Background
Methods
Study design
Study setting
Study population
Quantitative
Qualitative
Data collection
Quantitative
Qualitative
Data analysis
Quantitative
Qualitative
Data integration
Ethics
Results
Quantitative phase
Study participants
Variable | Total N | Q1 N (%) | Q2 N (%) | Q3 N (%) | Q4 N (%) | Q5 N (%) | |
---|---|---|---|---|---|---|---|
264 | 53 | 53 | 53 | 53 | 52 | ||
Sex | Male | 151 | 26 (17.2) | 31 (20.5) | 27 (17.9) | 32 (21.2) | 35 (23.2) |
Female | 113 | 27 (23.9) | 22 (19.5) | 26 (23.0) | 21 (18.6) | 17 (15.0) | |
Age | < 15 | 72 | 12 (16.7) | 27 (37.5) | 16 (22.2) | 11 (15.3) | 6 (8.3) |
15–24 | 30 | 9 (30.0) | 5 (16.7) | 2 (6.7) | 9 (30.0) | 5 (16.7) | |
25–34 | 55 | 7 (12.7) | 12 (21.8) | 11 (20.0) | 7 (12.7) | 18 (32.7) | |
35–44 | 42 | 11 (26.2) | 3 (7.1) | 8 (19.1) | 12 (28.6) | 8 (19.1) | |
45–54 | 23 | 3 (13.0) | 1 (4.4) | 5 (21.7) | 9 (39.1) | 5 (21.7) | |
55–64 | 18 | 6 (33.3) | 1 (5.6) | 4 (22.2) | 2 (11.1) | 5 (27.8) | |
> = 65 | 24 | 5 (20.8) | 4 (16.7) | 7 (29.2) | 3 (12.5) | 5 (20.8) | |
HH | Parent | 82 | 16 (19.5) | 30 (36.6) | 14 (17.1) | 13 (15.9) | 9 (11.0) |
Spouse | 53 | 15 (28.3) | 10 (18.9) | 13 (24.5) | 8 (15.1) | 7 (13.2) | |
Respondent | 119 | 22 (18.5) | 13 (10.9) | 21 (17.7) | 32 (26.9) | 31 (26.1) | |
Other | 10 | 0 (0.0) | 0 (0.0) | 5 (50.0) | 0 (0.0) | 5 (50.0) | |
Respondent’s education level | None | 203 | 42 (20.7) | 46 (22.7) | 44 (21.7) | 43 (21.2) | 28 (13.8) |
Primary | 46 | 11 (23.9) | 5 (10.9) | 9 (19.6) | 10 (21.7) | 11 (23.9) | |
Secondary | 11 | 0 (0.0) | 2 (18.2) | 0 (0.0) | 0 (0.0) | 9 (81.8) | |
Tertiary | 4 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 4 (100) | |
HH’s education level | No education | 209 | 44 (21.1) | 50 (23.9) | 43 (20.6) | 43 (20.6) | 29 (13.9) |
Primary | 33 | 8 (24.2) | 2 (6.1) | 9 (27.3) | 8 (24.2) | 6 (18.2) | |
Secondary | 17 | 1 (5.9) | 1 (5.9) | 1 (5.9) | 2 (11.8) | 12 (70.6) | |
Tertiary | 5 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 5 (100) | |
Respondent’s occupation | None | 73 | 13 (17.8) | 26 (35.6) | 21 (28.8) | 8 (11.0) | 5 (6.9) |
Subsistence farmer | 146 | 32 (21.9) | 22 (15.1) | 27 (18.5) | 35 (24.0) | 30 (20.6) | |
Formal | 7 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 7 (100) | |
Informal | 19 | 1 (5.3) | 2 (10.5) | 4 (21.1) | 4 (21.1) | 8 (42.1) | |
Student | 19 | 7 (36.8) | 3 (15.8) | 1 (5.3) | 6 (31.6) | 2 (10.5) | |
Employed | Yes | 50 | 1 (2.0) | 4 (8.0) | 10 (20.0) | 15 (30.0) | 20 (40.0) |
No | 158 | 40 (25.3) | 25 (15.8) | 33 (20.9) | 31 (19.6) | 29 (18.4) | |
Not applicableɣ | 56 | 12 (21.4) | 24 (42.9) | 10 (17.9) | 7 (12.5) | 3 (5.4) | |
HH’s occupation | None | 20 | 7 (35.0) | 2 (10.0) | 5 (25.0) | 5 (25.0) | 1 (5.0) |
Subsistence farmer | 206 | 46 (22.3) | 47 (22.8) | 40 (19.4) | 42 (20.4) | 31 (15.1) | |
Formal | 13 | 0 (0.0) | 1 (7.7) | 0 (0.0) | 2 (15.4) | 10 (76.9) | |
Informal | 25 | 0 (0.0) | 3 (12.0) | 8 (32.0) | 4 (16.0) | 10 (40.0) | |
HH employed | Yes | 67 | 2 (3.0) | 7 (10.5) | 13 (19.4) | 21 (31.3) | 24 (35.8) |
No | 195 | 51 (26.2) | 46 (23.6) | 39 (20.0) | 31 (15.9) | 28 (14.4) | |
Not applicableɣ | 2 | 0 (0.0) | 0 (0.0) | 1 (50.0) | 1 (50.0) | 0 (0.0) | |
Marital statusɸ | Single | 33 | 5 (15.2) | 8 (24.2) | 5 (15.2) | 5 (15.2) | 10 (30.3) |
Married | 131 | 30 (22.9) | 19 (14.5) | 26 (19.9) | 30 (22.9) | 26 (19.9) | |
