyday routines like 
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eating meals together as a family, which made it difficult to separate infected persons from 
the family during these routines (Brouwer et aI., 2014). 
To add to the above, many researchers have identified flaws in the healthcare system as a 
challenge faced by health care workers in implementing TBIC measures. The study by 
Brouwer and colleagues (2014) revealed that in Mozambique, the healthcare system, 
including availability of necessary logistics and the infrastructure, was a main hindrance to 
the use ofTBIC measures both by HCWs and patients. There was also shortage of materials 
like boots, respirators, and other equipment, leading to indifference and poor attitude 
towards use of respirators. It also showed that there were inadequate spacing of 
consultation and waiting rooms, coupled with poor ventilation systems including defective 
windows and doors (Brouwer et aI., 2014). Also, according to Buregyeya et aI., (2013), 
health professionals in some districts in Uganda also cited lack of space in waiting area to 
en5ure that TB suspects are separated is a challenge. Wynne and colleagues in their study 
also identified other health system issues like "poor referral practices between health units" 
and absence of laboratory capacity to test for TB in many health facilities as a challenge 
(Wynne et aI., 2014). Health professionals were therefore unable to test or diagnose 
patients even when they suspect an infection. Further, low motivation ofHCWs due to low 
pa). lack of control over career development and inadequate work conditions, has been 
identified as a challenge to TBIC implementation (Brouwer et aI., 2014). 
2.7 Measurement of Levels of Knowledge and Practice of HCWs on TBIC 
Generally, Health Care Workers' (HCWs) levels of knowledge and practices have been 
categorized into either good/adequate/proper or poor/improper in many studies. A cross-
sectional study by Buregyeya and colleagues (2016) among HCWs in Uganda, used a cut-
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off of >70% to indicate "adequate" knowledge levels (Buregyeya, Kasasa, & Mitchell, 
2016). Another study which assessed knowledge and practice of HCWs in Ethiopia, 
considered respondents with scores equal or above the mean as having "good 
knowledge/practice" and vice-versa (Demissie Gizaw et aI., 2015). In West Go.iiam Zone, 
Northwest Ethiopia, participants who scored SO% or more were considered to have had 
"proper TBIC practice levels" (Tamir et aI., 2016). Furthermore, another research used 
2::60% for assessing "good knowledge" while for "good practice" 2::50% was used 
(Temesgen & Demissie, 2014). A South A frican study considered higher knowledge scores 
as suggestive of "greater knowledge" (Cramm et aI., 2010). Thus, in this study, the measure 
of knowledge will be scoring equal to or above the mean (7.S) for "good knowledge" and 
below the mean for "poor knowledge." The measure of practice will be ~ 5.9 for "good 
practice"' and < 5.9 for "poor practice." 
2.8 Summary of Literature Review 
This chapler explored the relevant literature on implementation of tuberculosis infection 
control (TBIC) among health care workers. It recognized the various aspects of 
implementation ofTBIC among HCWs as stipulated by WHO in 2009, and identified the 
following levels of implementation of TBIC measures: Administrative and Managerial 
mea~urc~, Environmental Measures, and Personal Protection Measures. It also showed 
large gaps in training programs for HCWs, availability of TBIC materials (policy, 
guidelines, Information, Education and Communication materials, etc.) and PPEs, quality 
of environmental measures such as isolation rooms for TB patients, ventilation and 
infrastructural facilities. 
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CHAPTER THREE 
METHODS 
3.0 Introduction 
This chapter describes the methods employed for the study. It details the study design, 
study area, study population, variables and sampling procedure. It also covers data storage 
and protection, quality control, pre-testing of too Is, data analysis and ethical considerations. 
3.1 Study Design 
The study was cross-sectional in design using mixed-methods to collect information on the 
implementation of Tuberculosis Infection Control (TBIC) among health care workers at 
the Greater Accra Regional Hospital. The use of quantitative and qualitative methods 
provide broad and in-depth understanding of the phenomenon being studied (Johnson, 
Onwuegbuzie, & Turner, 2007). The mixed-method approach involved structured 
intervie .... s, direct observation and Key Informant Interviews (Klls). This was to enhance 
accuracy and triangulate information received from the participants. 
3.2 Study Area 
The study was conducted at the Greater Accra Regional Hospital in the Accra Metropolitan 
Assembly area in the Greater Accra Region. Greater Accra Region is one of the ten 
administrative regions of Ghana. It was reported to be the region with the second highest 
TB incidence of about 2,901 in 2014 (NTP, 2014, unpublished data). 
Accra Metropolitan Assembly (AMA) is divided into six sub metros namely Osu Klottey, 
Kpeshie, Okaikoi, Asheidu Keteke, Ablekuma and Ayawaso. The population peaks at age 
group 20- 24 (12.4% of the entire popUlation) followed by age group 25-29 (11.5% of the 
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entire population). A greater proportion (89%) of the AMA population aged 11 years and 
older are literates (Ghana Statistical Service, 2014). Accra Metropolitan has 218 health 
facilities consisting of 28 hospitals, 130 health centers and 60 other fonns of health post 
One hundred and eighty seven (187) of these health facilities are owned by private and 
non-governmental organizations. The main health problem of Accra metropolitan is 
infectious disease especially malaria and cholera due to poor sanitation and poverty (Ghana 
Statistical Service, 2014). 
The Greater Accra Regional Hospital was fonnally known as Ridge Regional Hospital with 
about 19 I-bed capacity. After the current renovation, the facility was equipped to a 600-
bed capacity. The Greater Accra Regional Hospital is one of four government hospitals in 
the metropolis and provides medical care ranging from general medicine to specialized 
medical care. The total medical staff strength of the facility is about 736. The hospital has 
a separate laboratory for TB testing with an average monthly acid fast bacilli request of79. 
The facility also has a DOT center responsible for dispensing TB drugs, monitoring and 
recording treatment progress of TB patients. Some staff at the DOT center are recruited 
and trained by the National Tuberculosis Program (NTP) in Ghana. 
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~ 
w.. .. ..  ~ 
-:-~. T--r-
..;.. -
_ Ghana 
Teet-. man 
$--......... CIII 
Kuma., 
o 
11-'90 
m 
r 
t 
,---> 
Figure 3.2: Map showing the location of the Greater Accra Regional Hospital 
3.3 Study Population 
The study population included all Health Care Workers (HCWs) directly involved in TB 
care and others involved in out-patient management at the Greater Accra Regional 
Hospital. This included medical staff of the following units: DOTS, ART, Medical, 
Surgical, Dental, OPD and Triage, Paediatrics (Child Health), Pharmacy, Physiotherapy, 
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Radiography, Diet Therapy. Nutrition, ENT, Eye, Laboratory and ANC. A survey at the 
units of interest indicated a total of20} Health Care Workers who were at post at the time 
of the study. 
3.3.1 Inclusion Criteria 
• Health Care Workers who were willing and consented to participate in the study. 
3.3.2 Exclusion Criteria 
Health Care Workers unwilling to consent were excluded from the study. 
Health Care Workers who were on any form ofleave were also excluded. 
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3.4 Study Variables 
Dependent variable: Tuberculosis Infection Control 
Table 3.1: List of Independent Variables 
Variables Definition Stale of 
Measurement 
Age Age at last birthday in years Discrete 
Gender Male or Female Categorical 
Job Category Professional category ofHCWs Categorical 
Educational Status No education, Primary, secondary, tertiary Categorical 
Marital Status Single. Married. Separated/Divorced, Categorical 
Widowed 
Professional years No. of years spent working in area of Continuous 
specialization 
Number of years at facility Number of years spent working in this Continuous 
facility 
Existing medical condition (s) Any record of existing medical condition (s) Categorical 
If yes, please state 
Availability ofTBIC materials Presence of written TBIC plan or policy Categorical 
Availability of PPEs 
Availability of IEC materials to infonn, 
educate and remind staff and patients on 
TBIC 
Triaging 
Prompt identification of patients with TB Categorical 
symptoms 
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Screening ofTB suspects Are cough patients (TB suspects) screened Categorical 
forTB 
Isolation ofTB patients Are suspected or diagnosed TB patients Categorical 
isolated from other clinic attendees? 
Availability of TB laboratory Presence of separate laboratory for TB Categorical 
for testing and reporting testing and reporting 
Education on cough etiquette Instruct patients with chronic cough on Categorical 
cough hygiene 
Covering nose and mouth when coughing or 
sneezing 
Training of staff on TBIC Were you trained on TBIC Categorical 
How many years ago? Continuous 
Screening ofHCWs Are HCWs periodically screened for TB? Categorical 
TB prevention and care Is there a prevention and care intervention Categorical 
interventions for HCWs for HCWs with TB 
Supervision and coordination Existence of a focal person to monitor Categorical 
effective implementation ofTBIC 
Existence of a focal person who coordinates 
with National TB Programme. 
Existence of Infection Control committee 
Availability of adequate Availability of functional natural or Categorical 
ventilation 
mechanical ventilation system 
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Windows 
Fans 
Wind~riven air extractor turbines 
(whirlybirds) installed in indoor waiting 
areas 
Ultraviolet gennicidal irradiation) 
Windows positioned on opposite sides of 
walls of wards or rooms 
Are windows opened daily 
Are outdoor waiting areas large enough to 
seat patients without crowding? 
Safe sputum disposal methods Availability of well-ventilated sputum Categorical 
booths at vantage points (outdoors in the 
facility) 
Sputum samples collected from booths 
Pt!r~onal protection measures Use ofN95 respirators by HeWs 
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3.5 Sampling and Sampling Procedure 
3.5.1 Sample Size Determination 
The sample size calculation for the HCWs was based on a total population of medical 
statfof201 who were at post within the study period from the following units; DOTS, 
ART, Medical, Surgical, OPD and Triage, ENT, Pharmacy, Radiography, Laboratory and 
Dental. Therefore using the sample size formula by Yamane 1967, 
N 
no = 1 + N(e)2 .................................. (1) 
where: 
n: sample size 
N: the population size of the HCW s, 20 I 
e: precision, 5% (0.05) 
Inputting the above into equation (I), the minimum sample size of Health Care Workers 
required for this study was given by: 
201 
no = 1+201(0.05)2 = 133.8 ~ 134 
Therefore, the minimum sample size for Health Care Workers was 134. 
3.5.2 Sampling Procedure 
A complete survey "as done to obtain the number and cadre of Health Care Workers 
(HCWs) in the various units of interest. The units: DOTS Center, ART, Medical, OPD, 
Triage, Paediatrics and Pharmacy, were selected using simple random sampling technique. 
Data collection started from 22nd May to 28th June, 2017. The proportion of Health Care 
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Workers selected from each category was based on the number of staff (n=20 I) present at 
the various units within the study period: nurses (n=73), Doctors (n=78), Pharmacists 
(n=15) and Allied Health Professionals (n=35). The constant proportion of 0.667 
[134120 I = 0.667] was multiplied by the number of persons in each job category to obtain 
the expected sample size for each category. Finally, the sample size for each category was 
used to obtain the percentage of persons that was selected. The Table below shows the 
sample size for each of the job categories in the study. 
Table 3.2: HCWs Distribution from Each Job Category 
Job Category Total Constant Sample Size Percent (%) from 
Number Proportion Required Each Group 
Doctors 73 0.667 49 36.57 
Nurses 78 0.667 52 38.81 
Pharmacy Personnel 15 0.667 10 7.45 
Allied Health Professionals 35 0.667 23 17.16 
Total 201 134 100 
The sample size (134) was apportioned to each selected unit based on the size of health 
care workers at post during the period of data collection. Stratification of the HeWs was 
done according to their job category. The sampling frame (list of health care workers by 
job category) for each stratum was obtained from the units and a simple random sampling 
method applied to recruit them. The random numbers were computer generated using 
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Microsoft Excel. The aim was to ensure that every Health Care Worker had an equal chance 
of being selected. 
3.5.3 Data Collection Instruments 
The Health Care Workers (HCWs) were made to read and sign the consent forms 
(Appendix I) given to them before they were administered the questionnaire (Appendix II). 
Concerns and questions regarding the study were also addressed. A semi-structured 
questionnaire adapted from Codjoe (2012) was modified according to the WHO guideline 
for reducing TB transmission in healthcare settings (WHO, 2009). The questionnaire was 
in four (4) sections. Section one (I) covered the socio-demographic information and work-
related demographics of the HCWs (age, gender, marital status, educational status, job 
category, professional working years, years worked in facility, current unit of work, 
training on TBIC and presence of any known medical condition). Section two (2) assessed 
the level of knowledge and practices of the Health Care Workers on TB and TB Infection 
Control (Mode of TB spread, classical signs/symptoms of TB, Persons with high risk of 
TB exposure and infection, cough etiquette, persons with greatest risk of TB spread in 
healthcare settings, use of PPEs, ways of identifying TB suspects etc). Section three (3) 
explored service factors influencing TBIC at the facility (availability of TBIC materials, 
availability of separate laboratory for TB testing and reporting, screening of TB patients 
and Staff, isolation of infectious patients and availability of intervention packages for 
HCWs). Section four (4) examined the environmental factors influencing TB infection 
control (size of waiting area, crowding, ventilation and availability of well-ventilated 
sputum booth). The questions on knowledge and practice were assessed using 10 and II 
responses respectively. "Yes" or "No" were scored as "I" and "0" respectively. Knowledge 
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or Practice scores above the mean score were considered as "good" while those below the 
mean were considered "poor" (Demissie Gizaw et aI., 2015). 
