Why are tuberculosis patients not treated earlier? A study of informal health practitioners in Bangladesh

Rifat, Mahfuza; Rusen, I. D.; Islam, Md. Akramul; Da, Enarson; Ahmed, Faheem; Ahmed, S. M.; Karim, Farina

doi:10.5588/ijtld.10.0205

Cited by 26 publications

(34 citation statements)

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“…This behaviour can cause a marked delay in starting appropriate TB medication, given the fact that TB medication in line with the NTP guideline is seldom present in the informal health sector. This has been observed in earlier studies from Bangladesh 4. Our study adds the important finding that this preference of the informal sector persists throughout the care seeking trajectory.…”

Section: Discussionsupporting

confidence: 86%

Care seeking in tuberculosis: results from a countrywide cluster randomised survey in Bangladesh

et al. 2014

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ObjectivesTo explore systematically the care seeking trajectories of tuberculosis (TB) cases up to four subsequent places of care and to assess the type of services provided at each place.MethodsTB cases detected actively during the 2007–2009 national TB prevalence survey and passively under the routine programme in the same period were interviewed by administering a standardised questionnaire. Care seeking and services provided up to four subsequent points were explored. Care seeking was further explored by categorising the providers into formal, informal and ‘self-care’ groups.ResultsA total of 273 TB cases were included in this study, of which 33 (12%) were detected during the survey and 240 (88%) from the TB registers. Out of the 118 passively detected cases who first sought care from an informal provider, 52 (44.1%) remained in the informal sector at the second point of care. Similarly, out of the 52, 17 (32.7%) and out of the 17, 5 (29.4%) remained in the informal sector at the third and fourth subsequent points of care, respectively. All the 33 actively detected cases had ‘self-care’ at the first point, and 27 (81.8%) remained with ’self-care’ up to the fourth point of care. Prescribing drugs (59–99%) was the major type of care provided by the formal and informal care providers at each point and was limited to the non-existent practice of investigation or referrals.ConclusionsFree TB services are still underutilised by TB cases and informal caregivers remained the major care providers for such cases in Bangladesh. In order to improve case detection, it is necessary that the National Tuberculosis Programme immediately takes effective initiatives to engage all types of care providers, particularly informal providers who are the first point of care for the majority of the TB suspects.

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Section: Discussionsupporting

confidence: 86%

Care seeking in tuberculosis: results from a countrywide cluster randomised survey in Bangladesh

et al. 2014

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“…12,21-23 However, we did not fi nd any signifi cant associations between sex and treatment delay in our study. The fi ndings from our study are consistent with those of another study conducted in Bangladesh, 7 in which the researchers found no signifi cant association between sex and treatment delay. Another contradictory fi nding was the association of informal health care with treatment delay.…”

Section: Other Findingssupporting

confidence: 83%

“…In that study, 52% of patients with treatment delays consulted informal providers fi rst (Pearson χ 2 , P < 0.05). 7 However, in our study, no signifi cant association was found between informal health care providers and treatment delays. In the study by Rifat et al, respondents were recruited from both urban and rural areas.…”

Section: Other Findingscontrasting

confidence: 49%

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Factors associated with treatment delay among tuberculosis patients referred from a tertiary hospital in Dhaka City: a cross-sectional study

Htike¹,

Islam

Hasan

et al. 2013

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“…Most of these deaths reflect diagnosis that is either delayed, missed, or never attempted. Strategies for improving TB diagnosis generally take one of three forms: (1) improvement of the "passive" diagnostic system (e.g., deploying new diagnostic tools, such as Xpert MTB/RIF [5,6] for diagnosis of people who present with TB symptoms); (2) "enhanced" diagnosis that aims to reduce delays in diagnosis for patients with recognizable symptoms, such as community awareness campaigns (7) and improved access to TB diagnostic services (8); and (3) "active" strategies that do not rely on patient presentation (e.g., household surveys [9], contact investigations [10]). The factors that determine the comparative effectiveness of these strategies in reducing populationlevel TB incidence remain largely unknown.…”

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confidence: 99%

Is Passive Diagnosis Enough?

Dowdy

Basu

Andrews

2013

Am J Respir Crit Care Med

103

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Rationale: Tuberculosis (TB) is characterized by a subclinical phase (symptoms absent or not considered abnormal); prediagnostic phase (symptoms noticed but diagnosis not pursued); and clinical phase (care actively sought). Diagnostic capacity during these phases is limited. Objectives: To estimate the population-level impact of TB casefinding strategies in the presence of subclinical and prediagnostic disease. Methods: We created a mathematical epidemic model of TB, calibrated to global incidence. We then introduced three prototypical diagnostic interventions: increased sensitivity of diagnosis in the clinical phase by 20% ("passive"); early diagnosis during the prediagnostic phase at a rate of 10% per year ("enhanced"); and population-based diagnosis of 5% of undiagnosed prevalent cases per year ("active"). Measurements and Main Results: If the subclinical phase was ignored, as in most models, the passive strategy was projected to reduce TB incidence by 18% (90% uncertainty range [UR], 11-32%) by year 10, compared with 23% (90% UR, 14-35%) for the enhanced strategy and 18% (90% UR, 11-28%) for the active strategy. After incorporating a subclinical phase into the model, consistent with population-based prevalence surveys, the active strategy still reduced 10-year TB incidence by 16% (90% UR, 11-28%), but the passive and enhanced strategies' impact was attenuated to 11% (90% UR, 8-25%) and 6% (90% UR, 4-13%), respectively. The degree of attenuation depended strongly on the transmission rate during the subclinical phase. Conclusions: Subclinical disease may limit the impact of current diagnostic strategies for TB. Active detection of undiagnosed prevalent cases may achieve greater population-level TB control than increasing passive case detection.Keywords: tuberculosis; diagnostic techniques and procedures; models; theoretical; epidemiology Improved diagnosis is a cornerstone of current efforts to control tuberculosis (TB) (1). For the last 15 years, the World Health Organization (WHO) and Stop TB Partnership have focused on improving TB case detection and treatment success, in part because key mathematical models predicted that meeting these targets would result in improved disease control (2). Although the directly observed therapy, short-course strategy has been scaled up globally and has saved more than 1 million lives (3), 1.4 million people still die every year from TB (4). Most of these deaths reflect diagnosis that is either delayed, missed, or never attempted. Strategies for improving TB diagnosis generally take one of three forms: (1) improvement of the "passive" diagnostic system (e.g., deploying new diagnostic tools, such as Xpert MTB/RIF [5,6] for diagnosis of people who present with TB symptoms); (2) "enhanced" diagnosis that aims to reduce delays in diagnosis for patients with recognizable symptoms, such as community awareness campaigns (7) and improved access to TB diagnostic services (8); and (3) "active" strategies that do not rely on patient presentation (e.g., household surveys [9], contact in...

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Why are tuberculosis patients not treated earlier? A study of informal health practitioners in Bangladesh

Abstract: Patients seeking care from informal practitioners access care more promptly, but have prolonged delays in initiating treatment. Further investigation on how to involve these practitioners in the programme should be evaluated.

Cited by 26 publications

References 0 publications

Care seeking in tuberculosis: results from a countrywide cluster randomised survey in Bangladesh

Care seeking in tuberculosis: results from a countrywide cluster randomised survey in Bangladesh

Factors associated with treatment delay among tuberculosis patients referred from a tertiary hospital in Dhaka City: a cross-sectional study

Is Passive Diagnosis Enough?

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