Factors associated with pre-diagnosis loss to follow up among Presumptive Tuberculosis patients in Mukono District, Uganda: a Prospective cohort study

Abstract

Background: A significant proportion of incident tuberculosis (TB) cases in Uganda are not notified. Some of the missing cases are patients who are identified as presumptive TB patients at health facilities but drop out of care before diagnosis of TB (pre-diagnosis loss to follow up (LTFU)).It is necessary to minimize this LTFU, to achieve a reduction in TB incidence and deaths but evidence on the magnitude and associated factors is still limited.Objective: This study aimed to determine the proportion and factors associated with prediagnosis LTFU among presumptive TB patients at selected hospitals in Mukono district. Methods: A prospective cohort study design with consecutive sampling was used. After screening and informed consent, 271 participants were enrolled, and exposure data was collected from them using a structured questionnaire in Kobo-collect software. They were followed up for 30 days to determine the proportion of pre-diagnosis. Ten key informant and 8 in-depth interviews were conducted to explore the reasons for LTFU. Quantitative data were analyzed with STATA version 14. Modified Poisson regression analysis was used to determine the factors associated with pre-diagnosis LTFU and thematic analysis used for the qualitative data. Results: The proportion of pre-diagnosis LTFU was 35.1% (95/271). Participants with a university or tertiary level education were at higher risk of LTFU compared to those with no formal education (adjusted risk ratio (aRR) 2.82, CI 1.22-6.49). Similarly, participants attending a public facility also had higher risk of LTFU compared to those who attended private not for profit (aRR 1.59, CI 1.05-2.42), those between 36 and 45 years had a higher risk of LTFU compared to participants above 46 years ( aRR 1.79, CI 1.08- 2.96), while participants who had come for anti-retroviral therapy (ART) drug refill had a higher risk compared to those who came because they were ill ( aRR 1.94, CI 1.20-3.13). Qualitatively, reasons for LTFU were: fear of positive TB results and stigma, missing home addresses and telephone information, financial constraints, and inadequate information from health workers about receiving results. Conclusions and recommendations: The proportion of pre-diagnosis LTFU was 35.1 %.Education, age, having come to the facility for ART drug refill and attending a public facility, were significantly associated with pre-diagnosis LTFU; while the fear of positive TB results and stigma, missing addresses information, financial constraints, and inadequate information from workers about receiving results, were the reasons for LTFU. Contextualized TB phone health messaging targeting those 36-45 years, and who require ART refill should be considered by hospitals. The National TB and Leprosy Program should also consider improving TB awareness in communities to address TB-related stigma.