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. 2025 Jan 7;20(1):e0316273.
doi: 10.1371/journal.pone.0316273. eCollection 2025.

Factors associated with the delay in diagnosis of extrapulmonary tuberculosis at the patient and health system level: A study from a rural setting in India

Shoaib Hassan  1   2 , Reza Yaesoubi  2 , Ole Bjørgaas Helle Magnus  3 , Mala Kanthali  4 , Manju Raj Purohit  4   5 , Tehmina Mustafa  1   3
Affiliations

Factors associated with the delay in diagnosis of extrapulmonary tuberculosis at the patient and health system level: A study from a rural setting in India

Shoaib Hassan et al. PLoS One. .

Abstract

Background: With the proportion of tuberculosis cases that are extrapulmonary tuberculosis (EPTB) increasing in recent years, understanding and addressing factors contributing to the prolonged time to diagnosis (TTD) of EPTB patients is vital.

Methods: We enrolled presumptive EPTB patients for a cohort study from 2018-2020 in Ujjain, India. Based on a structured questionnaire, the patients were interviewed for socio-demographic and clinical information, including previously visited health facilities (HF) for this illness. We analysed patients' TTD, healthcare access, and referral pathways.

Findings: EPTB (54%) and non-TB (58%) patients visited dispensaries during their first visit to a formal HF. Patients visited multiple HFs, including dispensaries (54%) and regional hospitals (32%), during 1-4 visits but did not receive an appropriate diagnosis. Less than 2% of the patients accessed private HFs. Most of the adult EPTB (83%) and non-TB (76%) patients were self-referred to our study site, where they were diagnosed. Our statistical models highlighted low-middle income groups, longer distances and longer travel time to HFs, and potentially less-empowered occupations as housewives with a prolonged TTD. Patients with a longer wait, including travel time, had a shorter TTD.

Conclusion: We found individual, societal-level, and structural barriers to healthcare access and utilisation and their association with diagnostic delay among adult and paediatric EPTB patients.

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Conflict of interest statement

The authors have no competing interests to declare.

Figures

Fig 1
Fig 1. Illustrates the time to diagnosis (TTD) of extrapulmonary tuberculosis (EPTB) patients and respective delays in healthcare access and utilisation.
Fig 2
Fig 2. Illustrations of healthcare access pathways followed by presumptive EPTB patients among adults.
Fig 3
Fig 3. Illustrations of healthcare access pathways followed by presumptive EPTB patients among children.
Fig 4
Fig 4. Time to diagnosis among the cohort of confirmed EPTB patients by age groups (excluding outliers and upper limit of the delay (number of days) at 90th percentile).
Fig 5
Fig 5. Time to diagnosis of confirmed EPTB patients among children (excluding outliers and upper limit of the delay (number of days) at 90th percentile).
Fig 6
Fig 6. Time to diagnosis of confirmed EPTB patients among adults (excluding outliers and upper limit of the delay (number of days) at 90th percentile).
Fig 7
Fig 7. Factors associated with the prolonged patient-level delay based on multivariable final regression model among the adult group of confirmed EPTB patients.
Fig 8
Fig 8. Factors associated with the prolonged health system-level phase-I delay based on multivariable final regression model among the adult group of confirmed EPTB patients.
Fig 9
Fig 9. Factors associated with the prolonged health system-level phase-II delay based on multivariable final regression model among the adult group of confirmed EPTB patients.
Fig 10
Fig 10. Factors associated with the prolonged patient-level delay based on multivariable final regression model among the children group of confirmed EPTB patients.
Fig 11
Fig 11. Factors associated with the prolonged health system-level phase-I delay based on multivariable final regression model among the children group of confirmed EPTB patients.
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