key: cord-0428953-p14ffby1
authors: Chisare, D. T.; Zinyama-Gutsire, R. B. L.; Chasela, C. S.
title: Organizational Readiness for the Implementation of a Three-Month Short-Course TB Preventive Therapy Regimen (3HP) in Four Health Care Facilities in Zimbabwe in 2020: A Mixed Methods Study
date: 2021-06-02
journal: nan
DOI: 10.1101/2021.05.26.21256736
sha: c20dd3a8e2919f05641056f759145c53f0b2b66d
doc_id: 428953
cord_uid: p14ffby1

Background: Tuberculosis preventive therapy (TPT) for latent TB infection has had limited success in Zimbabwe. The country plans to roll-out the three-month short-course TPT regimen (3HP) to address the implementation lag and poor uptake of the 6-9-month regimens. The study measured the level of organizational readiness while identifying barriers and facilitators to implement 3HP in four health facilities in Zimbabwe. Methods: A convergent, parallel mixed-methods approach was used to collect data from four primary healthcare clinics in Bulawayo and Harare Metropolitan provinces, Zimbabwe. Twenty healthcare providers completed a 35-item, self-administered questionnaire designed on a 5-point Likert scale and developed from the Weiner organizational readiness model. Nine of the providers and five TB program managers took part in 20-30 minute individual semi-structured key-informant interviews. Median scores with interquartile ranges were calculated wherein a score of 3.3 or greater indicated readiness. Differences between facilities were assessed using a Kruskal-Wallis rank test. Qualitative data on barriers and facilitators were transcribed and analyzed using a framework approach. Results: Readiness to implement 3HP across the four facilities was positive with a score of 3.8(IQR 3.3-4.1). The difference between the best 4.0(IQR 3.8-4.2) and worst performing facility 3.2(IQR 2.7-3.3) was 0.8 and statistically significant (p=0.039). The low facility score was due to poor contextual factors 2.5(IQR 2.0-3.3), task demands 2.6(IQR 2.3-2.9) and resource availability 2.1(IQR 1.5-2.5) scores. Key organizational readiness facilitators included healthcare provider and management buy-in; community willingness to generate demand for 3HP; strong collective capability through task-shifting, alignment with existing primary healthcare programs, perceived benefits, and need for 3HP. Barriers were negative past TPT experiences, suboptimal programmatic monitoring, inconsistent health provider remuneration, inadequate staffing, added workload, and an erratic supply chain across facilities. The organizational communication gap prompts the slow program implementation culture. Conclusions: The varied scores between facilities suggest distinct underlying conditions for readiness. Healthcare provider motivation is temporary based on the inconsistent resource supply, absence of TPT-specific monitoring and evaluation, and daily contextual challenges in facilities that must be addressed. Similar research is necessary for countries yet to implement 3HP to optimize the design or revision of delivery strategies and increase uptake of TPT. Keywords: Organizational readiness, TB preventive therapy, TPT, 3HP, Zimbabwe

Control Program. Performance indicators are not being met including the sub-optimal performance 108 of the current 6-month TPT [3] . Challenges include the shortage of skilled health workers, lack of 109 capacity to recruit additional staff, lack of funding and training to support monitoring of TPT 110 implementation exacerbated by stockouts of essential medication as a result of decades of crippling 111 economic challenges [5] . Persistent IPT drug stockouts, for instance, resulted in the interruption of the 112 TB prevention program [5] . As vital as the change from standard IPT to treatment by 3HP is, the 113 aforementioned challenges could limit the successful implementation of the program.

Organizational readiness (OR) is vital and a necessary precursor to ensure successful implementation 115 of the 3HP program in Zimbabwe. OR is defined as an implementation strategy to indicate the extent 116 to which an organisation is psychologically and behaviourally prepared to implement a new program 117 [6] . For example, an organization has to be willing and capable to implement a program for an effective 118 outcome [6] . Studies indicate that about 50% of programs fail due to poor organisational readiness 119 prior program implementation yet there is a dearth in the literature to indicate organizational 120 readiness to implement the 3HP program among high burden, low-income TB settings such as Zimbabwe [7] . Such a gap in knowledge affects the optimum response to the TB preventive efforts of 122 the country. An example highlighting the need to assess readiness before program implementation is 123 the low utilisation rates of the GeneXpert innovation to improve TB screening in Zimbabwe varying 124 from 50.4% to 63.5% despite its proven cost-effectiveness [5] . Similarly, piloting 3HP in facilities in 125 Zimbabwe without assessing OR, its perceived barriers, and facilitators by staff collectively could 126 present the failure to realize the real impact of 3HP. Therefore, determining OR is key to identify 127 bottlenecks as perceived by the organization's staff that could impede efforts to scale-up and to 128 develop recommendations for better implementation.

