Delayed consultation among pulmonary tuberculosis patients: a cross sectional study of 10 DOTS districts of Ethiopia

<p>Abstract</p> <p>Background</p> <p>Delays seeking care increase transmission of pulmonary tuberculosis and hence the burden of tuberculosis, which remains high in developing countries. This study investigates patterns of health seeking behavior and determines risk factors for delayed patient consultation at public health facilities in 10 districts of Ethiopia.</p> <p>Methods</p> <p>New pulmonary TB patients ≥ 15 years old were recruited at 18 diagnostic centres. Patients were asked about their health care seeking behaviour and the time from onset of symptoms to first consultation at a public health facility. First consultation at a public health facility 30 days or longer after onset of symptoms was regarded as prolonged patient delay.</p> <p>Results</p> <p>Interviews were held with 924 pulmonary patients. Of these, 537 (58%) were smear positive and 387 (42%) were smear negative; 413 (45%) were female; 451 (49%) were rural residents; and the median age was 34 years. Prior to their first consultation at a public health facility, patients received treatment from a variety of informal sources: the Orthodox Church, where they were treated with holy water (24%); private practitioners (13%); rural drug vendors (7%); and traditional healers (3%). The overall median patient delay was 30 days (mean = 60 days). Fifty three percent [95% Confidence Intervals (CI) (50%, 56%)] of patients had delayed their first consultation for ≥ 30 days. Patient delay for women was 54%; 95% CI (54%, 58%) and men 51%; 95% CI (47%, 55%). The delay was higher for patients who used informal treatment (median 31 days) than those who did not (15 days). Prolonged patient delay (≥ 30 days) was significantly associated with both patient-related and treatment-related factors. Significant patient-related factors were smear positive pulmonary disease [Adjusted Odds Ratio (AOR) 1.4; 95% CI (1.1 to 1.9)], rural residence [AOR 1.4; 95% CI (1.1 to 1.9)], illiteracy [AOR 1.7; 95% CI (1.2 to 2.4)], and lack of awareness/misperceptions of causes of pulmonary TB. Significant informal treatment-related factors were prior treatment with holy water [AOR 3.5; 95% CI (2.4 to 5)], treatment by private practitioners [AOR 1.7; 95% CI (1.1 to 2.6)] and treatment by drug vendors [AOR 1.9; 95% CI (1.1 to 3.5)].</p> <p>Conclusion</p> <p>Nearly half of pulmonary tuberculosis patients delayed seeking health care at a public health facility while getting treatment from informal sources. The involvement of religious institutions and private practitioners in early referral of patients with pulmonary symptoms and creating public awareness about tuberculosis could help reduce delays in starting modern treatment.</p

Cost implications of delays to tuberculosis diagnosis among pulmonary tuberculosis patients in Ethiopia

<p>Abstract</p> <p>Background</p> <p>Delays seeking care worsen the burden of tuberculosis and cost of care for patients, families and the public health system. This study investigates costs of tuberculosis diagnosis incurred by patients, escorts and the public health system in 10 districts of Ethiopia.</p> <p>Methods</p> <p>New pulmonary tuberculosis patients ≥ 15 years old were interviewed regarding their health care seeking behaviour at the time of diagnosis. Using a structured questionnaire patients were interviewed about the duration of delay at alternative care providers and the public health system prior to diagnosis. Costs incurred by patients, escorts and the public health system were quantified through patient interview and review of medical records.</p> <p>Results</p> <p>Interviews were held with 537 (58%) smear positive patients and 387 (42%) smear negative pulmonary patients. Of these, 413 (45%) were female; 451 (49%) were rural residents; and the median age was 34 years. The mean (median) days elapsed for consultation at alternative care providers and public health facilities prior to tuberculosis diagnosis was 5 days (0 days) and 3 (3 days) respectively. The total median cost incurred from first consultation to diagnosis was $27 per patient (mean =$59). The median costs per patient incurred by patient, escort and the public health system were $16 (mean =$29), $3 (mean =$23) and $3 (mean =$7) respectively. The total cost per patient diagnosed was higher for women, rural residents; those who received government food for work support, patients with smear negative pulmonary tuberculosis and patients who were not screened for TB in at least one district diagnostic centers.</p> <p>Conclusions</p> <p>The costs of tuberculosis diagnosis incurred by patients and escorts represent a significant portion of their monthly income. The costs arising from time lost in seeking care comprised a major portion of the total cost of diagnosis, and may worsen the economic position of patients and their families. Getting treatment from alternative sources and low index of suspicion public health providers were key problems contributing to increased cost of tuberculosis diagnosis. Thus, the institution of effective systems of referral, ensuring screening of suspects across the district public health system and the involvement of alternative care providers in district tuberculosis control can reduce delays and the financial burden to patients and escorts.</p

Primary health care in practice: A study in Mozambique

This study investigates the delivery of all aspects of Primary Health Care (PHC) in a case study of one urban health centre in Maputo, Mozambique. Within the context of overall social and economic change, Mozambique has given priority to primary health care as the driving force in its newly developed National Health Service. The urban and rural health centres are intended to be the principal vehicles for PHC delivery, and in this study one of Maputo's recently opened health centres was investigated by observing all clinic sessions, interviewing all health centre workers and collecting data from health centre records. It was found that a dichotomy exists between the tasks ascribed to the health centre in the PHC framework, and the feasibility of their execution given existing personnel and material resources. This derives in part from lack of involvement of PHC practitioners in the organisation and planning of PHC, plus resource allocation which remains in favour of secondary and tertiary rather than primary care. Prevention is accorded priority in PHC theory, yet investigation showed that the major demand on the health centre is for curative care. The quality of both curative and preventive care was evaluated and the need for training in specialist diagnostic skills, and a more socially-based understanding of the determinants of health status and risk emerged, respectively for the groups of workers in the two sectors. The level of contact between the curative and preventive sectors was investigated as was the integration of the health centre into the health service as a whole. The problems arising in these areas must be viewed in the context of the very recent development of a National Health Service in a country where, previously, curative care was available only in urban areas and virtually no preventive programmes existed. This study shows that significant steps are being taken to develop a comprehensive PHC programme in Maputo. More important still will be the extension of this level of care provision to the country as a whole.

