Factors associated with patient, and diagnostic delays in Chinese TB patients: a systematic review and meta-analysis

BMC Medicine

Jia Cao⁵  Caitlin Marshall¹  Hui Lin²  Yongqiao Bian⁶  Daikun Li³  Shenglan Tang⁴  John Ehiri¹  Ying Li⁶ 

[1] Division of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Avenue, Tucson, AZ, USA;Department of Epidemiology, College of Preventive Medicine, Third Military Medical University, No. 30 Gaotanyan Road, Shapingba District, Chongqing, China;Department of Laboratory Medicine, University-Town Hospital of Chongqing University of Medical Sciences, No. 55 Daxuecheng Road, Shapingba District, Chongqing, China;Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC, USA;Toxicology institute, College of Preventive Medicine, Third Military Medical University, No. 30 Gaotanyan Road, Shapingba district, Chongqing 400038, China;Department of Social Medicine and Health Service Management, College of Preventive Medicine, Third Military Medical University, No. 30 Gaotanyan Road, Shapingba District, Chongqing, China

关键词: Risk factors;    Diagnosis delay;    Patient delay;    Tuberculosis;   

Others  :  856974
DOI  :  10.1186/1741-7015-11-156

 received in 2013-04-15, accepted in 2013-05-22,  发布年份 2013

【 摘 要 】

Background

Delay in seeking care is a major impediment to effective management of tuberculosis (TB) in China. To elucidate factors that underpin patient and diagnostic delays in TB management, we conducted a systematic review and meta-analysis of factors that are associated with delays in TB care-seeking and diagnosis in the country.

Methods

This review was prepared following standard procedures of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and checklist. Relevant studies published up to November 2012 were identified from three major international and Chinese literature databases: Medline/PubMed, EMBASE and CNKI (China National Knowledge Infrastructure).

Results

We included 29 studies involving 38,947 patients from 17 provinces in China. Qualitative analysis showed that key individual level determinants of delays included socio-demographic and economic factors, mostly poverty, rural residence, lack of health insurance, lower educational attainment, stigma and poor knowledge of TB. Health facility determinants included limited availability of resources to perform prompt diagnosis, lack of qualified health workers and geographical barriers.

Quantitative meta-analysis indicated that living in rural areas was a risk factor for patient delays (pooled odds ratio (OR) (95% confidence interval (CI)): 1.79 (1.62, 1.98)) and diagnostic delays (pooled OR (95% CI): 1.40 (1.23, 1.59)). Female patients had higher risk of patient delay (pooled OR (95% CI): 1.94 (1.13, 3.33)). Low educational attainment (primary school and below) was also a risk factor for patient delay (pooled OR (95% CI): 2.14 (1.03, 4.47)). The practice of seeking care first from Traditional Chinese Medicine (TMC) providers was also identified as a risk factor for diagnostic delay (pooled OR (95% CI): 5.75 (3.03, 10.94)).

Conclusion

Patient and diagnostic delays in TB care are mediated by individual and health facility factors. Population-based interventions that seek to reduce TB stigma and raise awareness about the benefits of early diagnosis and prompt treatment are needed. Policies that remove patients’ financial barriers in access to TB care, and integration of the informal care sector into TB control in urban and rural settings are central factors in TB control.

