Factors contributing to pre-treatment loss to follow-up in adults with pulmonary tuberculosis: a qualitative evidence synthesis of patient and healthcare worker perspectives

BACKGROUND

Since 2018, over 14 million people have been treated for tuberculosis (TB) globally. However, pre-treatment loss to follow-up (PTLFU) has been shown to contribute substantially to patient losses in the TB care cascade with subsequent high community transmission and mortality rates.

OBJECTIVE

To identify, appraise, and synthesise evidence on the perspectives of patients and healthcare workers on factors contributing to PTLFU in adults with pulmonary TB.

METHODS

We registered the title with PROSPERO (CRD42021253212). We searched nine relevant databases up to 24 May 2021 for qualitative studies. Two review authors independently reviewed records for eligibility and extracted data. We assessed methodological quality with the Evidence for Policy and Practice Information Centre tool and synthesised data using the Supporting the Use of Research Evidence framework. We assessed confidence in our findings using Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual).

RESULTS

We reviewed a total of 1239 records and included five studies, all from low- and middle-income countries. Key themes reported by patients and healthcare workers were communication challenges among healthcare workers and between healthcare workers and patients; knowledge, attitudes, and behaviours about TB and its management; accessibility and availability of facilities for TB care; and human resource and financial constraints, weakness in management and leadership in TB programmes. Patients' change of residence, long waiting times, and poor referral systems were additional factors that contributed to patients disengaging from care. We had moderate confidence in most of our findings.

CONCLUSION

Findings from our qualitative evidence synthesis highlight multiple factors that contribute to PTLFU. Central to addressing these factors will be the need to strengthen health systems and offer people-centred care.

Health worker views on pre-treatment loss to follow-up in adults with pulmonary TB in Western Kenya

SETTING

County referral hospital in Western Kenya.

OBJECTIVES

To explore factors contributing to pre-treatment loss to follow-up (PTLFU) in adults with pulmonary TB and propose solutions to address PTLFU from healthcare worker (HCW) perspectives.

DESIGN

This was an exploratory qualitative study using thematic analysis.

RESULTS

We conducted 19 key informant interviews with HCWs representing laboratory, clinical care, management and the community. Participant age ranged from 26 to 62 years; 14 (74%) were females; and most (74%) had worked in TB care for ⩽5 years. They reported that patients experienced stigma and had misconceptions about TB that contributed to PTLFU. HCWs were hesitant to work in the TB clinic, which contributed to suboptimal patient care, leading to PTLFU. Unclear linkage between laboratory and clinician, and limited financial resources to track patients were among the healthcare system factors that led to PTLFU. HCWs suggested having proper patient preparation, assigning resources to track patients and holding regular interdisciplinary meetings as practical solutions to address PTLFU.

CONCLUSION

HCWs reported multiple factors that may influence PTLFU and recommended various solutions to address these. Knowledge of TB management, patient preparation, resources to track patients and multidisciplinary meetings will be central to addressing PTLFU.