Divorced/separated | 15 | 4 (26.7) | 1 (6.7) | 1 (6.7) | 4 (26.7 | 5 (33.3) | |
Widowed | 21 | 4 (26.7) | 2 (9.5) | 6 (28.6) | 4 (19.1) | 5 (33.3) | |
Meals per day | One | 90 | 20 (22.2) | 21 (23.3) | 18 (20.0) | 19 (21.1) | 12 (13.3) |
Two | 137 | 30 (21.9) | 30 (21.9) | 32 (23.4) | 21 (15.3) | 24 (17.5) | |
Three or more | 37 | 3 (8.1) | 2 (5.4) | 3 (8.1) | 13 (35.1) | 16 (43.2) | |
Meal satisfaction | Yes | 152 | 12 (7.9) | 31 (20.4) | 32 (21.2) | 39 (25.7) | 38 (25.0) |
No | 112 | 41 (36.6) | 22 (19.6) | 21 (18.8) | 14 (12.5) | 14 (12.5) | |
Alcohol consumption | Yes | 130 | 26 (20.0) | 22 (16.9) | 27 (20.8) | 27 (20.8) | 28 (21.5) |
No | 134 | 27 (20.2) | 31 (23.1) | 26 (19.4) | 26 (19.4) | 24 (17.9) |
TB treatment outcomes by wealth
Wealth index quintiles | Unsuccessful treatment N (%) | Successful treatment N (%) | Unadjusted O. R (95% CI) | p-value | Adjusted OR (95% CI) | p-value |
---|---|---|---|---|---|---|
Q1 (Poorest reference) | 33 (21.2) | 20 (18.5) | 1 | 1 | ||
Q2 | 34 (21.8) | 19 (17.6) | 1.08 (0.49–2.39) | 0.840 | 0.96 (0.42–2.19) | 0.920 |
Q3 | 34 (21.8) | 19 (17.6) | 1.08 (0.49–2.39) | 0.840 | 1.12 (0.49–2.54) | 0.794 |
Q4 | 34 (21.8) | 19 (17.6) | 1.08 (0.49–2.39) | 0.840 | 1.06 (0.46–2.41) | 0.894 |
Q5 (richest) | 21 (13.5) | 31 (28.7) | 0.41 (0.19–0.90) | 0.026 | 0.42 (0.18–0.99 | 0.047 |
TB treatment outcomes by socio-demographic characteristics
Variable | Unsuccessful treatment N (%) | Successful treatment N (%) | O.R (95% CI) | p-value | |
---|---|---|---|---|---|
Sex | Male | 86 (55.1) | 65 (60.2) | 1 | |
Female | 70 (44.9) | 43 (39.8) | 1.23 (0.75–2.02) | 0.414 | |
Age | < 15 | 46 (29.5) | 26 (24.1) | 1 | |
15–24 | 21 (13.5) | 9 (8.3) | 1.32 (0.53–3.30) | 0.554 | |
25–34 | 27 (17.3) | 28 (25.9) | 0.55 (0.27–1.11) | 0.096 | |
35–44 | 24 (15.4) | 18 (16.7) | 0.75 (0.35–1.64) | 0.476 | |
45–54 | 13 (8.3) | 10 (9.3) | 0.73 (0.28–1.91) | 0.527 | |
55–64 | 7 (4.5) | 11 (10.2) | 0.36 (0.12–1.04) | 0.059 | |
> = 65 | 18 (11.5) | 6 (5.6) | 1.70 (0.60–4.81) | 0.320 | |
HH | Parent | 51 (32.7) | 31 (28.7) | 1 | |
Spouse | 32 (20.5) | 21 (19.4) | 0.93 (0.46–1.88) | 0.832 | |
Respondent | 67 (43.0) | 52 (48.2) | 0.78 (0.44–1.39) | 0.405 | |
Other | 6 (3.9) | 4 (3.7) | 0.91 (0.24–3.49) | 0.893 | |
Respondent’s education level | No education | 122 (78.2) | 81 (75.0) | 1 | |
Primary | 28 (18.0) | 18 (16.8) | 1.03 (0.53–1.99) | 0.923 | |
Secondary | 4 (2.6) | 7 (6.5) | 0.38 (0.11–1.34) | 0.132 | |
Tertiary | 2 (1.3) | 2 (1.9) | 0.66 (0.09–4.81) | 0.685 | |
HH’s education level | No education | 129 (82.7) | 80 (74.1) | 1 | |
Primary | 18 (11.5) | 15 (14.0) | 0.74 (0.36–1.56) | 0.434 | |
Secondary | 7 (4.5) | 10 (9.3) | 0.43 (0.16–1.19) | 0.104 | |
Tertiary | 2 (1.3) | 3 (2.8) | 0.41 (0.07–2.53) | 0.339 | |
Respondent’s occupation | None | 43 (27.6) | 30 (27.8) | 1 | |
Subsistence farmer | 86 (55.1) | 60 (55.6) | 1.00 (0.56–1.77) | > 9.999 | |
Formal | 1 (0.6) | 6 (5.6) | 0.12 (0.01–1.02) | 0.052 | |
Informal | 14 (9.0) | 5 (4.6) | 1.95 (0.64–6.00) | 0.242 | |
Student | 12 (7.7) | 7 (6.5) | 1.20 (0.42–3.39) | 0.736 | |
Respondent’s employment | No | 89 (57) | 69 (63.9) | 1 | |
Yes | 28 (18.0) | 22 (20.4) | 0.99 (0.52–1.97) | 0.967 | |
Not applicableɣ | 39 (25.0) | 17 (15.7) | 1.78 (0.93–3.41) | 0.083 | |
