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Cycle 1

Principal Investigator:  Achilles Katamba, Makarere University 
NIH-Supported Collaborator: Adithya Cattamanchi, University of California, San Francisco
Title of NIH Award: TB Guideline Observation and Adherence in Low Income Countries (TB GOAL)
Project Dates: October 2013 - April 2019
Project Overview:

1-61 Katamba - Kizito poster
Kizito Samuel, a GHES Fellow, presenting poster at the 47th Union Meeting in Liverpool, UK in October 2016. (photo courtesy of PI Katamba)
Uganda has an estimated 67,000 annual TB cases (incidence 193/100,000 persons), but suffers from among the lowest case detection and treatment success rates of the 22 high-burden countries. Moreover, case detection and reporting among children is virtually non-existent. 
The recently published “Desk Guide for Diagnosis and Management of TB in Children”, developed with USAID funding, is an evidence-based, simple decision aid to improve early and accurate identification of children with TB in resource-constrained settings. However, uptake of the Desk Guide has been limited to date and little is known about how best to facilitate implementation in routine practice settings. The overall objective of the project is to develop and evaluate an intervention to facilitate successful adoption of the Desk Guide at primary health centers in Uganda. This project has 3 phases: 1) to identify barriers and enablers to implementation of the Desk Guide at primary health care facilities in Kampala; 2) to develop a multi-faceted intervention to promote Desk Guide implementation and adoption at primary health care facilities in Kampala; and 3) to evaluate the impact of the intervention on Desk Guide implementation at primary health care facilities in Kampala. These studies will take place at 8 Kampala City Council Authority clinics, which are representative of urban primary care centers in sub-Saharan Africa. The overall hypothesis is that a multi-faceted intervention will increase the proportions of 1) children identified as TB suspects; 2) child TB suspects evaluated for TB; and 3) children diagnosed and reported as TB cases. The research is consistent with USAID Uganda’s goal to strengthen health systems and improve the delivery of health services. This research will provide USAID and the Government of Uganda with important information on factors that influence Desk Guide use and strategies to promote its uptake at primary level health facilities, which will lead to increased diagnoses of pediatric TB in Uganda.

Summary of Recent Activities: 

During the fourth quarter of 2018 the project team continued its interventions at the four health facilities and expanded to a fifth Kampala City Council Authority (KCCA) health facility, Kitebi. The intervention covered the functions of education, persuasion, training, environmental restructuring, and enablement. The method of delivery was organized in two ways. The first involved delivering two hour Continued Medical Education (CME) seminars with all clinicians at health facility. A total of 60 health care workers attended the seminars. This was followed by a daily one hour on the job coaching by a pediatrician on how to evaluate children for TB. The daily routine involved one-hour CME between in the morning after which the pediatrician worked with clinicians in consultation rooms offering hands on skills and mentorship for evaluating children for TB. The pediatrician spent six weeks coaching staff at the health facility. The second part of the method deliver was distributing printed Health Care Guides and algorithms for the diagnosis of TB in Children, and placing them at all points where children are being evaluated in the primary health care clinic.

The team continued to provide support supervision and performance feedback about evaluating children for Tuberculosis (TB) through monthly reports about the number and proportion of children diagnosed and treated for TB, and process indicators including: i). Number and proportion of children screened for TB; ii). Number and proportion of children treated for TB if meeting clinical criteria; iii). Number and proportion of children tested for TB if only one symptom is present; iv). Number and proportion of children with presumptive TB screened for HIV; v). Number and proportion of children diagnosed with TB tested for HIV; vi). Number and proportion of children treated for TB if meeting microbiologic criteria; and vii). Number and proportion of children less than five years old provided INH prophylaxis. The quality of data has continued to improve with most the fields on the Patient Record Form being completed and the team has continued to enter Patient Record Forms (PRF) for both pre-intervention and post-intervention study periods. A total of 125,000 PRF records have been entered for the pre-intervention phase of the study while 15,000 records have been entered for the post-intervention phase.

The team had one manuscript published in the October edition of the International Journal of Tuberculosis and Lung Disease entitled A Quality of care in childhood tuberculosis diagnosis at primary care clinics in Kampala, Uganda, and is currently finalized a second paper they will submit next quarter titled A Theory-informed Approach to identify Barriers to Use of Guidelines for Diagnosis of Childhood Tuberculosis in Health Centers in Kampala, Uganda.

Health Cycle 1 Recipients