SummaryTo measure time to initial presentation and assess factors influencing the decision to seek medical attention, we interviewed 243 patients undergoing sputum examination for the diagnosis of tuberculosis (TB) at a rural health centre near Awassa, Ethiopia. A structured questionnaire was used. Median (mean + SD) patient delay was 4.3 (9.8 + 12.4) weeks. Delays over 4 weeks were significantly associated with rural residence, transport time over 2 h, overnight travel, transport cost exceeding US$1.40, having sold personal assets prior to the visit, and use of traditional medicine. The majority of patients cited economic or logistical barriers to health care when asked directly about causes of delay. Case-finding strategies for TB must be sensitive to patient delay and health systems must become more accessible in rural areas.

Setting. Ethiopia, Nepal, Nigeria, and Yemen. Objective. To reduce the time to complete sputum microscopy. Design. Cross-sectional surveys enrolling 923 patients with chronic cough in the 4 countries and using similar protocols. Spot-morning-spot sputum specimens were collected. An additional sputum specimen (Xspot) was collected one hour after the first, and the yields of the first two or the three specimens collected as spot-morning-spot or spot-Xspot-morning were compared. Results. 216 patients had ≥ one positive smear. 210 (97%) were identified by the spot-morning-spot, and 210 (97%) were identified by the spot-Xspot-morning specimens, with 203 and 200 identified by the first 2 specimens of each approach, respectively. Neither difference was significant. Conclusions. The time to complete smear microscopy could be reduced.

Summaryobjectives (i) To determine patient delay -the time from the onset of symptoms to presentation at a health facility -and its causes in patients undergoing sputum smear examination in Cameroon; and (ii) to compare the results with those of a previous study in Ethiopia.methods A cross-sectional study of 243 consecutive patients using a structured questionnaire. results Median (interquartile range) patient delay in Cameroon was 2.0 (1-4) weeks, shorter than the 4.3 (2-13) week delay in Ethiopia. Significantly fewer patients delayed more than 1, 2 and 3 months in Cameroon than in Ethiopia (P < 0.001). Delays in Cameroon were significantly associated with being the main income earner, the belief that TB is stigmatizing, and the use of traditional medicine -the latter being the only factor significant in both studies.conclusion Engaging traditional healers in TB control programs and reducing stigma through education could help to reduce patient delays, accelerate diagnosis, improve clinical outcomes and reduce disease transmission. These results, when placed in context of national human development indices, suggest that economic development, investment in health care and literacy may all be involved in improving access to TB services in sub-Saharan Africa.

It could be possible to diagnose TB in a single day by examining two spot specimens, but the feasibility needs to be confirmed on a larger scale.

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