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J Clin Tuberc Other Mycobact Dis. 2019 Dec 2;18:100136. doi: 10.1016/j.jctube.2019.100136. eCollection 2020 Feb.

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

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Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, United States.
Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda.
Uganda National Tuberculosis and Leprosy Program, Kampala, Uganda.
School of Biomedical Sciences, Makerere University College of Health Sciences, Kampala, Uganda.
Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda.
London School of Hygiene and Tropical Medicine, London, United Kingdom.
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.
Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.


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.


Implementation science; Quality improvement; Tuberculosis; Uganda

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