Care seeking and attitudes towards treatment compliance by newly enrolled tuberculosis patients in the district treatment programme in rural western Kenya: a qualitative study

<p>Abstract</p> <p>Background</p> <p>The two issues mostly affecting the success of tuberculosis (TB) control programmes are delay in presentation and non-adherence to treatment. It is important to understand the factors that contribute to these issues, particularly in resource limited settings, where rates of tuberculosis are high. The objective of this study is to assess health-seeking behaviour and health care experiences among persons with pulmonary tuberculosis, and identify the reasons patients might not complete their treatment.</p> <p>Methods</p> <p>We performed qualitative one-on-one in-depth interviews with pulmonary tuberculosis patients in nine health facilities in rural western Kenya. Thirty-one patients, 18 women and 13 men, participated in the study. All reside in an area of western Kenya with a Health and Demographic Surveillance System (HDSS). They had attended treatment for up to 4 weeks on scheduled TB clinic days in September and October 2005.</p> <p>The nine sites all provide diagnostic and treatment services. Eight of the facilities were public (3 hospitals and 5 health centres) and one was a mission health centre.</p> <p>Results</p> <p>Most patients initially self-treated with herbal remedies or drugs purchased from kiosks or pharmacies before seeking professional care. The reported time from initial symptoms to TB diagnosis ranged from 3 weeks to 9 years. Misinterpretation of early symptoms and financial constraints were the most common reasons reported for the delay.</p> <p>We also explored potential reasons that patients might discontinue their treatment before completing it. Reasons included being unaware of the duration of TB treatment, stopping treatment once symptoms subsided, and lack of family support.</p> <p>Conclusions</p> <p>This qualitative study highlighted important challenges to TB control in rural western Kenya, and provided useful information that was further validated in a quantitative study in the same area.</p

Healthcare provider perspectives on managing sexually transmitted infections in HIV care settings in Kenya: A qualitative thematic analysis.

BACKGROUND:The burden of sexually transmitted infections (STIs) has been increasing in Kenya, as is the case elsewhere in sub-Saharan Africa, while measures for control and prevention are weak. The objectives of this study were to (1) describe healthcare provider (HCP) knowledge and practices, (2) explore HCP attitudes and beliefs, (3) identify structural and environmental factors affecting STI management, and (4) seek recommendations to improve the STI program in Kenya. METHODS AND FINDINGS:Using individual in-depth interviews (IDIs), data were obtained from 87 HCPs working in 21 high-volume comprehensive HIV care centers (CCCs) in 7 of Kenya's 8 regions. Transcript coding was performed through an inductive and iterative process, and the data were analyzed using NVivo 10.0. Overall, HCPs were knowledgeable about STIs, saw STIs as a priority, reported high STI co-infection amongst people living with HIV (PLHIV), and believed STIs in PLHIV facilitate HIV transmission. Most used the syndromic approach for STI management. Condoms and counseling were available in most of the clinics. HCPs believed that having an STI increased stigma in the community, that there was STI antimicrobial drug resistance, and that STIs were not prioritized by the authorities. HCPs had positive attitudes toward managing STIs, but were uncomfortable discussing sexual issues with patients in general, and profoundly for anal sex. The main barriers to the management of STIs reported were low commitment by higher levels of management, few recent STI-focused trainings, high stigma and low community participation, and STI drug stock-outs. Solutions recommended by HCPs included formulation of new STI policies that would increase access, availability, and quality of STI services; integrated STI/HIV management; improved STI training; increased supervision; standardized reporting; and community involvement in STI prevention. The key limitations of our study were that (1) participant experience and how much of their workload was devoted to managing STIs was not considered, (2) some responses may have been subject to recall and social desirability bias, and (3) patients or clients of STI services were not interviewed, and therefore their inputs were not obtained. While considering these limitations, the number and variety of facilities sampled, the mix of staff cadres interviewed, the use of a standardized instrument, and the consistency of responses add strength to our findings. CONCLUSIONS:This study showed that HCPs understood the challenges of, and solutions for, improving the management of STIs in Kenya. Commitment by higher management, training in the management of STIs, measures for reducing stigma, and introducing new policies of STI management should be considered by health authorities in Kenya

Health facility characteristics and targeted staff mix for in-depth interviews.

