Diagnostic and treatment delay among pulmonary tuberculosis patients in Ethiopia: a cross sectional study

Abstract

Background: Delayed diagnosis and treatment of tuberculosis (TB) results in severe disease and a higher mortality. It also leads to an increased period of infectivity in the community. The objective of this study was to determine the length of delays, and analyze the factors affecting the delay from onset of symptoms of pulmonary tuberculosis (PTB) until the commencement of treatment.

Methods: In randomly selected TB management units (TBMUs), i.e. government health institutions which have diagnosing and treatment facilities for TB in Amhara Region, we conducted a cross sectional study from September 1-December 31/2003. Delay was analyzed from two perspectives, 1. Period between onset of TB symptoms to first visit to any health provider (health seeking period), and from the first health provider visit to initiation of treatment (health providers' delay), and 2. Period between onset of TB symptoms to first visit to a medical provider (patients' delay), and from this visit to commencement of anti-TB treatment (health systems' delay). Patients were interviewed on the same date of diagnosis using a semi-structured questionnaire. Logistics regression analysis was applied to analyze the risk factors of delays.

Results: A total of 384 new smear positive PTB patients participated in the study. The median total delay was 80 days. The median health-seeking period and health providers' delays were 15 and 61 days, respectively. Conversely, the median patients' and health systems' delays were 30 and 21 days, respectively. Taking medical providers as a reference point, we found that forty eight percent of the subjects delayed for more than one month. Patients' delays were strongly associated with first visit to non-formal health providers and self treatment (P < 0.0001). Prior attendance to a health post/clinic was associated with increased health systems' delay (p < 0.0001).

Conclusion: Delay in the diagnosis and treatment of PTB is unacceptably high in Amhara region. Health providers' and health systems' delays represent the major portion of the total delay. Accessing a simple and rapid diagnostic test for TB at the lowest level of health care facility and encouraging a dialogue among all health providers are imperative interventions.

Figure 1

The relation of the different delay periods. This figure indicates the relations of the different delay periods and the possible health providers visit, be it formal or non formal. It also indicates the operational definitions for the delay periods. For example, the second line from above shows the definition for the total delay, which is the delay period from the onset of cough until the commencement of anti- TB treatment.

Figure 2

Median delay period and inter quartile range (IQR) taking all health providers as a reference point. This figure shows the median delay periods taking all health providers as a reference points. It divides the delay periods in to four, namely health seeking period, health providers' delay, diagnosing facilities' delay and total delay. As can be seen from the figure, patients took 15 days to first visit a health provider after the onset of their cough. This indicates that patients seek for treatment relatively early irrespective of the type health provider visited. On the other hand the median health providers' delay was very long which shows the possible area for intervention activities.

Figure 3

Median delay periods and inter quartile range (IQR) taking only medical providers as a reference point. This figure tries to show the median delay period taking only medical providers as a reference point. The delay periods are divided in to three, namely patients', health systems' and total delay periods. In this figure, median patients' delay is higher compared to the median health-seeking period in figure 2, which shows that patients take relatively longer time until they consult medical providers that play a crucial role for early diagnosis of TB.