Health worker perspectives on barriers to delivery of routine tuberculosis diagnostic evaluation services in Uganda: a qualitative study to guide clinic-based interventions

We report a descriptive qualitative analysis of barriers to uptake of internationally recommended TB evaluation practices by providers at routine health centers in a high TB prevalence country. We found that health center staff perceived many of the same barriers reported previously by studies eliciting patient perspectives, including the time and costs associated with seeking and completing TB evaluation and stigma against patients with TB [10,31,32]. In addition, we identified specific health system factors that can be targeted for interventions. These ranged from behaviors relevant to the providers and other staff at the clinics (e.g., lack of training, low motivation of staff, and poor coordination of services) to direct availability of resources (e.g., stock-outs of supplies and drugs), both of which contribute to sub-standard TB evaluation. Next steps will focus on creating a series of targeted intervention strategies that have potential to modify provider behavior by addressing key predisposing, enabling, and reinforcing factors within this clinical setting.

Patient barriers to TB evaluation impacting initial access to TB diagnostic services have received considerable attention over the past several years. For example, previous studies have identified how long distances to health centers, direct and opportunity costs associated with seeking TB evaluation, and repeated visits to private practitioners or traditional healers delay TB evaluation [10,31]. These factors were well recognized by providers in our study and our findings indicate that providers clearly sense that these barriers continue to impact their ability to deliver high quality TB evaluation even after patients arrive at the clinic. To mitigate economic and geographic barriers, the WHO has recently endorsed a smear microscopy strategy in which two sputum specimens are collected and examined at the initial patient visit instead of over several days [33]. Our findings reinforce that TB programs in high burden countries should take steps to enable diagnosis of TB followed by initiation of treatment at a single health center visit, either through same-day microscopy or, where feasible, through use of novel semi-automated molecular diagnostic tests [34]. If implemented successfully, “test and treat” strategies are likely to have considerable impact on TB incidence and/or mortality [35].

Although same-day microscopy and semi-automated molecular tests clearly represent an important way forward to simplifying the diagnostic process, many health system barriers not unique to TB diagnosis are likely to blunt the impact of introducing new diagnostic strategies or tests if not addressed. Stock-outs of supplies and drugs and malfunctioning equipment are common at health centers in low-income countries [36]. Stock-outs not only affect the ability of staff to deliver quality care but also reinforce negative community perceptions about government health facilities, leading to patients seeking care in settings where TB testing and treatment are not routinely offered. Ministries of Health must also address barriers that may underlie the guideline concordant behaviors that will increase diagnostic service provision. These include low motivation of staff at government health facilities, partially related to concerns about the risk of acquiring TB infection from patients. Data are limited but suggest these concerns are real – health care workers in high burden countries have a 3-fold higher risk of developing TB and 6-fold higher risk of developing multidrug-resistant TB than the general population [37]. Last, poor coordination of clinic staff and services (including volunteers) was perceived as a key barrier to delivering high quality care. More attention is needed to how the timing and location of services impacts patients’ ability to receive all required care prior to completing their health center visit.

In order to build on the findings of these interviews, we propose some specific intervention strategies for application in field studies to address factors operating at multiple levels in the setting in which interventions are planned [38]. In this study we organized our qualitative findings on barriers into possible intervention components, using predisposing, enabling and reinforcing factors as intervention targets. This approach is based on a substantial literature that applies the PRECEDE model to planning health promotion activities in health care settings [39]. Our results suggest that a multi-faceted intervention to improve adherence to recommended TB evaluation practices should jointly address one of more of the following factors: 1) guideline training, leadership and peer support activities (such as mentoring/peer coaching, patient advocates, and/or opinion leaders) and visual job aides/referral materials to target knowledge, motivation of staff, stigma toward TB patients, and self-efficacy (i.e., predisposing factors); 2) adequate staff training in microscopy skills, patient counseling, and care coordination; utilization of tools such as checklists or mHealth strategies to improve supply management; same-day diagnosis and treatment of TB; task-shifting, including utilizing community health workers for community-based sputum collection, co-training of all staff as counselors, implementing cough screening by registration clerks (i.e. enabling factors), 3) performance feedback, recognition, and incentives to increase accountability (i.e., reinforcing factors). While what we presented in this paper focuses on interventions based at the health center, additional interventions that improve patient access and strengthen the larger health system are clearly needed to maximize the quality of TB evaluation services.

Our study has several potential limitations. First, the generalizability of our findings could be limited in that our study included health centers in a single country. However, the sampled health centers are from six geographically distinct districts in Uganda and provide similar services as district health centers found throughout sub-Saharan Africa. Second, our sampling of health center staff was incomplete and included only those available during site visits, limiting our ability to stratify our results by provider type. Finally, it is possible that staff were more comfortable highlighting certain barriers (such as supplies) over others (such as internal problems) that could jeopardize their standing if discussed with supervisors.