Understanding reasons for suboptimal tuberculosis screening in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho

Abstract

Lesotho has one of the highest tuberculosis (TB) incidence rates in the world, estimated at 654/100,000 population. However, TB detection remains low, with only 51% of people with TB being diagnosed and treated. The aim of this study was to evaluate implementation of TB screening and identify drivers of suboptimal TB screening in Lesotho. We used a convergent mixed methods study design. We collected data on the number of health facility visits and the number of clients screened for TB during March-August, 2019 from one district hospital and one health center. We conducted interviews and focus group discussions with patients and health workers to elucidate the mechanisms associated with suboptimal screening. Out of an estimated 70,393 visitors to the two health facilities, only 22% of hospital visitors and 48% of health center visitors were asked about TB symptoms. Only 2% of those screened at each facility said that they had TB symptoms, comprising a total of 510 people. Lack of training on tuberculosis screening, overall staff shortages, barriers faced by patients in accessing care, and health care worker mistrust of tuberculosis screening procedures were identified as drivers of suboptimal TB screening. TB screening could be improved by ensuring the availability of well-trained, incentivized, and dedicated screeners at health facilities, and by providing TB screening services in community settings.

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

“…Although in our setting, the greatest loss from the care cascade was at the initial step of screening people for tuberculosis symptoms [ 10 ], lack of decentralization of laboratory services at the health center was also a major contributor to low tuberculosis detection. Moreover, we found that patients may fail to complete their treatment successfully due to poverty and socioeconomic factors.…”

“…Qualitative and quantitative data were analyzed separately, and findings were then integrated for a deeper understanding of the barriers to completing the tuberculosis care cascade. A previous publication reported reasons for suboptimal tuberculosis screening–the first step of the care cascade [ 10 ]. This publication focuses on barriers to completing subsequent steps.…”

“…Key steps of the care cascade included completing the symptom screen upon entry to any part of the health facility, collecting sputum if symptoms were present, testing sputum by GeneXpert, recording tuberculosis diagnosis, initiating tuberculosis treatment and completing the prescribed treatment. We previously reported that only 22% of visitors to the hospital and 48% of visitors to the health facility completed tuberculosis symptom screening, which is the first step of the cascade [ 10 ].…”

“…Despite major efforts by the Government of Lesotho and its partners, only 33% of Lesotho’s total estimated tuberculosis cases were diagnosed in 2020, and out of the patients enrolled on tuberculosis treatment only 78% successfully completed their treatment [ 1 ]. We previously reported that challenges accessing health facilities and poor implementation of symptom screening within facilities were major contributors to missed diagnoses [ 10 ]. In this study, we assess the diagnostic and treatment cascade once individuals with tuberculosis symptoms have been identified in health centers.…”

Facilitators and barriers to implementing chest radiography in tuberculosis systematic screening of clinically high-risk groups in Ethiopia: A qualitative study

“…The implementation of systematic screening of TB in high-burden countries is influenced by multiple factors, including low screening and testing capacity, limited understanding of systematic screening techniques, and limited health workers’ competence in TB screening. 19 – 24 The characteristics of technological innovations and advancements, access, sensitivity, and specificity of chest X-ray techniques facilitate, while cost and providers’ lack of technical competency hinder, the adoption of chest X-rays in systematic TB screening. 25 – 29 …”