# Factors Associated with Patient’s Delay in Tuberculosis Treatment in Bahir Dar City Administration, Northwest Ethiopia

Authors: Endalew Gebeyehu; Muluken Azage; Gedefaw Abeje
Journal: BioMed Research International
 (2014)

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## Abstract

Background. Unknown proportions of tuberculosis cases remain undiagnosed and untreated as result of several factors which further increases the number of tuberculosis cases per index case. Objective. To identify factors associated with patient’s delay in initiating treatment of tuberculosis. Methods. Cross-sectional study was employed from January to April, 2013, in Bahir Dar Ethiopia. A total of 360 patients were included. Data were collected from tuberculosis patients using a semistructured questionnaire. Data were entered and analyzed using SPSS version 16 windows. Multivariate logistic regression analysis was used to identify factors associated with patient delay. Results. Of all patients, 211 (62%) sought medical care after the WHO recommended period (21 days). The median patient delays of smear positive, smear negative, and extrapulmonary patients were 27 (IQR: 10–59), 30 (IQR: 9–65), and 31 (IQR: 10–150) days, respectively, with statistically significant variations among them (ANOVA: F=5.96; P<0.003). Place of residence and educational status were the predictors of patient delay. Conclusion. Around two-thirds of all patients and more than half of smear positive tuberculosis patients were delayed in seeking medical care within the recommended period. Provision of DOTS service in the vicinity and health education on TB may reduce patient delay and its consequences.


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## Body

## 1. Introduction

Tuberculosis (TB) is a major public health burden throughout the world. Almost one-third of the world population (about 2 billion) is infected withMycobacterium tuberculosis and during the past decade even industrialized countries have faced a resurgence of tuberculosis. Currently, TB is the leading cause of mortality among infectious diseases worldwide. About 95% of TB cases and 98% of deaths due to TB occur in developing countries [1].Ethiopia is one of the 22 countries with high TB burden [1]. Literatures showed that many TB cases remain undiagnosed and untreated in many countries with high incidence of TB that increases the risk of TB transmission in the community [1–8]. Studies on different parts of the world showed that different factors are associated with patient delay. Studies done in African countries mentioned that residence was an important predictor of patient delay in initiating treatment [9–13]. Similarly in Asia and African countries being female was mentioned as a factor for predicting patient delay [9, 10, 13–15].According to the WHO Global TB report, 2012, Ethiopia ranks 13th in the list of 22 high burden countries (HBCs) and 4th in Africa, with an estimated prevalence of all forms of TB in 200 per 100,000 population [16]. Although treatment is available freely, patients are not able to initiate treatment as early as possible. In 2011, of all causes of death in the Amhara region TB was ranked 7th for adult death. Health facility reports showed that patients failed to seek medical care within the recommended period [17].There is paucity of credible evidence on the extent of delay in treatment seeking behavior of patients in Amhara region. Credible evidence on predictors of patient delay could be important information to look for new strategy to curb the death and spread of TB. Therefore this study aims to investigate the extent of patient delay and its influencing factors among tuberculosis patients in Bahir Dar town. Moreover, the data from this study will identify barriers for delay in care seeking to strengthen the strategies for prevention and treatment of TB patients.


## 2. Methods and Materials

### 2.1. Study Design and Period

Institution based cross-sectional study was conducted on tuberculosis patients at DOTS in public health facilities from January to April, 2013.


### 2.2. Study Setting

The study was conducted in Bahir Dar town which is the capital city of Amhara National Regional State. It is located at 565 km northwest of Addis Ababa, Ethiopia. The town has a population of 221,991 of whom 49% were male and the rest were female [18]. There were nine public healthcare facilities (one hospital and eight health centers) in Bahir Dar city administration at the time of the study. All public health institutions were providing smear microscopy and DOTS service to the community [19]. Bahir Dar town was selected because of its more numbers of clinics that conduct TB diagnosis through smear microscopic examination and DOTS service in the region to get the required sample size.