The outcomes of this study indicated the readiness to implement 3HP and possible influencing factors 130 within the selected facilities in Harare and Bulawayo Metropolitan provinces. By using this method, 131 we hope the quantitative measurement strengthened by the lived qualitative experiences will identify 132 operational metric challenges of the facilities useful to the National HIV/AIDS and TB Control Program 133 and address issues that might otherwise escalate into obstacles that could impede successful program 134 implementation [6] . This is critical because 3HP is a key TB prevention strategy to offset prior 135 suboptimal IPT implementation efforts [3] .

To date, no organizational readiness study for the 3HP program has been conducted in the sub-137 Saharan region, including Zimbabwe. The study will contribute towards the theoretical knowledge of 138 implementation readiness before introducing 3HP in facilities and also expand on the lack of 139 consensus on the measurement of readiness. Hopefully, the study will demonstrate the importance 140 of considering readiness at the early stages of program implementation as it serves as a proximal 141 indicator to successful, quality program implementation without undesired consequences. This will 142 encourage monitoring and evaluation of the program at scale-up as well as tightening of potential 143 loopholes in the implementation. Additionally, lessons learnt from the study can be adapted to 144 facilities in the other provinces and later national level to give a more generalizable picture of 3HP 145 implementation.

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In this study, elements in Weiner's (2009) 

This was a convergent, parallel mixed-methods study. Quantitative and qualitative data were collected 162 in the same phase of the research process to measure organizational readiness and to explore barriers 163 and facilitators that may affect readiness to implement 3HP in the four health facilities in Zimbabwe.

The elements were analyzed independently, and the findings were triangulated and interpreted 165 together. 

The target population for this study were facility level staff (health facility managers or more 182 commonly referred to as charge nurses , TB nurses and primary care practitioners) that had worked 183 on the frontline and will directly implement the 3HP program. In addition, key informants such as a 184 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 2, 2021. ; https://doi. org/10.1101 org/10. /2021 subset of the health facility staff (Charge nurses, TB nurses and primary care practitioners) as well as 185 non-frontline personnel within the implementation support structure of the facilities (National level 186 TB program managers inclusive of TB supply chain manager, the respective provincial-level TB 187 coordinators from the National HIV/AIDS and TB Control Programs; and TB program managers from 188 implementing and funding partners).

The study purposively selected 15 KII participants involved in the program that will implement 3HP in 191 facilities. Concurrently, at each facility level, there was a maximum of 5 staff members involved in TB 

Changes were channelled into the main study. The interviews were conducted privately by the PI in 210 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 2, 2021. ; https://doi. org/10.1101 org/10. /2021 three of the main local languages namely English, Shona and Ndebele at the participant workplaces 211 over a period of 5 days in Bulawayo and another 5 days in Harare. Data were collected as audio 212 recordings and field notes. The audio recordings were obtained to allow the investigator enough time 213 to listen and transcribe interviewees' responses accurately. The transcripts were returned to 214 participants for comment and/or correction. Field notes including descriptive and reflective 215 information were captured in a diary by the investigator during or after interviews to ensure richness 216 in the qualitative findings reported, interpreted and discussed. Table) .

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The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10. 1101 /2021 The survey participants (S1 Table 1 ) included nurses (73.7%, n=14), charge nurses (15.8%, n=3) and 259 primary care practitioners (10.5%, n=2). There were more females (84.2%, n=16) as compared to the 260 males (15.8%, n=3). Majority of facility 1 respondents were aged above 50 years (80.0%, n=4), while 261 the majority of the respondents in facility 3 were aged between 40 -50 years (60.0%, n=3) and 262 similarly in facility 4, most of the respondents were aged between 40 -50 years (50.0%, n=2). There 263 were no participants (0%, n=0) who had provided TB services for 6 -11 months however most had 264 provided TB services for more than 2 years (79%, n= 15) with 100% of the facility 3 respondents having 265 provided more than 2 years of TB service. Between the two provinces, Bulawayo Metropolitan had 266 slightly more respondents in the facilities (52.6%, n=10) compared to Harare Metropolitan (47.4%, n= 267 7) (S1 Table) . . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The overall OR median score across the four facilities was 3.8 (IQR 3.3 -4.1) above 3.3, the chosen 276 cut-off point for an acceptable level of readiness (S2 Table) .

