Open Access Research article

Provider experiences of the implementation of a new tuberculosis treatment programme: A qualitative study using the normalisation process model

Salla Atkins12*, Simon Lewin13, Karin C Ringsberg4 and Anna Thorson2

Author Affiliations

1 Health Systems Research Unit, Medical Research Council of South Africa, Cape Town, South Africa

2 Division of Global Health, Karolinska Institutet, Stockholm, Sweden

3 Global Health Unit, Norwegian Knowledge Centre for the Health Services, Oslo, Norway

4 Health Promotion Research Group, Nordic School of Public Health, Gothenburg, Sweden

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BMC Health Services Research 2011, 11:275  doi:10.1186/1472-6963-11-275

Published: 17 October 2011



Tuberculosis (TB) is a major contributor to the global burden of disease. In many settings, including South Africa, treatment outcomes remain poor. In contrast, many antiretroviral treatment (ART) programmes are achieving high levels of adherence and good outcomes. The ART programme model for maintaining treatment adherence may therefore hold promise for TB treatment. Changing treatment models, however, requires an assessment of how staff receive the new model, as they are responsible for programme implementation. Using the normalization process model as an analytic framework, this paper aims to explore staff perceptions of a new TB treatment programme modelled on the ART treatment programme.


A qualitative approach was used. Interviews and focus group discussions were conducted with clinic staff from five intervention clinics. Data were analysed initially using qualitative content analysis. The resulting categories were then organised under the constructs of the normalization process model.


Staff recounted a number of challenges with implementing the programme. Interviews and focus group discussions identified factors relating to the main categories of the normalization process model. The key issues hindering the normalisation of the programme within clinics related to the interactional workability, relational integration and skill-set workability constructs of the model. These included hierarchical relationships, teamwork, training needs and insufficient internalisation by staff of the empowerment approach included in the programme. Logistical and management issues also impacted negatively on the normalization of the programme at the clinics.


The normalization process model assisted in categorising the challenges experienced during implementation of the intervention. The results suggest that issues remain that need to be resolved before the programme is implemented more widely. Considerable work is needed in order to embed the intervention in routine clinic practice.