Delays to anti-tuberculosis treatment intiation among cases on directly observed treatment short course in districts of southwestern Ethiopia: a cross sectional study

Abstract

Background Delayed tuberculosis (TB) diagnosis and treatment increase morbidity, mortality, expenditure, and transmission in the community. This study assessed patient and provider related delays to diagnosis and treatment of TB. Methods A cross-sectional study was conducted among 735 new adult TB cases registered between January to December 2015 in 10 woredas equivalent to districts of southwestern Ethiopia. Data were collected through face-to-face interview of patients within the first 2 months of treatment initiation. Delay in days was tracked at three intervals: between onset of symptoms and self-presentation (Patient delay), Self-presentation to treatment initiation (Provider delay) and total delay. Days elapsed beyond median were used to define the delays. Bivariate and multiple logistic regression models were fit to identify predictors of delays and statistical significance was judged at p < 0.05. Result The median (inter-quartile range) of patient, provider and total delays were 25 (IQR;15–36), 22 (IQR:9–48) and 55 (IQR:32–100) days, respectively. More than half (54.6%) of the total delay was attributed to health system. Prior self-treatment [adjusted Odds Ratio (aOR)]: 1.72, 95% confidence interval [CI]:1.07–2.75), HIV co-infection (aOR:1.8, 95% CI: 1.05–3.10) and extra-pulmonary TB (aOR: 1.54,95% CI:1.03–2.29) were independently associated with increased odds of patient delay. On the other hand initial presentation to health posts or private clinics (aOR: 1.42, 95% CI: 1.01, 2.0) and patient delay (aOR: 1.81, 95% CI: 1.33–2.50) significantly predicted longer provider delay. Finally, having extra pulmonary TB (aOR: 1.6, 95% CI: 1.07–2.38), prior consultation of traditional healer (aOR: 3.72, 95% CI: 1.01–13.77) and use of holy water (aOR: 2.73, 95% CI: 1.11, 6.70) independently predicted longer total delay. Conclusion Tuberculosis patients waited too long time to initiate anti-TB treatment reflecting longer periods of morbidity and disease transmission. The delays are attributed to the patient, disease and health system related factors. Hence, improving community awareness, involving informal providers, health extension workers and TB treatment supporters can reduce the patient delay. Similarly, cough screening and improving diagnostic efficiencies of healthcare facilities should be in place to reduce the provider delays. Electronic supplementary material The online version of this article (10.1186/s12879-019-4089-x) contains supplementary material, which is available to authorized users.

Factors associated with treatment initiation delay among new adult pulmonary tuberculosis patients in Tigray, Northern Ethiopia

“…Being primary health center and private clinic was associated with higher odds of patient delay. This is similar to studies in Ethiopia [17,18], and Africa [33] but contrary to study from Ethiopia [30]. This is mainly due to low reliance or confidence of the patients on the lower health facilities as only about 35.2% of the health facility consulted patients had confidence in curing their illness at the lower health facilities (health centers) in this study.…”

“…Repeated visits to the lower health facilities (health centers and private clinic) were strongly associated with health system delay which is similar with studies done in Ethiopia [17], and Africa [24]. This might be due to the poor identification of TB patients by the health professionals as indicated in a recent study from Ethiopia where one third and nearly half of health care workers of public health facilities had poor knowledge and unsatisfactory practice on the management of tuberculosis infection [39].…”

“…In Ethiopia, delay varies from 60-120 days from onset of symptoms till initiation of treatment [8,11] with median patient delay of 20-90 days [8,12,13] and provider delay of 6-34 days [8,13,14]. Risk factors for delay include rural residence [15], lower educational level [16,14], being women, large family size, and stigma [16], being old age [15], first visit to non-formal health providers [14], first visit to health posts [6] and form of TB [15,16,17].…”

Knowledge, attitude and practice towards tuberculosis in Gambia: a nation-wide cross-sectional survey

“…Delays in case detection, notification and treatment are known to be associated with poor perception of and confidence in available health care facilities and staff; stigma and poor knowledge of TB including misconceptions regarding transmission and prevention [2,[13][14][15][16][17][18][19][20]. Care seeking behaviour has been shown to be influenced by knowledge about the symptoms and signs of TB [20][21][22][23]. Thus, interventions to address these societal or community-level factors are required to improve or contribute to TB case detection and treatment success.…”

Delay in treatment initiation and its association with clinical severity and infectiousness among new adult pulmonary tuberculosis patients in Tigray, northern Ethiopia

“…In Ethiopia the median TB patient's treatment initiation varies from settings to settings including 36 days in Desie [17], 28 days in Arsi [18], 90 days in Tigray [19], 97 days in East Wollega [20] and 80 days in Afar region [13].. The median health system and patient delays were 22 and, 30 days in the Amhara region [21,22], 22 and 25 days in the southern region [23], 9, and 30 days in the Tigray region [19,24]. However, there is limited evidence on the association of treatment initiation delay with clinical severity and level of infectiousness in Ethiopia and elsewhere.…”