At the individual facility level, a total of three of the four facilities had median scores above the 279 readiness cut-off point. Facility 4 within Harare Metropolitan province was below the cut-off of 3.3 as 280 it had an OR median score of 3.2 (IQR 2.7 -3.3). Low median scores were presented in the facility's 281 contextual factors 2.5(IQR 2.0 -3.3) , task demands 2.6 (IQR 2.3 -2.9) and resource availability 2.1(IQR 282 1.5 -2.5). The change commitment 3.7 (IQR 3.1 -4.2), change efficacy 3.3 (IQR 2.8 -3.6) and change 283 valence scores 4.2 (IQR 3.3 -4.8) of facility 4 were above the cut-off. Alternatively, Facility 3 within

Harare province had the highest OR median score of 4.0 (IQR 3.8 -4.2) although it presented a low 285 resource availability median score of 3.0 (IQR 2.8-3.3).Consequently, Bulawayo Metropolitan's facility 286 1 had a high level of readiness with an OR median score of 3.9 (IQR 3.9 -4.0). The facility presented 287 high median scores in the change commitment, efficacy, valence, contextual factors, task demands.

Nevertheless, facility 1 presented a low median score of 2.8 (IQR 2.5 -3.3) in the resource availability.

Facility 2 in Bulawayo Metropolitan province had an acceptable OR median score of 3.6 (IQR 3.4 -4.1) 290 however a low resource availability median score of 2.8(IQR 2.5 -3.3).

Significant differences were noted in the overall OR scores between the four facilities (p=0.039) (S2 293   Table 2 ). Within Harare province, significant differences were identified between facility 3 and 4 294 (p=0.016) wherein facility 3 readiness score was the highest compared to facility 4 which presented 295 the lowest score below the threshold. Although there were no statistically significant differences in 296 the change commitment , change efficacy, valence and task demands scores within provinces and 297 between the four facilities across the provinces; significant differences were identified in the 298 contextual factors between facility 3 and facility 4 within the Harare province (p= 0.016) and in the 299 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10. 1101 /2021 contextual factors between all of the four facilities (p=0.011). Marginal significant differences were 300 found in the resource availability scores between the two Harare facilities (p = 0.048) (S2 Table) .

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Six (n=6) TB nurses and three (n=3) charge nurses were among those interviewed at facility level.

Additionally, five (n=5) program managers from the implementation support structure of the facilities 307 (National , provincial and NGO levels) were interviewed. Four participants were male while ten were 308 female. Work experience ranged from 1 to 17 years.

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Although most of the facilities indicated conditional commitment, facility 4 respondents were not 339 willing to implement the program due to their perceived on-going facility issues. "Considering we have 340 our own challenges already yeah I don't think people will quickly embrace it, " explained a TB nurse. 

Management believed that the change was going to be a "clear process" (IDI 1) while facility 2 staff 351 stated that the program was going to be straightforward given that they were going to be trained 

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The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10. 1101 /2021 In a bid to increase acceptance and accountability, management aimed to sensitize "90 to 100%" 358 of the staff in facilities.

Barriers 361 Both levels of participants reported negative staff attitudes.

"… we had negative attitudes from the service providers and then the patients 363 themselves… knowing the possibilities of the adverse events." (IDI 1).

"The problem is that most of the nurses have attitude towards those patients. I am sorry 365 to say (uhm) but that is very natural. Attitude towards those TB patients with the fear 366 that they will catch TB in the process of nursing them… " (IDI 12).

The staff also reported a lack of confidence in the momentum. A TB nurse described that "…the 369 kickstart will be okay but on the way you find some problems cropping up…like there can be no CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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A positive factor was the perceived program appropriateness which was the relevance and 401 compatibility of the 3HP innovation to address problems within the existent program. A TB program 402 manager stated that "we do believe a lot of issues from the previous regimen , IPT will be addressed…"

Similarly, the change effort was perceived as a need and was described to be timely as to alleviate 404 medicine stockouts that facilities were experiencing. "The timing is right…we are running short of the 405 current IPT medicines," explained a TB nurse.

