Impact of geographic distance on appraisal delay for active TB treatment seeking in Uganda: a network analysis of the Kawempe Community Health Cohort Study

Kyle Fluegge,Christian Wejse,W Henry Boom,Catherine M Stein,Ezekiel Mupere,Brenda Okware,Hussein Kisingo,Mary Nsereko,Lashaunda L Malone

doi:10.1186/s12889-018-5648-6

Kyle Fluegge, Christian Wejse + Show 7 more

Open Access

https://doi.org/10.1186/s12889-018-5648-6

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Abstract

BackgroundAppraisal delay is the time a patient takes to consider a symptom as not only noticeable, but a sign of illness. The study’s objective was to determine the association between appraisal delay in seeking tuberculosis (TB) treatment and geographic distance measured by network travel (driving and pedestrian) time (in minutes) and distance (Euclidean and self-reported) (in kilometers) and to identify other risk factors from selected covariates and how they modify the core association between delay and distance.MethodsThis was part of a longitudinal cohort study known as the Kawempe Community Health Study based in Kampala, Uganda. The study enrolled households from April 2002 to July 2012. Multivariable interval regression with multiplicative heteroscedasticity was used to assess the impact of time and distance on delay. The delay interval outcome was defined using a comprehensive set of 28 possible self-reported symptoms. The main independent variables were network travel time (in minutes) and Euclidean distance (in kilometers). Other covariates were organized according to the Andersen utilization conceptual framework.ResultsA total of 838 patients with both distance and delay data were included in the network analysis. Bivariate analyses did not reveal a significant association of any distance metric with the delay outcome. However, adjusting for patient characteristics and cavitary disease status, the multivariable model indicated that each minute of driving time to the clinic significantly (p = 0.02) and positively predicted 0.25 days’ delay. At the median distance value of 47 min, this represented an additional delay of about 12 (95% CI: [3, 21]) days to the mean of 40 days (95% CI: [25, 56]). Increasing Euclidean distance significantly predicted (p = 0.02) reduced variance in the delay outcome, thereby increasing precision of the mean delay estimate. At the median Euclidean distance of 2.8 km, the variance in the delay was reduced by more than 25%.ConclusionOf the four geographic distance measures, network travel driving time was a better and more robust predictor of mean delay in this setting. Including network travel driving time with other risk factors may be important in identifying populations especially vulnerable to delay.

Highlights

Appraisal delay is the time a patient takes to consider a symptom as noticeable, but a sign of illness
Symptom duration is defined as the number of days from the first day of onset of any symptom attributed to tuberculosis until the first day of appropriate TB therapy [12]
Adjusting for the same factors, at the median Euclidean distance of 2.8 km, the variance in the delay was reduced by more than 25%. These results demonstrate that while driving time influenced changes in the mean delay, Euclidean distance was associated with precision of the delay interval length

Summary

Introduction

Appraisal delay is the time a patient takes to consider a symptom as noticeable, but a sign of illness [6]. Symptom duration is defined as the number of days from the first day of onset of any symptom attributed to tuberculosis until the first day of appropriate TB therapy [12] This definition frequently encompasses illness, utilization and system delay (see Fig. 1). Several studies of TB patients have considered this definition when deriving a quantitative (generally binary) measure of patient delay [13,14,15,16] Such a definition obscures the occurrence of existing, albeit nonspecific, symptoms that preceded the appraisal date (see Fig. 1)

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