Socio-Cultural and Health System Factors Affecting Tuberculosis Case Detection and Treatment in the Upper West Region of Ghana

Abstract

Background: Since the year 2005, Ghana has been implementing the new Stop TB strategy in all health facilities nationwide. This new strategy aims at increasing case detection rate (CDR) to 70% by 2010 and beyond. However, the Upper West Region (UWR) of Ghana could only increase case detection to 37% in 2010 and to 42.1% in 2014. This study therefore assesses the socio-cultural and health systems factors responsible for low case detection and prompt treatment. Methodology: This descriptive study employed a mixed method (quantitative and qualitative). The quantitative study adopted multi-stage sampling technique to select six hundred (606) respondents, ≥ 18 years from four randomly selected sub-districts across four districts in the region for a community survey. With regards to the qualitative study, purposive sampling technique was used to sample 15 people with tuberculosis, seven treatment supporters (for TB patients who had treatment supporters), 24 stakeholders; health workers at district hospitals, district health directorates, sub-district level, and traditional healers for in-depth interviews. In addition, eight focus group discussions (N=72) were conducted, stratified by gender and type of residence. The quantitative data was analyzed using STATA 13. Univariable, bivariable and multivariable logistic analysis were conducted with p-value of <0.05 considered as significant. The qualitative data were recorded digitally, transcribed verbatim and analyzed using thematic content analysis with the aid of NVivo 11 software. Data triangulation strategy was used to present both the quantitative and qualitative findings of the study. Results: The study revealed that TB locally referred to as korongkpong and kusibine can be caused by cough during sex, a curse or bewitchment. These beliefs had a profound influence on the health seeking behaviour for TB. The cultural connotations for the causes of TB made people with the condition to first seek health care from spiritualists and traditional healers. This affected case detection and prompt treatment. The study further found that females were 3.9 times more likely (aOR=3.93, 95% CI=1.1745, 3.1789) to use biomedical health facility than males for productive cough. People belonging to the least poor households were 3.7 (aOR=3.79, 95% CI=0.3392, 0.8127) times more likely to use biomedical health facilities with productive cough though people in the poorest socio-economic status are more vulnerable to TB. The study reported that there was low level of knowledge about TB in the study area. This low knowledge was further worsened by the various misconceptions about the disease in the community and low TB related promotion activities. The study further found that health workers were not routinely screening for TB among patients that report with cough. Of the 132 respondents who had reported to a health facility with cough for more than two weeks, only 31 (23.5%) of them were screened for TB with 13 (41.9%) of those screened having the disease. This lack of screening was further undermined by laboratory workers unwillingness to conduct sputum microscopy for TB diagnosis because of inadequate motivation. This resulted in delays in getting test results, a situation that affected patients’ confidence in the health system and encouraged the use of non-orthodox health care outlets and self-medication. Furthermore, the study found low coordination between district health directorate, hospitals and sub-district health facilities with regards to TB related work. This low coordination affected the screening of patients for TB and perception about motivation of staff involved in the clinical care aspect of TB control. Conclusions: Tuberculosis has been given a superstitious label by community members and therefore the treatment they seek is often inappropriate which undermined case detection and treatment. Health workers were not screening people who report at health facilities with productive cough for more than two weeks as required by the DOTS policy. Delays in getting test results and lack of coordination between district health directorates and district hospitals affected early case detection and favoured the use of non-orthodox health care outlets.