【 授权许可】

   
2013 Li et al.; licensee BioMed Central Ltd.

【 图 表 】

【 参考文献 】

• [1]World Health Organization: Global tuberculosis report. 2012. http://apps.who.int/iris/bitstream/10665/75938/1/9789241564502_eng.pdf webcite
• [2]Wang Y: [Report of the Fifth National Sampling Survey of TB Epidemiology]. Beijing: Military Medical Science Press; 2011:1-7.
• [3]Zhao Y, Xu S, Wang L, Chin DP, Wang S, Jiang G, Xia H, Zhou Y, Li Q, Ou X, Pang Y, Song Y, Zhao B, Zhang H, He G, Guo J, Wang Y: National survey of drug-resistant tuberculosis in China. N Engl J Med 2012, 366:2161-2170.
• [4]Donald PR, van Helden PD: The global burden of tuberculosis–combating drug resistance in difficult times. N Engl J Med 2009, 360:2393-2395.
• [5]World Health Organization: Early detection of tuberculosis: an overview of approaches, guidelines and tools. WHO Document: WHO/HTM/STB/PSI/2011.21. Geneva: World Health Organization; 2011. https://extranet.who.int/iris/restricted/bitstream/10665/70824/1/WHO_HTM_STB_PSI_2011.21_eng.pdf webcite
• [6]Huong NT, Vree M, Duong BD, Khanh VT, Loan VT, Co NV, Borgdorff MW, Cobelens FG: Delays in the diagnosis and treatment of tuberculosis patients in Vietnam: a cross-sectional study. BMC Publ Health 2007, 7:110. BioMed Central Full Text
• [7]Rajeswari R, Chandrasekaran V, Suhadev M, Sivasubramaniam S, Sudha G, Renu G: Factors associated with patient and health system delays in the diagnosis of tuberculosis in South India. Int J Tuberc Lung Dis 2002, 6:789-795.
• [8]Ngadaya ES, Mfinanga GS, Wandwalo ER, Morkve O: Delay in tuberculosis case detection in Pwani region, Tanzania. A cross sectional study. BMC Health Serv Res 2009, 9:196. BioMed Central Full Text
• [9]Chang CT, Esterman A: Diagnostic delay among pulmonary tuberculosis patients in Sarawak, Malaysia: a cross-sectional study. Rural Remote Health 2007, 7:667.
• [10]Zerbini E, Chirico MC, Salvadores B, Amigot B, Estrada S, Algorry G: Delay in tuberculosis diagnosis and treatment in four provinces of Argentina. Int J Tuberc Lung Dis 2008, 12:63-68.
• [11]Selvam JM, Wares F, Perumal M, Gopi PG, Sudha G, Chandrasekaran V, Santha T: Health-seeking behavior of new smear-positive TB patients under a DOTS programme in Tamil Nadu, India, 2003. Int J Tuberc Lung Dis 2007, 11:161-167.
• [12]Zhang QG: Factors associated with delayed identification of PTB. Anthol Med 2006, 25:655-657.
• [13]Demissie M, Lindtjorn B, Berhane Y: Patient and health service delay in the diagnosis of pulmonary tuberculosis in Ethiopia. BMC Publ Health 2002, 2:23. BioMed Central Full Text
• [14]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, 5:1013-1020.
• [15]Sendagire I, Van der Schim LM, Mubiru M, Konde-Lule J, Cobelens F: Long delays and missed opportunities in diagnosing smear-positive pulmonary tuberculosis in Kampala, Uganda: a cross-sectional study. PLoS One 2010, 5:e14459.
• [16]World Health Organization: Guidelines for the Management of Drug-Resistant Tuberculosis, WHO/TB/96.210 (Rev1). Geneva: WHO; 1997.
• [17]Golub JE, Mohan CI, Comstock GW, Chaisson RE: Active case finding of tuberculosis: historical perspective and future prospects. Int J Tuberc Lung Dis 2005, 9:1183-1203.
• [18]Finnie RK, 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, 16:394-411.
• [19]Storla DG, Yimer S, Bjune GA: A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Publ Health 2008, 8:15. BioMed Central Full Text
• [20]Xi HF, Li JJ: [Patient delay among migrants PTB]. Mod J Integr Traditional Chinese and Western Med 2011, 20:682-683.
