Barriers to Completing TB Diagnosis in Yemen: Services Should Respond to Patients' Needs

Abstract

Objectives and BackgroundObtaining a diagnosis of tuberculosis (TB) is a prerequisite for accessing specific treatment, yet one third of estimated new cases are missed worldwide by National Programmes. This study investigated economic, geographical, socio-cultural and health system factors hindering adults' attendance and completion of the TB diagnostic process in Yemen, to inform interventions designed to improve patient access to services.MethodologyThe study employed a mixed methods design comprising a cross-sectional survey and In-Depth-Interviews (IDIs) and Focus Group Discussions (FGDs) among patients abandoning the diagnosis or registering for treatment. Adults with cough of ≥2 weeks attending a large governmental referral centre in Sana'a, Yemen, between 2009 and 2010, were eligible to participate.Results497 and 446 (89.7%) participants were surveyed the first and second day of attending the services and 48 IDIs and 12 FGDs were also conducted. The majority of patients were disadvantaged and had poor literacy (61% illiterate), had travelled from rural areas (47%) and attended with companions (84%). Key barriers for attendance identified were clinic and transport costs (augmented by companions), distance from home, a preference for private services, strong social stigma and a lack of understanding of the diagnostic process. There were discrepancies between patient- and doctor-reported diagnosis and 46% of patients were unaware that TB treatment is free. Females faced more difficulties to attend than men. The laboratory practice of providing first-day negative smear results and making referrals to the private sector also discouraged patients from returning. Strategies to bring TB diagnostic services closer to communities and address the multiple barriers patients face to attend, will be important to increase access to TB diagnosis and care.

Evaluation of tuberculosis defaulters in Yemen from the perspective of health care service

“…The low socioeconomic status of Yemen makes travel cost a major barrier to undergoing treatment. A recent study performed in Yemen reported that travel cost acted as a major constraint in the diagnosis and continued treatment of patients, particularly those living in rural areas . Similar deductions have been reported in earlier studies performed in other developing countries .…”

“…The results show that living in rural areas is a main risk factor associated with TB treatment defaulting. The majority of TB patients travel from rural areas to urban areas for proper diagnosis and treatment due to the shortage of laboratory and health facilities in rural areas . This high percentage of defaulters from rural areas can be due to the poor economic situation in these areas and the low education level of defaulters from these areas .…”

“…Despite such increase, Yemen discloses no capacity or link to any partner laboratory for second‐line Drug Susceptibility Testing (DST) . Few studies have evaluated TB treatment default in Yemen . Moreover, the available studies did not identify constraints in TB treatment as well as the timing of default.…”

Are patients with pulmonary tuberculosis who are identified through active case finding in the community different than those identified in healthcare facilities?

“…An important proportion of these cases are missed because individuals with symptomatic TB fail to seek medical advice for various reasons. The nonspecific presentation of TB, an expectation that symptoms will improve spontaneously and factors such as widespread stigma and misunderstanding about TB can delay or prevent individuals from seeking health services [3], [4]. A further significant barrier to diagnosis is the high transport costs that may arise from multiple visits required for diagnosis [3], [4].…”

“…The nonspecific presentation of TB, an expectation that symptoms will improve spontaneously and factors such as widespread stigma and misunderstanding about TB can delay or prevent individuals from seeking health services [3], [4]. A further significant barrier to diagnosis is the high transport costs that may arise from multiple visits required for diagnosis [3], [4]. Missed or delayed TB diagnoses may lead to poorer individual outcomes and prolonged transmission, and it limits the impact of TB control measures [5].…”