Delays and barriers to early treatment initiation for childhood tuberculosis in India

Abstract

BACKGROUND: India accounts for 27% of global childhood tuberculosis (TB) burden. Understanding barriers to early diagnosis and treatment in children may improve care and outcomes.METHODS: A cross-sectional study was performed among 89 children initiated on anti-TB treatment from a public hospital in Pune during 2016, using a structured questionnaire and hospital records. Health care providers (HCPs) were defined as medical personnel consulted about the child's TB symptoms. Time-to-treatment initiation (TTI) was defined as the number of days between onset of TB symptoms and anti-TB treatment initiation. Based on Revised National TB Control Programme recommendations, delayed TTI was defined as >28 days.RESULTS: Sixty-seven (75%) of 89 enrolled children had significant TTI delays (median 51 days, interquartile range [IQR] 27–86). Sixty-six (74%) children visited 1–8 HCPs in the private sector before approaching the public sector. The median HCP delay was 28 days (IQR 10–75). Bacille Calmette-Guérin vaccination (aOR 10.96, P = 0.04) and loss of appetite (aOR 4.44, P = 0.04) were associated with delayed TTI.CONCLUSION: The majority of the children had TTI delays due to delays by HCPs in the private sector. Strengthening HCP competency in TB symptom screening and encouraging early referrals are crucial for rapid scaling up of early treatment initiation in childhood TB.

Contributing Factors in the Tuberculosis Care Cascade in India: A Systematic Literature Review

“…The most contributing factors that were documented at the health workforce level are overburdened manpower working in the TB program, 20 inappropriate referral by private providers, 17 , 22 unqualified practitioners considered as informal providers, 19 delay in referral for TB diagnosis from the private facilities, 10 , 19 , 26 inadequate trained manpower, 27 misinterpretation of provisional diagnosis, 26 etc. In addition to it, the health-care staff attitude and behaviour 21 , 24 , 26 and poor counseling capacities 18 , 21 were also found to be a risk factor such as health-care providers not explaining problems of stopping the medicine, or inappropriate attitude of the providers leading to the misconception or delays in care-seeking. This signifies that managerial and psychological skills are equally important in addition to the technical issues of human resources, lab diagnosis capacity, or the providers’ knowledge.…”

“…Among the demand-side factors, ignoring symptoms/hope that symptoms would go away on their own (denial and concealment), 19 self-medication/self-treating symptoms from nearby private chemists/home remedies or use of traditional healer, 19 , 24 , 26 , 33 , 39 , 42 lack of awareness about the disease and the services, 24 poor socio-economic conditions, 24 , 26 , 33 fear to get diagnosed or fears for social isolation, 26 addictions 26 , 28 , 33 and migration 42 mostly contribute towards the patient delay. Similarly, factors like visit to multiple health-care providers, 19 , 24 , 26 , 33 previous expenditure 43 or financial constraint, 26 access/residing in a non-DMC/PHI area, 35 refusal/self-medications, 26 denial 26 , 42 and migration 26 are among other demand-side factors evidenced for the diagnostic delay of the care cascade. From the system-side factors, in-appropriate provisional diagnosis/screening, 24 , 26 cross-referral issues and especially from the informal providers, 19 , 26 , 39 improper advising for relevant tests for diagnosis of TB 26 and delayed collection of reports of sputum microscopy 42 found to be significant contributing factors.…”

“…Similarly, factors like visit to multiple health-care providers, 19 , 24 , 26 , 33 previous expenditure 43 or financial constraint, 26 access/residing in a non-DMC/PHI area, 35 refusal/self-medications, 26 denial 26 , 42 and migration 26 are among other demand-side factors evidenced for the diagnostic delay of the care cascade. From the system-side factors, in-appropriate provisional diagnosis/screening, 24 , 26 cross-referral issues and especially from the informal providers, 19 , 26 , 39 improper advising for relevant tests for diagnosis of TB 26 and delayed collection of reports of sputum microscopy 42 found to be significant contributing factors.…”

“…Similarly, at the treatment level delay, among others provider’s poor patient-centric behaviour, 26 referral by the diagnostic provider to another provider for the initiation of treatment, 26 delay in reporting, 42 giving long periods of symptomatic treatment to patients 26 and among demand-side factors; multiple visits before initiation of treatment, 24 , 26 , 37 , 44 migration, 26 , 42 , 43 physical access to a health facility 36 found to be major contributing factors. Figure 2 summarizes all the factors (both system and demand-side) that contributed to different phases of delay in the care cascade.…”

Impact of the Fogarty Training Program on Trainee and Institutional Research Capacity Building at a Government Medical College in India

“…Encouragingly, the program facilitated identification of ground-up capacity strengthening needs that resulted in regular TB screening of medical students and publication of these findings in international peer-reviewed journals. On the other hand, the Group 2 scholars undertook research in alternative priority domains, such as childhood tuberculosis [19] and child contact screening with isoniazid preventive treatment [20].…”