• [21]He SD, Guo JF: [Factors associated with diagnostic delay of 142 PTB]. China Mod Med 2009, 16:21-22.
• [22]Huan ST, Zhang B, Yan F, Liu XY, Duan MHJ, Zhao FZ, Gong YL: [Analysis on patient delay and reasons for pulmonary tuberculosis in poor rural]. J Chinese Antituberculosis Assoc 2007, 29:70-73.
• [23]Wu ZJ, Zeng RY, Shen LT, Zhang JF: [Delay in identification of PTB in Shang Yang city]. Pract Prev Med 2008, 15:448-449.
• [24]TB Control Office in Ministry of Health in China: [Implementation Manual of the World Bank Tuberculosis Control Program in China]. 2nd edition. Beijing, China: Ministry of Health; 1992.
• [25]Cochrane Collaboration: Review Manager (RevMan) [Computer program]. Version 5.0. Copenhagen: The Nordic Cochrane Centre, the Cochrane Collaboration; 2008.
• [26]Moher D, Liberati A, Tetzlaff J, Altman D, Group TP: Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med 2009, 151:264-269.
• [27]Wells G, Shea B, O’Connell D, Petersen J, Welch V, Tugwell P: The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. In Proceedings of the 3rd Symposium on Systematic Reviews: Beyond the Basics. 3–5 July 2000. Oxford, UK: Center for Statistics in Medicine; 2000.
• [28]National Collaborating Centre for Environment Health: A primer for evaluating the quality of studies on environmental health: critical appraisal of cross-sectional studies. http://www.ncceh.ca/sites/default/files/Critical_Appraisal_Cross-Sectional_Studies_Aug_2011.pdf webcite
• [29]Public Health Resource Unit (PHRU): Critical Appraisal Skills Program (CASP). Oxford, UK: PHRU, Public Health Services; 2006. http://www.civilservice.gov.uk/wp-content/uploads/2011/09/Qualitative-Appraisal-Tool_tcm6-7385.pdf webcite
• [30]Elwood M: Critical Appraisal of Epidemiological Studies and Clinical Trials. 3rd edition. Oxford, UK: Oxford University Press; 2007.
• [31]Aschengrau A, Seage GR III: Essentials of Epidemiology in Public Health. Sudbury, MA: Jones & Bartlett Learning; 2003.
• [32]Cochran BG: The combination of estimates from different experiments. Biometrics 1954, 10:101-129.
• [33]Higgins JP, Thompson SG: Quantifying heterogeneity in a meta-analysis. Stat Med 2002, 21:1539-1558.
• [34]Wang W, Sun J, Abdullah AS, Xu B: [Barriers in accessing to tuberculosis care among non-residents in Shanghai: a descriptive study of delays in diagnosis]. Eur J Public Health 2007, 17:419-423. European journal of public health
• [35]Bai LQ, Xiao SY: [Factors associated with diagnostic delay for patients with smear-positive pulmonary tuberculosis in rural Hunan, China]. Chinese Journal of Tuberculosis and Respiratory Diseases 2004, 27:617-620.
• [36]Liao TH, Xu LZ: [Research on the Affection of Doctors’ Disease Diagnose Ability to the Pulmonary Tuberculosis Patient’s Economic Burden]. Chinese Health Service Management 2009, 1:8-10.
• [37]Yang JC, Du YP, Zhao YL, Zhang SC: [Patient delay and the impact factors for senile pulmonary tuberculosis in rural area]. Chinese Rural Health Service Administration 2010, 30:300-302.
• [38]Zhou YZ, Shen XB, Shi XQ, Lei PY, Li J, Wang SP, et al.: [Analysis on causes and countermeasures of delay diagnosis of Pulmonary tuberculosis patients in north GuiZhou]. Modern Preventive Medicine 2009, 36:4462-4464. 4469
• [39]Li AX, Wang YL: [Investigation of diagnostic delay of TB in Shang Qiu city]. Henan Journal of Preventive Med 2002, 13:292.
