Long delays and missed opportunities in diagnosing smear-positive pulmonary tuberculosis in Kampala, Uganda: a cross-sectional study

Abstract

Background: Early detection and treatment of tuberculosis cases are the hallmark of successful tuberculosis control. We conducted a cross-sectional study at public primary health facilities in Kampala city, Uganda to quantify diagnostic delay among pulmonary tuberculosis (PTB) patients, assess associated factors, and describe trajectories of patients' health care seeking.

Methodology/principal findings: Semi-structured interviews with new smear-positive PTB patients (≥ 15 years) registered for treatment. Between April 2007 and April 2008, 253 patients were studied. The median total delay was 8 weeks (IQR 4-12), median patient delay was 4 weeks (inter-quartile range [IQR] 1-8) and median health service delay was 4 weeks (IQR 2-8). Long total delay (>14 weeks) was observed for 61/253 (24.1%) of patients, long health service delay (>6 weeks) for 71/242 (29.3%) and long patient delay (>8 weeks) for 47/242 (19.4%). Patients who knew that TB was curable were less likely to have long total delay (adjusted Odds Ratio [aOR] 0.28; 95%CI 0.11-0.73) and long patient delay (aOR 0.36; 95%CI 0.13-0.97). Being female (aOR 1.98; 95%CI 1.06-3.71), staying for more than 5 years at current residence (aOR 2.24 95%CI 1.18-4.27) and having been tested for HIV before (aOR 3.72; 95%CI 1.42-9.75) was associated with long health service delay. Health service delay contributed 50% of the total delay. Ninety-one percent (231) of patients had visited one or more health care providers before they were diagnosed, for an average (median) of 4 visits (range 1-30). All but four patients had systemic symptoms by the time the diagnosis of TB was made.

Conclusions/significance: Diagnostic delay among tuberculosis patients in Kampala is common and long. This reflects patients waiting too long before seeking care and health services waiting until systemic symptoms are present before examining sputum smears; this results in missed opportunities for diagnosis.

Figure 1. Flowchart showing the patients included in the analysis of diagnostic delay in Kampala, Uganda 2007-8.

Legend: KCC = Kampala City Council, TB = Tuberculosis, PTB = Pulmonary tuberculosis.

Figure 2. Patients' trajectories through the health system.

Legend: The figure shows the health service delay of the patients from the last step of provider before the patient is finally diagnosed with TB. Length of the arrow is equivalent to the length of the delay drawn on scale. Other arrows are not drawn to scale. They just indicate the direction of patient's movement in search of the health care. The width of the arrow represents the number of patients who go from one point to the next. The number in the circles are the total number of patients that start from that point together with those that go through that care provider. In the hospital 2 patients did not experience health service delay. Nine patients did not experience health service delay at the KCC clinics. KCC = Kampala City Council.