title: Investigating Barriers to Tuberculosis Evaluation in Uganda Using Geographic Information Systems.
abstract: Reducing geographic barriers to tuberculosis (TB) care is a priority in high-burden countries where patients frequently initiate, but do not complete, the multi-day TB evaluation process. Using routine cross-sectional study from six primary-health clinics in rural Uganda from 2009 to 2012, we explored whether geographic barriers affect completion of TB evaluation among adults with unexplained chronic cough. We measured distance from home parish to health center and calculated individual travel time using a geographic information systems technique incorporating roads, land cover, and slope, and measured its association with completion of TB evaluation. In 264,511 patient encounters, 4,640 adults (1.8%) had sputum smear microscopy ordered; 2,783 (60%) completed TB evaluation. Median travel time was 68 minutes for patients with TB examination ordered compared with 60 minutes without (P < 0.010). Travel time differed between those who did and did not complete TB evaluation at only one of six clinics, whereas distance to care did not differ at any of them. Neither distance nor travel time predicted completion of TB evaluation in rural Uganda, although limited detail in road and village maps restricted full implementation of these mapping techniques. Better data are needed on geographic barriers to access clinics offering TB services to improve TB diagnosis.
authors.affiliation: Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut jross3@uw.edu.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Ross
authors.affiliation: Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Adithya
authors.initials: A
authors.lastname: Cattamanchi
authors.affiliation: Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Cecily R
authors.initials: CR
authors.lastname: Miller
authors.affiliation: Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Tatem
authors.affiliation: Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Achilles
authors.initials: A
authors.lastname: Katamba
authors.affiliation: Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Priscilla
authors.initials: P
authors.lastname: Haguma
authors.affiliation: Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: Margaret A
authors.initials: MA
authors.lastname: Handley
authors.affiliation: Division of Infectious Diseases, University of Washington, Seattle, Washington; Division of Pulmonary and Critical Care Medicine, Curry International Tuberculosis Center, San Francisco, California; Center for Vulnerable Populations, Division of General Internal Medicine, Department of Medicine, San Francisco General Hospital, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, California; MU-UCSF Research Collaboration, Clinical Epidemiology Unit, Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda; Department of Geography and Environment, University of Southampton, Highfield, Southampton, United Kingdom; Fogarty International Center, National Institutes of Health, Bethesda, Maryland; Department of Epidemiology of Microbial Diseases, School of Public Health, and Pulmonary, Critical Care, and Sleep Medicine Section, School of Medicine, Yale University, New Haven, Connecticut.
authors.forename: J Lucian
authors.initials: JL
authors.lastname: Davis
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D003430:Cross-Sectional Studies; D005260:Female; D040362:Geographic Information Systems; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012737:Sex Factors; D013183:Sputum / Q000382:microbiology; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000453:epidemiology; D014454:Uganda / Q000453:epidemiology; D055815:Young Adult