3.5.4 Key Informant Interviews 
Purposive sampling using maximum variation technique was employed to recruit seven (7) 
key individuals responsible for effective implementation of TBIC at the Greater Accra 
Regional Hospital. Purposive sampling technique is ''used in qualitative research for the 
identification and selection of infonnation rich cases related to the phenomenon of interest" 
(Palinkas et aI., 2015). Seven (7) key infonnants comprising of the Medical Director, 
Hospital Administrator. Accountant. Greater Accra Regional Physician in charge of TB 
care, Infection Prevention Control (IPC) focal person, DOTS Center In-charge and Head 
of TB Bacteriology Laboratory were purposively selected. A Key Infonnant Interview 
(KII) guide adopted from Adeleke (2012), and modified in accordance with the WHO 
Tuberculosis Infection Control guideline was used for the interviews. The infonnation 
obtained was used to triangulate infonnation provided by the HCWs and direct observation. 
The Key Infonnants Interviews (KIIs) lasted between 10-60 minutes and recorded using 
an audio recorder. Notes were also taken to ensure accuracy. The KIIs were carried out at 
the offices of the participants to ensure privacy. 
3.5.5 Direct Observation of Health Care Workers' Practice 
Health care workers were observed directly during their routine work to assess how they 
carried out TB infection control. An observation grid outlining observable measures of 
administrative, environment and personal protection was used. The researcher spent five 
(5) working days observing daily TBIC practices. This approach infonned on additional 
questions to include in semi-structured interviews and complemented the results thereof. 
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3.6 Quality Control 
3.6.1 Data Handling 
Data collection tools were pre-tested at the University of Ghana Hospital prior to 
data collection. 
Research Assistants were trained to accurately carry out the data collection. 
The study materials were well explained to the HeWs prior to interview. 
• Questionnaires and field notes were cross-checked by principal researcher. 
3.6.2 Data Storage I Data Protection 
All the questionnaires, checklists and transcripts were kept under lock and key in a cabinet. 
A soft copy of data collected were coded and locked on a computer using a password and 
only accessible to the principal researcher and others involved in the research work. 
3.6.3 Data Validation 
Research assistants were trained on appropriate data collection skills to ensure uniformity 
of data collected. Data collected daily on the field were checked and cleaned manually for 
completeness, clarity and consistency. 
3.6.4 Pre-testing of Tools 
The data collection tools were pre-tested at the University of Ghana Hospital using 20 
participants before the commencement of the study. The pre-testing helped to clarify the 
data collection tools and to ensure research adequacy and freedom from bias. It also 
unearthed ambiguity in the questions thereby enabling rephrasing of such questions, and 
ensured a logical flow of the items on the questionnaire. Further, it enabled the research 
team to ha\'e a better appreciation of the data collection process. 
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3.7 Data Analysis 
Quantitative data collected were entered into REDcap and Ex.cel and then transferred into 
STATA 14.0 for cleaning, merging and analysis. Data were cleaned by running the 
frequencies of the variables to check for any form of inconsistencies. The inconsistent data 
were then checked with the raw data from the questionnaire. Knowledge and practice 
scores were computed for all correct responses to the questions. There were 10 responses 
for assessing level of knowledge and 11 responses for assessing HCWs practice on TBIC. 
Scores equal to or above the mean (7.8 for knowledge level, and 5.9 for practice level) 
were termed "good" while those below the mean were considered "poor." Data were 
presented using frequency tables and charts where necessary. Mean and standard 
deviations were computed for continuous variables and proportions for categorical 
variables. Chi-square was used to determine the association between level of knowledge 
and practice, and demographic characteristics and Fisher's ex.act test was used when 
sample size was small. Cramers V was used to determine the strength of the association 
between level of knowledge and practice and demographic characteristics. Logistic 
regression was then used to determine the Odds Ratio for the independent variables, which 
were statistically significant. Significance was set at p<0.05. 
Qualitative data was analyzed manually. Thematic content analysis was used to analyze 
the transcribed data from key informant interviews and non-participant observation. 
Transcripts were read several times to get an overall picture of the contents and meaningful 
ideas coded, condensed and categorized into broader themes (Graneheim & Lundman, 
2004), such as availability of TBle materials, adequacy of ventilation at the facility, 
training of HCWs on TBIC, screening of HCWs and patients. Data were then interpreted 
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using insights, intuition and literature and presented in texts, verbal quotation. The 
qualitative rmding were used to triangulate the infonnation received from the HCWs and 
the direct observation. 
3.8 Limitations 
I. At the time of the study, the hospital was in a state of transition from its old building 
into a newly built ultra-modem facility. As such, responses were mixed reflecting 
the situation of both the old and new structures and facilities of the hospital. 
2. The study explored educational status of the Health Care Workers based on 
primary, secondary and tertiary educational level which resulted a skewed response 
toward tertiary education. As such, no variation was found during data analysis, 
leading to the exclusion of educational status from the logistic regression model. 
3. The use of a cross-sectional study. Cross sectional study design is a snapshot and 
responses can vary if measured at different times. 
3.9 Ethicatlssues 
This study obtained ethical clearance from Ghana Health Service Ethical Review 
Committee (GHS-ERC). A written infonned consent was obtained from the participants 
before they were recruited in the study. Pennission was also sought from the head of the 
Greater Accra Regional Hospital before the study commenced. 
3.9.1 Privacy and Confidentiality 
Interviews were done in a manner to ensure privacy and confidentiality. Each participant 
"as assigned a code to avoid using names and ensure anonymity. The infonnation collected 
from the interviews was treated confidential and available only to the researcher and other 
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custodians of the research. Hard copy of questionnaires was kept under lock and key in a 
box while soft copy of data was password protected on a laptop. The data will then be 
destroyed after five years. 
3.9.2 Voluntary Participation and Withdrawal 
The objectives and procedures of the study were well explained to the participants and they 
were made aware that they were free to participate or withdraw from the research any time 
without any negative effect. 
3.9.3 Benefits 
There was no direct monetary benefit in this study. However, participants were given 
souvenirs and also got the opportunity to add on to knowledge in the area ofTB infection 
control and its effective implementation for societal benefit. 
3.9.4 Cost/Compensation 
Participants did not incur any cost in this study. The study did not also provide 
compensation in the form of money to the participants. 
3.9.5 Declaration of Con nict ofinterest 
The researcher had no potential conflict of interest with respect to the study. 
3.9.6 Research Funding 
This research was funded by the NIH Fogarty International Centre through partnership with 
the University of Ghana, College of Health Sciences and the University of Florida. 
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CHAPTER FOUR 
RESULTS 
4.0 Introduction 
This chapter details the findings of this study in line with the set objectives. It is in four 
sections. Section one shows socio-demographic and work-related characteristics of 
participants. Section two presents the knowledge and practice of Health Care Workers on 
TB and TB Infection Control. Sections three and four present the service and 
environmental factors influencing the implementation ofTB infection control (TBIC). 
4.1 Socia-Demographic Cbaracteristics of Participants 
A total number of 137 Health Care Workers (HCWs) participated in the study. Majority, 
62 (45.3%) ofthe Health Care Workers were between the ages 18 to 29 years, and the mean 
age was 32.5 years (SD = 7.6). Almost two-thirds, 85 (62.0%) of the participants were 
females, and more than half, 76 (55.5%) were married (Table 4.1a). In terms of educational 
status, almost all, 136 (99.3%) of the participants had tertiary education. Also, 123 (89.8%) 
of the participants indicated that they had no medical condition, and none of the medical 
conditions indicated was tuberculosis. 
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Table 4.la: Socio-Demographic Characteristics of Health Care Workers (HCWs) 
Characteristics Number(n 137) Percent(%) 
Age (years)* 
18 to 29 years 62 45.3 
30 to 39 years 56 40.9 
40 to 49 years 9 6.6 
50 years and above 10 7.3 
Gender 
Male 52 38.0 
Female 85 62.0 
Marital Status 
Single 60 43.8 
Married 76 55.5 
Separated/Divorced 0.7 
Educational Status 
Secondary 0.7 
Tertiary 136 99.3 
Presence of medical condition 
No 123 89.8 
Yes 14 10.2 
Medical condition" 
Allergic Rhinitis 2 16.7 
Asthma 
2 16.7 
Back pain 
2 16.7 
Coccyx pain 
8.3 
Hypertension 4 
33.3 
Polycystic Ovarian Syndrome (PCOS) 1 
8.3 
-Mean Age of HCWs = (32.5 ± 7.6) years, Min. Age = 23 and Max. Age is 59 
--Total numberofHCWs with medical condition = 14. However, two participants did not indicate 
the medical condition. 
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A similar proportion of the participants were doctors, 50 (36.5%) or nurses, 52 (38.0%), 
and 25 (18.3%) being Allied Health professionals. More than half, 70 (51.1 %) of them had 
a total professional working years of less than five years. Additionally, 87 (63.5%) had 
worked in the study facility between one and five years. Further, 30 (21.9%) of the 
participants were from the medical unit. The OOTS and ART units which were directly 
involved in TB care had nine participants in this study (Table 4.lb). 
More than one-third, 53 (38.7%) of the participants reported that they had received some 
fonn of training on TB infection control in the facility. Of these, 29 (54.7%) were trained 
within the past year while 24 (45.3%) were trained over a year ago (Table 4.lb). 
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Table 4.1b: Work-related Demographics of Health Care Workers 
Characteristics Number~n! Pereeat !o/.~ 
Job category 
Doctor 50 36.5 
Nurse 52 38.0 
Phannacist 10 7.3 
Allied Health Professionals··· 25 18.3 
Professional working years 
Less than 5 years 70 5t.1 
>='5 to <10 years 42 30.7 
>=10 to <15 years 13 9.5 
>; 15 to <20 years 4 2.9 
20 years and above 8 5.8 
Years worked in facility 
Less than 1 year 7 5.1 
>= 1 to <5 years 87 63.5 
>=5 to <10 years 33 24.1 
>=10 to <15 years 5 3.7 
>= 15 to <20 years 2 1.5 
20 years and above 3 2.2 
Received Training on TOIC 
Yes 53 38.7 
No 84 61.3 
Period of last training received 
Less than or equal to one year ago 29 54.7 
Over a year ago 24 45.3 
Current Unit 
DOTS and ART 9 6.6 
Laboratory 10 7.3 
OPD 
6 4.4 
Medical 30 21.9 
Surgical 11 8.0 
Dental 
16 
Phannacy 11.7 
10 7.3 
Paediatrics 
25 18.3 
Other. .• • 20 14.6 
OPD ; Out Patient Department I, ART; Antiretroviral Therapy II DOTS - Directly Observed 
Treatment. Short-Course center 
"·Midwife. Dietician, Dentist, Lab Personnel, Radiographer. Physiotherapy Personnel. Health 
Aide, Dental Technical Officer 
•••• ANC, ENT. Eye. Public Health, Treatment Room. Physiotherapy, Diet Therapy. Radiography 
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The age of the participants in the key infonnant interviews ranged from 34 to 58 years with 
a mean age of 44.7 years. More than two-thirds, 5 (71.4%) of the participants had their 
Master's Degree. The number of years the participants had worked in the facility ranged 
from 2 to 18 years with a mean of 7.8 years working experience and these were mainly 
managers of the units. 
4.2 Level of Knowledge of HCWs 00 TB and TBIC 
The overall level ofknowledge was good in this study (Table 4.2), with 88 (64.2%) of the 
participants scoring equal or above the mean (7.8 ± 1.5). 
Almost all, 131 (95.6%) of the participants correctly identified "airborne" as the mode of 
TB spread, and 124 (90.5%) recognized people who are immune-compromised such as 
HIV/AIDS patients as individuals with high risk ofTB exposure and infection. 