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The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10. 1101 /2021 Additionally, all facility staff expressed that the program would be regarded as a priority. A charge 408 nurse echoed this as follows,

"TB is one of the priorities in any council clinic so I believe if 3HP is a prevention strategy 410 as part of TB programs, it would be a priority here."

The staff further discussed the relative advantages the program may offer such as lower costs going to decide whether they are willing to take 10, 13 tablets once a week at once or 431 they want to take 1 or 2 tablets every day for 6 months." (IDI 2).

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The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10. 1101 /2021 Although some facilities reported that the increased workload was due to facility staff 459 shortages, a MoHCC program manager stated that the workload should not be a challenge as CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10.1101/2021.05.26.21256736 doi: medRxiv preprint TB patients. They explain that they are "exposed waiting to get sick." A TB nurse and focal person 484 described that managerial oversight is inconsistent affecting facility staff. 

The managers believed that the whole organization "…has not been performing well in the last few 

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" The supplier's capacity did not turn out to be what they had initially committed [pause] 533 so they could not commit to the volumes that our country needed... another thing was 534 that the drug price … these are things that delayed rollout at country level." 535 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 2, 2021. ; https://doi. org/10.1101 org/10. /2021 It was further stated by the manager that "…we anticipate further delays now with the COVID-536 19 pandemic." Nevertheless, provision for sustainable funding after the initial implementation 537 phase remains unclear as the program heavily relies on partnering and actively present NGOs CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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• Overall buy-in from implementation staff and management. • Civil societies and support organizations are determined and generate demand for 3HP.

• Program buy-in is temporary and contingent on remuneration, workload and constant supply chain management in the facilities.

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The findings from this study identified fundamental facilitators and barriers which will prompt further 563 planning and improvement to the 3HP program prior to implementation in the four facilities. The 564 improvements could influence implementation effectiveness.

Three of the four facilities (facility 1,2 and 3) welcomed and saw a need to implement the intervention.

Our findings are supported by the measurements of readiness scores per facility which were above 569 the threshold. We believe the high scores demonstrated that staff in the three facilities were most 570 likely to collectively commit and demonstrate a more consistent, high quality use of the intervention 571 [6] . The results led to a similar conclusion in Shaw et al's study where high readiness scores reflected 572 the degree of commitment and efficacy among facilities towards implementing a telemedicine 573 behavioural program [15] . This is consistent with a South African study that used readiness scores to 574 indicate that four of five schools collectively valued a combined HIV and nutrition intervention highly 575 enough to commit to its implementation. Similar to our study, the two mixed methods studies used 576 adapted context-specific tools to measure readiness [6, 15] . Although this is widely accepted, an 577 apparent limitation is that the tools were adapted from contexts outside of the clinical or health fields 578 due to limited healthcare readiness studies [31] . It is worthy to further note that literature indicated 579 a paucity of studies assessing the level of readiness to implement 3HP in the Zimbabwean context and 580 the few studies on 3HP implementation were based in high-income countries such as Canada.

Our results also demonstrated that facility 4 of Harare Metropolitan province was not ready to 583 implement 3HP compared to the other 3 facilities. Additionally, staff in the facility qualitatively 584 indicated that "… we have our own challenges already…I don't think people will quickly embrace it."

At this stage of understanding, Weiner's theory suggests that low readiness reflects the need for 586 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10. 1101 /2021 additional support before implementation to curb the facility potentially resisting change, putting less 587 effort, persevering less in the face of challenges, and exhibiting compliant intervention utilisation [6] .

Our finding also showed that the low readiness in facility 4 was due to low contextual factors, task 589 demands and resource availability. The result of our study is then compared to Shaw et al's study 590 which found non-readiness in facilities due to a lack of commitment [15] and due to contextual factors 591 including leadership, fidelity, costs and partnerships in another review [32] . The difference in the 592 studies is attributed to the main limitation of the inconsistency of constructs measured which may 593 impact readiness to implement. For example, our study did not account for leadership whereas

Rubenstein et al's study used the CFIR framework which found the construct to be key in the non-595 readiness of facilities [33] . However, a review suggested that there is no gold standard in readiness 596 studies as existing issues were tailored to specific studies, interventions and settings [34] . From this 597 standpoint, we believe our study is the first to contribute important findings specific to the 3HP 598 intervention and possibly other TB program readiness studies.

