AN INVESTIGATION INTO THE CONTINUED CASES OF LOST TO FOLLOW-UP

TB PATIENTS: A CASE STUDY OF KAWAALA HEALTH CENTRE IV IN

KAMPALA, UGANDA.

BY

NABWIRE SARAH

B5W14403411431DU

SUPERVISOR: MR.OMUYA RONALD

A RESEARCH REPORT SUBMITTED TO THE COLLEGE OF HUMANITIES AND

SOCIAL SCIENCES IN PARTIAL FULFILLMENT FOR THE REQUIREMENTS OF

THE AWARD OF THE DEGREE OF BACHELOR OF SOCIAL WORK AND

SOCIAL ADMINISTRATION OF KAMPALA

INTERNATIONAL UNIVERSTY

SEPTEMBER, 2017

DECLARATION

I Nabwire Sarah declare to the best of my knowledge that this report is a result of my

effort from Kawaala HCIV and it has never been submitted to any university for any

ward.

1

APPROVAL

This is to affirm that this study titled “An investigation into the continued cases of Lost to

follow-up: a case study of Kawaala Health Centre IV, Kampala”. Has been done under

my supervision and is now ready for submission.

Signature

MR. OMUYA RONALD

(SUPERVISOR)

Date .~

DEDICATION

I dedicate this piece of work to my family ; thank you for your unending love, Francis my

brother for your continued efforts and encouragement, thanks a lot it has kept me moving,

to my friends; Morgan, Rachael, Sam, thank you for your care and comfort and to Denis

that I love you so much.

111

ACKNOWLEDGMENTS

This piece of work would not have been complete without the efforts of many people to

whom I am very grateful; however a few of these deserve special recognition.

First , I would like to extend my heartfelt gratitude to my siblings, the Wanderas of

Naguru for your moral support to me through all my life , thank you, it has made me get

this far in my education.

I extend my sincere thanks to my supervisor Mr. Omuya ,for his helpfiil guidance, you’ve

always encouraged me to dig deeper as well as carry out more research and I hope this

will soon be a success. To the entire KIU staff that has been of great help during my

whole stay at the University.

Lastly, to my work mates and classmates for the encouragement and support they gave

me throughout our stay at KIU.

Also, I wish to make special mention of the staff at Kawaala Health Centre IV for the

help they gave me during my study visits there.

God bless you all.

iv

LIST OF ACRONYMS AND ABBREVIATIONS

FA Field Assistants

GOU Government of Uganda

HCIV Health Centre Four

HIV Human Immunodeficiency Virus

KCCA Kampala City Council Authority

LTFU Lost to Follow-up

MDG Millennium Development Goals

MDR-TB Multi-Drug Resistant Tuberculosis

NTLP National Tuberculosis and Leprosy Program

NTP National Tuberculosis Program

PBC Pulmonary Bacteriologically Confirmed

PCD Pulmonary Clinically Confirmed

SDG Sustainable Development Goals

TB Tuberculosis

WHO World Health Organization

v

TABLE OF CONTENTS

DECLARATION.

APPROVAL

DEDICATION

ACKNOWLEDGMENTS iv

LIST OF ACRONYMS AND ABBREVIATIONS v

TABLE OF CONTENTS

ABSTRACT ~aii

CHAPTER ONE 1

INTRODUCTION 1

1.0 Introduction 1

1.1 Background 1

1 .2Problem statement 4

1.3 Objectives of the Study 4

1.3.1 General Objective 4

1.3.2 Specific Objectives of the Study 5

1.4 Research Questions 5

1.5 Significance of the study 5

1.6 Scope of the study 6

CHAPTER TWO 8

LITERATURE REVIEW 8

2.0 Introduction 8

2.1 Definition of Lost to Follow-up 8

2.2 GOU Interventions in TB Treatment 9

2.3Background factors associated with Lost to Follow-ups during TB treatment 12

vi

CHAPTER THREE .15

METHODOLOGY 15

3.0 Introduction 15

3.1 Research Design 15

3.2AreaofStudy 15

3.3 Study population 16

3.4. Sample Size 16

3.5 Data Collection Methods and Instruments 16

3.6 Data Quality Control 16

3.7 Procedure 16

3.8 Data Analysis 17

3.9 Limitationsof the Study 17

3.10 Ethical Considerations 18

CHAPTER FOUR 19

PRESENTATION OF THE FINDINGS 19

4.1 Characteristics of Patients 19

CHAPTER FIVE 23

DISCUSSION OF THE FINDINGS 23

REFERENCES 30

APPENDIX I 33

RESEARCH BUDGET 33

APPENDIX II 34

TIME FRAMEWORK 34

vii

ABSTRACT

This study was conducted to establish the extent to which background factors have

perpetuated the cases of lost to follow-up in the Tuberculosis treatment despite the

government of Uganda intervention to providing universal free treatment and care for

patients in all public health facilities. Patients’ lack of motivation to complete treatment

and rehabilitation remains a challenge. The study was conducted as a across sectional

investigation through the review and analysis of registers of all 298 patients that were

enrolled on TB treatment from January to December 2016 at Kawaala HCIV. A

univariate analysis of the data was done using measures of central tendency.

