Delay in diagnosis of pulmonary tuberculosis in low-and middle-income settings: systematic review and meta-analysis

Abstract

Background: Assessment of delays in seeking care and diagnosis of tuberculosis is essential to evaluate effectiveness of tuberculosis control programs, and identify programmatic impediments. Thus, this review of studies aimed to examine the extent of patient, health system, and total delays in diagnosis of pulmonary tuberculosis in low- and middle- income countries.

Methods: It was done following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Electronic databases were searched to retrieve studies published from 2007 to 2015 including Pubmed central, Springer link, Hinari and Google scholar. Searching terms were pulmonary tuberculosis, health care seeking, health care seeking behavior, patient delay, diagnostic delay, health system delay, provider delay, and doctor delay. Retrieved studies were systematically reviewed and summarized using Comprehensive Meta-analysis software.

Results: Forty studies involving 18,975 patients qualified for systematic review, and 14 of them qualified for meta-analysis. The median diagnostic delay ranged from 30 to 366.5 days [IQR = 44-77.8], with a 4-199 days [IQR = 15-50] and 2-128.5 days [IQR = 12-34] due to patient and health system delays, respectively. The meta-analysis showed 42% of pulmonary tuberculosis patients delayed seeking care by a month or more; uneducated patients [pooled OR = 1.5, 95%CI = 1.1-1.9] and those who sought initial care from informal providers [pooled OR = 3, 95%CI = 2.3-3.9] had higher odds of patient delay.

Conclusion: Delay in diagnosis is still a major challenge of tuberculosis control and prevention programs in low- and middle- income settings. Efforts to develop new strategies for better case-finding using the existing systems and improving patients' care seeking behavior need to be intensified.

Keywords: Diagnosis delay; Health system; Patient delay; Pulmonary tuberculosis.

Fig. 1

Illustration of patient, health system and total delay

Fig. 2

PRISMA flow diagram for article selection and screening

Fig. 3

median patient delay in Sub-Saharan Africa and other Low- and Middle-Income countries, 2007 to 2015

Fig. 4

median health system delay in Sub-Saharan Africa and other Low- and Middle-Income countries, 2007 to 2015

Fig. 5

median total delay in Sub-Saharan Africa and other Low- and Middle-Income countries, 2007 to 2015

Fig. 6

Forest plot showing the pooled proportion of patient delayed above 30 days to seek formal medical care

Fig. 7

Forest plot showing the association between sex and patient delay at 30 days cutoff

Fig. 8

Forest plot showing the association between sex and patient delay at 15 days cutoff

Fig. 9

funnel plot of the standard error of pooled proportion of patient delaye above  30 days

Fig. 10

Forest plot showing the association between residence and patient delay at 30 days cutoffs

Fig. 11

Forest plot showing the association between residence and patient delay at 15 days cutoffs

Fig. 12

Forest plot showing the association between educational status and patient delay at 30 days cutoff

Fig. 13

forest plot showing the association between 1st care seeking from informal provider and patient delay of PTB patients (30 days cutoff)

Fig. 14

Forest plot showing the association between HIV status and patient delay at 30 days cutoff