Our findings on the difference in facility scores at least hinted that each facility had specific underlying 601 conditions for readiness to implement 3HP. For example, one Harare Metropolitan province facility 602 had the highest readiness score while the other was not ready and had the lowest score among all of 603 the facilities. The difference between the two facilities was due to varying contextual factors and the 604 availability of resources which was supported by the qualitative findings as well. This is consistent with 605 two previous studies whereby intervention sites differed in readiness due to varying resource 606 availability and reported contextual conditions such as past experiences in implementing programs 607 per the specific setting [33] . It is worth discussing that our study's approach of including facility staff 608 plus supplemental qualitative accounts from different levels of management provided more detail on CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The findings demonstrated that change commitment, efficacy and valence were key facilitators of 614 readiness to implement 3HP. The key barriers emanating were task demands, contextual factors and 615 resource availability.

Change commitment was high among all the facilities and the finding was qualitatively supported by 619 the perception that there was overall buy-in from stakeholders. This result ties well with previous 620 studies that indicated that shared interest and commitment between managers and staff were found 621 to be important precursors for a successful intervention [19, 25, 6] . Although staff in the study 622 indicated that they were motivated, there was the possibility of temporary buy-in dependent on issues 623 such as inconsistent staff remuneration, increased work load and an inconsistent supply chain in 624 facilities. This is challenging and has led to frequent strikes in Zimbabwe among frustrated health care CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 staff may report high efficacy to perform tasks, it is possible that they may not be able to create 638 meaningful change due to the inability to mobilize resources in an efficacious manner for the desired 639 implementation effort [6] . Secondly, the efficacy to collectively perform tasks can be affected by 640 commitment and vice versa. For instance, Keshni (2020) stated that readiness is likely to be high when 641 members not only feel confident to perform tasks but also want to do so [14] . Similarly, we 642 demonstrated that the lack of confidence to implement previous TPT was attributed to by negative 643 staff attitudes. Therefore our findings contribute to the idea that efficacy is interrelated to 644 commitment. Lastly, apparent systematic challenges such as task co-ordination and flexi-working hour 645 system in the facilities may affect efficacy. In this case, our finding lends support to earlier studies 646 which popularly explain that discrepancies in efficacy are due to the differentiated roles in facilities 647 (i.e. nurses, charge nurses, administrators and medical directors) [21, 28] . Therefore for future work,

it is worthy to note that some questions in readiness tools may have more of a clinical meaning for 649 participants, for example in our study that were majorly nurses as compared to other studies that had 650 mostly leaders who may have more of an administrative meaning [28] .

Change Valence 653 Measured scores were supported by recurring textual findings that indicated that staff collectively 654 valued the program highly. Staff felt that the previous suboptimal TPT implementation would be 655 alleviated by the benefits of 3HP implementation, considered it a core priority within all facilities and 656 comprehended it enough to commit to its implementation. This is warranted by staff acknowledging 657 that they were willing (commitment) to implement the program because change in programs was 658 urgently needed for the well-being of their patients. Our findings therefore indicate the link between 659 change valence and commitment to positively influence readiness to implement. Our study is in line 660 with Weiner's theory (2009) and Keshni et al's study whereby change commitment was proposed as 661 a major function of change valence, that is, if organizational members value the change then the they 662 will want to implement the change [6, 14] . However, the main limitation is that individual perceptions 663 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10. 1101 /2021 Our study quantitatively confirmed that the facilities had distinct, acceptable contextual conditions 691 however the qualitative findings detailed a myriad of challenges particularly in facility 4. For instance, 692 support in facilities was rendered by key stakeholders however it was inconsistent and a further lack 693 of support for the staff's wellbeing was reported which both led to their negative attitudes. Izudi 694 revealed that TB staff commonly present negative attitudes due to fear of contraction of TB from their 695 patients affecting their performance to carry out tasks [29] . The provision of routine testing for staff 696 implementing the TB program in facilities was recommended by staff in our study. Another challenge 697 was the slow implementation of programs, for example facilities reported 4 year delays after trainings 698 to implement programs. Additionally, our results suggest that the high number of adverse events 699 associated with TPT contributed to the negative past experiences in facilities. We believe these 700 combined could result in staff not embracing the innovation and therefore could impede readiness 701 just as Amatayakul concluded that negative experiences could deter facilities from reaching 702 organizational readiness [30] . The difference in studies, however, is that our findings go beyond to CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The main limitation of the proposed study rests primarily on the sample size particularly the survey 739 sample which may not be statistically representative however the aim was firstly to analyse at the 740 facility, not the individual level and to strengthen understanding of the social processes involved in 741 implementation therefore sample size is of less concern. Although the sample size was large enough 742 to measure OR in the study, it restricted further additional statistical analysis. Notwithstanding,

