Tuberculosis treatment delays and associated factors within the Zimbabwe national tuberculosis programme

BMC Public Health

Charles Sandy³  Tsitsi Mutasa-Apollo³  Mkhokheli Ngwenya³  Barnet Nyathi²  Anthony D Harries⁴  Kudakwashe C Takarinda¹ 

[1]International Union Against Tuberculosis and Lung Disease, Paris, France

[2]TB CARE Project, International Union Against Tuberculosis and Lung Disease, Harare, Zimbabwe

[3]AIDS and TB Department, Zimbabwe Ministry of Health and Child Care, Causeway, Harare, Zimbabwe

[4]Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK

关键词: Zimbabwe;    Delay;    Treatment;    Tuberculosis;   

Others  :  1122839
DOI  :  10.1186/s12889-015-1437-7

 received in 2013-05-30, accepted in 2015-01-15,  发布年份 2015

【 摘 要 】

Background

Delayed presentation of pulmonary TB (PTB) patients for treatment from onset of symptoms remains a threat to controlling individual disease progression and TB transmission in the community. Currently, there is insufficient information about treatment delays in Zimbabwe, and we therefore determined the extent of patient and health systems delays and their associated factors in patients with microbiologically confirmed PTB.

Methods

A structured questionnaire was administered at 47 randomly selected health facilities in Zimbabwe by trained health workers to all patients aged ≥18 years with microbiologically confirmed PTB who were started on TB treatment and entered in the health facility TB registers between 01 January and 31 March 2013. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for associations between patient/health system characteristics and patient delay >30 days or health system delay >4 days.

Results

Of the 383 recruited patients, 211(55%) were male with an overall median age of 34 years (IQR, 28-43). There was a median of 28 days (IQR, 21-63) for patient delays and 2 days (IQR, 1-5) for health system delays with 184 (48%) and 118 (31%) TB patients experiencing health system delays >30 days and health system delays >4 days respectively. Starting TB treatment at rural primary healthcare vs district/mission facilities [aOR 2.70, 95% CI 1.27-5.75, p = 0.01] and taking self-medication [aOR 2.33, 95% CI 1.23-4.43, p = 0.01] were associated with encountering patient delays. Associated with health system delays were accessing treatment from lower level facilities [aOR 2.67, 95% CI 1.18-6.07, p = 0.019], having a Gene Xpert TB diagnosis [aOR 0.21, 95% CI 0.07-0.66, p = 0.008] and >4 health facility visits prior to TB diagnosis [(aOR) 3.34, 95% CI 1.11-10.03, p = 0.045].

Conclusion

Patient delays were longer and more prevalent, suggesting the need for strategies aimed at promoting timely seeking of appropriate medical consultation among presumptive TB patients. Health system delays were uncommon, suggesting a fairly efficient response to microbiologically confirmed PTB cases. Identified risk factors should be explored further and specific strategies aimed at addressing these factors should be identified in order to lessen patient and health system delays.

