Determinants of delayed diagnosis and treatment of tuberculosis in high-burden countries: a mixed-methods systematic review and meta-analysis

Abstract

Background: Globally, 30 countries with the highest tuberculosis (TB) burden bears 87% of the world’s TB cases. Delayed diagnosis and treatment are detrimental to TB prognosis and sustain TB transmission in the community, making TB elimination a great challenge, especially in these countries. Our objective was to elucidate the determinants and duration of delayed diagnosis and treatment of pulmonary TB in high TB burden countries. Methods: We conducted a systematic review and meta-analysis of quantitative and qualitative studies by searching four databases for literature published between 2008 and 2018 following PRISMA guidelines. For quantitative studies, we performed narrative synthesis of the covariates that were significantly associated with patient, health system, treatment, and total delays. The pooled median duration of delay and effect sizes of covariates were estimated using random-effects meta-analyses. We identified key qualitative themes using thematic analysis. Results: We included 124 articles from 14 low-and lower-middle-income countries (LIC and LMIC) and five upper-middle-income countries (UMIC) in this review. The pooled median duration of patient, health system, and treatment delay were 28 days (95%CI 20–30), 11.5 days (95%CI 3.9–24.7), and six days (95%CI 1–28.4), respectively. We found that the duration of delays was consistently shorter among UMIC compared to LIC and LMIC. There was consistent evidence that being female and rural residence was associated with longer patient delay. Furthermore, patient delay was also associated with other individual, interpersonal, and community risk factors such as poor TB knowledge, long chains of care-seeking through private/multiple providers, perceived stigma, financial insecurities, and poor access to healthcare. Health system and treatment delay were mediated by organizational and policy factors. These factors included the lack of resources and complex administrative procedures and systems at the health facilities. We identified data gaps in 11 high burden countries. Conclusions: This review detailed the determinants of delayed TB diagnosis and treatment in high burden countries. The gaps identified at different socio-ecological levels could be addressed through tailored approaches, education, and at a higher level, through health system strengthening and provision of universal health coverage to reduce delays and improve access to TB diagnosis and care.

Barriers That Interfere with Access to Tuberculosis Diagnosis and Treatment across Countries Globally: A Systematic Review

“…The male participants sought treatment and diagnosis less because of alcohol consumption and overt ego, confining symptoms for a long period. This agrees with the study by Teo et al, who found that women are simultaneously committed to many tasks that keep them away from personal healthcare, while men are patriarchal and therefore downplay healthcare. Health awareness tailored toward the specific need of each gender should be carried out, with focus on vulnerable populations.…”

Characterizing and Measuring Tuberculosis Stigma in the Community: A Mixed-Methods Study in Cambodia

“…Despite the effect of stigma on delayed TB diagnosis [ 7 ], IDI participants also reported that encouragements from family members, friends, and notably TB survivors were instrumental in facilitating TB care-seeking. One apparent link to the current TB policy in Cambodia was the implementation of the community directly observed treatment, short-course (C-DOTS).…”

Determinants of delayed diagnosis and treatment of tuberculosis in Cambodia: a mixed-methods study

“…Therefore, understanding the specific determinants of delayed diagnosis can be used as a practical guide to enhance outreach programs, increase community engagement to reach missing cases, and to improve TB control strategies. Recent systematic reviews have reported empirical evidence associating socio-demographic, clinical, health system, and economic factors with delayed diagnosis and treatment of TB [8][9][10]. In Cambodia, Sundaram and colleagues have reported that strong preference for private healthcare services, lack of awareness of TB symptoms, and misbeliefs regarding TB (such as TB is a hereditary disease and the ability to recover without treatment) may delay seeking TB diagnosis [11].…”