### 2.3. Sample Size and Sampling Procedures

The sample size was determined using the formula for estimation of population proportion (n = [(Zα/2)2*p*(1-p)] /d2) where: Zα/2 at 95% CI (1.96), d marginal error 0.05, and p proportion obtained from previous study in East Wollega, Ethiopia, in 2006 (0.63)[20]. With 5% none response rate, the total sample size of the study was 376. All adult tuberculosis patients registering for DOTS service in the clinics were the study population. Adults who were unable to respond and children were excluded from the study because they may not give appropriate responses to the questionnaire. All patients registering for DOTS were interviewed. To avoid double counting of patients when they change their DOTS clinic, reminder note was attached with the referral sheet to the receiving health facility.


### 2.4. Data Collection Tools and Quality Assurance

Data were collected using a semistructured questionnaire which has a question of sociodemographic and economic variables, accessibility, and availability of TB service and delay question. The questionnaire was prepared in English first and translated to the local language, Amharic and again back translation to English was made to ensure the consistency of the questions. In addition, pre test was done in an area different from the study area to validity the questionnaire. In this study, patient delay was measured by considering the time from initial onset of sign and symptoms of the disease to first consultation of healthcare facility by the patient. According to WHO recommendation the study subjects were grouped into those who delayed ≤21 days and those delayed >21 days and this binary classification was used to identify factors related to patient delay during logistic regression analysis [21]. The completeness of responses to the questionnaires was checked routinely during data collection. Questionnaires with incomplete response were excluded during data entry.


### 2.5. Data Analysis

Questions were coded and then data were entered and analyzed using SPSS version 16. Frequency runs, cross-tabulations, and sort were checked for data quality management. Descriptive statistics were used to summarize data and tables and figures were used to display results. Adjusted odds ratio with the combination of confidence interval andP value was calculated to identify factors associated with delay in seeking treatment using bivariate and multivariate logistic regression analysis.


### 2.6. Ethical Clearance

Ethical approval was obtained from Bahir Dar University Ethical Clearance Committee. Permission was taken from Bahir Dar City Health Office and the respective health facilities. Informed verbal consent was obtained from study participants. The study participants were assured that the data were used only for the study purpose and could not be passed to a third party. Moreover, privacy and confidentiality were maintained by giving codes for the questionnaire.


## 2.1. Study Design and Period

Institution based cross-sectional study was conducted on tuberculosis patients at DOTS in public health facilities from January to April, 2013.


## 2.2. Study Setting

The study was conducted in Bahir Dar town which is the capital city of Amhara National Regional State. It is located at 565 km northwest of Addis Ababa, Ethiopia. The town has a population of 221,991 of whom 49% were male and the rest were female [18]. There were nine public healthcare facilities (one hospital and eight health centers) in Bahir Dar city administration at the time of the study. All public health institutions were providing smear microscopy and DOTS service to the community [19]. Bahir Dar town was selected because of its more numbers of clinics that conduct TB diagnosis through smear microscopic examination and DOTS service in the region to get the required sample size.


## 2.3. Sample Size and Sampling Procedures

The sample size was determined using the formula for estimation of population proportion (n = [(Zα/2)2*p*(1-p)] /d2) where: Zα/2 at 95% CI (1.96), d marginal error 0.05, and p proportion obtained from previous study in East Wollega, Ethiopia, in 2006 (0.63)[20]. With 5% none response rate, the total sample size of the study was 376. All adult tuberculosis patients registering for DOTS service in the clinics were the study population. Adults who were unable to respond and children were excluded from the study because they may not give appropriate responses to the questionnaire. All patients registering for DOTS were interviewed. To avoid double counting of patients when they change their DOTS clinic, reminder note was attached with the referral sheet to the receiving health facility.


