title: Health worker perspectives on barriers to delivery of routine tuberculosis diagnostic evaluation services in Uganda: a qualitative study to guide clinic-based interventions.
abstract: BACKGROUND
  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. Health worker perspectives on barriers to improving TB diagnostic evaluation are critical for developing clinic-level interventions to improve guideline implementation.
  
  
  METHODS
  We 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.
  
  
  RESULTS
  We 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).
  
  
  CONCLUSIONS
  Our 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.
authors.affiliation: Department of Medicine, Division of Pulmonary & Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, Room 5K1, 1001 Potrero Avenue, San Francisco, California, 94110, USA. acattamanchi@medsfgh.ucsf.edu.|Curry International Tuberculosis Center, University of California San Francisco, San Francisco, California, USA. acattamanchi@medsfgh.ucsf.edu.|School of Medicine, University of California San Francisco, San Francisco, California, USA. acattamanchi@medsfgh.ucsf.edu.|Infectious Diseases Research Collaboration, Kampala, Uganda. acattamanchi@medsfgh.ucsf.edu.
authors.forename: Adithya
authors.initials: A
authors.lastname: Cattamanchi
authors.affiliation: Department of Medicine, Division of Pulmonary & Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, Room 5K1, 1001 Potrero Avenue, San Francisco, California, 94110, USA. cecily.miller@ucsf.edu.|Curry International Tuberculosis Center, University of California San Francisco, San Francisco, California, USA. cecily.miller@ucsf.edu.|Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA. cecily.miller@ucsf.edu.
authors.forename: Cecily R
authors.initials: CR
authors.lastname: Miller
authors.affiliation: School of Medicine, University of California San Francisco, San Francisco, California, USA. asa.tapley@ucsf.edu.
authors.forename: Asa
authors.initials: A
authors.lastname: Tapley
authors.affiliation: Infectious Diseases Research Collaboration, Kampala, Uganda. phaguma@muucsf.org.
authors.forename: Priscilla
authors.initials: P
authors.lastname: Haguma
authors.affiliation: Infectious Diseases Research Collaboration, Kampala, Uganda. eochom@yahoo.com.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Ochom
authors.affiliation: Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, California, USA. sara.ackerman@ucsf.edu.
authors.forename: Sara
authors.initials: S
authors.lastname: Ackerman
authors.affiliation: Department of Medicine, Division of Pulmonary & Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, Room 5K1, 1001 Potrero Avenue, San Francisco, California, 94110, USA. lucian.davis@ucsf.edu.|Curry International Tuberculosis Center, University of California San Francisco, San Francisco, California, USA. lucian.davis@ucsf.edu.|School of Medicine, University of California San Francisco, San Francisco, California, USA. lucian.davis@ucsf.edu.|Infectious Diseases Research Collaboration, Kampala, Uganda. lucian.davis@ucsf.edu.
authors.forename: J Lucian
authors.initials: JL
authors.lastname: Davis
authors.affiliation: School of MedicineMakerere University College of Health Sciences, Kampala, Uganda. akatamba@yahoo.com.|Infectious Diseases Research Collaboration, Kampala, Uganda. akatamba@yahoo.com.
authors.forename: Achilles
authors.initials: A
authors.lastname: Katamba
authors.affiliation: School of Medicine, University of California San Francisco, San Francisco, California, USA. handleym@medsfgh.ucsf.edu.|Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA. handleym@medsfgh.ucsf.edu.|Center for Vulnerable Populations, University of California San Francisco, San Francisco, California, USA. handleym@medsfgh.ucsf.edu.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Handley
mesh_terms: D000553:Ambulatory Care / Q000592:standards; D000554:Ambulatory Care Facilities / Q000191:economics / Q000592:standards / Q000600:supply & distribution; D000995:Antitubercular Agents / Q000600:supply & distribution; D001291:Attitude of Health Personnel; D003365:Costs and Cost Analysis; D003695:Delivery of Health Care; D005260:Female; D006282:Health Personnel / Q000193:education / Q000592:standards; D006304:Health Status; D006801:Humans; D008403:Mass Screening / Q000191:economics / Q000458:organization & administration / Q000592:standards; D010362:Patients' Rooms / Q000600:supply & distribution; D011639:Public Opinion; D036301:Qualitative Research; D057545:Social Stigma; D014376:Tuberculosis / Q000175:diagnosis* / Q000191:economics; D014454:Uganda
chemical_list: D000995:Antitubercular Agents