Health worker perspectives on barriers to delivery of routine tuberculosis diagnostic evaluation services in Uganda: a qualitative study to guide clinic-based interventions
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Date
2015
Journal Title
Journal ISSN
Volume Title
Publisher
BMC health services research
Abstract
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.
Description
Keywords
Tuberculosis, Qualitative research, Diagnosis, Provider behavior, PRECEDE
Citation
Cattamanchi, A., Miller, C. R., Tapley, A., Haguma, P., Ochom, E., Ackerman, S., ... & Handley, M. A. (2015). Health worker perspectives on barriers to delivery of routine tuberculosis diagnostic evaluation services in Uganda: a qualitative study to guide clinic-based interventions. BMC health services research, 15(1), 1-10. DOI 10.1186/s12913-014-0668-0