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Mulaku MN, Ochodo E, Young T, Steingart KR. Pre-treatment loss to follow-up in adults with pulmonary TB in Kenya. Public Health Action 2024; 14:34-39. [PMID: 38798784 PMCID: PMC11122711 DOI: 10.5588/pha.23.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/25/2024] [Indexed: 05/29/2024] Open
Abstract
SETTING County referral hospital in western Kenya. OBJECTIVES To ascertain the proportion of pre-treatment loss to follow-up (PTLFU) and associated patient factors in adults with pulmonary TB (PTB) in western Kenya. DESIGN A retrospective data review of laboratory and treatment registers for adults with bacteriologically confirmed PTB between January 2018 to December 2021. We defined PTLFU as failure to initiate treatment within 14 days of diagnosis. We used multivariable logistic regression modelling to identify patient factors associated with PTLFU. RESULTS Of 476 patients with PTB, 67.2% were male; the mean age was 36.1 years; 37.0% were HIV-positive; 5.7% had a history of anti-TB treatment; 40.6% were not traceable in the treatment register; 202 (42.4%, 95% CI 38.1-46.9) experienced PTLFU. Age ≥55 years (aOR 2.6, 95% CI 1.0-6.7) and providing only an address (aOR 34.2, 95% CI 18.7-62.5) or only a telephone contact number (aOR 22.3, 95% CI 3.5-141.1) were associated with PTLFU. Sex, HIV status, history of anti-TB treatment and place of residence were not associated with PTLFU. CONCLUSION PTLFU contributes markedly to TB patient losses in western Kenya. Strengthening systems for documenting patient information and actively monitoring PTLFU are crucial for attrition reduction.
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Affiliation(s)
- M N Mulaku
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- Department of Pharmacology, Clinical Pharmacy, and Pharmacy Practice, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - E Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - T Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - K R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Mulaku MN, Nyagol B, Owino EJ, Ochodo E, Young T, Steingart KR. Factors contributing to pre-treatment loss to follow-up in adults with pulmonary tuberculosis: a qualitative evidence synthesis of patient and healthcare worker perspectives. Glob Health Action 2023; 16:2148355. [PMID: 36548521 PMCID: PMC9788701 DOI: 10.1080/16549716.2022.2148355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Since 2018, over 14 million people have been treated for tuberculosis (TB) globally. However, pre-treatment loss to follow-up (PTLFU) has been shown to contribute substantially to patient losses in the TB care cascade with subsequent high community transmission and mortality rates. OBJECTIVE To identify, appraise, and synthesise evidence on the perspectives of patients and healthcare workers on factors contributing to PTLFU in adults with pulmonary TB. METHODS We registered the title with PROSPERO (CRD42021253212). We searched nine relevant databases up to 24 May 2021 for qualitative studies. Two review authors independently reviewed records for eligibility and extracted data. We assessed methodological quality with the Evidence for Policy and Practice Information Centre tool and synthesised data using the Supporting the Use of Research Evidence framework. We assessed confidence in our findings using Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual). RESULTS We reviewed a total of 1239 records and included five studies, all from low- and middle-income countries. Key themes reported by patients and healthcare workers were communication challenges among healthcare workers and between healthcare workers and patients; knowledge, attitudes, and behaviours about TB and its management; accessibility and availability of facilities for TB care; and human resource and financial constraints, weakness in management and leadership in TB programmes. Patients' change of residence, long waiting times, and poor referral systems were additional factors that contributed to patients disengaging from care. We had moderate confidence in most of our findings. CONCLUSION Findings from our qualitative evidence synthesis highlight multiple factors that contribute to PTLFU. Central to addressing these factors will be the need to strengthen health systems and offer people-centred care.
