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Implementation science to improve the quality of tuberculosis diagnostic services in Uganda.

  • Cattamanchi, Adithya1, 2
  • Berger, Christopher A1
  • Shete, Priya B1, 2
  • Turyahabwe, Stavia2, 3
  • Joloba, Moses4, 5
  • Moore, David Aj2, 6
  • Davis, Lucian J2, 7
  • Katamba, Achilles2, 8
  • 1 Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, United States. , (United States)
  • 2 Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda. , (Uganda)
  • 3 Uganda National Tuberculosis and Leprosy Program, Kampala, Uganda. , (Uganda)
  • 4 School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda. , (Uganda)
  • 5 Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda. , (Uganda)
  • 6 London School of Hygiene and Tropical Medicine, London, United Kingdom. , (United Kingdom)
  • 7 Epidemiology of Microbial Diseases and Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health; Pulmonary, Critical Care, and Sleep Medicine and Yale Center for Implementation Science, Yale School of Medicine, New Haven, United States. , (United States)
  • 8 Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda. , (Uganda)
Published Article
Journal of clinical tuberculosis and other mycobacterial diseases
Publication Date
Feb 01, 2020
DOI: 10.1016/j.jctube.2019.100136
PMID: 31879703


Nucleic acid amplification tests such as Xpert MTB/RIF (Xpert) have the potential to revolutionize tuberculosis (TB) diagnostics and improve case finding in resource-poor settings. However, since its introduction over a decade ago in Uganda, there remain significant gaps along the cascade of care for patients undergoing TB diagnostic evaluation at peripheral health centers. We utilized a systematic, implementation science-based approach to identify key reasons at multiple levels for attrition along the TB diagnostic evaluation cascade of care. Provider- and health system-level barriers fit into four key thematic areas: human resources, material resources, service implementation, and service coordination. Patient-level barriers included the considerable costs and time required to complete health center visits. We developed a theory-informed strategy using the PRECEDE framework to target key barriers by streamlining TB diagnostic evaluation and facilitating continuous quality improvement. The resulting SIMPLE TB strategy involve four key components: 1) Single-sample LED fluorescence microscopy; 2) Daily sputum transport to Xpert testing sites; 3) Text message communication of Xpert results to health centers and patients; and 4) Performance feedback to health centers using a quality improvement framework. This combination of interventions was feasible to implement and significantly improved the provision of high-quality care for patients undergoing TB diagnostic evaluation. We conclude that achieving high coverage of Xpert testing services is not enough. Xpert scale-up should be accompanied by health system co-interventions to facilitate effective implementation and ensure that high quality care is delivered to patients.

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