<p>Health facility characteristics and targeted staff mix for in-depth interviews.</p

Characteristics of healthcare providers interviewed (<i>n =</i> 87).

<p>Characteristics of healthcare providers interviewed (<i>n =</i> 87).</p

Risk Factors for Inadequate TB Case Finding in Rural Western Kenya: A Comparison of Actively and Passively Identified TB Patients

<div><p>Background</p><p>The findings of a prevalence survey conducted in western Kenya, in a population with 14.9% HIV prevalence suggested inadequate case finding. We found a high burden of infectious and largely undiagnosed pulmonary tuberculosis (PTB), that a quarter of the prevalent cases had not yet sought care, and a low case detection rate.</p><p>Objective and methods</p><p>We aimed to identify factors associated with inadequate case finding among adults with PTB in this population by comparing characteristics of 194 PTB patients diagnosed in a health facility after self-report, <i>i.e.,</i> through passive case detection, with 88 patients identified through active case detection during the prevalence survey. We examined associations between method of case detection and patient characteristics, including HIV-status, socio-demographic variables and disease severity in univariable and multivariable logistic regression analyses.</p><p>Findings</p><p>HIV-infection was associated with faster passive case detection in univariable analysis (crude OR 3.5, 95% confidence interval (CI) 2.0–5.9), but in multivariable logistic regression this was largely explained by the presence of cough, illness and clinically diagnosed smear-negative TB (adjusted OR (aOR) HIV 1.8, 95% CI 0.85–3.7). Among the HIV-uninfected passive case detection was less successful in older patients aOR 0.76, 95%CI 0.60–0.97 per 10 years increase), and women (aOR 0.27, 95%CI 0.10–0.73). Reported current or past alcohol use reduced passive case detection in both groups (0.42, 95% CI 0.23–0.79). Among smear-positive patients median durations of cough were 4.0 and 6.9 months in HIV-infected and uninfected patients, respectively.</p><p>Conclusion</p><p>HIV-uninfected patients with infectious TB who were older, female, relatively less ill, or had a cough of a shorter duration were less likely found through passive case detection. In addition to intensified case finding in HIV-infected persons, increasing the suspicion of TB among HIV-uninfected women and the elderly are needed to improve TB case detection in Kenya.</p></div

Selection of TB patients (N = 282) included in the analysis.

<p>Footnote to Figure1: PTB = Pulmonary Tuberculosis *PTB patients classified as new by the TB clinics, i.e. who did not receive TB treatment in the last 2 years. †HDSS = Health and Demographic Surveillance System. The Asembo and Gem areas are included in the HDSS since 2002 and the Karemo area since 2007. Patients from Karemo are not included in this analysis.</p

Risk factors associated with the probability of passive case detection among 197 HIV-infected pulmonary TB patients.

<p>OR = odds ratio CI = confidence interval sd = standard deviation.</p>*<p>adjusted for HIV, age, sex and use of alcohol. Only HIV and socio-demographic factors were considered in the model.</p

Risk factors associated with the probability of passive case detection among 85 HIV-uninfected pulmonaryTB patients.

<p>OR = odds ratio CI = confidence interval sd = standard deviation.</p>*<p>adjusted for HIV, age, sex and use of alcohol. Only HIV and socio-demographic factors were considered in the model.</p

Factors associated with the probability of passive case detection by HIV-status, adjusted for cough, ability to work and smear-status in all PTB patients (n = 282), smear-positive patients only (n = 123), and patients reporting a cough for more than 2 weeks (n = 198).

<p>CI = Confidence interval PTB = pulmonary tuberculosis.</p><p>Missing variables (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0061162#pone-0061162-t001" target="_blank">table 1</a> and <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0061162#pone-0061162-t002" target="_blank">2</a>) were multiply imputed before logistic regression.</p>*<p>Not all effects reach statistical significance in the small group of smear-positives, but the full model is shown to show trends.</p