Abstract
BackgroundStudies of the quality of tuberculosis (TB) diagnostic evaluation of patients in high burden countries have generally shown poor adherence to international or national guidelines. Health worker perspectives on barriers to improving TB diagnostic evaluation are critical for developing clinic-level interventions to improve guideline implementation.MethodsWe conducted structured, in-depth interviews with staff at six district-level health centers in Uganda to elicit their perceptions regarding barriers to TB evaluation. Interviews were transcribed, coded with a standardized framework, and analyzed to identify emergent themes. We used thematic analysis to develop a logic model depicting health system and contextual barriers to recommended TB evaluation practices. To identify possible clinic-level interventions to improve TB evaluation, we categorized findings into predisposing, enabling, and reinforcing factors as described by the PRECEDE model, focusing on potentially modifiable behaviors at the clinic-level.ResultsWe interviewed 22 health center staff between February 2010 and November 2011. Participants identified key health system barriers hindering TB evaluation, including: stock-outs of drugs/supplies, inadequate space and infrastructure, lack of training, high workload, low staff motivation, and poor coordination of health center services. Contextual barrier challenges to TB evaluation were also reported, including the time and costs borne by patients to seek and complete TB evaluation, poor health literacy, and stigma against patients with TB. These contextual barriers interacted with health system barriers to contribute to sub-standard TB evaluation. Examples of intervention strategies that could address these barriers and are related to PRECEDE model components include: assigned mentors/peer coaching for new staff (targets predisposing factor of low motivation and need for support to conduct job duties); facilitated workshops to implement same day microscopy (targets enabling factor of patient barriers to completing TB evaluation), and recognition/incentives for good TB screening practices (targets low motivation and self-efficacy).ConclusionsOur findings suggest that health system and contextual barriers work together to impede TB diagnosis at health centers and, if not addressed, could hinder TB case detection efforts. Qualitative research that improves understanding of the barriers facing TB providers is critical to developing targeted interventions to improve TB care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-014-0668-0) contains supplementary material, which is available to authorized users.
Highlights
Studies of the quality of tuberculosis (TB) diagnostic evaluation of patients in high burden countries have generally shown poor adherence to international or national guidelines
In Uganda, which is one of the 22 high TB burden countries according to the World Health Organization (WHO), we found that only 21% of patients with cough greater than 2 weeks’ duration were referred for sputum smear microscopy, 73% of patients referred completed sputum smear examination, and 71% of patients with a positive sputum examination were initiated on TB treatment [2]
We focused on health system and contextual barriers to changing provider behavior in relation to key processes associated with TB diagnosis, and used the PRECEDE framework to classify modifiable barriers as predisposing, enabling and reinforcing factors that could be targeted with clinic-level interventions [22]
Summary
Studies of the quality of tuberculosis (TB) diagnostic evaluation of patients in high burden countries have generally shown poor adherence to international or national guidelines. There are two over-arching reasons for under-diagnosis: failure of patients to access TB diagnostic services and failure of providers to diagnose and treat TB among patients who do access TB diagnostic services The latter represents a failure of the health system and, if addressed, an opportunity to increase TB case detection and treatment rates. Studies of the quality of TB evaluation (i.e., diagnostic workup of patients with symptoms suggestive of TB) in high burden countries have generally shown poor adherence to international or national guidelines. Similar findings of providers not following guidelines for TB diagnosis and treatment have been reported from the public and private sector in many other high burden countries [3,4,5,6,7,8,9]
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