Understanding barriers to tuberculosis diagnosis and treatment completion in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho

Abstract

Background Lesotho is one of the 30 countries with the highest tuberculosis incidence rates in the world, estimated at 650 per 100,000 population. Tuberculosis case detection is extremely low, particularly with the rapid spread of COVID-19, dropping from an estimated 51% in 2020 to 33% in 2021. The aim of this study is to understand the barriers to tuberculosis diagnosis and treatment completion. Methods We used a convergent mixed methods study design. We collected data on the number of clients reporting symptoms upon tuberculosis screening, their sputum test results, the number of clients diagnosed, and the number of clients who started treatment from one district hospital and one health center in Berea district, Lesotho. We conducted in-depth interviews and focus group discussions with 53 health workers and patients. We used a content analysis approach to analyze qualitative data and integrated quantitative and qualitative findings in a joint display. Findings During March-August, 2019, 218 clients at the hospital and 292 clients at the health center reported tuberculosis symptoms. The full diagnostic testing process was completed for 66% of clients at the hospital and 68% at the health center. Among clients who initiated tuberculosis treatment, 68% (61/90) at the hospital and 74% (32/43) at the health center completed treatment. The main barriers to testing and treatment completion were challenges at sample collection, lack of decentralized diagnostic services, and socioeconomic factors such as food insecurity and high patient movement to search for jobs. Conclusions Tuberculosis diagnosis could be improved through the effective decentralization of laboratory services at the health facility level, and treatment completion could be improved by providing food and other forms of social support to patients.

Tuberculosis commodities supply chain performance in the WHO African region: A scoping review

“…Stock outs also extended to laboratory commodities. Stock outs of key diagnostics was reported three studies [ 27 , 29 , 44 ]. In relation to the programmatic impact, one study reported that stock out led to service interruption for a duration of up to 15 days [ 37 ].…”

“…The negative consequences were largest in the poorer districts where a 10% increase in TB drug stock outs led to a 3.25% decline in the TB cure rate and a 2.78% decline in the TB success rate [ 25 ]. Stock outs were found to be associated with financial hardship as patients incurred out-of-pocket expenditures or for go care altogether [ 31 , 44 ]. Stock outs of medicines for children led to higher rates of loss to follow up amongst children [ 45 ].…”

“…A multi-country study showed that all countries had in place PSM plans that complied with the external funders, such as the Global Fund [34]. Availability and distribution 1 (4%) [27] General* 9 (36%) [28][29][30][31][32][33][34][35] Logistics Management Information Systems (LMIS) 4 (16%) [36][37][38][39] Service delivery** 6 (24%) [40][41][42][43][44][45] *General means the study tackled various stages of the logistics systems without a dominant focus on one area *Service delivery means the study had a major focus on the impact of supply chain performance on patient management at the point of care (facility) https://doi.org/10.1371/journal.pgph.0003219.t002…”

Nutritionally acquired immunodeficiency must be addressed with the same urgency as HIV to end tuberculosis

“…Importantly, malnourished persons are also at increased risk of supratherapeutic concentrations and associated toxicity from drugs like ethambutol and aminoglycosides [30]. Heartbreakingly, some PWTB discontinue their TB therapy because their appetites reappear during TB therapy and they lack access to food [31]. This is illustrated in the following quotation from a mixed methods study in Lesotho: "The challenges that I have recognized is that they make you feel very hungry more often.…”

“…Sometimes that is bad because there are no piece jobs [daily work] at all. You find that you eat a lot in a short space of time, that doesn't sit well with the wife even though she won't say it, but you will recognize her displeasure" [31].…”