HH’s occupation | None | 14 (9.0) | 6 (5.6) | 1 | |
Subsistence farmer | 122 (78.2) | 84 (77.8) | 0.62 (0.23–1.69) | 0.351 | |
Formal | 4 (2.6) | 9 (8.3) | 0.19 (0.04–0.87) | 0.032 | |
Informal | 16 (10.3) | 9 (8.3) | 0.76 (0.22–2.68) | 0.672 | |
HH employment | No | 119 (76.3) | 76 (70.4) | 1 | |
Yes | 36 (23.1) | 31 (28.7) | 0.74 (0.42–1.30) | 0.295 | |
Not applicableɣ | 1 (0.6) | 1 (0.9) | 0.64 (0.04–10.36) | 0.752 | |
Marital status | Single | 20 (12.8) | 13 (12.0) | 1 | |
Married | 72 (46.2) | 59 (54.6) | 0.79 (0.36–1.73) | 0.560 | |
Divorced/ separated | 11 (7.1) | 4 (3.7) | 1.79 (0.47–6.83) | 0.396 | |
Widowed | 13 (8.3) | 8 (7.4) | 1.06 (0.34–3.25) | 0.924 | |
Meals per day | One | 51 (32.7) | 39 (36.1) | 1 | |
Two | 88 (56.4) | 49 (45.4) | 1.37 (0.80–2.37) | 0.253 | |
Three | 17 (10.9) | 20 (18.5) | 0.65 (0.30–1.40) | 0.272 | |
Meal satisfaction | No | 71 (45.5) | 41 (38.0) | 1 | |
Yes | 85 (54.5) | 67 (62.0) | 0.73 (0.44–1.21) | 0.223 | |
Alcohol consumption | No | 84 (53.9) | 50 (46.3) | 1 | |
Yes | 72 (46.2) | 58 (53.7) | 0.74 (0.45–1.21) | 0.228 | |
HIV status | Negative | 149 (95.5) | 103 (95.4) | 1 | |
Positive | 7 (4.5) | 5 (4.6) | 0.97 (0.30–3.13) | 0.956 |
Variable | Unadjusted OR (95% CI) | p-value | Adjusted OR (95% CI) | p-value |
---|---|---|---|---|
Wealth index quintiles | ||||
Q1 (Poorest reference) | 1 | 1 | ||
Q2 | 1.08 (0.49–2.39) | 0.840 | 0.96 (0.42–2.19) | 0.920 |
Q3 | 1.08 (0.49–2.39) | 0.840 | 1.12 (0.49–2.54) | 0.794 |
Q4 | 1.08 (0.49–2.39) | 0.840 | 1.06 (0.46–2.41) | 0.894 |
Q5 (richest) | 0.41 (0.19–0.90) | 0.026 | 0.42 (0.18–0.99 | 0.047 |
Respondent’s occupation | ||||
None | 1 | 1 | ||
Subsistence farmer | 1.00 (0.56–1.77) | > 9.999 | 1.92 (0.90–4.10) | 0.091 |
Formal | 0.12 (0.01–1.02) | 0.052 | 0.45 (0.04–5.11) | 0.523 |
Informal | 1.95 (0.64–6.00) | 0.242 | 4.71 (1.18–18.89) | 0.029 |
Student | 1.20 (0.42–3.39) | 0.736 | 1.05 (0.34–3.22) | 0.936 |
Respondent’s employment | ||||
No | 1 | 1 | ||
Yes | 0.99 (0.52–1.97) | 0.967 | 1.01 (0.45–2.28) | 0.986 |
Not applicableɣ | 1.78 (0.93–3.41) | 0.083 | 2.71 (1.11–6.62) | 0.029 |
Healthcare system factors and TB treatment outcomes
Pre-treatment LTFU
Qualitative phase
Treatment barriers and motivators
Dimension | Barrier | Motivator |
---|---|---|
Intrapersonal | Shortage of money | Perceived benefits of taking medication |
Lack of food to eat before taking medication | ||
Interpersonal | Stigma and the fear of being stigmatized | Social support from family and friends such as food, money, bedside care |
Treatment support from HCWs like counselling, follow-up calls | ||
Environmental | Migration in search of food, pasture and water for animals, mining and porous borders | Health system and community support by NGOs |
Difficulties in transportation due to limited modes of transport, long travel distances and weather | Adapting service delivery mechanisms to meet needs through teamwork and internal reorganization | |
Drug and equipment stock-outs | Strengthening lower-level facilities through support supervision, mentorship, capacity building and training | |
Lack of access to financial support while sick to meet basic needs | Community engagement through community sensitization, radio talk shows and directly at the health facilities |
TB treatment barriers