Demographic variables were compared using the Chi-square tests. The study established

more males (62.4%) contracted Tuberculosis and more HIV positive patients (55.1%)

contracted the disease as an opportunistic co- infection. Although a higher percentage of

(63.2%) of TB patients was cured, the study further established that (5.4%) was still

worryingly high and this occurrence was more commonly among patients of 15 years and

more (93.3%). This study concluded that there is a clear co-relation between background

factors and Lost To Follow-Upamong TB patients and therefore recommends that further

interventions in TB treatment should specifically target these but also make aim for other

possible variables like mass sensitization and education, community linkages efforts play

a central role in attaining desired TB treatment success targets.

viii

CHAPTER ONE

INTRODUCTION

1.0 Introduction

The study investigated the background factors influencing the increasing cases of Lost to

follow-up(LTFU) in the treatment and care of Tuberculosis (TB) in Uganda despite the

availability of free treatment and care for TB patients in all public health facilities across

the country.

The study was carried out at one Kampala Capital City Authority (KCCA) Health Centre

(HC) IV called Kawaala HC IV.

This chapter presents the background of the study, statement of the problem, objectives

of the study, research questions, scope of the study and significance of the findings.

Li Background

TB is a bacterial disease which in humans is caused by an organism called

Mycobäcterium tuberculosis and the bacteria usually infects the lungs. But in some

individuals the TB germ can also affect all other parts of the body except the hair and

nails. When people with lung TB cough, sneeze, spit, or even talk, they propel the TB

germs into the air. A healthy person needs to inhale only a few of these germs to become

infected; making the disease airborne.

The signs and symptoms depend on which area of the body has been infected. These

signs may include: coughing that lasts two or more weeks, coughing out blood stained

sputum, chest pain or pain with breathing or coughing, noticeable weight loss, fatigue,

fever, excessive sweating especially at night lasting for 2 weeks or longer, loss of

appetite, poor weight gain among children, history of contact with a TB patient among

children etc.

TB can be treated and cured. The World Health Organization (WHO) Global TB report

of 2016 states that TB treatment averted 49 million deaths globally between 2000 and

2015.

The testing and treatment services are free in all public health facilities. The patients that

have started treatment are expected to take their medicines continuously for a period of

six months and then be reviewed after for response to the prescribed drug.

Although there have been globally concerted efforts to provide free Tuberculosis (TB)

treatment services in public health facilities, TB remains a major global health problem

causing~ill-health and death among millions of people each year and ranks as the second

leading cause of death from an infectious disease worldwide, after Human

Immunodeficiency Virus (HIV).

According to World Health Organization Global TB Report (2014) there were 8.7 million

new cases and 1.4 million deaths in 2013 and almost one million deaths among HIV

positive TB patients. According to WHO (2016) important diagnostic and treatment gaps

persist. Globally there was a 4.3 Million gap between incident and notified cases, with

India, Indonesia and Nigeria accounting for almost half of this gap.

2

Sendagire et al (2012) argues that retaining patients on TB treatment is .a major challenge

in many countries. Interruption of treatment has been associated with failure and death.

Levels of defaulting of up to 26% have been reported in Africa. Defaulting levels tend to

be especially high in urban areas. In Uganda, an estimated 14% of the new smear-positive

patients defaulted from treatment in 2006, while in Kampala city, where a quarter of the

notified TB cases in Uganda are registered, defaulting levels are around 20%.

Owing to the fact that there are gaps in the universal TB treatment and care interventions,

a number of patients have abandoned or failed to complete the treatment course. A

patient who has had treatment for at least one month but then discontinues it for two

months or more is referred to as Lost to follow-up. Stopping treatment too soon or

skipping doses can allow the bacteria that are still alive to become resistant to the

prescribed drugs, leading to a TB strain that is much more dangerous and difficult to

treat. The NTLP Annual Report 2015-2016 on TB Treatment Outcomes states that of the

26, 632 new Pulmonary Bacteriologically Confirmed (PBC) cases notified in 2014/2015,

79% were successfully treated (51% cured), 5% died, and 1% failed while 11% were lost

to follow up, which is over twice high the WHO target of 5%.

