Browsing by Author "Mulaku, Mercy Namuma"

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    Pre-treatment loss to follow-up in adults with pulmonary tuberculosis in Kenya - contributing factors and evidence-based interventions
    (Stellenbosch : Stellenbosch University, 2024-03) Mulaku, Mercy Namuma; Young, Taryn; Ochodo, Eleanor; Steingart, Karen R.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Global Health. Health Systems and Public Health.
    ENGLISH SUMMARY: Background: Tuberculosis incidence and mortality are not falling fast enough to meet global targets. Pre-treatment loss to follow-up (PTLFU), when people who are diagnosed with tuberculosis are lost to care before starting treatment, has been shown to contribute substantially to patient losses in the tuberculosis care cascade with subsequent high mortality rates and ongoing community transmission. A systematic review found a high proportion (up to 38%) of PTLFU in Africa. With Kenya having limited evidence on PTLFU, I aimed to describe the scope of, associated factors, and strategies to reduce PTLFU in adults with pulmonary tuberculosis. Methods: I achieved these objectives by conducting: (i) a qualitative evidence synthesis (QES) of patient and healthcare worker (HCW) perspectives on PTLFU; (ii) a retrospective review of laboratory and treatment registers of people with pulmonary tuberculosis to determine the proportion of people experiencing PTLFU and associated patient factors; (iii) key informant interviews to explore the experiences and perspectives of HCWs on PTLFU; and (iv) a scoping review of studies with quantitative data to map evidence on interventions to reduce PTLFU, identify gaps in existing knowledge, and develop a conceptual framework to guide intervention implementation.I categorized the interventions according to patient, HCW, and healthcare system levels. Results: (i) QES identified five studies describing multiple factors contributing to PTLFU: insufficient knowledge about tuberculosis and its management; poor HCW attitudes toward people with tuberculosis; communication challenges between HCWs and patients; difficulty accessing care; and weakness in tuberculosis program management. (ii) the retrospective review of laboratory and treatment registers found that, of 476 people with pulmonary tuberculosis (verified by Xpert MTB/RIF and smear microscopy), 42.4%, (95% confidence interval 38.1 to 46.9) experienced PTLFU. Age 55 and older and providing only an address or telephone number were associated with PTLFU while sex, HIV status, history of tuberculosis treatment, and residence were not. (iii) 19 key informant interviews highlighted multiple challenges leading to PTLFU: misconceptions about tuberculosis, stigma, hesitancy of HCWs to work in the tuberculosis clinic, and unclear linkage between laboratory and clinician. (iv) I identified seven interventions that reduced PTLFU: treatment support groups; mobile notifications; community health workers; integrated HIV/TB services; Xpert MTB/RIF as the initial diagnostic test; computer-aided detection with chest radiography screening; and multi-component strategies incorporating health education, home visits, and counselling. Intervention barriers included stigma and inadequate human and financial resources; enablers included mobile phones and TB testing and results on the same day. Key implementation considerations were the availability, accessibility, and acceptability of the interventions, political commitment, resources, and infrastructure. Conclusion: PTLFU affects a high proportion of people with tuberculosis in western Kenya. Multiple factors relating to patients, HCWs, and the healthcare system contribute to PTLFU. Interventions to reduce PTLFU involve providing people-centred care and strengthening healthcare systems by use of multi-component packages and community health workers. Improving systems for documenting patient information and timely delivery of test results are needed. Future research should be people-centred and consider perspectives of people with tuberculosis, as well as the social and economic factors affecting PTLFU.