• [40]Shi SJ, Li L: [Investigation of Correlative Factors leading to Delayed Diagnosis of Smear-positive TB Cases]. Anhui Journal of Prevent Medicine 2006, 12:367-368. 391
• [41]Yu XH, Wu GY, Gong YL, Zhao FZ, Wang GL: [Spreads the Piece Negative Pulmonary Tuberculosis Sickness Diagnosis Level to the Patient Economic Burden Influence Research]. Chinese Primary Health Care 2007, 21:8-9.
• [42]Zhang YL, Kan XH, Han L: [Analysis on Delayed-detection Situation of New Smear-positive Cases With Pulmonary Tuberculosis in Anhui Province]. Anhui Journal of Preventive Medicine 2011, 17:328-329. 356
• [43]Cai T, Wang J, Xu GM: [Survey on the management of newly diagnosed PTB]. Youjiang Medical Journal 2007, 35:703-704.
• [44]Chai LX, Sun J, Lu XM: [Analysis on the cause of patient delay of PTB in rural area of Dingxi city]. The Journal of the Chinese Antituberculosis Association 2008, 30:553-554.
• [45]Tian HY, Jiao XL, Liu CY: [Survey on the identification delay of newly diagnosed PTB.]. China, Public Health 2001, 17:164.
• [46]Yang ZH, Cui P, Chen Z: [Research on detective delay and influence factors in youth patients with pulmonary tuberculosis.]. Clin Focus 2011, 26:1029-1032.
• [47]Cao GH: [Diagnostic delay of newly diagnosed PTB in Zhenzhou City]. Chinese J School Doctor 2002, 12:527.
• [48]Geng H, Zhou CC, Liu ZM, Xu LZ, Tao WW, Li HT, Bi XL, Wang YF, Zheng YC, Li CJ: [Delay in seeking medical consultation among pulmonary tuberculosis patients in migrants]. Chinese J Public Health 2010, 26:77-978.
• [49]Shi JS, Jia CX, Zhang HM: [The research on detection delay and patient’s delay influencing factors of rural new smear positive pulmonary TB of Ji’ning City]. Preven Med Tribune 2008, 14:621-622.
• [50]Cheng G, Tolhurst R, Li RZ, Meng QY, Tang S: Factors affecting delays in tuberculosis diagnosis in rural China: a case study in four counties in Shandong Province. Trans R Soc Trop Med Hyg 2005, 99:355-362.
• [51]Li X, Jiang S, Li X, Mei J, Zhong Q, Xu W, Li J, Liu X, Zhang H, Wang L: Predictors on delay of initial health-seeking in new pulmonary tuberculosis cases among migrants population in East China. PLoS One 2012, 7:e31995.
• [52]Lin X, Chongsuvivatwong V, Geater A, Lijuan R: The effect of geographical distance on TB patient delays in a mountainous province of China. Int J Tuberc Lung Dis 2008, 12:288-293.
• [53]Zhang X, Chen L, Zhang ZJ: Analysis of the cause for misdiagnosis of elderly smear-positive tuberculosis patients. J Clin Pulmonary Med 2008, 13:1449-1450.
• [54]Hou SY, Xiao AQ, Li GM, Liu X: Analysis for diagnostic delay of new smear positive patients. Bull Chinese Antituberculosis Assoc 2001, 23:225-227.
• [55]Liu HM: Survey on 290 smears positive PTB. J Hengyang Med Coll 2000, 28:416-417.
• [56]Li CJ, Xu LZ, Liao TH, Liu ZM, Cheng J, Wang YF: Diagnosis and treatment of elderly tuberculosis patients in Shandong province. Chinese J Public Health 2010, 26:220-221.
• [57]Lian GQ, Liu ZM, Huang CM: Diagnostic delay of newly diagnosed PTB. Int Med Health Guidance News 2003, 9:50-51.
• [58]Zhao P, Li XJ, Zhang SF, Wang XS, Liu CY: Social behavior risk factors for drug resistant tuberculosis in Mainland China: a meta-analysis. J Int Med Res 2012, 40:436-445.
• [59]Glanz K, Rimer BK, Viswanath K (Eds): Health Behaviour and Health Education – Theory, Research and Practice. 4th edition. San Francisco, USA: John Wiley and Sons; 2008:468-469.