【 授权许可】

   
2015 Takarinda et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]World Health Organization (WHO): Global tuberculosis report 2013. WHO, Geneva, Switzerland: WHO, 2013. [www.who.int/iris/bitstream/10665/91355/1/9789241564656_eng.pdf]
• [2]Corbett EL, Watt CJ, Walker N, Maher D, Williams BG, Raviglione MC, et al.: The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med 2003, 163(Suppl 9):1009-21.
• [3]Pablos-Méndez A, Sterling TR, Frieden TR: The relationship between delayed or incomplete treatment and all-cause mortality in patients with tuberculosis. JAMA 1996, 276(Suppl 15):1223-8.
• [4]Aït-Khaled N, Alarcón E, Armengol R, Bissell K, Boillot F, Cameniro JA, et al.: Management of tuberculosis: a guide to the essentials of good practice. 6th edition. International Union Against Tuberculosis and Lung Disease, Paris, France; 2010.
• [5]Sreeramareddy CT, Panduru KV, Menten J, Van den Ende J: Time delays in diagnosis of pulmonary tuberculosis: a systematic review of literature. BMC Infect Dis 2009, 9:91. BioMed Central Full Text
• [6]Storla DG, Yimer S, Bjune GA: A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Public Health 2008, 8:15. BioMed Central Full Text
• [7]Finnie RKC, Khoza LB, van den Borne B, Mabunda T, Abotchie P, Mullen PD: Factors associated with patient and health care system delay in diagnosis and treatment for TB in sub-Saharan African countries with high burdens of TB and HIV. Trop Med Int Health 2011, 16(4):394-411.
• [8]Odusanya OO, Babafemi JO: Patterns of delays amongst pulmonary tuberculosis patients in Lagos, Nigeria. BMC Public Health 2004, 4:18. BioMed Central Full Text
• [9]Ministry of Health and Child Welfare Zimbabwe: Zimbabwe National Tuberculosis Control Programme Manual. 4th edition. Ministry of Health and Child Welfare, Harare, Zimbabwe; 2010.
• [10]Ministry of Health and Child Welfare Zimbabwe: National HIV Testing and Counselling Trainee’s Manual. Ministry of Health and Child Welfare, Harare, Zimbabwe; 2007.
• [11]Ministry of Health and Child Welfare Zimbabwe: National Guidelines for TB/HIV Co-management. Ministry of Health and Child Welfare, Harare, Zimbabwe; 2007.
• [12]World Health Organisation (WHO) Regional Office for the Eastern Mediterranean: Diagnostic and treatment delay in tuberculosis: An in-depth analysis of the health seeking behaviour of patients and health system response in seven countries of the Eastern Mediterranean Region. Cairo, Egypt: WHO; 2006.[http://applications.emro.who.int/dsaf/dsa710.pdf]
• [13]Lusignani LS, Quaglio G, Atzori A, Nsuka J, Grainger R, Da Conceicao PM, et al.: Factors associated with patient and health care system delay in diagnosis for tuberculosis in the province of Luanda, Angola. BMC Infect Dis 2013, 13(Suppl 1):168. BioMed Central Full Text
• [14]Wandwalo ER, Mørkve O: Delay in tuberculosis case-finding and treatment in Mwanza, Tanzania. Int J Tuberc Lung Dis 2000, 4(Suppl 2):133-8.
• [15]Lawn SD, Afful B, Acheampong JW: Pulmonary tuberculosis: diagnostic delay in Ghanaian adults. Int J Tuberc Lung Dis 1998, 2(Suppl 8):635-40.
• [16]Pronyk RM, Makhubele MB, Hargreaves JR, Tollman SM, Hausler HP: Assessing health seeking behavior in rural South Africa. Int J Tuberc Lung Dis 2001, 5(Suppl 7):619-27.
• [17]Yimer S, Bjune G, Alene G: Diagnostic and treatment delay among pulmonary tuberculosis patients in Ethiopia: a cross sectional study. BMC Infect Dis 2005, 5:112. BioMed Central Full Text
• [18]Liam CK, Tang BG: Delay in the diagnosis and treatment of pulmonary tuberculosis in patients attending a university teaching hospital. Int J Tuberc Lung Dis 1997, 1(Suppl 4):326-32.
• [19]Kiwuwa MS, Charles K, Harriet MK: Patient and health service delay in pulmonary tuberculosis patients attending a referral hospital: a cross-sectional study. BMC Public Health 2005, 5:122. BioMed Central Full Text
• [20]Rojpibulstit M, Kanjanakiritamrong J, Chongsuvivatwong V: Patient and health system delays in the diagnosis of tuberculosis in Southern Thailand after health care reform. Int J Tuberc Lung Dis 2006, 10(Suppl 4):422-8.
