Uptake of home-initiated tuberculosis evaluation during household contact investigation in Kampala, Uganda: A mixed-methods study

Background Home-initiated tuberculosis (TB) evaluation could improve test uptake and linkage to care among at-risk contacts of active TB index patients. However, there is a need to systematically explore why contacts accept, decline, or are unable to complete these services. We sought to describe the barriers to home-based sputum collection as part of enhanced household contact investigation for TB in Kampala, Uganda. Methods Using a parallel convergent mixed-methods design, we collected quantitative data describing home sputum collection among 82 household contacts of active TB patients and qualitative interviews from a sub-sample of 19 of those contacts. Data were analyzed in parallel to produce a more complete picture of the underlying barriers to home sputum collection. Results Men were significantly more likely than women to provide sputum when eligible (p=0.04). Contacts who reported risk factors for or symptoms of TB but no active cough where significantly less likely to provide sputum (p=0.05). Education level was not associated with differences in home sputum collection success. In interviews, contacts pointed to support from and for the index patient as a facilitator. Contacts were particularly enthusiastic about the convenience of home-based sputum collection compared to visiting a clinic. Lost or insufficient sputum containers, difficulty producing sputum on demand, and shame emerged as barriers to collecting sputum at home. Conclusions Uptake of sputum collection might be improved by addressing opportunity barriers prior to the visit, possibly through equipment checklists and improved community health worker training. More research is needed on the effects of TB stigma on willingness to produce sputum, even in the privacy of one’s own home.