Tracing Tuberculosis Patients Lost to Follow-up: A Mixed-Methods Study of Community Health Promoter-Led Tracing in Kenya.

Tuberculosis (TB) remains a major global public health threat, with an estimated 10.7 million incident cases and 1.23 million deaths in 2024. Treatment interruption undermines TB control efforts, yet the effectiveness of Community Health Promoters (CHPs) in tracing patients lost to follow-up (LTFU) is poorly understood. We assessed the proportion of LTFU TB patients successfully traced through CHP-led tracing strategy and explored challenges of implementation CHP strategy. We conducted a mixed-methods cross-sectional study in Kilifi County, Kenya, among adult TB patients recorded as LTFU between July 2022 and December 2023. Patients identified through the national electronic TB surveillance system were linked to their respective community health units and assigned to CHPs for tracing. CHPs attempted to contact patients by telephone and through repeated household visits and, where necessary, sought information from relatives, neighbours, and local administrative leaders. For successfully traced patients, quantitative data were collected using structured questionnaires. Qualitative data were collected through five focus group discussions with 30 traced TB patients and 30 in-depth interviews with CHPs, TB clinic staff, programme managers, and County Health Management Team members. Qualitative data were coded and analysed thematically using a primarily deductive approach guided by the study objectives, while allowing additional themes to emerge. Of 140 patients identified for tracing, 36 (25.7%, 95% confidence interval 18.7-33.8) were successfully traced; 90 (64.3%) had relocated outside Kilifi County and 14 (10.0%) had died. Qualitative findings indicated that treatment interruption was driven by financial hardship, including transport costs, medication side effects, stigma, and difficulties maintaining continuity of care after relocation. CHPs supported treatment adherence through health education, counselling, appointment reminders, and household follow-up. However, their ability to trace patients was constrained by patient mobility, limited financial support for community-based activities, shortages of health workers, competing responsibilities, and gaps in systems for tracking patients across administrative boundaries. CHP-led tracing reached only one-quarter of LTFU TB patients, largely because many had relocated outside the county. Health systems should strengthen patient tracking across county boundaries and equip CHPs with the resources, staffing, and support needed for effective community-based TB tracing.