Weiner, suggests that OR measures should be descriptive and not evaluative (6). Moreover, the 744 generalizability of the results may be limited to the four facilities that were operated by the same 745 entities however as in implementation science, the key is to draw on lessons learned to inform policy 746 and implementation approaches in similar contexts(6).

Although the ORIC tool was adapted to suit the study context and design, the resource availability 749 subscale was slightly below the threshold Cronbach alpha level. However due to the shown acceptable 750 overall Cronbach alpha scale indicating the tool's high reliability in consistency, the subscale was 751 retained. Another limitation is construct bias wherein the selected Weiner OR conceptual model to 752 guide the study may have omitted other constructs that affect readiness including implementation 753 climate (14). Additionally, constructs within the conceptual model overlap and are not always discrete.

Future studies are required to improve OR models and their constructs. Nevertheless, the current 755 study provides insight into readiness factors that relate to the implementation of a TB preventive 756 therapy which has received little attention thus far.

The study employed mixed methods which provided several merits. The combination and 759 triangulation of the quantitative and qualitative analysis methods facilitated understanding the 760 complexity of organizational readiness to implement 3HP. The quantitative helped measure the level 761 of readiness and its factors as a useful benchmark of the sites. The qualitative offered insight into the 762 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10. 1101 /2021 challenges and influences of readiness. The interviews were held until saturation was achieved which 763 is important in exhaustively underscoring the reasons for the measured scores in facilities.

In conclusion, three of the four facilities were ready to implement 3HP in Harare and Bulawayo

Metropolitan province. Facility four of Harare Metropolitan province was not ready to implement due 768 to low task demands, contextual and resource availability factors. Each facility had differing strengths 769 and weaknesses to be deemed ready to implement the intervention, but these would likely not be 770 revealed without triangulation of OR scores and interview data. Potential factors that could either 771 facilitate or hinder effective implementation were identified to allow enhancements to be made to 772 the intervention implementation strategy. Facilitators identified were change commitment, efficacy 773 and valence which should be considered in developing the steps towards meeting acceptable 774 readiness levels to implement 3HP in facilities. The barriers included were task demands, contextual 775 factors and resource availability.

The study findings demonstrate the necessity for further research to assess OR prior to 3HP TPT 778 implementation in health facilities. Considering the limitation to generalize our findings, the study 779 should be scaled up in other high TB settings in Zimbabwe as well as the other high TB burden 780 countries yet to implement 3HP. Although implementation of the TPT program change will be 781 staggered into phases, our study assessed readiness at one point in time as opposed to continuous 782 assessment. We recommend the periodic evaluation of readiness within health facilities for optimal 783 delivery of the program to ensure successful implementation. It is worthwhile to note that conditions 784 for readiness per facility can differ therefore OR is critical for efforts to carefully attune 785 implementation according to the strengths and barriers present at each facility. Moreover,

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The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10. 1101 /2021 policymakers need to take into account that facilities with less readiness to implement may require 787 more flexibility to reach the intended program merits. CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 2, 2021. ; https://doi.org/10. 1101 /2021 

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The authors would like to thank the Ministry of Health and Child Care of Zimbabwe and Clinton Health 811 Access Initiative, Zimbabwe for providing access to personnel involved in the 3HP program under

IMPAACT4B. We would also like to thank the respective Bulawayo and Harare City Council Health 813 Service Departments including the facilities for providing access for the collection of data for the study.

Thank you to the participants for consenting to partake in the study.