It is under this background that the researcher was interested in finding out the

background factors associated with the increasing numbers of TB patients abandoning

treatment, yet at all public health facilities in Uganda TB treatment and care is free.

3

1.2Problem statement

The Government of Uganda (GOU) has intensified its efforts in the fight against TB.

Namagembe (2017) states thatl 12 health facilities in over 60 districts across the country

are equipped with the Genexpert TB machine. This intervention is far more effective than

the smears that are on the other hand also more widely spread across the whole country.

However, despite these and other interventions ( for example, early diagnosis and DOT

[Kirenga et al,20 14]) intended to rid the population of the highly fatal TB, patients have

also increasingly abandoned treatment and care; contributing to the high prevalence of

the disease: 36 cases for every 100,000 among children only (2016 National TB

Prevalence Survey).

This has therefore prompted the researcher to carry out a study intended to investigate the

background factors contributing to the increasing LTFU cases yet there is free treatment

and management of TB in all health facilities across the country. This will help to inform

the government of Uganda in planning relevant interventions in order to achieve the

World Health Organization’s (WHO) goal of eliminating TB as a public health threat by

2035.

1.3 Objectives of the Study

1.3.1 General Objective

This study sought to investigate the contributory background factors associated with non

adherence to TB treatment despite the availability of free universal treatment in all public

health facilities in Uganda.

4

1.3.2 Specific Objectives of the Study

i. Determine the proportion of patients regarded as lost to follow up abandoning

treatment at Kawaala HCIV.

ii. Describe the background factors associated to cases of Lost to Follow Up during

TB treatment at Kawaala Health Centre IV.

1.4 Research Questions

i. What proportion of patients on TB treatment in Kawaala HCIV is lost to

follow-up?

ii. What are the background factors associated to cases of lost to follow-up during

TB treatment?

1.5 Sighificance of the study

The findings of the study will be of the following significance:

Health authorities in Uganda and the world at large will get to ascertain the relationship

between background factors and lost to follow-up in TB treatment and thereby design

interventions that are more relevant to patient characteristics.

Health workers at different health facilities managing TB will get to understand how

and the need to retain patients on TB treatment until declared cured or complete for TB

treatment.

5

All health facilities involved in the management and treatment of TB will use the findings

of this study to improve their information systems and data management so as to

accurately record and report the LTFU cases to improve health interventions.

Other researchers will use the finding of this study as baseline data for their studies and

also as a basis for further research to influence TB treatment and management policy.

1.6 Scope of the study

The study was conducted on the background factors influenced by the increasing cases of

Lost to Follow-Up in the treatment and management of TB. It was conducted in one of

the Kampala Capital City Authority clinics called Kawala HC IV. The study was

conducted between May and August 2017.The researcher used a quantitative research

design. In particular, a cross-sectional design with TB patients for the entire population

o120 1 6’n the treatment register who were initiated on TB treatment was considered.

6

1.7 Definition of Key terms

Lost to follow-up: A patient who has had treatment for at least one month but then

discontinues it for two months or more.

TB: TB is a bacterial disease which in humans is caused by an

organism called Mycobacterium tuberculosis and the bacteria

usually infects the lungs.

HC IV This is a mini hospital that serves a county or a parliamentary

constituency. It should have a senior doctor and other doctors, a

ward for men, women and children besides having an operating

theatre for carrying out emergency operations.

BACKGROUND: The conditions that form the setting within which something is

experienced OR information essential to understanding of a

problem or situation.

7

CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

By examining related works of other researchers and scholars, this chapter will highlight

the definition of LTFU, establish the already existing knowledge and literature about the

variables of LTFU patients on TB treatment, and the GOU intervention of providing them

free treatment to combat the vice. It will also establish the proportion of LTFU patients in

the selected KCCA clinic of Kawaala HCIV in Kampala as well as describing the

background reasons surrounding their defaulting on the free TB treatment.

2.1 Definition of Lost to Follow-up

In clinical medicine, a person who has not returned for continued care or evaluation (e.g.

because of death, disability, relocation, or drop-out) is a Lost to follow-up (Medical

Dictionary, 2009).

Lost to follow -up is a TB patient who starts treatment for one month or more and whose

treatment is then interrupted for 2 consecutive months or more (WHO, 2007).

Lost to follow-up has also been defined as patients who at one point in time were actively

participating in a clinical research trial, but have become lost (either by error in a

computer tracking system or by being unreachable) at the point of follow-up in the trial

(Wikipedia).

8

A defaulter is a patient who had documented discontinuation of anti-TB treatment for

two or more consecutive months due to reasons other than physician’ s advice. (Elbireer,

Guwatudde, Mudiope, Ssekandi, and Manabe ,201 1).

