Contributors of Tb Treatment Non-Adherence Among Patients in Kisumu East Sub County, Kisumu County Kenya: A Focus on the Health Service Delivery Pillar

Abstract

Tuberculosis (TB) remains a significant global health challenge, affecting approximately one-third of the global population and ranking as the leading cause of death from a single infectious pathogen. The TB prevention and control program aims to eliminate TB by 2030. However, progress toward this goal has been slow, partly due to challenges such as TB treatment non-adherence. Studies indicate that poor adherence to TB treatment increases TB incidence, the emergence of drug-resistant TB, and poor treatment outcomes. In Kenya, the Ministry of Health has implemented various interventions to address TB treatment non-adherence. Despite these efforts, the country still reports a high non-adherence rate of 35%. To address this, Kenya launched its revised TB treatment guidelines in 2021, emphasizing a patient-centered approach with a strong focus on treatment adherence. This study examined health service delivery factors associated with TB treatment adherence among TB patients. The primary objectives were to determine the prevalence of TB treatment non-adherence and identify service delivery and treatment processes influencing adherence in Kisumu East Sub-County. The study adopted a hospital-based cross-sectional design using a mixed-methods approach. A census of 102 consenting TB patients in Kisumu East Sub-County participated, alongside 12 health facility staff (two per facility, selected by cadre). Quantitative data on TB treatment adherence and health service delivery factors were collected using a semi-structured questionnaire, while qualitative data on service delivery influences were obtained from key informant interviews with healthcare workers. Medication adherence was measured using the Morisky Medication Adherence Scale (MMAS-8) and categorized as a dichotomous variable. Binary and multivariate logistic regression analyses were conducted to determine the association between service delivery factors and TB treatment adherence. Quantitative data were analyzed using STATA version 15.1 at a 95% confidence interval, while qualitative data were analyzed using NVIVO version 14. Findings indicated that 74% of TB patients adhered to their treatment regimen, while 26% (CI: 18%-36%) were non-adherent. Healthcare worker-related factors and service delivery processes played a critical role in influencing adherence. Patients who felt supported by healthcare workers were significantly more likely to adhere to treatment (aOR = 7.947, 95% CI: 2.214-28.527, p = 0.001). This finding aligned with qualitative data, where healthcare workers emphasized that targeted patient education on managing TB and treatment side effects enhanced adherence, consistent with the self-efficacy model. Additionally, patients whose treatment support partners did not receive orientation were 90% less likely to adhere to treatment compared to those whose partners were oriented (aOR = 0.099, 95% CI: 0.015-0.685, p = 0.019). This highlights a gap in adherence to the Ministry of Health's Directly Observed Therapy (DOT) guidelines. In conclusion, the study identifies gaps in healthcare workers' empathy in service delivery and adherence to DOT standards and guidelines. Strengthening patient support, enhancing healthcare workers’ empathetic engagement, and ensuring the proper implementation of DOT guidelines are essential for improving TB treatment adherence.