## 2.4. Data Collection Tools and Quality Assurance

Data were collected using a semistructured questionnaire which has a question of sociodemographic and economic variables, accessibility, and availability of TB service and delay question. The questionnaire was prepared in English first and translated to the local language, Amharic and again back translation to English was made to ensure the consistency of the questions. In addition, pre test was done in an area different from the study area to validity the questionnaire. In this study, patient delay was measured by considering the time from initial onset of sign and symptoms of the disease to first consultation of healthcare facility by the patient. According to WHO recommendation the study subjects were grouped into those who delayed ≤21 days and those delayed >21 days and this binary classification was used to identify factors related to patient delay during logistic regression analysis [21]. The completeness of responses to the questionnaires was checked routinely during data collection. Questionnaires with incomplete response were excluded during data entry.


## 2.5. Data Analysis

Questions were coded and then data were entered and analyzed using SPSS version 16. Frequency runs, cross-tabulations, and sort were checked for data quality management. Descriptive statistics were used to summarize data and tables and figures were used to display results. Adjusted odds ratio with the combination of confidence interval andP value was calculated to identify factors associated with delay in seeking treatment using bivariate and multivariate logistic regression analysis.


## 2.6. Ethical Clearance

Ethical approval was obtained from Bahir Dar University Ethical Clearance Committee. Permission was taken from Bahir Dar City Health Office and the respective health facilities. Informed verbal consent was obtained from study participants. The study participants were assured that the data were used only for the study purpose and could not be passed to a third party. Moreover, privacy and confidentiality were maintained by giving codes for the questionnaire.


## 3. Results

Of the total 376 study participants, 360 (96%) were included in the study, whereas the remaining were excluded due to data incompleteness during data analysis. Of the study participants, 59.4% were males, 33.9% lived in rural areas, and 34.2% were illiterate. Fifty-eight percent of the study participants had extrapulmonary TB. Two-thirds of the study participants lived within 10 Km radius to public health facility (Table1).Table 1
Characteristics of tuberculosis patients in DOTS clinic of public healthcare facilities in Bahir Dar city administration, Northwest Ethiopia.
Variables
Frequency (n=360)
Percent
Sex
Male
214
59.4
Female
146
40.6
Age
<20
39
10.8
20–39
243
67.5
≥40
78
21.7
Place of residence
Urban
238
66.1
Rural
122
33.9
Marital status
Single
152
42.2
Married
168
46.7
Widowed
14
3.9
Divorced
26
7.2
Education status
Illiterate
124
34.2
Read and write
38
10.6
Elementary
56
15.6
Junior/secondary
80
22.2
College and above
62
17.5
Occupation
Employee
42
11.7
Merchant
24
6.7
Farmer
73
20.3
Daily laborer
57
15.8
Student
65
18.1
Housewife
99
27.5
Smoking habit
Yes
17
4.7
No
343
95.3
Type of tuberculosis
Pulmonary
153
42.5
Extrapulmonary
207
57.5
Distance to the nearest healthcare facility
<10 km
270
75
≥10 km
90
25