• [21]Needham DM, Foster SD, Tomlinson G, Godfrey-Faussett P: Socio-economic, gender and health services factors affecting diagnostic delay for tuberculosis patients in urban Zambia. Trop Med Int Health 2001, 6(Suppl 4):256-9.
• [22]Lienhardt C, Rowley J, Manneh K, Lahai G, Needham D, Milligan P, et al.: Factors affecting time delay to treatment in a tuberculosis control programme in a sub-Saharan African country: the experience of The Gambia. Int J Tuberc Lung Dis 2001, 5(Suppl 3):233-9.
• [23]Zachariah R, Harries AD, Manzi M, Gomani P, Teck R, Phillips M, et al.: Acceptance of anti-retroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport. PLoS One 2006, 1:e121.
• [24]Cambanis A, Yassin MA, Ramsay A, Bertel Squire S, Arbide I, Cuevas LE: Rural poverty and delayed presentation to tuberculosis services in Ethiopia. Trop Med Int Health 2005, 10(Suppl 4):330-5.
• [25]Ukwaja KN, Alobu I, Nweke CO, Onyenwe EC: Healthcare-seeking behavior, treatment delays and its determinants among pulmonary tuberculosis patients in rural Nigeria: a cross-sectional study. BMC Health Serv Res 2013, 13:25. BioMed Central Full Text
• [26]Pirkis JE, Speed BR, Yung AP, Dunt DR, MacIntyre CR, Plant AJ: Time to initiation of anti-tuberculosis treatment. Tuber Lung Dis 1996, 77(Suppl 5):401-6.
• [27]Güneylioglu D, Yilmaz A, Bilgin S, Bayram U, Akkaya E: Factors affecting delays in diagnosis and treatment of pulmonary tuberculosis in a tertiary care hospital in Istanbul. Turkey Med Sci Monit 2004, 10(Suppl 2):CR62-7.
• [28]Ngamvithayapong J, Yanai H, Winkvist A, Diwan V: Health seeking behaviour and diagnosis for pulmonary tuberculosis in an HIV-epidemic mountainous area of Thailand. Int J Tuberc Lung Dis 2001, 5(Suppl 11):1013-20.
• [29]Demissie M, Lindtjorn B, Berhane Y: Patient and health service delay in the diagnosis of pulmonary tuberculosis in Ethiopia. BMC Public Health 2002, 25(Suppl 2):23. BioMed Central Full Text
• [30]Long NH, Johansson E, Lonnroth K, Eriksson B, Winkvist A, Diwan VK: Longer delays in tuberculosis diagnosis among women in Vietnam. Int J Tuberc Lung Dis 1999, 3(Suppl 5):388-93.
• [31]Jurcev-Savicevic A, Mulic R, Kozul K, Ban B, Valic J, Bacun-Ivek L, et al.: Health system delay in pulmonary tuberculosis treatment in a country with an intermediate burden of tuberculosis: a cross-sectional study. BMC Public Health 2013, 13:250. BioMed Central Full Text
• [32]Steingart KR, Sohn H, Schiller I, Kloda LA, Boehme CC, Pai M, et al.: Xpert® MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults. Cochrane Database Sys Rev 2013, 1:CD009593.
• [33]Ministry of Health and Child Care: Guidelines for the Programmatic Management Of Drug Resistant Tuberculosis in Zimbabwe. Ministry of Health and Child Care, Harare, Zimbabwe; 2013.
• [34]World Health Organisation (WHO): Automated real-time nucleic acid amplification technology for rapid and simultaneous detection of tuberculosis and rifampicin resistance: Xpert MTB/RIF assay for the diagnosis of pulmonary and extrapulmonary TB in adults and children. Policy update. Geneva, Switzerland: WHO; 2013. [http://apps.who.int/iris/bitstream/10665/112472/1/9789241506335_eng.pdf?ua=1]
• [35]Ministry of Health and Child Welfare Zimbabwe (MOHCW), Central Statistical Office (CSO): National Health Profile 2006. MOHCW and CSO, Harare, Zimbabwe; 2006.
• [36]Gershon AS, Wobeser W, Tu JV: Delayed tuberculosis treatment in urban and suburban Ontario. Can Respir J 2008, 15(Suppl 5):244-8.
• [37]Xu X, Liu J-H, Cao S-Y, Zhao Y, Dong X-X, Liang Y, et al.: Delays in care seeking, diagnosis and treatment among pulmonary tuberculosis patients in Shenzhen, China. Int J Tuberc Lung Dis 2013, 17(Suppl 5):615-20.
• [38]Murimwa TC, Sandy C, Mugurungi O, Edginton ME, Reid T: What proportion of patients diagnosed with TB and started on treatment in Manicaland Province, Zimbabwe, are registered? Int Health 2012, 4(Suppl 4):320-2.
• [39]Mihalea H, Richardson D. Public-Private Mix: involving pharmacies and other providers in TB control – A Cambodia case study. Phnom Penh, Cambodia: PATH 2011. [http://www.path.org/publications/files/CP_cambodia_ppm_tb_cs.pdf]