Use of a context-specific package to increase sputum smear monitoring among people with pulmonary tuberculosis in Uganda: a quality improvement study

Background People with bacteriologically confirmed pulmonary tuberculosis (BC-PTB) require sputum smear monitoring (SSM) to ascertain response to anti-TB treatment and cure from TB disease. We aimed to increase SSM at 2, 5 and 6 months among people with BC-PTB from the baseline (March to July 2021) of 68%, 37% and 39%, respectively, to 90% in February 2022 by implementing a context-specific improvement package at a rural health facility in northeastern Uganda. Methods We designed a continuous quality improvement (CQI) study for people with BC-PTB, developed and tested an improvement package that consisted of the following context-specific measures: (1) line listing of all eligible persons for SSM; (2) use of reminder stickers to identify eligible persons for SSM; (3) use of community health workers to conduct home visits for people with missed clinic visits; and (4) integration of SSM into community-based ART points for distant persons. We implemented the measures using the plan-do-study-act cycle and tracked the progress in SSM through monthly data reviews and analyses. Results SSM at 2 months improved from 68% (17/25) at the baseline to 74% (32/43) during phase I (p=0.818) and then to 94% (17/18) during phase II (p=0.562). SSM at 5 months improved from 37% (11/29) at the baseline to 82% (41/50) during phase I (p=0.094) and then to 100% (10/10) during phase II (p=0.688). SSM at 6 months improved from 39% (9/23) at the baseline to 59% (28/39) during phase I (p=0.189) and then to 100% (12/12) during phase II (p=0.487). Conclusion The use of a context-relevant CQI package was accompanied by improved SSM at 2, 5 and 6 months among people with BC-PTB. Trends are encouraging but this should be considered as preliminary report because of limited numbers. These data can inform the design of a fully powered randomised controlled trial.