Attribution 4.0 International (CC BY 4.0)editor: Boeckmann, MelanieArakelyan, StellaMacGregor, HayleyVoce, Anna S.Seeley, JanetGrant, Alison D.Kielmann, Karina2022-11-102022-11-102022-11-092022-05-04Arakelyan, S., MacGregor, H., Voce, A.S., Seeley, J., Grant, A.D. and Kielmann, K. (2022) ‘Beyond checklists: Using clinic ethnography to assess the enabling environment for tuberculosis infection prevention control in South Africa’, PLOS Global Public Health. Edited by M. Boeckmann, 2(11), p. e0000964. Available at: https://doi.org/10.1371/journal.pgph.0000964.https://eresearch.qmu.ac.uk/handle/20.500.12289/12640https://doi.org/10.1371/journal.pgph.0000964From PLOS via Jisc Publications RouterHistory: collection 2022, received 2022-05-04, accepted 2022-10-12, epub 2022-11-09Acknowledgements: We acknowledge the important contributions of Gimenne Zwama, Thandeka Smith and Zama Khanyile in conducting and documenting the ethnographic fieldwork in KZN. We are grateful to the health clinic managers and health workers for their time, interest, and motivation to participate in this study. We thank our colleagues from the Umoya omuhle project for the rich inter-disciplinary discussions and exchange of ideas.Publication status: PublishedFunder: Economic and Social Research Council; funder-id: http://dx.doi.org/10.13039/501100000269; Grant(s): ES/P008011/1Funder: Bloomsbury Set, Research England; Grant(s): CCF17-7779Funder: Economic and Social Research Council; Grant(s): ES/P008011/1Funder: Wellcome Trust Strategic Core Award; Grant(s): Africa Health Research Institute, ref. 201433/A/16/AStella Arakelyan - ORCID: 0000-0003-0326-707X https://orcid.org/0000-0003-0326-707XThe qualitative data reported on in this paper was archived in the UK Data Service’s Discover catalogue with a unique DataCite Digital Object Identifier (DOI). The link to our data is: http://doi.org/10.5255/UKDA-SN854435.Sub-optimal implementation of infection prevention and control (IPC) measures for airborne infections is associated with a rise in healthcare-acquired infections. Research examining contributing factors has tended to focus on poor infrastructure or lack of health care worker compliance with recommended guidelines, with limited consideration of the working environments within which IPC measures are implemented. Our analysis of compromised tuberculosis (TB)-related IPC in South Africa used clinic ethnography to elucidate the enabling environment for TB-IPC strategies. Using an ethnographic approach, we conducted observations, semi-structured interviews, and informal conversations with healthcare staff in six primary health clinics in KwaZulu-Natal, South Africa between November 2018 and April 2019. Qualitative data and fieldnotes were analysed deductively following a framework that examined the intersections between health systems ‘hardware’ and ‘software’ issues affecting the implementation of TB-IPC. Clinic managers and front-line staff negotiate and adapt TB-IPC practices within infrastructural, resource and organisational constraints. Staff were ambivalent about the usefulness of managerial oversight measures including IPC protocols, IPC committees and IPC champions. Challenges in implementing administrative measures including triaging and screening were related to the inefficient organisation of patient flow and information, as well as inconsistent policy directives. Integration of environmental controls was hindered by limitations in the material infrastructure and behavioural norms. Personal protective measures, though available, were not consistently applied due to limited perceived risk and the lack of a collective ethos around health worker and patient safety. In one clinic, positive organisational culture enhanced staff morale and adherence to IPC measures. ‘Hardware’ and ‘software’ constraints interact to impact negatively on the capacity of primary care staff to implement TB-IPC measures. Clinic ethnography allowed for multiple entry points to the ‘problematic’ of compromised TB-IPC, highlighting the importance of capturing dimensions of the ‘enabling environment’, currently not assessed in binary checklists.Licence for this article: http://creativecommons.org/licenses/by/4.0/Copyright: © 2022 Arakelyan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.http://creativecommons.org/licenses/by/4.0/Research ArticleMedicine and health sciencesPeople and placesComputer and information sciencesEngineering and technologyBiology and life sciencesarticle2022-11-09