Abstract
Objectives and BackgroundObtaining a diagnosis of tuberculosis (TB) is a prerequisite for accessing specific treatment, yet one third of estimated new cases are missed worldwide by National Programmes. This study investigated economic, geographical, socio-cultural and health system factors hindering adults' attendance and completion of the TB diagnostic process in Yemen, to inform interventions designed to improve patient access to services.MethodologyThe study employed a mixed methods design comprising a cross-sectional survey and In-Depth-Interviews (IDIs) and Focus Group Discussions (FGDs) among patients abandoning the diagnosis or registering for treatment. Adults with cough of ≥2 weeks attending a large governmental referral centre in Sana'a, Yemen, between 2009 and 2010, were eligible to participate.Results497 and 446 (89.7%) participants were surveyed the first and second day of attending the services and 48 IDIs and 12 FGDs were also conducted. The majority of patients were disadvantaged and had poor literacy (61% illiterate), had travelled from rural areas (47%) and attended with companions (84%). Key barriers for attendance identified were clinic and transport costs (augmented by companions), distance from home, a preference for private services, strong social stigma and a lack of understanding of the diagnostic process. There were discrepancies between patient- and doctor-reported diagnosis and 46% of patients were unaware that TB treatment is free. Females faced more difficulties to attend than men. The laboratory practice of providing first-day negative smear results and making referrals to the private sector also discouraged patients from returning. Strategies to bring TB diagnostic services closer to communities and address the multiple barriers patients face to attend, will be important to increase access to TB diagnosis and care.
Highlights
Tuberculosis (TB) is one of the leading causes of adult morbidity and mortality [1] and the poorest sections of society carry the highest burden of disease [2]
Survey participants expressed a high level of satisfaction concerning their experience, while IDIs and Focus Group Discussions (FGDs) provided a platform for participants to convey criticism and reveal a plethora of obstacles
Most first-day participants indicated that women had the same access to healthcare as men (419 of 497; 84.3%; 95% CI = 80.9–87.2%)
Summary
Tuberculosis (TB) is one of the leading causes of adult morbidity and mortality [1] and the poorest sections of society carry the highest burden of disease [2]. Limited access to TB diagnosis is a barrier to accessing treatment and one third of the estimated new cases of TB are missed by National TB Programmes [3]. Increasing case detection is an international priority, the obstacles to accessing services are complex and rooted in disadvantage and exclusion [4]. Obtaining a diagnosis of TB is a prerequisite for obtaining free treatment [5], yet diagnostic facilities are often sparsely distributed, in rural settings, and access can be difficult [6] and costly [7]. Symptomatic adults do not reach formal services and remain in the community
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