### 3.1. Patient Delay

The median patient’s delay of smear positive, smear negative, and extrapulmonary patients was 27 (IQR: 10–59), 30 (IQR: 9–65), and 31 (IQR: 10–150), respectively. The overall median patient delay was 30 days (IQR: 10–96, and the 10th and 90th percentiles were 2 and 385 days, resp.). The maximum patient delays in smear positive, smear negative, and extrapulmonary TB patients were 365, 380, and 3650 days, respectively. Ninety-one patients (25.3%) and 24 (6.7%) came after 90 days and one year, respectively. The mean (±SD) patient delay in smear positive, smear negative, and extrapulmonary TB patients was 56 (102), 64 (98), and 192 (467) days, respectively. In ANOVA analysis patient delay had shown a statistically significant variation by categories of TB (F=5.96; P<0.003). A total of 211 (61.7%) patients sought medical service after 21 days which is out of the range recommended by WHO. Of all delays, 52% of smear positive and 57.7% of smear negative patients and 61.4% of extrapulmonary TB patients sought medical advice after 21 days (Table 2).Table 2
Patient delay by TB categories in Bahir Dar city administration, Northwest Ethiopia, 2013.
Smear positiveN (%)
Smear negativeN (%)
Extrapulmonary TBN (%)
TotalN (%)
Patient delay in days (≤21 days)
1–7 days
16 (21.3)
19 (24.4)
46 (22.2)
81 (22.5)
8–14 days
10 (13.3)
11 (4.1)
18 (8.7)
39 (10.5)
15–21 days
10 (13.3)
3 (3.8)
16 (7.7)
29 (8.1)
Total
36  (48.0)
33  (42.3)
80  (38.6)
149  (38.3)
Patient delay in days (>21 days)
22–30 days
8 (10.7)
9 (11.5)
23 (11.1)
40 (11.3)
31–60 days
14 (18.7)
15 (19.2)
20 (9.7)
49 (13.6)
61–90
5 (6.7)
7 (9.0)
19 (9.2)
31 (8.6)
>90 days
12 (16.0)
14 (17.9)
65 (31.4)
91 (25.3)
Total
39  (52.0)
45  (57.7)
127  (61.4)
211  (61.7)The most frequent reasons mentioned by those who sought treatment after 21 days were thinking that symptoms will disappear (90%), financial problem (28.4%), work overload (18.5%), transport problem (8.0%), health facility being too far (7.1%), being afraid of a long process at health facility (4.7%), being severely ill and unable to reach (4.7%), on traditional treatment (3.3%), and others (2.8%) (Figure1).Figure 1
Reasons for patient delay among TB patients in public health facilities of Bahir Dar city administration, Northwest Ethiopia (there were multiple responses).


### 3.2. Factors Associated with Patient Delay

Analysis result of bivariate regression indicated that place of residence, education status, and occupation (farmer and student) were statistically significant association with patient delay (Table3). But only education status remained statistically significant (P<0.05) after controlling confounding effect with multivariate regression by entering those variables that have a P value of ≤0.2. Illiterate patients were 3.73 times {AOR: 3.73, 95% CI (1.87, 7.44)} more delayed when compared to patients with college and above educational status. Similarly, patients with eight to twelve grade educational status were 2.74 times {AOR: 2.74, 95% CI (1.36, 5.49)} more delayed when compared to patients with college and above educational status (Table 3).Table 3
Logistic regression analysis of factors associated with patient delay in public health care facilities of Bahir Dar town, Northwest Ethiopia.
Variables
Patient delay
COR (95% CI)
AOR (95% CI)
≤21 days
>21 days
Sex
Male
87
127
1.08 (0.70, 1.65)
Female
62
84
1.00
Age
<20
19
20
0.56 (0.26, 1.22)
20–39
103
140
0.72 (0.42, 1.22)
≥40
27
51
1.00
Place of residence
Urban
114
124
1.00
1.00
Rural
35
87
2.29
(
1.43,3.65
)
*
*
1.74 (1.04, 2.90)
Marital status
Single
65
87
1.00
Married
65
103
1.18 (0.76, 1.85)
Widowed
6
8
1.00 (0.33, 3.01)
Divorced
13
13
0.75 (0.33, 3.79)
Education level
Illiterate
38
86
4.75
(
2.47,9.15
)
*
*
*
3.73
(
1.87,7.44
)
*
*
*
Read and write
15
23
3.22
(
1.39,7.46
)
*
*
2.58
(
1.08,6.15
)
*
Elementary
20
36
3.78
(
1.76,8.11
)
*
*
3.39
(
1.57,7.33
)
*
*
Junior/secondary
34
46
2.84
(
1.42,5.68
)
*
*
2.74
(
1.36,5.49
)
*
*
College and above
42
20
1.00
1.00
Occupation
Employee
26
16
1.00
Merchant
12
13
1.92 (0.70, 5.31)
Farmer
20
53
4.31
(
1.92,9.66
)
Daily laborer
25
32
2.08 (0.92, 4.69)
Student
23
42
2.97
(
1.33,6.63
)
Housewife
44
55
2.03 (0.97, 4.25)
Smoking habit
Yes
8
9
0.79 (0.85, 1.99)
No
141
202
1.00
Distance to the nearest health institutions
<10 km
114
156
1.00
≥10 km
35
55
1.15 (0.71, 1.87)
*
P-value < 0.05, **P-value < 0.01, ***P-value < 0.001.


