Date of Award

Fall 12-2018

Degree Name

Doctor of Philosophy (PhD)

Advisor(s)

GRETCHEN L. GEMEINHARDT, PHD, MBA

Second Advisor

PAUL J. ROWAN, PHD, MPH

Third Advisor

SHERYL A. MCCURDY, PHD

Abstract

Background: Timeliness of Tuberculosis (TB) treatment is critical to stopping its transmission and preventing disease complications and death. Efficiency in identifying and treating presumptive TB cases is critical to reducing delays.

Aims: We determined the association between health service-related factors and delays in initiating TB treatment within primary care settings in Uganda. Perspectives of healthcare workers on practices underlying healthcare facility level delays were also described.

Methods: A mixed methods study was conducted based on facility-register records of 1199 treated TB cases and key informant interviews with 27 outpatient staffs. Health service-related factors (size, ownership, number of laboratory personnel, diagnostic technology used for diagnosis, sequencing of TB tests and timing with the week of the lab test) were fitted into a linear regression model to identify predictors of TB care process durations and to identify predictors of treatment delay. Qualitative data was analyzed for themes related to healthcare workers’ observations and experiences regarding facility level delays.

Results: Median total time for treatment initiation was two days with median time for laboratory results turnaround and for initiating treatment each being one day. Independent predictors of prolonged TB care processes were a weekend laboratory visit (ẞ=0.36, 95%CI 0.11, 0.60) and retesting after an index negative result (ẞ=1.17, 95%CI 0.64, 1.69) for laboratory turnaround time; and diagnosis by Gene Xpert test (ẞ=0.39, 95%CI 0.07 0.71) and having a repeat test irrespective of index result ((ẞ=0.51, 95%CI 0.08, 0.93) if index result was negative, and (ẞ=0.26, 95%CI 0.06, 0.45) if positive). Factors that increased likelihood of prolonged TAT and or TxIT were weekend lab visit 2.06(1.49, 2.84), diagnosis by Xpert test (aOR 1.79, 95% CI 1.04, 3.10) and repeat testing [aOR 3.49, 95%CI 1.81, 6.75] if index result is negative and [aOR 1.81, 95%CI 1.27, 2.60] if positive). Healthcare workers observed that presumptive TB cases were kept in queues alongside other patients, and staff had a negative attitude to TB patients despite knowing recommended timesaving TB care procedures.

Conclusion: Factors increasing risk of healthcare facility level delay were related care procedures more than a healthcare facility’s structure. Despite knowing recommended procedures that minimize delays, healthcare workers report several challenges hampering implementation of protocols.

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