It should be noted that the various scholars on LTFU do not differ at all. Their conclusion

is that LTFU may in some instances be only as result of error on part of the health

facility, but on the whole it is largely a patient-driven occurrence.

2.2 GOU Interventions in TB Treatment

The GOU in its efforts to totally eradicate TB in the country ratified the Millennium

Development Goals (MDGs) and their successors; the Sustainable Development Goals

(SDGs).Of particular interest is MDG and SDG number 6. According to the Revised

National strategic plan 2015/16 report; Case holding among drug susceptible TB cases

has remained a challenge in the country. For example, of the 2014/15 new

bacteriologically confirmed cohort, only 79% were successfully treated (51% cured and

28% treatment completed) while 21% had unfavorable outcomes (5% died, 1% failed,

4% wei’e not evaluated, and 11% were lost to follow up).

The chronic nature of TB demands that two or more kinds of drugs are taken for periods

ranging between 6 and 12 months, depending on the treatment regimen. Because of this,

motivation to complete treatment fluctuates in intensity, and loss of follow up may be

considered at many stages during treatment. Thus the most difficult task in TB control is

to persuade patients to take their drugs regularly and for the required duration

(Nakanwagi et al, 2010).

9

A study carried out that included 331 retreatment patients (68% males), with a median

age of 36 years, 93 (2 8%) of whom were relapse smear-positive, 21(6%) treatment after

failure, 159 (48%) return after loss to follow-up, 26 (8%) relapse smear-negative and 32

(10%) relapse cases with no smear performed. This clearly shows that the dropout rate is

higher than the recommended WHO target of 5% in LTFU.

Owing to the fact that many national and international efforts are exerted against T.B

prevention and control but still the patients are failing to complete their treatment to be

declared cured or completed treatment. The internationally accepted WHO strategy for

TB control, the DOTS program was implemented since 1997 Nevertheless; coverage of

DOTS service is still minimal and has made little progress on treatment adherence in

some resource- meager countries such as Uganda meanwhile in Nairobi too in

2006,Nairobi had the highest notification rate at 652/100000 among the TB control

regions, further the highest defaulter rate (out of control), Bernard N Mature etal.

Meanwhile the NTLP Annual Report 2015-2016 on TB Treatment Outcomes: Of the 26,

632 new PBC cases notified in 2014/2015, 79% were successfully treated (51% cured),

5% died, and 1% failed while 11% were lost to follow up which is twice high the WHO

target of 5%. The unfavorable outcomes could be due to poor recording and reporting,

inadequate engagement of families as well as communities in providing treatment support

to patients.

It is therefore important to note that the problem of lost to follow up actually exists and

there is need to address it(Sendagire etal, 2012).

10

Retaining patients on TB treatment is a major challenge in many countries. Interruption

of treatment has been associated with failure and death. Levels of defaulting of up to 26%

have been reported in Africa. Defaulting levels tend to be especially high in urban areas.

In Uganda, an estimated 14% of the new smear-positive patients defaulted from treatment

in 2006, while in Kampala city, where a quarter of the notified TB cases in Uganda are

registered, defaulting levels are around 20 %( Sendagire, Ibid).

Non-compliant patients were more likely to be workers. This was attributed to the fact

that the travelling time for an employed patient represents a time absent from work.

Coupled with the fact that some employers may not take kindly to the frequent long

periods during which TB patients need to attend health facilities for treatment, means that

long-term treatments such as that for TB may pose huge problems for such individuals. In

the present study, the possible explanation for non-compliance among employed patients

could be because they belonged to lower socio-economic strata and they were the sole

bread earning members of their family. These factors may put a lot of stress on them, to

the extent that as soon as they begin to feel better, they will choose to return to work to

continue to provide for their families (O’Boyle et al, 2013)

It is upon this background that the researcher decided to look at these background factors

associated with the phenomenon and came up with information as well as

recommendations to the challenge; hence the study.

11

2.3Background factors associated with Lost to Follow-ups during TB treatment

This study documents some of the background factors associated with an increased risk

of loss to follow-up and treatment non-compliance which may include sex, age,

geographical location, type of patient, type of TB, type of treatment regimen and HIV

status. According to Gopi et al(nd) age affects adherence to TB medication where old age

increases the risk of loss to follow(1). It was shown that the default rate among cases

diagnosed at health facility was significantly higher in the older age group of 45 years or

more compared to that of 15-44 years of age.

Gopi et al (nd) continues to emphasize the relationship between sex and loss to follow-

up. Looking at the survey component done at the health facility which indicated that the

default rates among males and females were 17.0% and 8.4% respectively and the

difference was statistically significant (p<O.0 1). However, the survey component canied

out in the community showed a difference by sex where the default rates among males

and females were 24.4% and 17.6%.