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Affiliation(s)
- Mercy Namuma Mulaku
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Department of Pharmacy, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Bruce Nyagol
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Eddy Johnson Owino
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Eleanor Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Taryn Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Mulaku MN, Corrie OM, Odero I, Young T, Steingart KR, Ochodo E. Health worker views on pre-treatment loss to follow-up in adults with pulmonary TB in Western Kenya. Public Health Action 2023; 13:77-82. [PMID: 37736575 PMCID: PMC10446661 DOI: 10.5588/pha.23.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/22/2023] [Indexed: 09/23/2023] Open
Abstract
SETTING County referral hospital in Western Kenya. OBJECTIVES To explore factors contributing to pre-treatment loss to follow-up (PTLFU) in adults with pulmonary TB and propose solutions to address PTLFU from healthcare worker (HCW) perspectives. DESIGN This was an exploratory qualitative study using thematic analysis. RESULTS We conducted 19 key informant interviews with HCWs representing laboratory, clinical care, management and the community. Participant age ranged from 26 to 62 years; 14 (74%) were females; and most (74%) had worked in TB care for ⩽5 years. They reported that patients experienced stigma and had misconceptions about TB that contributed to PTLFU. HCWs were hesitant to work in the TB clinic, which contributed to suboptimal patient care, leading to PTLFU. Unclear linkage between laboratory and clinician, and limited financial resources to track patients were among the healthcare system factors that led to PTLFU. HCWs suggested having proper patient preparation, assigning resources to track patients and holding regular interdisciplinary meetings as practical solutions to address PTLFU. CONCLUSION HCWs reported multiple factors that may influence PTLFU and recommended various solutions to address these. Knowledge of TB management, patient preparation, resources to track patients and multidisciplinary meetings will be central to addressing PTLFU.
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Affiliation(s)
- M N Mulaku
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
- Department of Pharmacology, Clinical Pharmacy, and Pharmacy Practice, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - O M Corrie
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - I Odero
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - T Young
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - K R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - E Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Oga-Omenka C, Bada F, Agbaje A, Dakum P, Menzies D, Zarowsky C. Ease and equity of access to free DR-TB services in Nigeria- a qualitative analysis of policies, structures and processes. Int J Equity Health 2020; 19:221. [PMID: 33302956 PMCID: PMC7731779 DOI: 10.1186/s12939-020-01342-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/01/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction Persistent low rates of case notification and treatment coverage reflect that accessing diagnosis and treatment for drug-resistant tuberculosis (DR-TB) in Nigeria remains a challenge, even though it is provided free of charge to patients. Equity in health access requires availability of comparable, appropriate services to all, based on needs, and irrespective of socio-demographic characteristics. Our study aimed to identify the reasons for Nigeria’s low rates of case-finding and treatment for DR-TB. To achieve this, we analyzed elements that facilitate or hinder equitable access for different groups of patients within the current health system to support DR-TB management in Nigeria. Methods We conducted documentary review of guidelines and workers manuals, as well as 57 qualitative interviews, including 10 focus group discussions, with a total of 127 participants, in Nigeria. Between August and November 2017, we interviewed patients who were on treatment, their treatment supporter, and providers in Ogun and Plateau States, as well as program managers in Benue and Abuja. We adapted and used Levesque’s patient-centered access to care framework to analyze DR-TB policy documents and interview data. Results Thematic analysis revealed inequitable access to DR-TB care for some patient socio-demographic groups. While patients were mostly treated equally at the facility level, some patients experienced more difficulty accessing care based on their gender, age, occupation, educational level and religion. Health system factors including positive provider attitudes and financial support provided to the patients facilitated equity and ease of access. However, limited coverage and the absence of patients’ access rights protection and considerations in the treatment guidelines and workers manuals likely hampered access. Conclusion In the context of Nigeria’s low case-finding and treatment coverage, applying an equity of access framework was necessary to highlight gaps in care. Differing social contexts of patients adversely affected their access to DR-TB care. We identified several strengths in DR-TB care delivery, including the current financial support that should be sustained. Our findings highlight the need for government’s commitment and continued interventions.