## 3.1. Patient Delay

The median patient’s delay of smear positive, smear negative, and extrapulmonary patients was 27 (IQR: 10–59), 30 (IQR: 9–65), and 31 (IQR: 10–150), respectively. The overall median patient delay was 30 days (IQR: 10–96, and the 10th and 90th percentiles were 2 and 385 days, resp.). The maximum patient delays in smear positive, smear negative, and extrapulmonary TB patients were 365, 380, and 3650 days, respectively. Ninety-one patients (25.3%) and 24 (6.7%) came after 90 days and one year, respectively. The mean (±SD) patient delay in smear positive, smear negative, and extrapulmonary TB patients was 56 (102), 64 (98), and 192 (467) days, respectively. In ANOVA analysis patient delay had shown a statistically significant variation by categories of TB (F=5.96; P<0.003). A total of 211 (61.7%) patients sought medical service after 21 days which is out of the range recommended by WHO. Of all delays, 52% of smear positive and 57.7% of smear negative patients and 61.4% of extrapulmonary TB patients sought medical advice after 21 days (Table 2).Table 2
Patient delay by TB categories in Bahir Dar city administration, Northwest Ethiopia, 2013.
Smear positiveN (%)
Smear negativeN (%)
Extrapulmonary TBN (%)
TotalN (%)
Patient delay in days (≤21 days)
1–7 days
16 (21.3)
19 (24.4)
46 (22.2)
81 (22.5)
8–14 days
10 (13.3)
11 (4.1)
18 (8.7)
39 (10.5)
15–21 days
10 (13.3)
3 (3.8)
16 (7.7)
29 (8.1)
Total
36  (48.0)
33  (42.3)
80  (38.6)
149  (38.3)
Patient delay in days (>21 days)
22–30 days
8 (10.7)
9 (11.5)
23 (11.1)
40 (11.3)
31–60 days
14 (18.7)
15 (19.2)
20 (9.7)
49 (13.6)
61–90
5 (6.7)
7 (9.0)
19 (9.2)
31 (8.6)
>90 days
12 (16.0)
14 (17.9)
65 (31.4)
91 (25.3)
Total
39  (52.0)
45  (57.7)
127  (61.4)
211  (61.7)The most frequent reasons mentioned by those who sought treatment after 21 days were thinking that symptoms will disappear (90%), financial problem (28.4%), work overload (18.5%), transport problem (8.0%), health facility being too far (7.1%), being afraid of a long process at health facility (4.7%), being severely ill and unable to reach (4.7%), on traditional treatment (3.3%), and others (2.8%) (Figure1).Figure 1
Reasons for patient delay among TB patients in public health facilities of Bahir Dar city administration, Northwest Ethiopia (there were multiple responses).