A study carried out in Southwest of Ethiopia among tuberculosis patients at Jimma

University hospital also showed no significant differences in terms of gender and age for

patients who were classified as Lost To Follow-Up. In the same study it was concluded

that HIV negative TB patients were more prone to loss to follow-up as opposed to HIV

positive TB patients. Indeed being HIV positive appeared to be associated with lost to

follow-up in the univariate but not in the multivariate analysis (Akesa, 2015).

12

In a survey done in 2007 at the Infectious Diseases Institute clinic (IDI), an urban HIV

clinic in Kampala Uganda by Sawsaw, Osman Abdalla, results indicated that the annual

default ,rate from TB treatment was at 30% and a number of health facility-specific

factors and individual characteristics were found to be associated with TB treatment

default like; long waiting time in the treatment Centre, lack of health education, conduct

of clinic staff, running out of drugs and fear of side effects of anti-TB treatment etc.

Another case control-study carried out in Brazilian Amazon, by Malucia dasilva etal,

retorted that; treatment default is influenced by a number of factors: lack of knowledge

about the disease, distance from the health post, partial or complete regression of

symptoms in the first two months of treatment, the side effects associated with the

medication, male gender, age, the use of toxic substances and hospitalization during

treatment pre-existing pulmonary disease, previous default, TB/HIV co-infection,

absence of supervised treatment and poor quality of patient care at the Health Unit.

Furthermore a study carried out by USAID in Gulu District referral hospital in Northern

Uganda reported that with an average of 80 patients every quarter diagnosed with active

TB and initiated on treatment, the quarterly treatment completion rate from January to

September was reported to range from 18.3% to 27.7% and several factors contributed to

poor out comes in reaching the national target for completion of TB treatment. The TB

clinic, staffed primarily by nurses and nursing assistants. In addition to the human

resource limitation, the patient information system including the TB registers and patient

13

held-cards was often inaccurate or incomplete. The patient information system also

lacked contact information for proactive client follow-up and this is the reason why the

problem of lost to follow-up is still a challenge because there is no way of tracking those

clients that fail to return for routine clinical review.

The Uganda Radio Network (URN) is an independent Ugandan subscription

based news agency headquartered in Kampala. In April 2014, it released a report which

expressed concern on the alarming rate of TB patients defaulting on treatment in

Kitgum District. The report cited that in Lagoro sub county 53 of the 60 registered

tuberculosis patients had defaulted on treatment and disappeared without trace.

14

CHAPTER THREE.

METHODOLOGy

3.0 Introduction

This chapter presents a detailed description of the research design that was adopted for

the study, the study area, study population, sample size, data collection methods, tools,

and limitations of the study among others.

3.1 Research Design

This was a cross sectional study which collected secondary data from the TB treatment

register of Kawaala Health Center IV to determine the proportion of Lost To Follow-Up

and the background characteristics that determine Lost To Follow-Up.

3.2 Area of Study

The study was carried out in Kampala Capital City Authority (KCCA), specifically in the

HC IV of Kawaala. KCCA is located in Buganda region, in the central part of the

Uganda. Kawaala Health Center IV is located in the Rubaga Municipality of KCCA on

Kawaala Village.

This particular health center was chosen for the study due to the fact that it is located an

urban area and so more likely to have high TB incidences and prevalence due to

congestion of people. Kawaala is among the health centers that are located in areas which

are predominantly inhabited by people of lower socio-economic standing and such people

are more susceptible to defaulting on treatments owing to the fact that they are

preoccupied with achieving basic daily necessities of life like food and shelter.

15

3.3 Study population

The population of the study comprised of all patients that were initiated on TB treatment

for the year 2016.

3.4. Sample Size

A total of all the patients diagnosed TB positive in the year 2016 were considered in this

study.

3.5 Data Collection Methods and Instruments

This was a retrospective study that focused on the review of documents, in specific the

TB treatment registers. The study of documents method was used because of its ability to

cover the whole span of a year that the researcher intended to investigate since all the

patient information during that period was contained in the documents.

3.6 Data Quality Control

There was a regular cross checking, inspection and scrutinizing of information on the

research instruments at the end of the day of data collection by the researcher to ensure

accuracy, relevance, completeness, consistency and uniformity of the data. Double entry

of data and data cleaning was conducted before data analysis.

3.7 Procedure

Upon approval of the research proposal, the researcher got an introductory letter from the

Head of Department College of humanities and social sciences, Faculty of Applied

16

psychology Kampala International University. This letter was presented to the facility

inhcargeat Kawaala HC IV. This was done so as to seek permission to carry out the study

at the facility. After seeking permission, the researcher was then given access to the

treatment register and all the fields were entered in a database using Redcap.