As a result of financial constraints, participants lacked adequate food to meet their nutritional needs. Both former TB patients and HCWs used different expressions to demonstrate the perception that adequate nutrition is needed during TB treatment. Participants reported that they preferred to take their medications after a meal, usually milk or porridge, with some reporting that they did not take their medication if they failed to get food. Notably, patients reported that they had no sources of financial aid while sick and appealed for support, particularly from the government in terms of foodThere is no way you can get money to board a motorcycle, so you come on foot to get your drugs and when you return, you go and look for a job to get something to cook. [Female FGD participant]
The demand to make a living while on treatment contributed to poor treatment outcomes. TB patients in the region were noted to be highly mobile and nomadic, often migrating from their usual place of residence. This was attributed to economic activities like agriculture and mining. HCWs acknowledged that LTFU is a major problem in the Karamoja region due to the mobile communities that made follow-up tedious. The porous borders, particularly with Kenya, made it easy for patients to get LTFU during treatment. Some patients also moved deliberately ‘as a way of dodging drugs.’ Only one formally employed participant reported sick leave for the duration of TB treatment.What we have to say is that you as government please rescue us in terms of some food because every day what we eat is the tree leaf that is why this disease has refused to go because of hunger. [Male FGD participant]
Limited modes of transport within the region and long distances were highlighted as challenges for both the HCWs and TB patients in delivering and accessing healthcare services respectively. HCWs reported that difficulties in accessing transport was not only detrimental to service delivery but also demotivated them. Transport difficulties affected services such as providing support supervision, updating registers, fieldwork activities, transporting TB samples to designated units and transporting TB results.We have also found that there is a lot of mobility among the patients ( … ) the moment you are to continue on treatment, they have disappeared. This is a nomadic area; they will have disappeared to another place and finding them may be difficult. [Male HCW]
( … ) it a very long distance even if you went in a car you will reach late. When I came back here, it was a Sunday and there were no nurses so I just relaxed until the TB came back ( … ) [Female FGD participant]
TB patients reported experiencing stigma and abandonment from family members. Stigma and the fear of being stigmatised influenced patient’s behaviour before, during and after the TB treatment. One participant decided to relocate during treatment because of stigma while another was driven to seek treatment far away from her home as quoted below:( … ) they need to offer transport for us. We are ready to work at any time, whenever we are called to do any work. [Female HCW]