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Table 4.2: Knowledge of Healtb Care Workers on TB and TBIC 
Number Percent 
Characteristics 
(n) (%) 
Mode of TB spread 
Airborne 131 95.6 
Through blood or physical contact 6 4.4 
Persons with higher risk ofTB exposure and infection 
Persons who are Immuno-compromised. HIV/AIDS patients Yes 124 90.5 
No 13 9.5 
Symptom Identification 
Coughing out blood Yes 114 83.2 
No 23 16.8 
Weight Loss Yes 120 87.6 
No 17 12.4 
Night Sweats Yes 112 81.8 
No 25 18.3 
fever Yes 36 26.3 
No 101 73.7 
Persons with greatest risk for TB spread in Healthcare setting 
Undiagnosed coughing patients 97 70.8 
lie Ws who do not use respirators when attending to TB 
patients 
35 25.6 
Don't know 
3.7 
Cough etiquette 
Covering mouth with tissue or upper arm during cough or 
sneezing Yes 128 93.4 
No 9 6.6 
Cough etiquette is required of all persons at all times Yes 86 62.8 
No 51 37.2 
Best and cheapest way to reduce TB bacilli in tbe air 
Use of natural ventilation (doors. windows) and maximizing 
cross-ventilation) 
120 87.6 
Other (mechanical ventilation, use of respirators, hand 
hygiene) 
17 12.4 
Overall Knowledge Level 
Poor knowledge 
49 
Good Knowledge 35.8 
TB Tuberculosis 88 64.2 
HIV/AIDS Human Immune Virus/Acquired Immune Deficiency 
Syndrome 
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Concerning signs and symptoms ofTB patients, 120 (87.6%) of the participants mentioned 
weight loss as a classical sign while only 36 (26.4%) identified fever as a classical sign of 
TB. More than two-thirds, 97 (70.8%) identified undiagnosed coughing patients as 
potential risk groups for TB spread in Healthcare settings. For cough etiquette, 86 (62.8%) 
admitted that cough etiquette is required of all persons at all times. Additionally, 120 
(87.6%) of the HeWs recognized the use of natural ventilation (doors, windows) and 
maximizing cross-ventilation as the best and cheapest way to reduce TB bacilli in the air 
(Table 4.2). 
4.3 Relationship between Level of Knowledge and Demographic Characteristics 
of HCWs 
Table 4.3 shows the relationship between level of knowledge and demographic 
characteristics of the HCWs. Gender, marital status and current unit of work were the 
variables that exhibited a statistically significant relationship with level of knowledge. 
Majority, 60 (70.6%) of the females had good knowledge relative to 28 (53.9%) of the 
males with good knowledge (V= 0.17, P = 0.047). A significantly higher proportion of the 
Hews who were married, 55 (72.4%) recorded high level of good knowledge compared 
with the HeWs who were single, 32 (53.3%), [V= 0.21, P = 0.036]. The unit in which a 
health worker worked in the hospital determined the level of knowledge. Thus, it was not 
surprising that all of the HeWs directly involved in TB care (DOTS and ART) recorded 
"good knowledge" ofTB and TBIC, while 8 (80.0%) of the Pharmacy and 23 (76.7%) of 
the Medical unit HeWs also displayed good knowledge. However, majority, 7 (70.0%) of 
thl: laboratory HeWs and 9 (56.3%) of the dental unit HeWs recorded poor knowledge. 
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The difference in knowledge ofTB and TBIC by unit was statistically significant (V=O.36, 
p=O.OIS). 
Age, educational status, job category, professional working years, years worked in the 
facility and training received on TBIC did not show any significant statistical relationship 
with knowledge ofTB and TBIC. All adults between 40 to 49 years had good knowledge. 
Further, 39 (62.9%) of HCWs aged 18 to 29 years, and 35 (62.5%) of HeWs aged 30 to 
39 years also had good knowledge (Table 4.3). 
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Table 4.3: Relationship between Level of Knowledge and Demographic 
Characteristics of HCWs 
Knowledge level 
Good Poor Cramers 
Characteristics Cat!:,Bo!I KnowledGe KnowledGe V P-Value 
Gender Male 28 (53.9) 24(46.2) 0.170 0.047· 
Female 60 (70.6) 25 (29.4) 
Age Category 18 to 29 years 39 (62.9) 23 (37.1) 0.210 0.082 
30 to 39 years 35 (62.5) 21 (37.5) 
40 to 49 years 9 (100.0) 0(0.0) 
50 years and above 5 (50.0) 5 (50.0) 
Marital Status Single 32 (53.3) 28 (46.7) 0.207 0.036· 
Married 55 (72.4) 21 (27.6) 
SeparatedlDivorced 1(100.0) 0(0.0) 
Educational Status Secondary I (100.0) 0(0.0) -0.064 0.642 
Tertiary 87 (64.0) 49(36.1) 
Job Category Nurse 31 (59.6) 21 (40.4) 0.181 0.217 
Doctor 36 (72.0) 14 (28.0) 
Phannacist 8 (80.0) 2 (20.0) 
Allied Health 
Professional 13 (52.0) 12 (48.0) 
Professional Working 
Years Less than 5 years 47 (67.1) 23 (32.9) 0.194 0.267 
>=5 to <10 years 23 (54.8) 19 (45.2) 
>=10 to <15 years 11 (84.6) 2 (15.4) 
>= 15 to <20 years 3 (75.0) 1 (25.0) 
20 years and above 4 (50.0) 4 (50.0) 
Facility Working Years Less than I year 4 (57.1) 3 (42.9) 0.152 0.760 
>= 1 to <5 years 55 (63.2) 32 (36.8) 
>=5 to < 10 years 22 (66.7) II (33.3) 
>=10 to <15 years 4 (80.0) 1(20.0) 
>= 15 to <20 years 2 (100.0) 0(0.0) 
20 years and above 1(33.3) 2 (66.7) 
Current Unit of Work DOTS and ART 9 (100.0) 0(0.0) 0.360 
Medical 0.018· 23 (76.7) 7 (23.3) 
Surgical 8 (72.7) 3 (27.3) 
OPD& Triage 3 (50.0) 3 (50.0) 
Phannacy 8 (80.0) 2 (20.0) 
Dental 7 (43.8) 9 (56.3) 
Paediatrics 16(64.0) 9(36.0) 
Laboratory 3 (30.0) 7 (70.0) 
Other II (55.0) 
Received Training on 9 (45.0) 
TBIC Yes 3 (64.2) 30 (35.7) 
No 0.0014 0.987 
* 54(64.3) Significant at p<0.05 19(35.9) 
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Generally, the majority of all job categories had good knowledge scores, with Pharmacist 
(80.0%) and Doctors (72.0%) recording the highest. Likewise, the majority ofa ll categories 
for professional working years and years worked in the facility of study had good 
knowledge scores (Table 4.3). In terms of training on TBIC, there was no significant 
variation of the knowledge level between the participants who have received training 
(64.2% good knowledge level), and those who have not received training (64.3% good 
knowledge). 
4.4 Health Care Worker Factors Associated with Level of TB and TBIC 
Knowledge 
From Table 4.4, females had 2.06 times the odds of good knowledge compared to the males 
and this was significant (95% CI 1.00-4.22). The odds of the good knowledge increased to 
2.80 after adjusting for age, marital status,job category, current unit of work, years worked 
in facility and training on TBIC (95% CI 0.98-7.97). The Health Care Workers between 
the ages of 30 to 39 years had 2% reduced odds of good knowledge compared to those who 
were aged 18 to 29 years (95% CI 0.47-2.07). The participants who were married were 
2.29 times more likely to have good knowledge compared to those who were single (95% 
CI 1.12-4.68). However, multivariate logistic regression models that included variables for 
gender. age, job category, current unit of work, years worked in facility and training on 
TBIC revealed that marital status is the strongest determinant of knowledge, AOR 3.19 and 
95% CI (1.11-9.13). 
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Table 4.4: Odds Ratio ofSoeio-demograpbic and Work-related Factors Associated 
witb Level of Knowledge of Healtb Care Workers on TO and TOIC 
Cha racteristics Category COR (9S% CI) AOR(95%CI) 
Gender 
Male Ref Ref 
Female 2.06 (1.00-4.22)· 2.80 (0.98-7.97) 
Age Category 
18 to 29 years Ref Ref 
30 to 39 years 0.98 (0.47-2.07) 0.98 (0.30-3.17) 
40 to 49 years I I 
50 years and above 0.59 (0.15-2.26) 0.39 (0.04-4.09) 
Marital Status 
Single Ref Ref 
Married 2.29 ( 1.12-4.68). 3.19 (1.11-9.13)· 
SeparatedlDivorced I I 
Job Category 
Nurse Ref Ref 
Doctor 1.74 (0.76-3.99) 2.98 (0.78-11.43) 
Pharmacist 2.71 (0.52-14.05) 0.92 (0.08-10.75) 
Allied Health 
Professional 0.73 (0.28-1.92) 1.39 (0.20-9.80) 
Current Unit 
OOTS and ART Ref Ref 
Medical 2.69 (0.79-9.12) 1.61 (0.27-9.55) 
Surgical 2.18 (0.44-10.73) 1.04 (0.10-11.02) 
OPD& Triage 0.82 (0.13-5.08) 0.56 (0.06-5.50) 
Phannacy 3.27 (0.55-19.45) I 
Dental 0.64 (0.17-2.39) 0.32 (0.06-1.88) 
Paediatrics 1.45 (0.44-4.84) 0.62 (0.11-3.66) 
Laboratory 0.35 (0.07-1.76) 0.27 (0.03-2.15) 
Other I 1 
Years worked in facility 
Less than I year Ref Ref 
>= I to <5 years 1.29 (0.27-6.13) 1.84 (0.26-12.84) 
>= 5 to <10 years 1.50 (0.28-7.91) 1.79 (0.19-17.31) 
>=\0 to <15 years 3.00 (0.21-42.62) 1.82 (0.07-46.88) 
>= 15 to <20 years I I 
20 years and above 0.38 (0.02-6.35) 1.39 (0.03-66.74) 
Received Training on TBIC 
No Ref Ref 
Yes 
*Significant association, p<0.05 0.99 (0.49-2.04) 0.54 (0.21-1.43) 
COR Crude Odds Ratio AOR-Adjusted Odds Ratio 
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Participants who were doctors had an increased odds of good knowledge compared to 
nurses [COR=1.74, 95% CI (0.76-3.99)]. After adjusting for gender, age, marital status, 
current unit of work, years worked in facility and training on TBIC, the odds of good 
knowledge increased to 2.98 (95% CI 0.78-11.43). Pharmacists also recorded 2.71 times 
the odds of good knowledge compared to the nurses (95% CI 0.52-14.05). However, the 
odds of good knowledge reduced by 8% after adjusting for the other variables (95% CI 
0.08-10.75). 
The Health Care Workers at the medical and surgical unit had increased odds of good 
knowledge [COR= 2.69 (95% CI 0.79-9.12)] and [COR= 2.18 (95% CI 0.44-10.73)] 
respectively although not significant (p>0.05). On the other hand, AOR were 1.61 (95% 
CI 0.27-9.55) and 1.04 (95% CI 0.10-11.02) respectively in the multivariate models. Years 
worked in facility and training on TBIC did not show any significant association with TBIC 
knowledge (Table 4.4). One of the KIIs indicated that, 
., '" One sad Ihing is Ihal, when we even organize Ihe workshop for Ihem, 
lhe Iraining, Ihey will regisler, and they will not sit 10 enjoy the learning 
and leaching process that will go on. Few minutes, you will see them on 
lheir phone and they will walk out, and the presenter will also be 
presenting. .. So Ihey don 'I actually benefit fully from Ihe training programs 
that we organize in thisfacility ... .. (KII-04, GARH). 
4.5 Level of Practice of Health Care Workers (HCWs) of TB Infection Control 
From Table 4.5, the overall level of practice of the Health Care Workers was good, with 
83 (60.6%) scoring equal to or above the mean (5.9 ± 1.5). The minimum SCore was 2 \\'hile 
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the maximum score 9. Most, 119 (86.91'10) of the HCWs mentioned that they use chronic 
cough for> 2 weeks as a means of identifying TB suspects. However, only 17 (12.4%) use 
presence of fever to identify the suspects. 
Majority, 125 (91.2%) of health workers interviewed reported that they screened people 
suspected ofTB while 100 (73.0%) of them separated TB patients from other patients. Fast 
tracking of smear positive cases to minimize stay in hospital and education of patients on 
cough etiquette were minimally practiced by the HCWs. Thirty-seven (27.0%) of health 
workers practiced fast tracking of smear positive cases while 33 (24.1 %) practiced 
education of patients on cough etiquette. 
More than half, 73 (53.3%) of the health workers provided nose masks to coughing 
patients while 113 (82.5%) of them reported that they use personal protective equipment 
when working with high risk individuals (Table 4.5). 
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Table 4.5: Practice of HCWs regarding TB Infection Control at the Greater Accra 
Regional Hospital 
Number Percent 
Cbaracteristics 
(n=137) ('Yo) 
Promptly Identify TO suspects using signs/symptoms 
Chronic cough> 2 weeks Yes 119 86.9 
No 18 13.1 
Coughing out blood Yes 46 33.6 
No 91 66.4 
Weight Loss Yes 81 59.1 
No 56 40.9 
Night Sweats Yes 53 38.7 
No 84 61.3 
Fever Yes 17 12.4 
No 120 87.6 
Screening of suspected TO patients 
Screen TB suspects 125 91.2 
Do not screen TB suspects 12 8.8 
Separation of TO Patients 
Separate TB patients 100 73.0 
Do not separate TB patients 37 27.0 
Fast track smear positive cases to minimize stay in facility 
Yes 
37 27.0 
No 
100 73.0 
Educate cougbing patients on cough etiquette 
Yes 
33 
No 24.1 
104 75.9 
Pro\lide nose mask or tissue to coughing patients 
Yes 
No 73 53.3 
64 46.7 
Use of Personal Protecti\le Equipment 
Yes 
No 113 82.5 
24 17.5 
O\lerall Practice Le\lel 
Good Practice 
Poor Practice 83 60.6 
54 39.4 
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4.6 Relationship between Level of Practice and Demographic characteristics of 
Health Care Workers 
Tables 4.6a and 4.6b present the relationship between the level of practice of the HCWs on 
TBIC and their demographic characteristics. 