3.8 Data Analysis

The researcher conducted a multivariate analysis. Continuous data was analyzed using

measures of central tendency (mean and median) with standard deviations and

interquartile ranges respectively. The researcher summarized the categorical data using

percentages. Data was presented using tables. For categorical variables, Chi-square test

was used to make any comparisons as required.

3.9 Limitations of the Study

The study should have been conducted in all public health facilities across the country

that are involved in the management and treatment of TB however, the time and financial

constraints that the researcher met in the whole research process dictated a selection of

one clinic that represents both rural and urban. The researcher not only had to meet the

full cost of the study, but also the period of four months that the researcher was allowed

to develop a proposal, collect and analyze data and compile and submit a report was not

sufficient for a more comprehensive study. Also, the localization of the study to just one

health facility may limit the generalization of the findings but the researcher feels that

those findings will be representative enough to influence TB management and treatment

across Uganda and the world over.

17

3.10 Ethical Considerations

Permission was sought from the facility incharge at Kawaala HCIV before data

collection. The researcher ensured confidentiality of all participants’ information by

assigning identification numbers rather than using their names and stored the information

with a password that was kept strictly confidential and used only by the researcher.

18

CHAPTER FOUR.

PRESENTATION OF THE FINDINGS

4.1 Characteristics of Patients

A total of 298 who initiated TB treatment from4thJanuary 201 6to 23’~December

2Ol6were included in this study. Out of these, 186 (62.4%) were males and the median

age was 30 (IOR: 24-3 8) years. More than seven-tenth (70.1%) of TB patients were

bacteriologically confirmed, 23.5% clinically diagnosed, and 6.4% extra pulmonary. One

hundred and sixty three (55.1%) were HIV-positive, 44.6% were HIV-negative, and only

one with unknownlmissing status.276 (92.9%) of the patients were new and 9 (3.0%)

were returned after default or regarded as relapse. Regarding their TB treatment history,

177(63.2%) got cured, 60(21.4%) completed but not yet confirmed cured, 15 (5.4%) lost

to follow-up, 13 (4.6%) died, 11(3.9%) transferred out and only 4 (1.4%) were recorded

as failure. The patient characteristics included are summarized in Table 4.1.

Table 4.1: Characteristics of TB patients initiating TB treatment at Kawaala HCIV

in Uganda in 2016.

Variable Frequency Percent

Sex’

Female 112 37.6

Male 186 62.4

Age 31 (SD: 10.95)

Patient Category

New 276 92.9

Relapse 9 3

19

LTFU 5 1.7

Failure 7 2.4

Treatment Outcome

Completed 60 21.4

Cured 177 63.2

Died 13 4.6

Failure 15 5.4

LTFU 15 5.4

Transferred out 11 3.9

Types of diagnosis

Extra pulmonary 19 6.4

Bacteriologically confirmed 209 70.1

Clinically diagnosed 70 23.5

HIV test result

Positive 163 55.1

Negative 132 44.6

Unknown 1 0.3

20

4.2 Loss to Follow-Up (LTFU) during Treatment

All TB’ patients were supposed to start treatment and follow treatment until they were

declared as cured or completed as was also in a study carried out in Nairobi province Of

the 298 TB patients followed, the minimum follow-up time was one month and the

maximum was eight months. Fifteen patients (5.4%) were lost to follow-up of their

treatment. With regard to timing of LTFU, 3 were lost to follow-up during the first two

months of treatment. This was also reported by Bernard Mature etal in a case control

study; Factors associated with Default from Treatment among TB patients in Nairobi

Province where results showed that of the 945 Defaulters 22.7 %( 215) and 20.4 %( 193)

abandoned treatment within the first and second months (Intensive phase) of treatment

respectively. 7 during the next 3-4 months, and 5 after four months of TB treatment

initiation. Time until LTFU treatment among tuberculosis patients ranged from 14 days

to 120 days.

The statistics also show 3.9%(l 1) patients as transferred out ;this doesn’t clearly show

their treatment outcomes from the clinics they were transferred to and in any case they

could also be lost because there was no proof of treatment continuation in the registers

for those patients that were transferred out. There’s a weak follow-up system for these

patients. Although the receiving health facilities are responsible for reporting patient

treatment outcomes to the referring facilities, this communication is failing.

21

4.3 Demographic Factors Associated with LTFU

Among the 15 LTFU treatments, 6 (40.0%) of them were HIV-positive and 9 (60.0%)

were negative. From 112 female and 186 male patients, 3 (20.0%) and 12 (80.0%),

respectfvely, were lost to follow-up TB treatment. Lost to follow-up also more frequently

occurred among patients who were 15 years and older at 14 (93.3%) compared to those in

the age group of 5-l4years which showed none and 0-4 years with only one patient lost to

follow-up.