Former TB patients described experiences in which they missed drugs because they were not available from the facility. HCWs also noted that although there has been an improvement in the supply of laboratory equipment and drugs used in managing TB, occasionally they experienced stock-outs which resulted in LTFU particularly among paediatric patients. Equipment challenges included GeneXpert cartridges stock-out, breakdown of microscopes and X-ray machines and power shortages despite local solar power systems leading to difficulties in correctly diagnosing and following up TB patients.All the people who were mine feared me; even my own mother feared me, all the family members fear me so when I saw that everyone was fearing me, I went up to Tokora on foot carrying my baby on the back. [Female FGD participant]
Then the other challenging part is the stock-out of drugs. ( … ) Last December we had medicines for adults, but the problem, we did not have paediatric formulations for TB treatment: the whole December, we did not have anything. [Male HCW]
TB treatment motivators
I did not have money. If my wife went to sell charcoal, she would bring for me. When she hasn’t gone then I also don’t have. [Male FGD participant]
Former TB patients noted that after initiating treatment, their symptoms started to subside and for some, this motivated them to continue treatment. On the other hand, the improvement experienced while on treatment made some patients stop taking treatment as they believed they were cured.Yeah, for me the other factor that made it possible to come for my appointments was reminders, at least I had reminders most of the times. [Male FGD participant]
The HCWs noted that both the government and non-governmental organisations (NGOs) are working in the region to support TB programs. This collaboration has been credited for improving the quality, efficiency and reach of TB services particularly through community dialogues. Community engagement through which health education is delivered either through community sensitization meetings, radio talk shows or at health facility entry points is credited for improvements in TB treatment. These efforts were intensified after identifying Karamoja as a TB ‘hot spot’ and realizing that some TB patients often fail to complete. HCWs also credited adaptions to services delivery at the health facility to improvements in TB care. One noted that the number of LTFU cases was higher in 2018 than in 2019 and credited this drop to teamwork and adopting a task-shifting approach in which TB drug refills were carried out by any staff member on the TB unit.The good thing about that drug is that when you take it you stop coughing. [Male FGD participant]
Support supervision, mentorship, capacity building and training were credited for strengthening lower-level facilities and a reduction in treatment default rate. Support supervision through a top-down demand for accountability was seen as a beneficial process by both the supervisors and the HCWs at the facilities. It also served as a tool to address challenges in motivation and attitudes to providing TB care.One of it is high collaboration with partners. Partners have been helping us too much ( … ) we have always moved with them to mentor our staff, we also do contact tracing with them, we have also distributed food that was given by OPM [0ffice of the Prime Minister] government to our district to make sure that our clients, TB AND HIV clients, benefit from it. [Male HCW]