## 3.2. Factors Associated with Patient Delay

Analysis result of bivariate regression indicated that place of residence, education status, and occupation (farmer and student) were statistically significant association with patient delay (Table3). But only education status remained statistically significant (P<0.05) after controlling confounding effect with multivariate regression by entering those variables that have a P value of ≤0.2. Illiterate patients were 3.73 times {AOR: 3.73, 95% CI (1.87, 7.44)} more delayed when compared to patients with college and above educational status. Similarly, patients with eight to twelve grade educational status were 2.74 times {AOR: 2.74, 95% CI (1.36, 5.49)} more delayed when compared to patients with college and above educational status (Table 3).Table 3
Logistic regression analysis of factors associated with patient delay in public health care facilities of Bahir Dar town, Northwest Ethiopia.
Variables
Patient delay
COR (95% CI)
AOR (95% CI)
≤21 days
>21 days
Sex
Male
87
127
1.08 (0.70, 1.65)
Female
62
84
1.00
Age
<20
19
20
0.56 (0.26, 1.22)
20–39
103
140
0.72 (0.42, 1.22)
≥40
27
51
1.00
Place of residence
Urban
114
124
1.00
1.00
Rural
35
87
2.29
(
1.43,3.65
)
*
*
1.74 (1.04, 2.90)
Marital status
Single
65
87
1.00
Married
65
103
1.18 (0.76, 1.85)
Widowed
6
8
1.00 (0.33, 3.01)
Divorced
13
13
0.75 (0.33, 3.79)
Education level
Illiterate
38
86
4.75
(
2.47,9.15
)
*
*
*
3.73
(
1.87,7.44
)
*
*
*
Read and write
15
23
3.22
(
1.39,7.46
)
*
*
2.58
(
1.08,6.15
)
*
Elementary
20
36
3.78
(
1.76,8.11
)
*
*
3.39
(
1.57,7.33
)
*
*
Junior/secondary
34
46
2.84
(
1.42,5.68
)
*
*
2.74
(
1.36,5.49
)
*
*
College and above
42
20
1.00
1.00
Occupation
Employee
26
16
1.00
Merchant
12
13
1.92 (0.70, 5.31)
Farmer
20
53
4.31
(
1.92,9.66
)
Daily laborer
25
32
2.08 (0.92, 4.69)
Student
23
42
2.97
(
1.33,6.63
)
Housewife
44
55
2.03 (0.97, 4.25)
Smoking habit
Yes
8
9
0.79 (0.85, 1.99)
No
141
202
1.00
Distance to the nearest health institutions
<10 km
114
156
1.00
≥10 km
35
55
1.15 (0.71, 1.87)
*
P-value < 0.05, **P-value < 0.01, ***P-value < 0.001.


## 4. Discussion

Early detection of cases and treating TB patients are one of the strategies of WHO to reduce the diseases morbidity and mortality throughout the world. The overall median patient delay in this study was 30 days. This finding is lower than studies done in Ethiopia (60–63 days) [4, 22, 23] and other countries, Nepal (50 days) [24] and Tanzania (120 days) [12]. However, it is almost consistent with another study done in Ethiopia (28 days) [20]. The median patient’s delays of smear positive, smear negative, and extrapulmonary patients were 27, 30, and 31 days, respectively, which is lower than the median patient delays for smear positive (90 days), smear negative (60 days), and extrapulmonary tuberculosis patients (90 days) done in Tigray region, Ethiopia, in 2001 [23]. The discrepancies may be due to accessibility of healthcare facilities since more than two-thirds of participants in this study are living in urban setting. Moreover, it may be the contribution of implementation of health extension programme which promotes healthcare activities in Ethiopia.In this study, 58% of the study participants were extrapulmonary TB which is higher than the study done in Ethiopia, Tigray (39%) [23] and WHO report 2012 (32%) [16]. This difference may be due to the flow of high proportion of referral and nonreferral patients for availability of extrapulmonary TB diagnosis facility at Bahir Dar where the referral hospital is located.In this study, educational status of below college level was an independent predictor for patient delay. Illiterate patients and patients with eight to twelve educational status are 3.73 and 2.74 times more likely delay when compared to patients with college and above educational status, respectively. This could be due to the fact that those patients who had education status of college and above level have better information access about TB and more likely to seek medical care from healthcare facilities at early stage of the diseases. Similar findings were reported in previous studies [25, 26]This study has a limitation of recall bias since patient delay was measured by asking about initiation of sign and symptoms retrospectively. Due to the nature of the cross-sectional study design underreporting or overreporting of patient delay is unavoidable.


## 5. Conclusions

In this study, more than sixty percent of TB patients sought treatment after WHO recommended periods (21 days) and educational status was the predictor of patient delay. Therefore, provision of health education on TB should be strengthened to reduce patient delay.



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*Source: 701429-2014-05-20.xml*