| dc.description.abstract | Background:
In 2019, Uganda notified only 74% of estimated TB cases against an END TB target of 90%. This
gap between estimated incident TB cases and those accessing TB treatment is due to a combination
of underdiagnosis (people not accessing TB services or not being evaluated for TB when they do)
and underreporting (people diagnosed with TB not linked to TB treatment - pretreatment loss to
follow up). Previous studies from Uganda have shown that 25-40% of persons diagnosed with TB
experience pretreatment loss to follow-up (LFU). We aimed to study factors associated with and
reasons for pretreatment loss to follow-up in order to design a theory-informed intervention to
improve linkage to treatment for patients diagnosed with TB using Xpert® MTB/RIF testing at
selected public health facilities in central and eastern Uganda.
Methods:
We carried out four sub studies at ten public health facilities across ten districts. We purposively
selected health facilities from three levels of the healthcare system involved in TB care (three
primary care facilities, four district hospitals and three tertiary referral hospitals). First, we carried
out a cross sectional study to describe the magnitude of and patient/health facility factors
associated with pretreatment LFU. We then traced patients who experienced pretreatment LFU to
determine their vital status. We compared vital status of patients who experienced pre-treatment
LFU to that of patients successfully initiated TB treatment to determine the effect of pretreatment
LFU on TB associated mortality. We also determined the effect of pre-treatment mortality on
overall health facility estimates of TB associated mortality. Next, we carried out a qualitative study
based on the Capacity, Opportunity, and Motivation for Behavior (COM-B) model to understand
patient and health facility level barriers to and facilitators for linkage to TB treatment. We also
identified intervention components from the Behavior Change Wheel that could alleviate identified
barriers to and enhance facilitators for linkage to TB treatment. Finally, we conducted a quasiexperimental
pre-/post-interventional study at one tertiary referral hospital to test the feasibility
and preliminary effectiveness of the chosen intervention components. Data analysis involved
descriptive statistics, multivariable logistic regression and Kaplan Meier survival curves (I-II) while thematic analysis was used for the qualitative study. The Pearson chi-squared test was used
to compare the proportion of patients linked to TB treatment within two weeks of diagnosis in the
intervention period (October to December 2019) using the period June to August 2019 as the
comparison period.
Results:
Sub-study I: Across the ten health facilities, 100/510 (19.6%) patients were not initiated on TB
treatment within two weeks of diagnosis (pretreatment LFU). Not having a phone number recorded
in the clinic registers (aOR 7.93, 95%CI 3.93-13.05); being HIV-infected (aOR 1.83; 95% CI:
1.09-3.26) and receiving care from a health facility performing more than 12 Xpert tests per day
(aOR 4.37, 95%CI 1.69-11.29) were significantly associated with pretreatment LFU.
Sub-study II: Out of the 100 patients not linked to TB treatment, we successfully traced 49 patients.
In the six months following TB diagnosis, mortality was higher among patients who experienced
pretreatment LFU 48.1/1000py vs 22.9/1000py (HR 3.18, 95% CI 1.61 – 6.30). After incorporating
pre-treatment deaths among patients who experienced pretreatment LFU, health facility level
estimates of TB associated mortality increased from 8.4% (95% CI 6.1%-11.6%) to 10.2% (95%
CI 7.7%-13.4%).
Sub-study III: At the health facility, lack of knowledge about the proportion of patients not initiated
on TB treatment; difficulty communicating sputum results from the laboratory and difficulty
tracing patients due to inadequate recording of patient addresses were the main barriers to linkage
to TB treatment. At the patient level, long turnaround time for sputum results; lack of transport
funds to return to health facilities to collect sputum results and stigma were the main barriers to
linkage to TB treatment. The most important facilitators identified were quick access to sputum
test results either on the date of first visit (same-day diagnosis) or on the date of first return and
availability of TB treatment. We identified education of healthcare workers, restructuring of the
service environment to improve sputum results turnaround time and improving communication of
test results from the lab to the healthcare workers to the patients as relevant intervention functions
to alleviate some of the barriers to and enhance facilitators of TB treatment initiation. Sub-study IV: The median time from sample collection to provision of sputum results improved
from 14 hours (IQR 4-47) in the pre-intervention period to 4 hours (IQR 3-6) in the intervention
period. The proportion of patients started on treatment within two weeks of diagnosis improved
from 58.8% (40/68) before the intervention to 89.1% (49/55) during the intervention (difference
30.3%, 95% CI 16.0% - 44.6%, p<0.01) while the proportion of patients receiving a same-day
diagnosis increased from 7.4% (5/68) to 27.3% (14/35) during the intervention (difference 17.6%,
95% CI 6.6% - 33.2%, p<0.01).
Conclusion
A significant proportion of patients diagnosed with TB experienced pretreatment LFU. These
patients were more likely to die from TB than those who were successfully linked to TB treatment.
Because the majority of these deaths occurred outside the healthcare system and were not
incorporated into health facility level estimates for TB associated mortality, the health impact of
TB was inaccurately measured. Barriers to TB treatment initiation existed at both the patient and
health facility level and required a multifaceted intervention to be overcome. An intervention that
involved educating healthcare workers, restructuring of the work environment and enabling quick
and efficient communication between healthcare workers and patients was feasible to implement
and showed potential to reduce pretreatment LFU. Further evaluation of this intervention should
be considered. | en_US |
