Delays are still a challenge in Tuberculosis control-Cross-sectional study from South India

Back ground: Delays are important challenges in tuberculosis control and a number of socio demographic and healthcare system factors are associated with them. The study objectives were to quantify delays and associated factors in healthcare seeking and treatment initiation in tuberculosis patients. Methods and materials: The study was conducted in a Tuberculosis Unit (TU) in Tamil Nadu, India. Seventy eight individuals who had tuberculosis were interviewed. Delay in healthcare seeking was defined as more than 2 weeks (interval between onset of symptom to healthcare seeking) and delay in treatment initiation was defined as more than 1 week (interval between healthcare seeking to treatment initiation). Prevalence of delays was calculated. Odds ratios were calculated for plausible risk factors for delays and binary logistic regression was done. Results: Median interval was 15 days (IQR: 7 to 30 days) for healthcare seeking and 4 days (IQR: 3 to 8 days) for treatment initiation. Prevalence of delay was 51.3% for healthcare seeking and 26.9% for treatment initiation. Lower educational status (adjusted OR4.506, p-value: 0.015) and rural residence (adjusted OR3.748, p-value: 0.013) were significantly associated with delay in healthcare seeking. Extra-pulmonary tuberculosis (adjusted OR5.620, p-value: 0.013) was significantly associated with delay in treatment initiation. Conclusions: Delays were still a problem in tuberculosis control. Rural residence and lower educational status are barriers for healthcare seeking. Improvement of rural infrastructure may help to reduce delay in healthcare seeking. Capacity building in healthcare facilities to diagnose extra-pulmonary tuberculosis may address delay in treatment initiation. Key-words: Delays in tuberculosis, Tuberculosis prevention and control, Organization and administration Introduction: Early detection of TB is emphasized in Revised National Tuberculosis Control Program. [1] An untreated TB patient can infect 10 to 15 close contacts in one year. [2] Delays affecting TB control occur in two ways, patient delay and health care system delay, [3] and factors influencing delays can be categorized into ‘factors influencing health-seeking behavior’ and ‘factors influencing the health system effectiveness’. [4] Number of socio-demographic factors and healthcare system factors are associated with delays. [5] The objectives of our study were to quantify delays in health care seeking and treatment initiation in patients diagnosed with tuberculosis and to study the factors affecting these delays. Indian Journal of Basic and Applied Medical Research; December 2016: Vol.-6, Issue1, P. 307-313 308 www.ijbamr. com P ISSN: 2250-284X , E ISSN : 2250-2858 Methodology Study setting and study population: This was a cross sectional study conducted in March 2013 in a Tuberculosis Unit (TU) area, run by Community Health Department of a medical college in Tamil Nadu. The area has 21 peripheral health institutions (PHI). The study subjects were the newly diagnosed with tuberculosis patients with age 18 years and above. Sample size and sampling technique: In a previous study it was found that 50.98% patients with tuberculosis experienced delay in healthcare seeking. [6] Sample size of 96 was calculated using an α-error of 5% and a relative precision of 20%. Consecutive sampling was done from TU register from January 2012. Study was concluded with 78 participants due to time constraints. Study tools and variables: Structured face to face interview was conducted with a peer reviewed and pilot tested questionnaire. The study variables included age, sex, location of residence (rural/urban), structure of house, education, history of tobacco smoking and alcohol use, type of TB, interval for healthcare seeking (days between onset of symptoms to first contact with the healthcare provider) and interval for treatment initiation (days between first contact with the healthcare provider and initiation of Anti Tuberculosis Therapy (ATT)). Delay in healthcare seeking was defined as more than 2 weeks interval based on Revised National Tuberculosis Control Program (RNTCP) criterion for ‘tuberculosis suspect’. [1] Delay in treatment initiation was arbitrarily defined as more than 1 week. Data entry and analysis: Data entry was done using epidata version 3.1 and data analysis was done using SPSS version 20.0. Median and inter quartile ranges (IQR) were calculated for the time intervals. Chisquare test was done for association between delays and other variables. Odds ratios were calculated and then binary logistic regression was done to determine independent risk factors. Ethics: Voluntary written informed consent was taken from the participants. Privacy was ensured for interview and confidentiality is maintained. Results Characteristics of study participants: Out of 78 participants, 67 (85.9%) had pulmonary tuberculosis (Table 1). The study participants were predominantly males (65.4%), only 15 (19.2%) were elderly (age above 60 years), 42 (53.8%) were illiterate or had only primary education, 21 (26.9%) lived in temporary housing structures and 47 (60.3%) were from rural area (Table 1). History of smoking was reported by 34 (43.6%) and history of alcohol use was reported by 30 (38.5%) participants (Table 1). Delay in health care seeking and associated factors: Median interval for health care seeking was 15 days with IQR 7 to 30 days. The interval for healthcare seeking was within 2 weeks for 38 (48.7%), between 2 weeks to 1 month for 22 (28.2%), between 1 month to 3 month for 10 (12.8%) and more than 3 months for 8 (10.3%) participants. Delay in healthcare seeking (more than 2 weeks) was seen in 40 (51.3%, 95% CI41.0% to 62.6%) participants. The factors explored for association with this delay were age, sex, education, structure of house, residence locality and history of smoking (Table 2). Rural residence (adjusted OR=3.748, 95% CI1.319 to 10.651; pvalue: 0.013) and lower level of formal education (adjusted OR=4.506, 95% CI1.346 to 15.085; pvalue: 0.015) were independently associated with delay in health care seeking (Table 2). Indian Journal of Basic and Applied Medical Research; December 2016: Vol.-6, Issue1, P. 307-313 309 www.ijbamr. com P ISSN: 2250-284X , E ISSN : 2250-2858 Delay in treatment initiation and associated factors: Median interval for treatment initiation was 4 days with IQR 3 to 8 days. The interval for treatment initiation was within 3 days for 34 (43.6%), between 4 to 7 days for 23(29.5%), between 8 days to 1 month for 18 (23.1%) and more than 1 month for 3 (3.8%) participants. Delay in treatment initiation (more than 7 days) was seen for 21 (26.9%, 95% CI16.9% to 36.9%) participants. The factors explored for association with this delay were type of tuberculosis, age, sex, residence locality and history of alcohol use (Table 3). Extra-pulmonary TB (adjusted OR=5.620, 95% CI1.167 to 27.067; p-value: 0.031) was the only factor independently associated with delay in treatment initiation (Table 3). Table 1. Characteristics of Study Participants Characteristics (n=78) Frequency Percentage Disease Category Pulmonary 67 85.9% Extra-pulmonary 11 14.1% Gender Male 51 65.4%