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 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-square Variables TB outcome (p value) Age min/4 1 5-14 0 3.89 (0.143) 15/max 14 Sex Male 12 2.08 (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 REFERENCES ~cess~ GM, etal Survival Analysis ofLoss to Follow-Up Treatment among Tuberculosis Patients at Jimma University Specialized Hospital, Jimma, Southwest Ethiopia. Bryman, A(2008 ). Social research methods. 3~C~ Edition. New York, Oxford University Press. CDC (2005) Guideline for preventing the transmission of n2ycobacterium Tuberculosis in health care settings. Communication strategyfor TB/HIV Collaboration in Uganda. March 2006. Community Contribution to TB care: Practice and policy. Elbireer 5, etal (2011). Tuberculosis treatment default among HIV-TB co-infected patients in urban Uganda. In tropical medicine and international health vol.1 6.No 8(nd) Blackwell punishers limited. Esther Achen, HIV Clinic, HIV in charge and HIV teams, TuesdayNov-20 12. Improving TB. Farlex and Partners (2009). Medical dictionary Gawatudde etal (2003) Burden of TB in Kampala. Gawatudde etal (2010) TB in Household contacts. Gopi PG, etal. Failure to InitiateTtreatrnent for Tuberculosis patients diagnosed in a community survey and at health facilities under a DOTS programme in a District of South India. Short Communication. Indian J Tuberc [Internet]. [cited 2017 Oct 9]; Available from: http ://medind.nic.iniibr/tos/j3/ibrtosi3p 153 .pdf Kirenga, JB (2014) treatment outcome of new Tuberculosis patients hospitalized in Kampala, Uganda: A prospective cohort study. 30 Kombo,D.K and Tromp; D.L.A(2006)Proposal and thesis writing: An introduction. Nairobi. Pauline Publications Africa MacPherson P, Houben RM, Glynn JR, Corbett EL, Kranzer K. Pre-treatment loss to follow-up in tuberculosis patients in low- and lower-middle-income countries and high-burden countries: a systematic review and meta-analysis. Bull World Health Organisation Ministry of health manual of the National Tuberculosis and Leprosy. Programme; 2nd Edition(20 10) Nakanwagi, A etal( 2010) Characteristics and treatment out comes of Tuberculosis Retreatment cases in Three Regional Referral Hospitals, Uganda National Communication strategy for Tuberculosis control. National Tuberculosis and Leprosy prograinme and Health promotion and Education Division. October (2015). New vision newspaper for 7th July-20 17 NTLP Annual report for2Ol4-2015 on TB treatment out come Obuku etal Oso,W.Y &Onen.D(2005)A general guide to writing research proposal and report .Kisumu. Options Press and publishers. Scientific writing by Jennifer Peat. Sizomu.A, Brucker,M and Muwonge Moses(2014). Family planning in Uganda: A review ofNational and Districtpolicies and Budgets, Kampala.DSW Ssendagire, I etal (2012) urban movement and alcohol intake strongly predict defaulting from Tuberculosis treatment 31 Stop TB Initiative (2010) Treatment of Tuberculosis guidelines: WHO. Treatment completion rates: Experience from Gulu Regional Referral Hospital, Uganda. Uganda National TB guidelines for Tuberculosis Infection control in health care facilities, Congregate settings and Households (2011) WHO report (2007) Global TB Report. WHO Treatment Guidelines; Treatment oftuberculosis Guidelines ~ Edition. WHO. Definitions and reporting framework for tuberculosis — 2013 revision. 2014 [cited 2017 Oct 10] 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