The quality of tuberculosis diagnosis in districts of Tigray region of Northern Ethiopia

Background: Low detection of smear-positive and over-diagnosis of smear-negative Pulmonary Tuberculosis (PTB) are major problems in Ethiopia. Non-adherence to diagnostic guidelines could be contributing to the poor detection of tuberculosis. Objective: To assess the quality of diagnosis based on the national tuberculosis guidelines.Methods: A retrospective diagnostic audit was made in eight districts among patients aged 815 years that were on TB treatment between 12/10/2001 and 15/05/2002. A team of three physicians reviewed patient charts, sputum microscopy and radiograph registers to assess diagnostic criteria used to each patient. Results: A total of 237 patients were reviewed: 42 were smear-positive, 101 were smear-negative PTB and 94 were extra-pulmonary tuberculosis. The diagnosis was considered correct in 33 of the 42 smear-positive PTB patients and incorrect in 9 patients. Of 101 smear-negative PTB patients, 31 (31%) were diagnosed as per the national diagnostic guideline. In more than half of patients treated for lymph node tuberculosis their diagnosis was inconsistent with the national diagnostic guideline.Conclusion: Non-adherence to the national guidelines is a major problem in district hospitals. This calls for action to promote clinicians' adherence to the national diagnostic guidelines.The Ethiopian Journal of Health Development Vol. 19 2005: 13-2

Community knowledge, attitudes and practices on pulmonary tuberculosis and their choice of treatment supervisor in Tigray, Northern Ethiopia

Background: We planned to raise public awareness and decentralize directly observed tuberculosis treatment at village level using volunteer community members in order to reduce prolonged delays in seeking care and improve compliance to tuberculosis treatment. We do not know the magnitude of tuberculosis knowledge gap and preferred modality of tuberculosis treatment supervision among the public in Tigray. Objectives: To assess knowledge of pulmonary tuberculosis and to determine level of acceptance regarding villagebased tuberculosis treatment using volunteers among the general public.Method: A cross sectional survey was conducted among 838 adults (915 years) in 8 districts of Tigray region. Respondents selected from 70 villages using a multistage cluster sampling technique were interviewed using a pre-tested questionnaire in July 2002. Result: The mean and median knowledge score of respondents about pulmonary tuberculosis (PTB) was 5.24 and 6.67 (maximum score of 10) respectively. Female respondents (Adjusted Odds Ratio (AOR)=1.86; 95% Confidence interval (CI)=1.39-2.47), illiterates (AOR=1.64; 95% CI=1.1-2.47) and rural residents (AOR=1.95; 95% CI=1.37- 2.76) were more likely to have a low level of knowledge score. Among respondents who had prior knowledge of PTB (n=717), 599 (83.5%) accepted the idea of tuberculosis (TB) treatment by volunteer community members. Illiterates, rural residents, married and respondents with large family size were more likely to support supervised TB-treatment using volunteers. Respondents' preferred treatment supervisors were: volunteer community health workers (60%), public health staff (16.5%) and family members (12.7%).Conclusion: There is a wide knowledge gap among the public regarding PTB. The idea of organizing directly observed TB treatment using volunteers appears to be accepted. The Ethiopian Journal of Health Development Vol. 19 2005: 21-2

Delays and care seeking behavior among tuberculosis patients in Tigray of Northern Ethiopia

Background: Delayed initiation of treatment among tuberculosis patients is a common problem which might contribute to the high burden of tuberculosis in Ethiopia. There is paucity of evidence on the magnitude of delay and why patients fail to seek modern care early in Tigray. Objectives: To assess patient and health service delays and factors for delay among tuberculosis patients. Methods: Adult tuberculosis patients who began treatment (12/10/2001-15/05/2002) in 47 public health institutions were interviewed using a pre-tested questionnaire to gather information about their health seeking behaviour. Patient charts were also reviewed to determine the magnitude of delays. Result: The median patient delay for 42 pulmonary smear positive, 101 pulmonary smear negative and 94 extra-pulmonary tuberculosis patients was 90 days, 60 days and 90 days respectively, while the overall median health service delay was 9 days. Delayed first consultation (>21 days since onset of illness) was significantly higher among patients with no formal education (Adjusted Odds Ratio (AOR)=2.46; 95%Confidence Interval (CI)=1.21-5.01), among those treated first by a private and/or traditional practitioner (AOR=2.9; 95% CI=1.42-6.08), among those who thought their illness not serious (AOR=2.39; 95% CI= 1.52-3.78) and among those who suspected they had tuberculosis (AOR=2.5; 95% CI=1.18-5.29). Conclusion: This unacceptably long patient delay calls for identification and inclusion of feasible strategies to promote early treatment in the national tuberculosis control program. The Ethiopian Journal of Health Development Vol. 19 2005: 7-1