• [60]Gerein N, Green A, Mirzoev T, Pearson S: Health system impacts on maternal and child health. In Maternal and Child Health: Global Challenges, Programs and Policies. Edited by Ehiri J. New York: Springer; 2009:83-97.
• [61]Zhang T, Tang S, Jun G, Whitehead M: Persistent problems of access to appropriate, affordable TB services in rural China: experiences of different socio-economic groups. BMC Publ Health 2007, 7:19. BioMed Central Full Text
• [62]Tang S, Tang S: Tuberculosis Control in China: it’s Time to Rethink Current Strategies. Durham, NC: Duke Word Press Sites; 2012. https://globalhealth.duke.edu/media/blogs/china/tuberculosis-control-china-its-time-rethink-current-strategies webcite
• [63]Center for Disease Control and Prevention: Promoting Cultural Sensitivity: a Practical Guide for Tuberculosis Programs to Persons from China. Atlanta, GA, USA: CDC Press; 2008. http://www.cdc.gov/tb/publications/guidestoolkits/EthnographicGuides/China/chapters/china.pdf webcite
• [64]World Health Organization: Addressing Poverty in TB Control: Options for National TB Control Programmes. WHO/HTM/TB/2005.352; 2005. http://whqlibdoc.who.int/hq/2005/WHO_HTM_TB_2005.352.pdf webcite
• [65]Lu SH, Tian BC, Kang XP, Zhang W, Meng XP, Zhang JB, Lo SK: Public awareness of tuberculosis in China: a national survey of 69,253 subjects. Int J Tuberc Lung Dis 2009, 13:1493-1499.
• [66]Courtwright A, Turner AN: Tuberculosis and stigmatization: pathways and interventions. Public Health Rep 2010, 125:34-42.
• [67]Hipgrave D: Communicable disease control in China: from Mao to now. J Glob Health 2011, 1:224-238.
• [68]Liu Q, Smith H, Wang Y, Tang S, Wang Q, Garner P: Tuberculosis patient expenditure on drugs and tests in subsidies, public services in China: a descriptive study. Trop Med Int Health 2010, 15:26-32.
• [69]Liu Y, Rao K: Providing health insurance in rural China: from research to policy. J Health Polit Policy Law 2006, 31:71-92.
• [70]Long Q, Smith H, Zhang T, Tang S, Garner P: Patient medical costs for tuberculosis treatment and impact on adherence in China: a systematic review. BMC Publ Health 2011, 11:393. BioMed Central Full Text
• [71]Wei X, Zou G, Yin J, Walley J, Yang HX, Kliner M, et al.: Providing financial incentives to rural-to-urban migrants in Shanghai: an intervention study. Infect Dis Poverty 2012, 1:9. BioMed Central Full Text
• [72]Beith A, Eichler R, Weil D: Worldwide: Incentives for Tuberculosis Diagnosis and Treatment. Center for Global Development. http://www.cgdev.org/doc/books/PBI/12_CGD_Eichler_Levine-Ch12.pdf webcite
• [73]Cai J, Chen X: Project description. In A Model of Tuberculosis Control in China. Final Evaluation Report on Tuberculosis Control under the World Bank Loaned China Infectious and Endemic Disease Control Project. Edited by Cai J, Chen X. Beijing: People’s Medical Publishing House; 2003.
• [74]Lin W, Liu GG, Chen G: The urban resident basic medical insurance: a landmark reform towards universal coverage in China. Health Econ 2009, 18:S83-S96.
• [75]Department of Disease Control of Ministry of Health: Guideline on Enforcement of Chinese Tuberculosis Control Program. Beijing, China: Ministry of Health; 2008.
• [76]Lu H, Yan F, Wang W, Wu L, Ma W, Chen J, Shen X, Mei J: Do transportation subsidies and living allowances improve tuberculosis control outcomes among internal migrants in urban Shanghai, China? West Pac Surveillance Response J 2013, 4:19-24.
• [77]Jia Z, Cheng S, Wang L: Tuberculosis control in China: striving for sustainability. Lancet 2012, 379:2149.