Understanding Factors Associated with Low Tuberculosis Detection in Low Resources Settings: A Mixed-Method Study in the Kingdom of Lesotho

Background: Lesotho has one of the highest tuberculosis incidence rates globally. Yet, according to a new World Health Organization’s report, tuberculosis case finding remains low despite government efforts to improve primary health care and significant multilateral and bilateral funding for tuberculosis. Methods: We used a convergent mixed-method approach to study gaps in the tuberculosis care cascade and factors associated with the low tuberculosis case detection in Lesotho’s Berea and Khubetsoana regions from March to August 2018. The steps of the tuberculosis care cascade include screening, diagnosis, initiation of treatment, and completion of treatment. We collected data on the number of patients completing the tuberculosis care cascade from one district hospital and one health center. The qualitative component consisted of interviews and focus group discussions with patients and health workers on elucidating the mechanisms associated with low case detection. Results: The tuberculosis cascade evaluation showed that the completion was lowest for the initial step of the cascade, which is symptom screening. Out of an estimated 70,393 visitors to the two health facilities, only 22% of hospital visitors and 48% of visitors at the health center were asked about tuberculosis symptoms even though the policy is to screen every visitor. Only 2% of those screened at each facility said that they had tuberculosis symptoms, comprising 510 people. Among the 510 people with symptoms, 134 (26.2%) of them were diagnosed with tuberculosis. Among those diagnosed with TB, 133 (99%) were initiated on treatment, and the treatment success rate was 70%. Lack of trained tuberculosis screeners at the health center, overall staff shortages, barriers faced by patients in accessing care, and internal mistrust of tuberculosis screening were identified as drivers of low tuberculosis case detection. Conclusion: Tuberculosis screening finding in Berea and Khubetsoana is low. Lack of adequate infrastructure, skilled human resources, and long distances to the facilities for patients are significant factors behind the low tuberculosis case detection.