Job category, professional working years, current unit of work and level of knowledge were 
significantly associated with the level of practice of HCWs in implementing TBIC. 
Majority, 42 (84.0%) of the doctors exhibited good practice while 8 (32.0%) of the Allied 
Health Professionals recorded good practice (V= 0.40, p<O.OOI). With reference to 
professional working years, most, 7 (87.5%) of the HCWs who had worked for 20 years 
and above had good practice while more than two thirds of the participants who had worked 
between 10 and 15 years had poor practice (V=0.32, p=O.005). A greater proportion of the 
staff from Medical unit, 26 (86.7%) and Surgical unit, 9 (8\.8%) displayed good practice. 
On the contrary, majority, 8 (80.0%) of the staff from the Laboratory and 12 (75.0%) of 
the staff from Dental unit had poor practice (V= 0.47, p<O.OOI). In terms of level of 
knowledge, a greater proportion, 64/88 (72.7%) of those with good knowledge had good 
practice (V= 0.33, p<O.OO I). 
Gender. age category, marital status, years worked in the facility, receiving training on 
TBIC and presence ofa known medical condition were not statistically significant with the 
level of practice of the Health Care Workers. Thirty-four (65.4%) of the male HCWs had 
good TBIC practice compared to the females. Majority, 7 (70.0%) of the participants aged 
50 years and above exhibited good practice while 41 (66.1 %) of those aged 18 to 29 years 
recorded good level of practice. Almost, equal proportion of health workers who were 
single 36 (60.0%) and married 46 (60.5%) had good practice. In terms of years worked in 
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the facility. all of the participants who had worked in the facility between 15 years and 20 
years had good TBIC practice while 5 (71.4%) of those who had worked for less than a 
year displayed good level of practice. 
A greater proportion. 10/14 (71.4%) of the Health Care Workers who indicated that they 
had known medical condition(s) had good TBIC practice (Table 4.6a and Table 4.6b). 
There was almost no difference in the level of TBIC practice among the HCWs who had 
received training on TBIC, 32 (60.4%) and to those who had not, 51 (60.7%). 
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Table 4.6a: RelatioDsbip betweeD Level of Practice aDd Socio-demograpbic 
Cbaracteristics of HCWs 
Level of Practice 
Good Poor Cramen 
Characteristics Cat!lo!2: Practice Practice V P-value 
Gender Male 34 (65.4) 18 (34.6) -0.077 0.368 
Female 49(57.7) 36 (42.4) 
Age Category 18 to 29 years 41 (66.1) 21 (33.9) 0.133 0.486 
30 to 39 years 30(53.6) 26 (46.4) 
40 to 49 years 5 (55.6) 4 (44.4) 
50 years and ahove 7 (70.0) 3 (30.0) 
Marital Status Single 36 (60.0) 24 (40.0) 0.069 1.000 
Married 46 (60.5) 30 (39.5) 
Separated/Divorced 1(100.0) 0(0.0) 
Job Category Nurse 27 (51.9) 25(48.1) 0.398 <0.001· 
Doctor 42 (84.0) 8 (16.0) 
Pharmacist 6(60.0) 4 (40.0) 
Allied Health 
Professional 8 (32.0) 17 (68.0) 
Less than 5 years 50(71.4) 20 (28.6) 0.318 0.005· 
>=5 to <10 years 20 (47.6) 22 (52.4) 
>=10 to <15 years 4 (30.8) 9 (69.2) 
>= 15 to <20 years 2 (50.0) 2 (50.0) 
20 years and ahove 7 (87.5) 1 (12.5) 
Facility Working Years Less than I year 5 (71.4) 2 (28.6) 0.146 0.805 
>=1 to <5 years 54 (62.1) 33 (37.9) 
>=5 to < 10 years 17 (51.5) 16 (48.5) 
>=10 to <15 years 3 (60.0) 2 (40.0) 
>= 15 to <20 years 2 (100.0) 0(0.0) 
20 years and above 2 (66.7) I (33.3) 
*Significant at p<O.05 
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Table 4.6b: Relationsbip between Level of Practice and Socio-demograpbic 
Cbaracteristics 
Level of Practice 
Good Poor Cramen 
Characteristics CateG°!l Practice Practice V P-value 
Current Unit of Work DOTS and ART 4 (44.4) 5 (55.6) 0.466 <0.001· 
Medical 26 (86.7) 4 (13.3) 
Surgical 9 (81.8) 2 (18.2) 
OPD& Triage 2 (33.3) 4 (66.7) 
Pharmacy 6 (60.0) 4 (40.0) 
Dental 4 (25.0) 12 (75.0) 
Paediatrics 16 (64.0) 9 (36.0) 
Laboratory 2 (20.0) 8(80.0) 
Other 14 (17.0) 6 (30.0) 
Yes 10(71.4) 4 (28.6) -0.075 0.283 
No 73 (59.4) 50 (40.7) 
Yes 32 (60.4) 21 (39.6) 0.003 0.969 
No 51 (60.7) 33 (39.3) 
Level of Knowledge Good Knowledge 64 (72.7) 24 (27.3) 0.333 <0.001· 
Poor Knowledge 19p8.8} 30 ~61.2} 
*p<0.05 is considered statistically significant 
4.7 Work-related Factors Associated witb Level of Practice of Healtb Care 
Workers on Tuberculosis Infection Control 
The odds of good practice (Table 4.7) was 4.86 times (95% CI 1.92-12.34) higher among 
doctors compared to nurses. However, the odds increased to 7.91 (95%Cll.73-36.18) after 
adjusting for current unit of work, professional working years, training received on TBIC 
and level of knowledge on TB and TBIC. Contrary, the odds of good practice was 56% 
(95% CI 0.16-1.19) less among the Allied Health Professionals compared to the nurses 
although not significant; adjusting for the other variables further reduced the odds of good 
TBIC practice to 82% (95% CI 0.02-1.35) less compared to the nurses. 
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There was significantly higher odds of good practice among HCWs at the Medical unit 
compared to the units directly involved in TB care (DOTS and ART unit), (COR=8.13 95% 
CI 1.51-43.78). The multivariate analysis showed an AOR of 2.60 (95% CI 0.28-24.22). 
Furthermore, the HCWs in other units (ENT, Eye, ANC, Diet Therapy, Radiography, and 
Physiotherapy) were 2.92 times (95% CI 0.57-14.82) more likely to exhibit good practice 
compared to those at DOTS and ART. After adjusting for job category, professional 
working years, received training on TBIC and level of knowledge, this odds of good TBIC 
practice significantly increased to 8.84 (95% CI 1.03-75.56) among the workers in other 
unit compared to DOTS and ART (Table 4.7). 
The health care workers who had worked for 20 years or more were 2.80 times (95% CI 
0.32-24.24) more likely to display good practice compared to those who had worked for 
less than five years, although not significant. Further, this odds of good TBIC practice 
increased to 15.51 (95% CI 0.88-272.70) after the multivariate analysis. On the other hand, 
those who had worked between 5 and 10 years, and 10 and 15 years had significantly 
reduced odds ofTBIC practice [COR=0.36 95% CI 0.16-0.81); COR=0.18 95% CI 0.05-
0.64)] respectively compared to those who had worked for less than five years (Table 4.7). 
Training was not significantly associated with level of practice. The odds of good practice 
among those who had some form of training on TBIC was almost the same as those who 
had not been trained (COR= 0.99 95% CI 0.49-1.99). However, after adjusting for job 
category, current unit of work, professional working years and level of knowledge, the 
odds of good practice was 1.60 times (95% CI 0.54-4.75) higher among those who had 
been trained compared to those who had not been trained, although not significant (Table 
4.7). 
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There is also a statistically significant relationship between level of knowledge and level 
of practice. The Health Care Workers with good knowledge were 4.21 times (95% C12.0 \-
8.84) more likely to have had good practice compared to those with poor knowledge After 
adjusting for job category, current unit of work, professional working years and training 
on TBIC, the odds of good TBIC practice increased to 5.83 (95% CI 2.07-16.43) (Table 
4.7). 
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Table 4.7: Odds Ratio ofSocio-demographic and Work-related Factors A550ciated 
witb Level ofTBIC Practice 
Characteristics COR (95% CI2 AOR !9S·/0 el2 
Job Catgeory 
Nurse Ref Ref 
Doctor 4.86 (1.92-12.34)· 7.91 (1.73-36.18). 
Pharmacist 1.39 (0.35-5.50) 2.26 (0.21-24.04) 
Allied Health Professional 0.44 (0.16-1.19) 0.18 (0.02-1.35) 
Current Unit 
DOTS and ART Ref Ref 
Medical 8.\3 (1.51-43.78)· 2.60 (0.28-24.22) 
Surgical 5.63 (0.75-42.36) 0.62 (0.04-10.11) 
OPD& Triage 0.63 (0.07-5.35) 0.30 (0.02-3.99) 
Pharmacy 1.88 (0.30-11.63) I 
Dental 0.42 (0.07-2.36) 0.16 (0.01-1.79) 
Paediatrics 2.22 (0.47-10.45) 0.75 (0.09-6.50) 
Laboratory 0.31 (0.04-2.38) 1.51 (0.08-29.SI) 
Other 2.92 (0.57-14.82) S.84 (1.03-75.56)* 
Professional working years 
Less than 5 years Ref Ref 
>; 5 to <10 years 0.36 (0.16-O.8W 0.95 (0.26-3.39) 
>= IOto<15years O.IS (0.05-0.64)* 0.15 (0.02-1.1 0) 
>= 15 to <20 years 0.40 (0.05-3.04) 1.22 (0.07-21.45) 
20 years and above 2.80 (0.32-24.24) 15.51 (0.SS-272.70) 
Recei\'ed Training on TOIC 
No Ref Ref 
Yes 0.99 (0.49-1.99) 1.60 (0.54-4.75) 
Level of Knowledge 
Poor Knowledge Ref Ref 
Good Knowfedse 4.21 {2.01-S.84~* 5.83 (2.07-f6.43~. 
*Significant association at p<0.05 COR= Crude Odds Ratio AOR-Adjusted Odds Ratio 
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4.8 Service Factors Influencing Implementation of TBIC at tbe Greater Accra 
Regional Hospital 
Table 4.8 explored the service factors influencing TB infection control at the Greater Accra 
Regional Hospital. Generally, the Health Care Workers perceived screening of patients, 
availability of separate TB laboratory and availability of personal protective equipment as 
the service factors promoting sustained implementation of TBIC at the Greater Accra 
Regional Hospital. However, inadequate TBIC materials, lack of an isolation ward and the 
absence of staff screening were perceived as factors inhibiting sustained implementation 
ofTB infection Control in the facility. 
Availability of TBIC policy at the health facility was reported by 67 (48.9%) of the 
participants. However, 56 (40.9%) of them did not know of the availability of such policy. 
Most of the participants in the Key Informant Interviews (KlIs) also indicated the absence 
ofa TBIC policy in the facility: 
., There is one for Infection, Prevention and Control. I think it was launched 
around 201312015, when the Ebola scare came. So IPC came all on the 
agenda, so there was a national policy ... we don 'I have a separate one for 
TB. Because we are part oft he Ghana Health Service facilities, we all join 
what the headquarters produces. So they produce the guidelines and al/ 
facilities are supposed to adhere to i/. .. (KII-03, GARH) 
"No [we don't have a structured TBIC policy in the facility] we are using 
the National TB Control Programme policies; and the Ghana Health 
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Service (GHS) has policies on management ofi nfectious diseases. So those 
two are integrated in managing TR." (KJl-07, GARH) 
"For thisfacility, No, we are all using the national guideline. So that's what 
we use . .. (KII-04, GARH) 
A copy of the National Infection Prevention Control Policy was sighted during the direct 
observation process. 
With reference to the existence of a TBIC committee or focal person in charge of TB 
infection control, more than half, 93 (67.1)010) of the HCWs specified that there was a TBlC 
committee or focal person in the facility (Table 4.8). 
The Klls also indicated the existence of a TBIC committee or focal person in the facility 
for sustained TB Infection control. 
"Yes, we have fa TRte committee or focal person). We have our Quality 
Assurance Team ... there are other members who constitute the committee. 
t was part of it. It is not limited to only TR, It is for all other infections in 
the facility ... "(KII-04, GARH). 
"Rather, we have a permanent team headed by a TB focal 
person/coordinator, and we also have another coordinator for ART. The 
two work together because TB has a link with HIV, so the two collaborate. 
