title: Why tuberculosis service providers do not follow treatment guideline in Ethiopia: a qualitative study.
abstract: OBJECTIVE
  Little is known about the reasons why tuberculosis (TB) service providers do not follow TB treatment guidelines. A better understanding of their real-world experiences associated with non-compliance with guideline may highlight opportunities for enhanced TB care. Whether the problem is actual or perceived may also affect the type of intervention needed to overcome the barrier. This study aimed to explore TB service providers' reasons for not complying with TB treatment guidelines.
  
  
  METHODS
  A descriptive qualitative design was used. Focus group discussions were held with 39 service providers involved in TB care. The study was carried out in the Tigray region of Ethiopia, in four of the six zonal hospitals. Data were analysed using content analysis.
  
  
  RESULTS
  The main reasons for non-compliance with TB treatment guidelines were: (1) insufficient diagnostic modalities, limiting the capacity to correctly diagnose TB and provide the right regimen; (2) ambiguity in guideline recommendations especially for specific subgroups of patients, making it difficult to prioritize them to the right regimen; and (3) poor documentation concerning referred patients, with no appropriate examination and difficulty obtaining information from previously treated patients.
  
  
  CONCLUSIONS
  Non-compliance may reflect valid questions about the applicability of guideline recommendations in the local context of health care. Special consideration should be given to previously treated patients, as an important factor influencing guideline compliance. Guideline compliance may also be improved by a better strategy to retest those patients whose initial tests are negative in health care contexts where TB is frequently missed.
authors.affiliation: Department of Medicine, Mekelle University, Ethiopia; Department of General Practice, Maastricht University/CAPHRI School for Public Health and Primary Care, The Netherlands.
authors.forename: George
authors.initials: G
authors.lastname: Mala
authors.forename: Albine
authors.initials: A
authors.lastname: Moser
authors.forename: Geert-Jan
authors.initials: GJ
authors.lastname: Dinant
authors.forename: Mark
authors.initials: M
authors.lastname: Spigt
mesh_terms: D004282:Documentation; D005002:Ethiopia / Q000453:epidemiology; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006282:Health Personnel; D006297:Health Services Accessibility; D006801:Humans; D017410:Practice Guidelines as Topic; D036301:Qualitative Research; D014397:Tuberculosis, Pulmonary / Q000628:therapy*
keywords: clinical practice guideline; decision support; non-compliance; qualitative research; resource-poor settings