On Chi-square analysis, at 5% probability level, all, that is, age, sex, HIV status were

statistically not significant with lost to follow-up (p value>0.05) as illustrated by Table

4.2.

Table 4.2: Chi-square analysis of factors related to TB treatment outcomes at Kawaala

HCVI in Uganda in 2016.

Chi-squareVariables TB outcome

(p value)

Age min/4 1

5-14 0 3.89 (0.143)

15/max 14

Sex Male 122.08 (0.149)

Female 3

HIV status Positive 6

Negative 9 1.55 (0.462)

Unknown 0

22

CHAPTER FIVE.

DISCUSSION OF THE FINDINGS

The government of Uganda has intensified its efforts to fight against Tuberculosis and in

over 60 District across the country, Health facilities have been equipped with genexpert

machines for fast TB diagnosis so as patients are started on TB treatment immediately.

TB treatment and care is free in all public health facilities across the country. Despite the

government’s efforts to end TB infections with free treatment, many patients are failing

to adhere to the TB treatment. World Health Organization places high emphasis on

achieving high compliance levels than finding new cases. Non-compliance increases the

likelihood of developing multi-drug resistance TB (MDR-TB) and extreme-drug resistant

TB (XDR-TB). This will further increase the burden of a disease that is already very

great and increases the costs of its management.

This research was done so as to analyze the possible reasons for non-adherence to TB

treatment. It is a retrospective study that involved the review and analysis of documents.

During the study all TB treatment registers of the year 2016 were reviewed and data was

collected for analysis.

In this study, the researcher found out that, the total number of patients that were initiated

on TB treatment in 2016 was 298. Out of these 186(62.4%) were males, 112(37.6%) were

females with the median age of 30(IOR: 24-38) years. More than seven-tenth (70.1%)

were bacteriologically confirmed, 23.5% were clinically diagnosed and 6.4% had extra

pulmonary TB. 163(55.1%) were HIV-positive, 44.6% were HIV-negative and only one

had an unknown/missing status. 276 (92.9%) of the patients were new and 9 (3.0%) were

regarded as relapse.

23

Regarding their TB treatment history, 177 (63.2%) got cured, 60 (21.4%) completed but

were not yet confirmed cured, 15 (5.4%) lost to follow-up, 13 (4.6%) died, 11(3.9%)

transferred out and only 4 (1.4%) were recorded as failure.

Of all patients initiating first-line TB treatment during 2016,15(5.4%) were lost to

follow-up. This is a lower rate documented compared to the NTLP Annual Report 2015-

2016 on TB Treatment Outcomes which documented an 11% lost to follow-up. This

result is also not consistent with the one documented in the sub-Saharan Africa (18%) by

a systematic review and meta-analysis by MacPherson et al (2014). This is due to the

population considered for this study where only one KCCA clinic was considered but this

was documented under the study limitations. It might also be due to the massive rollout

of household contact investigation programs and this being one of the clinics that is

currently participating in the program. The 5.4% of lost to follow-up rate was slightly

higher than the WHO recommended target of less than 5% nationally(WHO,2014)

despite the extensive expansion of services and the massive rollout of contact

investigation programs. This calls for more comprehensive approaches to reduce Lost to

Follow-Up among TB patients by targeting those risk factors for treatment interruptions.

Previous studies have identified wide ranges of factors associated with loss to follow-up

treatment among TB patient including age, sex, HIV status and others. In the current

study the researcher identified that, the same factors mentioned are associated with Lost

to Follow-Up.

24

In view of the first objective, the research established that, of the 15 who were LTFU, 3

patients were female and the 12 patients were male composing the biggest percentage of

LTFU.

In view of the second objective that was to find out the background factors associated

with the cases of LTFU. The research established that of the 15 who were lost to follow-

up, 6 of them were HIV-positive and of the positives 4 patients were males clearly

showing that more men do not adhere to treatment than women and this could be because

men have poor health seeking behaviors than women and also them being HIV-positive,

they were challenged by the number of drugs they had to take, it was hard for them to

take drugs for both disease and as a result many had their treatment interrupted.

Conclusion

This study investigated the continued cases of lost to follow-up in Tuberculosis treatment

and care, taking Kawaala Health Centre IV as a case study. This was in relation to the

persistence of the situation in which TB patients failed to adhere to treatment and care yet

this was readily and universally available at all public health facilities across the country

and also provided free of charge. The study specifically sought to determine the

proportion of patients regarded as LTFU and also describe the background factors leading

to the increasingly persistent cases of LTFU during TB treatment.