And they also work closely with our laboratory, because oft he sputum tests, 
and some other aspects of TB necessary for confirmation from the sputum, 
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elc. So, Ihese 3 unilS work together, with supportfrom management. .. (KII-
06,GARH). 
The existence ofstaffTB screening mechanism for HCWs was reported as being absent by 
105 (76.6%) of the participants as there was no system in place for periodic staff screening 
for TB. The participants in the KlIs on the other hand, held divergent views about staff 
screening for TB in the hospital: 
"/ am not sure ift here is a programme to screen staff; we haven't budgeted 
for that, which / am aware ofa s ofn ow. .. (KII-02, GARH) 
··/1 is available but people do not patronize" (KII-03, GARH) 
" ... They {the staff] are not interested, yet we have told them. When / get 
the opportunity to speak at every fora Ihat is held in the facility, / hit on it. 
/ can say apart from my staff members, all the others don't come Uor TB 
screening]. But for us working directly at TB unit, we do it twice every year. 
This year, / have done the first one; / am still waiting. I will do the second 
one. / have told my staff members; they will also do theirs." (KII-04, 
GARH) 
"No, if Ihey suspect that the symploms you are manifesting, you are likely 
{IO have TBJ, Ihen they screen them. Last year I heard one of the staff 
contracted TB or something like that. .. (KII-07, GARH). 
Concerning special interventions for HCW s who might be infected with TB on the job, 51 
(37.2%) responded that there was no such special intervention. Further, more than half, 81 
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(59.1%) of the HeWs stated that they were not aware if the facility had any such 
intervention package for staff(Table 4.8). Responses from the KIIs also affirmed that there 
was no special intervention for HeWs who might be infected with TB while on the job: 
"Not a special {intervention] as such, but we have made arrangements for 
every stajJto be on insurance. Secondly, by a collective agreement, we are 
to meet 50% ofc osts that are not covered by the National Health Insurance 
Scheme. Beyond that, where there is a crucial need. management will 
exercise discretion to support that. Those are the arrangements we have in 
lerms ofs taffh ealth care paclcages . .. (KII-02, GARH). 
,., don't know there is apaclcage ffor stajJinfected with TB]; but I know we 
have enablers that support the TB programme . .. (KIl-6, GARH) 
.. No. They don 'I give anything. It's always from the National. Even for 
that. like' said. wilh 'The Enabler' paclcage, Ihere was somethingfor staff; 
now it has been wilhdrawnfor some time now. What they are now looking 
al is support/or MDR palients. For that, they have somethingfor treatment 
administralion. II goes to the staff who is actually involved in patients 
care . .. (KII-04, GARH) 
Regarding the availability of an isolation ward for separation of infectious TB patients, 
almost half, 66 (48.2%) of the HeWs indicated the absence of an isolation ward in the 
facility, while 30 (22.9%) stated that they know of any isolation ward in the facility. The 
KIIs also reported the absence of an isolation ward in the old health facility: 
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"The problem is that we don't have afunctioning Isolation Ward currently; 
only the verandas are used That is a minus, because they are supposed to 
be cared for in an isolation ward Therefore, that is a something we don't 
have which we have tofactor into our plans." (KII-OI, GARH) 
..... For our new facility ... we have now separated TB cases from the new 
facility because the whole place is air-conditioned, even though there are 
some isolation wards in there. So we have separate wards for TB cases 
now . .. (KII-03, GARH) 
Sixty-six (48.2%) of the participants reported that the hospital had a separate laboratory for 
TB testing and reporting while 38 (27.7%) indicated that they were not aware ofa separate 
TB laboratory in the facility. Direct-observation also revealed the existence of a separate 
laboratory for TB testing and reporting. 
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Table 4.8: Sen-ice Factors Influencing Implementation ofTBIC at tbe Greater 
Accra Regional Hospital 
Service Factors Number (n=137) Percent (%) 
Availability ofTBIC Policy 
Presence ofTBIC Policy 67 48.9 
Absence ofTBIC Policy 14 10.2 
Don't know 56 40.9 
Existence of a TBIC Committee or Focal Person 
Existence ofa TBIC Committee 93 67.9 
Absence of a TBIC Committee 5 3.7 
Don't know 39 28.5 
Screening of StatT for T8 
Presence of staff screening 29 21.2 
Absence of statT screening 105 76.6 
Don't know 3 2.2 
Availability of Special Intervention for HCWs 
Special Intervention present 3.7 
No special Intervention 51 37.2 
Don't know 81 59.1 
Availability ora Separate TB Lab 
Presence of a separate lab 66 48.2 
No separated lab 33 24.1 
Don't know 38 27.7 
Availability ofTB Isolation Ward 
Presence of an isolation ward 41 31.3 
No isolation ward 66 48.2 
Don't know 30 22.9 
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4.9 Environmental Factors InOuencing TB Infection Control at the Greater Accra 
Regional Hospital 
Table 4.9 explored the environmental factors influencing the implementation of TB 
infection Control in the facility. Generally, there was no environmental factor perceived as 
promoting sustained implementation of TBIC in the facility. However, the HCWs 
perceived small waiting area, poor ventilation and absence of a well-ventilated sputum 
booth for safe sputum production and disposal as inhibitors to sustained implementation of 
TBIC in the facility. 
More than half, 77 (56.2%) of the participants indicated that the size of the patients waiting 
areas were too small to accommodate patients without crowding, while majority, 104 
(75.9%) reported that they sometimes experience crowding at the waiting areas. 
Respondents in the KlIs had this to say: 
.. The space [waiting area] was not adequate, especially with the old place. 
Now, we can say that there has been an improvement. But with the cu"ent 
tight environment with a centralized air-conditioning, I am not sure it is 
good/or TB infection control." 
(KII-Ol, GARH) 
"Taking the OPD setting/or example, the place is overcrowded; there is no 
proper ventilation. " (KII-04, GARH) 
"Our concern was the way the OPD down there was closed in. It is very 
tight and ventilation was not the best. That was and still is our problem ... 
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even the fans just circulate that same stale air. which you need to take out; 
so you need something to extract the stale air out. .. (KII-03, GARH) 
Direct observation at some of the units showed presence of crowding at the patient 
waiting areas. 
The predominant ventilation type reported by participants was mixed ventilation (use of 
both natural and mechanical ventilation). Responses from the KIIs indicated that the 
facility used either natural, mechanical or mixed ventilation: 
..... We have windows; we open the windows. When dealing with TB. we do 
not use the fans; we use natural ventilation. .. (KII-06, GARH) 
"For our new facility. it is mainly air-conditioned. .. .. (KII-03, GARH) 
Ninety-six percent of the participants who used natural ventilation reported that they 
"always" open the doors and windows during work hours (Table 4.9). 
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Table 4.9: Environmental Facton Influencing Implementation of TBIC at tbe 
Greater Accra Regional Hospital 
Environmental Factors Number (n=137) 
Availability of Well-Ventilated Sputum Booth 
Presence of a sputum booth 3.65 
Absence of sputum booth 104 75.91 
Don't know 28 20.44 
Frequency of sputum collection • 
Daily 60.0 
Don't know 2 40.0 
Size ofwaitinl area 
Large waiting area 39 28.47 
Small waiting area 77 56.2 
Don't know 21 15.33 
Crowding in waiting areas 
Crowded 104 75.91 
Not crowded 31 22.63 
Don't know 2 1.46 
Kind of Ventilation in facility 
Natural Ventilation 24 17.52 
Mechanical Ventilation 46 33.58 
Mixed Ventilation 67 48.91 
Frequency of opening windows ...... 
Allday 53 96.36 
TiIIMid~y 1.82 
Rarely 
1.82 
Maintenance of Mechanical Ventilation Equipment ....... 
I t06 months 11 8.94 
6 to 12 months 4.07 
As per breakdown 57 46.34 
Rarely (More than 1 year) 
6 4.88 
Don't know 
44 35.77 
* n 5 selected 'yes' tor availability ofwell-ventilated sputum booth. However 2 HeWs did not give any 
response 
•• n~55 responded to frequency of opening windows 
••• Only 123 HeWs responded to question 
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One hundred and four (75.9%) of the HeWs stated that there were no sputum booths in the 
hospital for safe sputum production and disposal. Some of the participants had this to say, 
"Apart from the washrooms which everybody uses, I do not think we have 
something lilre that {well-ventilated sputum booth]. .. (IDI-03, GARH) 
We do not have a vantage point (sputum booth] where we ask the 
patients to go and produce the specimen. We just ask the patients to go to 
an open space and produce the specimen and come ..... ODI -06, GARH) 
This was also confirmed through direct observation. 
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CHAPTER FIVE 
DISCUSSION 
5.0 Introduction 
This study aimed at assessing the Implementation of Tuberculosis Infection Control 
Measures among Health Care Workers at the Greater Accra Regional Hospital, Ghana. 
This chapter presents an in depth discussion ofthe study findings in line with the following 
specific objectives: Level of knowledge and Practice of Health Care Workers on TB 
Infection Control; Service Factors Influencing Sustained Implementation of TB Infection 
Control and Environmental Factors Influencing Sustained Implementation ofTB Infection 
Control. 
5.1 Level of Knowledge of Health Care Workers (HCWs) on TB and TBIC 
Overall, the HCWs exhibited good level of knowledge. The findings of this study are 
supported by the findings ofTemesgen & Demissie, (2014) among health professionals in 
Northwest Ethiopia, where they reported that "majority of the respondents had good TBIC 
knowledge." However, the observed level of knowledge (64.2%) in this study was lower 
than the 74.4% reported by Temesgen and Colleague. This is congruent with finding from 
a survey in rural South Africa where more than 90% of health care professionals identified 
the classical TB symptoms other than fever, which was identified by 58.9% (Kanjee, 
Catterick, Moll, Amico, & Friedland, 2011). Similarly, the level of knowledge reported in 
this study is consistent with the finding of Buregyeya, Kasasa, et aI., (2016) where 69% of 
the Health Care Workers studied were classified as having adequate knowledge. Also, the 
level of knowledge on TBIC was generally high among health care professionals in rural 
South Africa (Kanjee et aI., 20 II). 
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Although most health workers in this study rightly identified the classical symptoms ofTB, 
mode ofTB transmission, proper cough etiquettes, and persons with high risk ofTB spread, 
a significant majority (73.7%) failed to identify fever as part of the symptoms, hence the 
relatively lower level of knowledge recorded. The overall knowledge level had a bearing 
on the level of practice since approximate equal level of practice was found. 
In this study, only gender, marital status and current unit of work were found to have 
significant association with TBIC knowledge level. Knowledge was highest amongst 
females (70.6%) than males, the married (72.4%) compared to the single and divorced 
HCWs. Similarly, knowledge was higher (100%) among those working at the DOTS and 
ART units than those in the other units. This result is similar to a research conducted in 
North Eastern Nigeria on HCWs' knowledge, awareness and compliance with standard 
precautions, which reported that women had higher knowledge than men (Abdulraheem, 
Amodu, Saka, Bolarinwa, & Uthman, 2012). The high knowledge levels among the 
workers at the DOTS and ART units could be due to their direct daily involvement in TB 
care and education of patients and the public on TB and its control. On the other hand, only 
30% of the staff at the laboratory had good knowledge on TB and TBIC, which may be 
due to their focus on working on specimen rather than interacting and/or educating patients 
and the public, which they perceived as the role of those directly involved with patient care. 
On the other hand, educational status, job category, training, professional working years, 
and years worked in facility did not have any significant relationship with level of 
kno .... ledge. This is contrary to the findings of Demissie Gizaw et aI., (2015) where 
educational status was significantly associated with level of knowledge. The reason for the 
difference may be attributed to the diflerent categories of educational status used for the 
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two studies; this study categorized it into primary, secondary, tertiary and other levels, 
while Demissie Gizaw and colleagues categorized educational status into diploma, first 
degree, and second degree and above. 
Further, this study did not find any significant association between level of knowledge and 
training received on TB infection control. However, this contrasts the findings of 
Temesgen & Demissie, (2014) where training was statistically significant with level of 
TBIC knowledge. The probable reason in this study may be due to improper staff attitude 
towards training. 
5.2 Level of Practice of HCWs on TB and TBIC 
The overall level of practice of the HCWs was good with more than half (60.6%) of the 
HCWs having good TBIC practice. This is consistent with the report from Northwest 
Ethiopia where they recorded an overall level of practice of63.3% (Temesgen & Demissie, 
2014). However, the level of practice in this study was higher than what was recorded by 
Tamir et aI., (2016) in the West Goijam Zone, Ethiopia (38.0%) and by Demissie Gizaw et 
al., (2015) in Addis Ababa, Ethiopia (48.6%). 
