Abstract
BackgroundNigeria ranks fourth among 22 high tuberculosis (TB) burden countries. Although it reached 99% DOTS coverage in 2008, current case detection rate is 40%. Little is known about delays before the start of TB therapy and health-seeking behaviour of TB patients in rural resource-limited settings. We aimed to: 1) assess healthcare-seeking behaviour and delay in treatment of pulmonary TB patients, 2) identify the determinants of the delay in treatment of pulmonary TB.MethodsWe conducted a cross-sectional study of adult new pulmonary TB patients notified to the National Tuberculosis Control Programme (NTP) by three rural (two mission/one public) hospitals. Data on health-seeking and delays were collected using a standardised questionnaire. We defined patient delay as the interval (weeks) between the onset of cough and the first visit to any health provider, and health system delay as the time interval (weeks) between patient's first attendance to any health provider, and the onset of treatment. Total delay is the sum of both delays. Multiple linear regression models using nine exposure variables were built to identify determinants of delays.ResultsOf 450 patients (median age 30 years) enrolled, most were males (55%), subsistent farmers (49%), rural residents (78%); and 39% had no formal education. About 84% of patients reported first consulting a non-NTP provider. For such patients, the first facilities visited after onset of symptoms were drug shops (79%), traditional healers (10%), and private hospitals (10%). The median total delay was 11 (IQR 9–16) weeks, patient delay 8 (IQR 8–12) and health system (HS) delay 3 (IQR 1–4) weeks. Factors associated with increased patient delay were older age (P <0.001) longer walking distance to a public facility (<0.001), and urban residence (P <0.001). Male gender (P = 0.001) and an initial visit to a non-NTP provider (P = 0.025) were independent determinants of prolonged HS delay. Those associated with longer total delay were older age (P <0.001), male gender (P = 0.045), and urban residence (P<0.001).ConclusionOverall, TB treatment delays were high; and needs to be reduced in Nigeria. This may be achieved through improved access to care, further education of patients, engagement of informal care providers, and strengthening of existing public-private partnerships in TB control.
Highlights
Nigeria ranks fourth among 22 high tuberculosis (TB) burden countries
Two-thirds of the patients in the study sought treatment more than four weeks after onset of symptoms, higher than in Malaysia (52%) [19], Iran (12%) [20], Ethiopia (41%) [21], Spain (43%) [22], Zambia (35%) [23] and the Philippines (50%) [24], but lower than in urban Nigeria (83%) [10]. This suggests that the proportion of patients who sought treatment more than four weeks after onset of TB symptoms were higher in Nigeria compared to other countries, overall, with the current public enlightenment campaigns [12,13], there have been a reduction in the proportion of patients who delayed for more than a month before consulting the health system
Given the high coverage of Directly Observed Treatment Short Course (DOTS) in Nigeria, and the very low case detection rate [8], our findings suggest that TB patients face major barriers to care and many of them remain undetected
Summary
Nigeria ranks fourth among 22 high tuberculosis (TB) burden countries. It reached 99% DOTS coverage in 2008, current case detection rate is 40%. Since the late 1990s, the coverage of Directly Observed Treatment Short Course (DOTS) has increased in many developing countries, but this was not coupled with a parallel rise in the case detection rate [3]. A systematic review in Sub-Saharan Africa showed that travel time and consultation with a traditional healer was associated with patient delay [5]. As these factors can vary in different populations and health systems, it is important to evaluate factors affecting patient/health system delay in specific settings
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