title: Theory-Informed Interventions to Improve the Quality of Tuberculosis Evaluation at Ugandan Health Centers: A Quasi-Experimental Study.
abstract: BACKGROUND
  Tuberculosis (TB) remains under-diagnosed in many countries, in part due to poor evaluation practices at health facilities. Theory-informed strategies are needed to improve implementation of TB evaluation guidelines. We aimed to evaluate the impact of performance feedback and same-day smear microscopy on the quality of TB evaluation at 6 health centers in rural Uganda.
  
  
  METHODS
  We tested components of a multi-faceted intervention to improve adherence to the International Standards for Tuberculosis Care (ISTC): performance feedback and same-day smear microscopy. The strategies were selected based on a qualitative assessment guided by the Theory of Planned Behavior and the PRECEDE model. We collected patient data 6 months before and after the introduction of each intervention component, and compared ISTC adherence in the pre- and post-intervention periods for adults with cough ≥ 2 weeks' duration.
  
  
  RESULTS
  The performance feedback evaluation included 1,446 adults; 838 (58%) were evaluated during the pre-intervention period and 608 (42%) during the post-intervention period. Performance feedback resulted in a 15% (95%CI +10% to +20%, p<0.001) increase in the proportion of patients receiving ISTC-adherent care. The same-day microscopy evaluation included 1,950 adults; 907 (47%) were evaluated during the pre-intervention period and 1,043 (53%) during the post-intervention period. Same-day microscopy was associated with a 14% (95%CI +10% to +18%, p<0.001) increase in the proportion of patients receiving ISTC-adherent care.
  
  
  CONCLUSIONS
  Performance feedback and same-day microscopy should be considered along with ISTC training as part of a multi-faceted intervention to improve the quality of TB evaluation in other high TB burden countries.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Lelia H
authors.initials: LH
authors.lastname: Chaisson
authors.affiliation: School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Infectious Diseases Research Collaboration, Kampala, Uganda.
authors.forename: Achilles
authors.initials: A
authors.lastname: Katamba
authors.affiliation: Infectious Diseases Research Collaboration, Kampala, Uganda.
authors.forename: Priscilla
authors.initials: P
authors.lastname: Haguma
authors.affiliation: Infectious Diseases Research Collaboration, Kampala, Uganda.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Ochom
authors.affiliation: Infectious Diseases Research Collaboration, Kampala, Uganda.
authors.forename: Irene
authors.initials: I
authors.lastname: Ayakaka
authors.affiliation: National Tuberculosis and Leprosy Control Programme, Uganda Ministry of Health, Kampala, Uganda.
authors.forename: Frank
authors.initials: F
authors.lastname: Mugabe
authors.affiliation: Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Cecily
authors.initials: C
authors.lastname: Miller
authors.affiliation: Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Eric
authors.initials: E
authors.lastname: Vittinghoff
authors.affiliation: Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America; Infectious Diseases Research Collaboration, Kampala, Uganda; Curry International Tuberculosis Center, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: J Lucian
authors.initials: JL
authors.lastname: Davis
authors.affiliation: Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America; University of California San Francisco Center for Vulnerable Populations, San Francisco General Hospital and Trauma Center, San Francisco, California, United States of America.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Handley
authors.affiliation: Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America; Infectious Diseases Research Collaboration, Kampala, Uganda; Curry International Tuberculosis Center, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Adithya
authors.initials: A
authors.lastname: Cattamanchi
mesh_terms: D000328:Adult; D003371:Cough / Q000209:etiology; D005260:Female; D006801:Humans; D008297:Male; D008856:Microscopy, Fluorescence; D008954:Models, Biological; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D011785:Quality Assurance, Health Care; D019035:Rural Health Services / Q000592:standards; D012424:Rural Population; D013183:Sputum / Q000382:microbiology; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000382:microbiology; D014454:Uganda