This study also highlights that 91.2% of the HeWs indicate that they screen suspects for 
TB in the facility. This is higher than the study done in Ethiopia, where 71.6% of the health 
workers reported that they undertake TB screening at their departments (Tamir et aI., 
2016), and a study in Uganda, where only 43% of health professionals claimed to screen 
suspects for TB (Buregyeya et aI., 2013). The high level of screening in the facility of this 
stud) rna) mainly be due to the presence of task-shifting officers positioned at various units 
to pick-up any TB suspect for screening. It may also be influenced by the presence of a 
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committed TB Coordinator and team, as deduced from the direct observation and key 
informant interviews. Regarding the use of personal protective equipment (N95 respirators 
and surgical masks), 82.5% of them reported that they use PPEs when attending to high 
risk individuals. From the direct observation done in this study, N95 respirators were rarely 
used and were reserved for the management of suspected MDR cases. A study by Tamir 
and colleagues recorded low proportion of health professionals (23.5%) use of N-95 
respirators at the health centers (Tamir et aI., 2016). The discrepancies in the proportions 
may be explained by the high usage of surgical masks instead of the N95 respirators by the 
HCWs in this study. Kanjee and Colleagues (2011) reported that more than half (54.7%) 
of their respondents "always" used respirators when attending to TB case or suspects in 
rural South Africa (Kanjee et aI., 2011). 
On the contrary, fast tracking of smear positive cases to minimize patient stay in hospital 
was minimally practiced by the health care workers (27.01%), as was similarly observed 
in other studies (Brouwer et aI., 2014; Temesgen & Demissie, 2014). In this study, patients 
were attended to on "first come, first served" basis. This inability to fast track patients may 
be due to high patient turnout and high workload on staff as observed through direct 
observation. In addition, only 24.1% of HCWs slated that they educate patients on cough 
etiquette and this is lower than 77.4% reported in South Africa (Kanjee et aI., 2011), and 
60% in Ethiopia (Tamir et aI., 2016). 
The findings of this study reveal further that job category, professional working years, 
current unit of work and level of knowledge were significantly associated with TBIC 
practice levels among Ilews (p<0.05). Similar finding were recorded by Tamir et aI., 
(2016) where the working department of the health professionals as well as their knowledge 
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status influenced the level of TBIC practice. Tuberculosis Infection Control practices is 
highest among doctors (84.0%) in this study compared to the other professionals. Also, 
HCWs with professional working years of 20 and above have the highest level of good 
practice compared to other range of years. In terms of current unit of work, it was recorded 
that practice ofTBIC measures is highest among workers of the medical unit (86.7%) than 
all other units, whereas less than half (44.4%) of the 1 workers directly related with TB care 
- DOTS and ART units- have good practice. This is contrary to findings by Demissie 
Gizaw et al. (2015), where experience in TB clinic was a major predictor of practice. 
Furthermore, a significant relationship was identified between HCWs' knowledge on TB 
and TBIC, and their practice irrespective of other factors. Majority (72.7%) of the 
participants with good knowledge had good level of TBIC practice. Those with good 
knowledge were 4.1 times more likely to exhibit good practice compared to those with 
poor knowledge. This supports the findings of Temesgen & Demissie (2014), where 
knowledge was a strong predictor of good TBIC practice. 
The high proportion of HCWs at the medical unit with good practice may be because the 
medical unit is directly responsible for housing patients with TB and other infectious 
diseases within the facility. 
On the contrary, gender, age, marital status, years worked in the facility, presence of a 
known medical condition, and training on TBIC are not significant with level of TBIC 
practice, unlike the findings of Demissie Gizaw and colleagues, where tuberculosis-related 
training was significantly associated with TBIC practice (Demissie Gizaw et al.. 2015). 
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5.3 Service Factors Influencing Sustained Implementation of TBIC 
Health Care Workers perceived screening of patients. availability of separate TB laboratory 
and availability of personal protective equipment as the service factors promoting sustained 
implementation of TBIC in this study. However. a study in Mozambique. assessing the 
challenges faced by health care workers showed that prioritization of patients with cough, 
use of respirators. cough hygiene. proper ventilation and education were perceived as the 
most important measures (Brouwer et aI., 2014). 
On the other hand. this study identified inadequate TBIC materials (policy, IEC materials 
PPEs etc). lack of an isolation ward and the absence of staff screening as service factors 
perceived by the HCWs to be inhibiting sustained implementation ofTB infection Control 
in the facility. 
Participants (48.9%) reported that there is a TBIC policy within the facility. but most of 
the responses from the Klls rather indicated the absence of a TBIC policy in the facility. A 
survey of knowledge. attitude and practice of staff on TBIC in rural South Africa indicated 
that insufficient supply of PPEs (respirators) were the perceived barriers to sustained 
implementation of TB Infection Control (Kanjee et al.. 2011). Also. Brouwer and 
colleagues in their study identified lack of necessary TBIC materials or equipment 
(respirators and other protective equipment) and lack of clear guidelines as part of the 
challenges to effective implementation. One of the health care providers stated that, . There 
is priority to give respirators 10 the TB program, isn 'I it? We, Ihe others, use those o/paper 
that do not protect at all. "-Medical (Brouwer et al.. 2014). 
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Concerning the periodic screening of staff for TB, majority of the responses indicate that 
there was no such measure in the facility. However, some of the key informant interviews 
reveal that such measures exist but poorly patronized due to stigmatization and poor staff 
attitude. Staff screening was identified as a critical part of reducing TB transmission in 
healthcare settings (Costa, Silva. Ferreira. & Nienhaus, 2011). 
5.4 Environmental Facton Influencing Sustained Implementation ofTBIC 
All the environmental factors in this study are perceived to be inhibitors rather than 
promoters of sustained implementation of TBIC measures in the facility. These factors 
included small waiting area, poor ventilation system, and absence of a well-ventilated 
sputum booth for safe sputum production and disposal. 
Over 50% of the responses from the participants indicate that the sizes of the patients 
waiting areas are small to accommodate patients without crowding. Similar findings were 
reported from a study in Mozambique in which it was stated that poor infrastructure, 
inadequate space and lack of fans were perceived as challenges to use TBIC measures. 
According to a respondent of that study, "Our physical space is small. [. .. ] There are no 
fans. nothing. .. -Medical (Brouwer et aI., 2014). A study in Uganda by Buregyeya et aI., 
(2013) also showed that less than 50% of patient waiting rooms were adequately ventilated. 
The small size of the waiting areas can be mainly due to the old facility structure, which 
was built over three decades ago; however, new facilities are being added to reduce the 
crowding. 
Most (96.4%) of the participants who use natural ventilation report that they "always" open 
the doors and windows during work hours, compared to a 65.5% and 69.1 % recorded for 
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doors and windows respectively in South Africa (Kanjee et aI., 2011). This agrees with the 
findings from the direct observation at the study site. The high discrepancy may be 
attributed to the temperate climate of the study location relative to South Africa. 
The facility had no vantage point or sputum booth for safe sputum production and disposal; 
as such, patients are directed to produce sputum samples in open locations, potentially 
exposing the whole populace to TB nuclei droplets. The unavailability of the booth can be 
attributed to the lack of space within the facility. 
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CHAPTER SIX 
CONCLUSION AND RECOMMENDATION 
6.1 Conclusion 
The overall level of knowledge and practice of TB Infection Control measures among 
Health Care Workers at the Greater Accra Regional Hospital is good. Generally, female 
health care workers have better knowledge than the males. Current unit of work is 
significantly associated with level of knowledge. Also, level of knowledge of TB and 
TBIC, and job category are the main significant predictors ofTBIC practice. 
The main service factor promoting sustained implementation of TBIC is the screening of 
suspected TB patients. However, inadequate TBIC materials (TBIC policy, IEC materials 
and PPEs), lack of an isolation ward and absence of staff screening for TB are perceived 
to be the major inhibiting factors to effective implementation ofTBIC measures. 
6.2 Recommendations 
I. The Management of the Greater Accra Regional Hospital should work closely with 
the TB coordinator to ensure periodic staff screening for TB. 
2. The Management of the Greater Accra Regional Hospital should provide properly 
ventilated isolation units for separating infectious TB patients. 
3. The HCWs need to be supervised by both hospital management and NTP to ensure 
that TBIC measures/practices are strictly adhered to within the hospital setting. 
4. The National Tuberculosis Programme (NTP) should ensure that adequate logistics 
(TBIC policy, PPEs and IEC materials) are made available for sustained 
implementation ofTBIC measures. 
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REFERENCES 
Abdulraheem, I., Amodu, M., Saka, M., Bolarinwa, 0., & Uthman, M. (2012). Knowledge, 
Awareness and Compliance with Standard Precautions among Health Workers in North 
Eastearn Nigeria. Journal ofC ommunity Medicine & Health Education, 2(3),10-14. 
https:l/doi.orgllO.4172Ijcmhe.1000131 
Adams 5, Ehrlich R. Ismail N, Quail Z, Jeebhay MF. (2013). Occupational Health Challenges 
Facing the Department of Health: Protecting employees against tuberculosis and caring for 
former mineworkers with occupational health disease. In: Padarath A, English R. editors. 
South African Health Review 2012113. Durban: Health Systems Trust. 
http://www.hst.org.zaIpubl icationslsouth-african-hea1th-review-20 12113 
Adeleke, O. (2012). Barriers to Implementation of Tuberculosis Infection Control amongst South 
African Health Care Workers. Masters Thesis, 96-99. 
Amo-Adjei, J. (2013). Views of health service providers on obstacles to tuberculosis control in 
Ghana. Infectious Diseases ofP overty, 2( I), 9. https:lldoLorgil0.1186/2049-9957-2-9 
Baussano, I., Nunn, P., Williams, B., Pivetta, E., Bugiani, M., & Scano, F. (2012). Tuberculosis 
among Health Care Workers, 17(3). https:lldoi.orgllO.320IleidI703.100947 
Brouwer, M., Coelho, E., Das Dores Mosse. c.. Brondi, L., Winterton, L., & Van Leth, F. (2014). 
Healthcare workers' challenges in the implementation of tuberculosis infection prevention 
and control measures in Mozambique. PLoS ONE, 9(12). 
https://doi.orglI0.1371/joumal.pone.0114364 
Brusaferro, 5., Arnoldo, L., Cattani. G., Fabbro, E., Cookson, B., Gallagher, R., ... Santos, C. V. 
(2015). Harmonizing and supporting infection control training in Europe. Journal of 
Hospital Inf/!ction, 89(4), 351-356. https:lldoi.org/10.1016/j.jhin.2014.12.005 
Buregyeya, E., Kasasa, 5., & Mitchell, E. M. H. (2016). Tuberculosis infection control 
knowledge and attitudes among health workers in Uganda: a cross-sectional study. BMC 
Infectious Diseases, 16(1),416. https:lldoi.org/10.1186/sI2879-016-1740-7 
Buregyeya, E., Mitchell, E. M. H., Rutebemberwa, E., Criel, B., & Kiguli, J. (2016). Tuberculosis 
in Uganda: a qualitative study, (October). https:lldoi.orgllO.1007/sI0389-012-0503-1 
Buregyeya, E., Nuwaha, F., Verver, 5., Criel, B., Colebunders, R., Wanyenze, R., ... Mitchell, E. 
M. (2013). Implementation of tuberculosis infection control in health facilities in Mukono 
and Wakiso districts, Uganda. BMC Infectious Diseases, I 3( I), 360. 
https:lldoi.orgllO.1186/1471-2334-13-360 
Castel a, J., Silva, R., Ferreira, J., & Nienhaus, A. (2011). Original Article, 37(April). 636-645. 
Chen, B., Liu, M., Gu, H., Wang, X., Qiu, W., Shen, J., & Jiang, J. (2016). Implementation of 
tuberculo~is infection control measures in designated hospitals in Zhejiang Province, China: 
are we domg enough to prevent nosocomial tuberculosis infections? BMJ Open, 6(3). 
e010242. https:lldoi.orglI0.1136Ibmjopen-2015-010242 
Codjoe, A. (2012). Assessment of Tuberculosis Infection Prevention and Control Practices 
Among Healthcare Workers in Tema General Hospital. Master's Thesis. Retrieved from 
http:l .. ugspace.ug.edu.ghlhandlelI234567 89/5491 O/OOAhttp://ugspace.ug.edu.ghlbitstreamlI2 
79 
University of Ghana  http://ugspace.ug.edu.gh
34567891549 III IAgnes Codjoe_Assessment of Tuberculosis Infection Prevention and 
Control Practices Among Healthcare Workers in Tema General Hospital_2012.pdf 
Costa, J. C. T. da, Silva, R., Ferreira, J., & Nienhaus, A. (2011). Active tuberculosis among health 
care workers in Portugal. Jomal Brasileiro de Pneumologia : Publicacao Oficial Da 
Sociedade Brasileira de Pneumologia E Tisilogia, 37(5), 636-645. 