The study established that cases of LTFU appeared from as early as 13 days into

treatment to 548 days and these accounted for up to 5.4 %of those patients that enrolled

for treatment and care. The study further established that LTFU was an occurrence

25

majorly among patients that were 15 years or older (93.3%), non-existent among those

between 5 and 14 years, and only 2.98% among those between 0 and 4 years. Further

still, the study established that LTFU occurred more frequently among HIV-positive

patients (at 55.1%) and generally the phenomenon occurred more frequently among men

at (80.0%). Finally, the 5.4%LTFU incidence was lower than the regional and global

incidenèe of 11% though very significantly high for an urban health Centre because poor

adherence to treatment means that patients remain infectious for longer and are more

likely to relapse or emerge to drug resistant tuberculosis which may increase the cost of

treatment. In view of these findings, the study concludes thus:

LTFU was an occurrence not exclusive to a specific section of the population, in other

words all those enrolling for TB treatment were likely to abandon treatment in case any

one or a combination of the background factors leading to the situation was present.

The background factors that led to the existence of LTFU in TB treatment were majorly

demographic, including age, sex, HIV status and socio-economic status. These

notwithstanding, there were several other factors that had not been given consideration by

this particular study yet they too had a bearing on the phenomenon. Among these was the

inadequate treatment support, non-aggressive mass education about TB, the kind of TB

that a patient was suffering from and the length of time taken by each visit to a health

facility.

26

Recommendations

The researcher has argued that interventions to combat LTFU must be designed in view

of demographic factors of patients generally because the phenomenon is not exclusively

borne of one particular background factor but by a combination of all depending on the

patient and their circumstances.

The study has also shown patients begin to abandon treatment as early as the second

week of enrolment. Also the study established that the incidence of LTFU in Uganda was

commendably lower than the regional and global incidence. It is against this background

that the recommendations below are made. Despite its limitations, this study should be

relevant in the total eradication of LTFU cases in TB treatment and care. Basing

generalizations on the findings of this study, the researcher recommends that:

Interventions to address the issue of LTFU should be designed to address the background

factors leading to the persistence of the phenomenon. The aforesaid background factors

include the core demographic variables like age and sex. Also, these interventions should

address the extraneous factors like socio- economic background of the patients,

knowledge on duration of treatment.

The health authorities in Uganda should address the fact that the national LTFU

incidence is far lower than the regional and global. The low incidence depicts a situation

of logistical limitations confounding the findings of this and any other study because the

circumstances of TB treatment and care are still incomplete in themselves. In other

words, chances are that many TB positive patients are going undetected, thereby

27

rendering all other efforts to combat the disease irrelevant because of it being a highly

contagious airborne malady.

Treatment support for the patients and mass-sensitization, (prior attendance to a TB

health education session, awareness campaigns that TB is curable as other diseases)

should be intensified in order to motivate those patients already enrolled for treatment to

complete their treatment schedules and also encourage the community, To void future

infections and re-infections by equipping them with information necessary to undertake

informed decisions in relation to the disease.

With the findings of the study indicating that more HIV-positive patients (55.1%) were

again the LTFU in TB treatment, health authorities should design joint clinics for both

TB and HIV/AIDS treatment and care because in the current arrangement the two clinics

are attended separately; hence increasing the likelihood of the patient missing this clinic

or the o~her or both.

Areas for Further Research

The conundrum of LTFU despite free universal TB treatment can be addressed better if

further research is done on more effective mass sensitization and the role of educational

institutions in the fight against TB. Also, the medicines that are given to both TB and

HIV patients need further research into so that more combined drugs treating the co

infections are developed because currently these patients are given medicines for each

disease separately, which makes taking them inconveniencing.

28

Statistically more men were found to be lost to follow-up than women; further research

should be carried out to establish why more men fail to adhere to treatment than women

so that interventions brought rid this vice.

29

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32

APPENDIX I

RESEARCH BUDGET

Serial Item Description Total

NO. estimated

1 Stationery 1 ream of duplicating paper. 20,000

Binding of proposals and reports at 4000 per 16,000

copy

2 Research 1 FA at 10,000shs per day for 1 month. 300,000

assistance

3 Travel Visits tothe health Centre 100,000

4 Communication Airtime 50,000

5 Miscellaneous 100,000

TOTAL 586,000UGX

ii

APPENDIX II

TIME FRAMEWORK

Phase/Activity Time(Weeks) Dates

Development, Writing and Presentation of Proposal 4 April-i 5th to May~2Oth~20 17

Development and pretesting of instruments 1 ~2nt~9th -May-20 17

Data collection 4 June-i to June-30~-20 17

Data organization analysis and interpretation 4 July lstto July-31 st.20 17

Report writing and submission of final copy 3 August 1st to August~3 1st -2017

34