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Affiliation(s)
- Charity Oga-Omenka
- The School of Public Health of the University of Montreal (ÉSPUM), 7101, Parc avenue, 3rd floor, Montreal, Quebec, H3N 1X9, Canada. .,Centre de recherche en santé publique, Université de Montréal (CReSP), Montreal, Canada. .,McGill University International TB Centre, Montreal, Quebec, Canada.
| | - Florence Bada
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Aderonke Agbaje
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Patrick Dakum
- International Research Center of Excellence, Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Dick Menzies
- McGill University International TB Centre, Montreal, Quebec, Canada.,Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
| | - Christina Zarowsky
- The School of Public Health of the University of Montreal (ÉSPUM), 7101, Parc avenue, 3rd floor, Montreal, Quebec, H3N 1X9, Canada.,Centre de recherche en santé publique, Université de Montréal (CReSP), Montreal, Canada.,School of Public Health, University of the Western Cape, Cape Town, South Africa
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Understanding the gaps in DR-TB care cascade in Nigeria: A sequential mixed-method study. J Clin Tuberc Other Mycobact Dis 2020; 21:100193. [PMID: 33102811 PMCID: PMC7578750 DOI: 10.1016/j.jctube.2020.100193] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Despite the availability of free drug-resistant tuberculosis (DR-TB) care in Nigeria since 2011, the country continues to tackle low case notification and treatment rates. In 2018, 11% of an estimated 21,000 cases were diagnosed and 9% placed on treatment. These low rates are nevertheless a marked improvement from 2015 when only 3.4% were diagnosed and 2.3% placed on treatment of an estimated 29,000 cases. This study describes the Nigerian DR-TB care cascade from 2013 to 2017 and considers factors influencing gaps in care. Methods Our study utilized a mixed-method design. For the quantitative component, we utilized the national diagnosis and treatment databases, as well as the World Health Organization’s estimates for prevalence to construct a 5-year care cascade: numbers of patients at each level of DR-TB care, including incident cases, individuals who accessed testing, were diagnosed, initiated treated and completed treatment in Nigeria between 2013 and 2017. Using retrospective data for patients diagnosed in 2015, we performed the Fisher’s exact test to determine the association between patient (age and gender) and provider/patient (region- north or south) variables, permitting a closer look at the gaps in care revealed across the 5 years. Barriers to care were explored using framework thematic analysis of 57 qualitative interviews and focus group discussions with patients, including 5 cases not initiated on treatment from the 2015 cohort, treatment supporters, community members, healthcare workers and program managers in 2017. Results A 5-year analysis of cascade of care data shows significant, but inadequate, increases in overall numbers of cases accessing care. On average, between 2013 and 2017, 80% of estimated cases did not access testing; 75% of those who tested were not diagnosed; 36% of those diagnosed were not initiated on treatment and 23% of these did not finish treatment. In 2015, children and patients in Northern Nigeria had odds of 0.3 [95% CI 0.1–0.7] and 0.4 [0.3–0.5] of completing treatment once diagnosed; while males were shown to have a 1.34 [95% CI 1.0–1.7] times greater chance of completing treatment after diagnosis. The main themes from qualitative data identified barriers to care along the care cascade at individual, family and community, as well as health systems levels. At the individual level, a lack of awareness of the true cause of disease and the availability of ‘free’ care was a recurring theme. Family interference was found to be a particular challenge for children and women. At the health system level, low index of suspicion, lack of rapid diagnostic tools and human resource shortages appeared to limit patients’ access. Conclusions Any gains in diagnostic technology and shorter regimens are lost with inadequate access to DR-TB services. The biggest losses in the Nigerian cascade happen before treatment initiation. There is a need for urgent action on identified gaps in the DR-TB cascade in order to improve care continuity at multiple stages, improve health service delivery and facilitate TB control in Nigeria.
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