Cramm, J. M., Finkenflilgel, H. J., Meller, V., & Nieboer, A. P. (2010). TB treatment initiation 
and adherence in a South African community influenced more by perceptions than by 
knowledge of tuberculosis. BMC Public Health, 10(1), 72. https:lldoi.org/10.1186/1471-
2458-10-72 
Demissie Gizaw, G., Aderaw Alemu, Z., & Kibret, K. T. (2015). Assessment of knowledge and 
practice of health workers towards tuberculosis infection control and associated factors in 
public health facilities of Addis Ababa, Ethiopia: A cross-sectional study. Archives of 
Public Health, 73(1), IS. https://doi.org/10.1186/s13690-015-0062-3 
Dodor, E. A., & Kelly, S. J. (2010). Manifestations of tuberculosis stigma within the healthcare 
system: The case of Sekondi-Takoradi Metropolitan district in Ghana Health Policy, 98(2), 
195-202. https:lldoi.org/http://dx.doi.org/IO.I 0 16/j.heaIthpol.20 I 0.06.0 17 
Efstathiou, G., Papastavrou, E., Rafiopoulos, V., & Merkouris, A. (201 I). Factors influencing 
nurses' compliance with Standard Precautions in order to avoid occupational exposure to 
microorganisms: A focus group study, 1-12. 
Engelbrecht, M. c., & Van Rensburg, A. J. (2013). Tuberculosis infection control practices in 
primary healthcare facilities in three districts of South Africa. Southern African Journal of 
Epidemiology and Infoction, 28(4), 221-226. 
https:lldoi.org/10.IOS01l0158782.2013.11441554 
Escombe, A. R., Huaroto, L., Ticona, E., Burgos, M., Sanchez, I., Carrasco, L., ... Moore, D. A. 
J. (2010). Tuberculosis transmission risk and infection control in a hospital emergency 
department in Lima, Peru, 14(March), 1120-1126. 
Escombe, A. R., Oeser, C. c., Gilman, R. H., Navincopa, M., Ticona, E., Pan, W., ... Friedland, 
J. S. (2007). Natural Ventilation for the Prevention of Airborne Contagion, 4(2). 
https:lldoLorglI0.1371/journal.pmed.0040068 
Ghana Ministry of Health. (2009). Policy and Guidelines for Infection Prevention and Control in 
Health Care Facilities, (April). 
Ghana Statistical Service. (2014). 2010 Population and Housing Census: Accra Metropolitan 
Assembly. accra. 
Graneheim., U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: 
concepts, procedures and measures to achieve trustworthiness, 105-1 12. 
https:lldoi.orgiIO. 10 16/j.nedt.2003.1 0.00 I 
Grobler, L., Mehtar,.S., Dheda, K., Adams, S., Babatunde, S., van der Walt, M., & Osman, M. 
(2016). ~he e~ldemlology of tuberculosis in health care workers in South AtTica: a 
systematl~ review. BMC Health Services Research, J 6( I), 416. 
https: ;dot.orglI0.1186/sI2913-016_1601_5 
80 
University of Ghana  http://ugspace.ug.edu.gh
Jensen. P. A .• Lambert, L. A., ladennarco, M. F., & Ridzon, R. (2005). Guidelines for Preventing 
the Transmission ofMycobacteriwn tuberculosis in Health-Care Settings, 2005. CDC 
Morbidity and Mortality Weeldy Report, 54(RR-17). Retrieved from 
https:llwww.cdc.gov/mmwr/pdflrr/rr5417.pdf 
Johnson, R. B., Onwuegbuzie, A. J., & Turner, L. A. (2007). Toward a Definition of Mixed 
Methods Research, 1(2), 112-133. Retrieved from 
https:llstudy.sagepub.comlsitesidefaultifileslJohnson_2007.pdf 
Kanjee, Z .• Catterick, K., Moll, A. P., Amico, K. R., & Friedland, G. H. (2011). Tuberculosis 
infection control in rural South Africa: Survey of knowledge, attitude and practice in 
hospital staff. Journal ofH ospital Infection, 79(4),333-338. 
https:lldoi.orglI0.1016/j.jhin.2011.06.0t7 
Kuyinu, Y. A .• Mohammed, A. S., Adeyeye. O. 0., Odugbemi, B. A., Goodman, O. 0., & 
Odusanya, O. O. (2016). Tuberculosis infection control measures in health care facilities 
otTering tb services in Ikeja local government area, Lagos, South West, Nigeria. BMC 
Infectious Diseases, 16(1), 126. https:lldoi.orglIO.l186/sI2879-016-1453-y 
Menon, S. (2013). Preventing nosocomial MDR TB transmission in sub Saharan Africa: where 
are we at? Global Journal ofH ealth Science, 5(4), 200-10. 
https:lldoi.orglI0.5539/GJhs.v5n4p200 
Minnery. M., Contreras, c., Perez, R., Sol6rzano, N., Tintaya, K., Jimenez, J., ... Lecca, L. 
(2013). A Cross Sectional Study of Knowledge and Attitudes Towards Tuberculosis 
amongst Front-Line Tuberculosis Personnel in High Burden Areas of Lima, Peru. PLoS 
ONE, 8(9). https:lldoi.orglI0.1371/journal.pone.0075698 
Nardell, E. A., & Dhannadhikari. A. (2010). Turning otT the spigot: Reducing drug-resistant 
tuberculosis transmission in resource-limited settings. International Journal o/Tuberculosis 
and Lung Disease, 14(10),1233-1243. 
National Tuberculosis Control Programme Annual Report (2011). Annual Report on 
Tuberculosis. Unpublished data 
Palinkas, L. A., Horwitz, S. M .. Green, C. A., Wisdom, J. P., Duan, N., Hoagwood, K., ... 
Northwest, K. P. (2015). Purposeful Sampling for Qualitative Data Collection and Analysis 
in Mixed Method Implementation Research. Adm Policy Ment Health., 42(5), 533-544. 
https:l/doLorg/I0.1007/sI0488-013-0528-y.Purposeful 
Peterson, K., Novak, D., Stradtman, L., Wilson, D., & Couzens, L. (2015). Hospital Respiratory 
Protection Practices in 6 U . S . States: A Public Health Evaluation StUdy. American 
Journal of Infection Control, 43(1), 63-71. https:lldoi.orglI0.1016/j.ajic.2014.1O.008 
Raka, L. (2010). Prevention and Control of Hospital-Related Infections in Low and Middle 
Income Countries, 125-131. 
Rutanga. C., Lowrance, D. W., Oeltmann, J. E., Mutembayire, G., Willis, M., Uwizeye, C. B ..... 
Gasana, M. (20 \5). Latent tuberculosis infection and associated factors among health care 
workers in Kigali, Rwanda. PLoS ONE, 10(4), 1-14. 
https:!ldoi.orglI0.1371/journal.pone.0124485 
Shenoi, S. V., Escombe, A. R., & Friedland, G. (2010). Transmission of Drug-Susceptible and 
81 
University of Ghana  http://ugspace.ug.edu.gh
Drug-Resistant Tuberculosis and the Critica1lmportance of Airborne Infection Control in 
the Era of HI V Infection and Highly Active Antiretroviral Therapy Rollouts. Clin Infect Dis 
., 50(Suppl 3). https:lldoi.orglI0.1086/651496.Transmission 
Sissolak, D., Marais, F., & Mehtar, S. (201 I). TB infection prevention and control experiences of 
South African nurses - a phenomenological study. BMC Public Health, 11(1),262. 
https://doi.orglI0.1186/1471-2458-11-262 
Tamir, K., Wasie, B., & Azage, M. (2016). Tuberculosis infection control practices and 
associated factors among health care workers in health centers of West Go.iiam zone, 
Northwest Ethiopia: a cross-sectional study. BMC Health Services Research, 16(a), 359. 
https:·'doi.orglI0.1186/s12913-016-1608-y 
Temesgen. C., & Demissie, M. (2014). Knowledge and practice of tuberculosis infection control 
among health professionals in Northwest Ethiopia; 20 II. BMC Health Services Research, 
/-I( I), 593. https:lldoi.org!IO.] I 86/s 12913-0 14-0593-2 
Tudor, c., Walt, M. Van Der, Margot, B., Dorman, S. E., Pan, W. K., Yenokyan, G., & Farley, J. 
E. (2014). Tuberculosis among health care workers in KwaZulu-Natal, South Africa: a 
retrospective cohort analysis, 1--9. 
United Nations. (2015). Transforming our world: The 2030 agenda for sustainable development. 
https:llsustainabledevelopment.un. orglcontentldocuments/7891 Transforming'Y0200ur%20 W 
orld Pdf, (1),1-5. hnps:lldoi.orglIO. I 007/s 13398-014-0 I 73-7.2 
Woith, W. M. . Volchenkov, G., & Larson, J. L. (2012). Barriers and Facilitators Affecting 
Tuberculosis Infection Control Practices of Russian Health Care Workers.lnt J Tuberc 
Lung Dis, J6 (8), 1092-1096. https:lldoi.org!10.5588/ijtJd.10.0779.Barriers 
WHO (2009). Implementing the WHO Policy on TB Infection Control in Health-Care Facilities, 
Congregate Settings and Households, 151. https:lldoi.orglWHOIHTMlTB/2009.419 
WHO (2010). Joint WHO/ILO policy guidelines on improving health worker access to 
prevention, treatment and care services for HIV and TB. In. Geneva: World Health 
Organisation. 
WHO (2016). Global tuberculosis report 2016, 21 I. https:lldoi.org!ISBN 978 92 4 1565394 
Wynne, A .. Richter, S., Banura, L., & Kipp, W. (2014). Challenges in tuberculosis care in 
Western Uganda: Health care worker and patient perspectives. International Journal of 
Africa NurSing Sciences, 1,6--10. hnps:lldoi.orglIO. 1016/j.ijans.2014.05.00 I 
Yamane, T. (1967). Statistics, An Introductory Analysis. New York: Harper and Row. 
Zaman. K. (2010). Tuberculosis: A Global Health Problem. Editorial, 28(2),111-113. 
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APPENDICES 
Appendix I: Participant Information Sbeet and Consent Form 
Title of thesis: "Assessment of Implementation of Tuberculosis Infection Control 
Measures among Health Care Workers at the Greater Accra Regional Hospital" 
Principal Investigator: Portia Dzivenu, P.O. Box KB 143, Korle Bu, Accra, Ghana. 
Mobile: +233249047414. 
You are being invited to take part in a research project, which forms part of my Masters' 
thesis titled "Assessment of Implementation of Tuberculosis Infection Control 
Measures among Health Care Workers at tbe Greater Accra Regional Hospital. The 
study period is from April 2017 to June, 2017. Please take some time to read the information 
presented here, which will explain the details of this project. Please ask the researcher any 
questions about any part of this project that you do not fully understand. It is very important 
that you are fully satisfied that you clearly understand what this research entails and how 
you could be involved. Also, your participation is entirely voluntary and you are free to 
decline to participate. [fyou say no, this will not affect you in any way. You are also free 
to withdraw from the study at any point. even after agreeing to participate. 
Aim of the stUdy: To assess the implementation of Tuberculosis Infection Control Measures 
among Health Care Workers at the Greater Regional Hospital. 
Procedure: I will be interviewing and/or administering questionnaires to you to gather 
information on implementation of TBIC among health care workers in this facility. The 
interview will last about 15 minutes. I will also be observing some of your activities related 
to TB Infection Control. This observation is to enable me observe the administrative. 
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environmental and personal protection measures to the implementation ofTBIC. Please note 
that it is not meant to monitor your perfonnance. 
Confidentiality and Anonymity: Interview will be conducted in a confined 
roomlenvironment to ensure privacy and confidentiality. Your responses and infonnation 
provided during this interview is strictly confidential. Your name will not be linked to your 
responses as you will be identified only by a study number or code. All recorded tapes, notes 
and questionnaires will be stored in a cabinet under lock and key, and destroyed after five 
years. 
Benefits: There will be no direct monetary benefit in this study. However, you will be given 
a souvenir and will get the opportunity to add on to knowledge in the area of TB infection 
control and its effective implementation for societal benefit. 
Cost/Compensation 
There is no direct cost to be incurred in this study. The study will also not provide 
compensation of any fonn to the participants. 
Potential risks or interruption: I understand how busy your schedule might be in executing 
your duties in the facility (applicable to HCWs only). In the course of the interview, if you 
need to attend to your duties, please feel free to infonn the researcher so you may be excused. 
Please note that some of the questions may prove uncomfortable to you and you are free to 
choose not to answer any question as well. 
This study has been reviewed and approved by the Ghana Health Service Ethical and 
Re,"iew Committee. Please should you have any question, you may contact: Portia 
Dzh"enu (principal investigator) on +233249047414 or via email: 
pdzivenurast.ug.edu.gh, Prof. Margaret Lartey (UG-Florida, Principal investigator) 
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011 +l3J2441658S1 or Ma. Hanaah Frimpong (Ghana Health Service Etbical Review 
COlllmittee Administrator) on +233507041223. 
Declaration by participant 
By signing below, I ...................................................... agree to take part in a 
research study entitled "Assessment of Implementation of TubereulosillnfeetioD 
Coatrol among Healtb Care Workers at tbe Greater Accra Regional Hospital 
I declare that I understand all that has been explained to me about the study- objectives 
and procedures and I voluntarily agree to participate in this study. 
