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.