Signatureffhumb print of participants Date 
Signature of Researcher Date 
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Appendix II: Semi-Structured Questionnaire for Health Care Workers (HCWs) 
Code: •...... Interviewer: ....................................... Date: 
Dear Participant, 
This study aims at assessing the implementation of tuberculosis (TB) infection control 
measures among health care workers at the Greater Accra Regional Hospital. The questions 
will require about 15 minutes for completion. The findings of this study will contribute to 
improving the measures that need to be put in place to reduce the spread of TB in health 
facilities. 
Section A: Socio-Demographic Information 
Kindly provide details for the following information. Respond by ticking (v) or writing in 
the spaces provided. 
Age: Gender: [a] Male [b) Female 
Marital Status: [a] Single [b) Married [c) SeparatedlDivorced 
[d) Widowed [e) Others, Specify ......................... .. 
Educational Status: [a] No Education [b) Primary [c) Secondary 
[d) Tertiary [e) Others, Please Specify .............. . 
Joh Category: ..... Professional Working Years: . 
Current UniUDept.: ......... . Job Title: 
Number of Years Worked in this Facility: .. 
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Please do you have any known medical condition (s)? [a] Yes [b) No 
If Yes, Please SpecifY ..........................•......................................... 
Please specify your knowledge and practice of tuberculosis infection control. Kindly 
tick (V) appropriate answer (s). 
1. How is TB spread? 
a) If uninfected person comes into contact with the blood of person containing the TB 
bacilli. 
b) When TB bacilli droplets become suspended in the air and someone breaths in the 
bacilli 
c) A person infected with TB can spread the bacteria through physical contact 
d) When an infected person prepares food and introduces the TB germs into the food. 
2. Who are persons with high risk ofTB exposure and infection? (Tick all that apply). 
a) Persons who live in crowded, poorly ventilated setting where TB is common 
b) Persons who are immune-compromised, such as HIY/AIDS patients 
c) Persons who are sexually active 
d) Persons who share common cooking ware, utensils and cups 
3. What kind of signs/symptoms do you think people with TB have? (Tick all that apply) 
a) Chronic cough (lasting for more than 2 weeks) 
b) Coughing out blood 
c) Frequent urination 
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d) Night sweats 
e) Weight loss 
f) Fever 
g) Don't know 
4. In healthcare setting, who are the persons with the greatest risk for TB spread? 
a) Coughing patients who have not been diagnosed as having TB and are not receiving 
treatment. 
b) Health care workers who do not use respirators when attending to TB patients 
c) Don't know 
d) Other specify .............. . 
5. What is the best and cheapest way of reducing TB bacilli in the air? 
a) Use natural ventilation by opening windows and doors and maximizing cross-
ventilation 
b) Provide respirators or N95 masks to all staff involved in TB care 
c) Install a mechanical ventilation system 
d) Wash hands with soap and water before and after every patient contact 
e) Don't know 
6. Does this facility have a general Infection Prevention and Control policy? 
a) Yes b) No c) Don't know 
If yes, do you have access to the policy? ... 
What is the content of the policy? 
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7. Is there an Infection Control (IC) Policy for TB specifically? 
a) Yes b) No c) Don't know 
If yes, do you if the TBIC policy has been revised over the past 5 years? 
a) Yes b) No c) Don't know 
8. Is there an Infection Control (lC) Committee or responsible person for monitoring in 
place? 
a) Yes b) No c) Don't know 
9. Have you received any training on TB Infection Control? 
a) Yes b) No 
If Yes, how often? ........................................ . ........................... . 
If  Yes, please indicate its usefulness? 
a) Extremely useful b) Very useful c) Moderately useful d) Somewhat useful 
e) Not useful 
10. Does the facility screen staff for TB? 
a) Yes b) No 
If Yes, on what basis? a) Periodic b) Symptomatic 
If Periodic, how often? '" .................................... . 
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II. Does the facility have a special care intervention for Health Care Workers who might 
get infected with TB on the job? 
a) Yes b) No c) Don't know 
If Yes, what kind of interventions are provided? ............................................ . 
12. How do you identity suspected TB patients? 
13. Are suspected patients screened for TB? 
a) Yes b) No c) Don't know 
14. What laboratory facilities do you have for TB testing and reporting? 
15. Does the facility have a separate laboratory for TB testing and reporting? 
a) Yes b) No c) Don't know 
16. Are suspected or diagnosed TB patients separated from other patients? 
a) Yes b) No c) Don't know 
If Yes, is there an isolation ward specifically for TB patients? 
a) Yes b) No c) Don't know 
17. Does the facility have express treatment ("fast tracking") for smear positive cases to 
minimize the stay of these patients in the facility? 
a) Yes b) No c) Don't know 
1f  yes, what express services do you offer? 
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...................................................................................................... 
18. What do you understand by Cough Etiquette? (Tick all tbat may apply). 
a) It is when someone says "excuse me" after coughing in public 
b) (t should be required of all patients, but not necessary for healthcare workers 
c) It is required of all persons in the facility at all times 
d) It includes covering your mouth with handkerchief, tissue, or upper arm when one 
coughs or sneezes 
e) It inc ludes washing hands with soap and water after handling respiratory secretions! 
cleaning hand with alcohol-based rub or hand sanitizer 
f) Putting respiratory secretions in a tissue and then dispose of in a waste bin 
g) Don't know 
h) Other, specify ....................................................... . 
19. Does the facility have Information, Education and Communication (IEC) materials like 
posters and signs on cough etiquette? 
a) Yes b) No c) Don't know 
(fYes, in what instances do you use them? .................................... .. 
20. Do you provide nose masks or tissues for coughing patients? 
a) Yes b) No 
21. Does the facility have a well-ventilated sputum booths at vantage points (outdoors in 
all relevant units)? 
a) Yes b) No c) Don't know 
IrYes, how often are the sputum samples collected? ........................... . 
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22. Do you consider the outdoor waiting area of the facility large enough to seat patients 
without crowding? 
a) Yes b) No c) Cannot tell 
How many patients can the sitting area seat .......................................... ? 
23. Do you experience crowding of patients and/or attendants in waiting areas sometimes? 
a) Yes b) No 
If yes, what accounts for the overcrowding? 
24. What kind of ventilation do you use in your facility? 
a) Natural ventilation, like windows, doors, etc 
b) Mechanical Ventilation like fans, air-conditioners, etc 
c) Mixed Ventilation 
If Natural Ventilation, how often are the windows opened? ......................... . 
25. How often are the mechanical ventilation equipment maintained? 
a) 1- 6 months 
b) 6-12 months 
c) As per breakdown of equipment 
d) Don't know 
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26. Which kind of Personal Protective Equipment (PPE) do you use? 
a) Respirators (N95 or FFP2) b) Surgical Masks c) None 
27. How would you rate the quantity of PPE (respirators and surgical masks) given to 
HCWs by the facility? 
a) Adequate b) Inadequate c )No PPEs at al1 
28. What are some of the factors that promote the implementation ofTB Infection Control 
measures in your facility? ..................................................................... . 
29. What are some of the factors that inhibit effective implementation of TB Infection 
Control in your facility? 
30. Kindly indicate any further issues, concerns, suggestions you have regarding the 
effective implementation of TB Infection Control at the Greater Accra Regional 
Hospital? 
............................................................ 
Thank you for your kind participation and cooperation! 
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Appendix III: Key Informant Interview guide 
Initials of participants ..............................................................  
PositionlDesignation: .............................................. , ................. . 
Age: ........... , ............................G ender: Male I Female 
Level of education: ...................................................... .. 
Working years ....................... , ................................... . 
Yearslmonths worked at facility: ................................... . 
[I] Do you know if there is any TSlC Measures being implemented in this facility? 
Probe: if Yes, When did it start? 
[2] How is it being implemented? 
Probe: What is the documented TSIC plan in place? What is the composition of the committee 
in place? How often do they meet if yes? 
[3] Who is responsible for the implementation ofTBlC Measures in this facility? 
Probe: Who does the person report to? 
[4] How many times has TSlC Measures being reviewed since its inception? 
Probe: Who reviewed it and were the results communicated to you? 
[5] What is your role in the implementation ofTSIC in this facility? 
Probe on perceived role in administrative, environmental and personal protection measures 
[7] Have you ever been trained or trained HCWs on TSlC Measures? 
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Probe: Give details of the training - content, duration, by whom and when 
[8] What are the factors facilitating sustained implementation ofTBIC in this facility? 
[9] What are the challenges you face in the implementation ofTBIC? 
Probe: can you mention some of them? Interviewer to list examples under administrative, 
environmental or personal protection measures without leading participants. 
[10] What recommendation would you give to improve the implementation ofTBIC among 
Health Care Workers in this facility? 
Thank You for your time! 
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Appendix IV: Direct Observation Checklist 
Name of Observer ................................................ . 
Record time observation starts ........................................ . 
Record time observation ends ......................................... . 
General Comments on clinic environment: (Cleanliness, size, patient load at time of 
observation, observable bureaucracy in HCWlPatient interaction) 
For each observation, give observed reason for "Yes" or "No" under "comment" 
Code Activity beiD2 observed CommeDt 
E Are patients over-crowded in hall ways or waiting areas? 
A Are patients promptly identified in waiting areas or as soon 
as they enter clinic? 
A Are coughing patients promptly attended to by HCWs? 
(Note how long it took before attending to patient) 
p Do HCWs involved in TB care wear respirators? (lfnot, 
any observable reasons why) 
p Do HCWs remove respirators sometimes? (Note observable 
reasons) 
A Did you observe HCW(s) distributing nose mask! tissue to 
patients? (Any shortage observed) 
A Do patients comply with use of masks or was it removed at 
any point in time? (Note observable reasons) 
A Availability oflEC materials for cough etiquette 
A Are sputum booths available? (Located in clinic waiting room 
areal outside waiting room area within premises! outside 
j)femises) 
A Are sputum samples collected in designated booths? (observe 
~utum booths and comment) 
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Are windows positioned on opposite side of wall? 
o\re windows opened daily? (In waiting areas, consultation 
'Ooms ... ) 
nd comment on behaviour of HCWs in carrying out above TBIC 
md interaction with patients (Note promoters and inhibitors to the 
tation ofTBIC) 
ninistrative measures, E-Environmental measures, P-Personal Protection measures 
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Appendix V: Ghana Health Service Ethical Approval 
Portia Dzivenu 
umv.sity ofObana 
School of Public Health 
Leann, Allera 
The GIwIa Health Service Ethics Review Comm_ hal reviowcd and given approval for tho implomenwion of 
your Study ProtoCol. 
GHS-ERC Number GUS-ERe: 37102117 
Project Title Assessment of ImplemenlatioD ofTuberculosi.lnfec:tion Control Meuurea 
among Health Care Workers at tha Oreatar Accra Rmlional Holl\'lilal 
Approval Dale 19'" ADriL 2017 
Expiry Dale Ilg ADrIL 2018 
GIlS·ERC Decision Ann"""", 
Tblo approval ......1 . ... lb. (ollowl_, rtum the Prlnd. ... lav. .l lllator 
• Submission of yearly progress "'pDrt of the study to the llIhic:l Review Committee (ERC) 
• Renewal ofc lhieal approval if th. IllUdy 1_ fur more than 12 months, 
• Reporting of all _iou. odvene ovonll related 10 this IllUdy to the ERC wilbin three day. verbally and 
..v cn days in writing. 
• Submisaioo of • final repDrt after completion of the study 
• IIIfonning ERe if study ""nnot be implemented or is discontinued and .....o ns wby 
• Infbrming the ERC and your lponIOI' (where appJic:lble) beI'oroany publication of tho reaoarch findings 
PIeaoe note that any tDOdirlC8lion nf the slWiy without ERC approval ofthc amendment is invalid. 
The ERC may observe or _ to be ob""rved procedurea and """,ods of th. study during and after 
implementation. 
Kindly q .... 1be protocol idcnlilic:alion number in all futuro correopoadcnce in ",Ie:ion to this IIJIIIIO"I'd protocol 
SIGNEDpR~2:;~S' . 
(GHS·ERC VICE-CHAIRPERSON) 
C:: The O.rc<:tor, Reaean;h &; Dom:lopmenl Division, GIwIa Health SorviI:e, Accra 
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Appendix VI: Approval for Use of Study Site 
-, 
I 
UNIVERSITY OF GHANA 
DEPARTMENT OF HEA~TH POLICY, 
PLANNING AND MANAGEMENT 
SCHOOL OF PUBLIC HEALTH 
Ref. No.: 
The Mcclical Director 
Greater Accra Regional HDIpital 
P. O. Box PMB 214 
Accra 
Dear Sir, 
ill your 1'ac:ility. 
y 0lII1I BiDceraly, 
~ 
Or. ReubenEsena 
Head of Department 
COLLEGE OF HEALTH SCIENCES 
P.O eo. LG It Logon. Acero. Glwmo 
• Teleohone: +233 10) 289 109 006 • Email: hrp"'OuQ .• du v. • W.b'I'.: _ p,.bl :t-oolttll,lg.edu.gh 
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