Tuberculosis Care-seeking Research Articles

Enhancing Knowledge and Beliefs: The Impact of a Gender-transformative Training Program on Tuberculosis Care in Southern Nigeria

Background: Gender-related barriers significantly impede care-seeking for tuberculosis (TB), leading to poor treatment outcomes. This study aimed to assess changes in knowledge and beliefs following a training program on gender-transformative TB programming among stakeholders in Southern Nigeria. Methods: A cross-sectional pretest/posttest design was employed to evaluate the training’s effectiveness among participants from September 2023 to March 2024. A 2-day training session was conducted using a standardized training manual. Participants included members of TB civil society organizations and other relevant stakeholders. A standardized questionnaire was administered before and after the training. Results: Of the 304 respondents, 160 (52.6%) were aged 40 years or younger, with a mean age of 39.6 (±10.5) years; 184 (60.5%) were female. The mean pretest knowledge score was 7.20 (±1.16), which increased to 8.44 (±1.12) posttraining (t = −15.20; P < 0.001). Similarly, the mean score for the gender responsiveness to the TB programming scale improved from 30.6 (±5.4) pretest to 32.8 (±4.9) posttest (P < 0.001). Conclusion: The training significantly enhanced stakeholders’ knowledge of TB and their understanding of gender responsiveness in TB programming. These findings underscore the necessity for ongoing sensitization of TB service providers and the promotion of TB education and stigma reduction efforts to ensure gender-responsive and inclusive TB service delivery. Continuous awareness initiatives are essential to challenge deep-rooted negative sociocultural beliefs and gender norms affecting TB programming.

Factors associated with tuberculosis care-seeking and diagnostic delays among childhood pulmonary tuberculosis in Zhejiang Province, China: a 10-year retrospective study

We conducted a retrospective study to investigate risk factors for tuberculosis care-seeking delay and diagnostic delays among pediatric pulmonary tuberculosis cases in Zhejiang Province from 2013 to 2022. Among 1274 cases, 49.61% experienced tuberculosis care-seeking delays (> 14 days from symptom onset to first hospital visit) and 14.91% faced diagnostic delays (> 14 days from initial consultation to diagnosis). The proportion of care-seeking delays ranged from 37.42 to 64.89%, while diagnostic delay fluctuated from 6.11 to 21.02%. Urban residence (OR = 0.78, 95% CI 0.62–0.98, P = 0.030), first visiting a municipal-level hospital (OR = 0.57, 95% CI 0.45–0.72, P < 0.001), and diagnostic method (OR = 0.66, 95%CI 0.52–0.84, P < 0.001) were associated with tuberculosis care-seeking delay, whereas first visiting a municipal-level hospital (OR = 2.05, 95% CI 1.49–2.80, P < 0.001) was linked to diagnostic delay. Further analysis using a 28-day cutoff point revealed that children aged 0–4 years, those from migrant populations, laboratory-confirmed patients, and those who first visited a county-level hospital were more likely to experience delays in seeking tuberculosis care. Thus, society should pay more attention to the health of rural, migrant, and 0–4-year-old children, as they are at higher risk of experiencing tuberculosis care-seeking delays.

Estimating and Explaining the Differences in Health Care Seeking by Symptom Burden Among Persons With Presumptive Tuberculosis: Findings From a Population-Based Tuberculosis Prevalence Survey in a High-Burden Setting in India.

There is a lack of research evidence on the quantitative relationship between symptom burden and health care seeking among individuals with presumptive tuberculosis (TB). Data were derived from a cross-sectional population-based TB survey conducted between February 2021 and July 2022 in 32 districts of India. Eligible and consented participants (age >15 years) underwent TB symptom screening and history elicitation. Fairlie decomposition analysis was used to estimate the net differences in health care seeking due to varied symptom burden-from 1+ burden (>1 symptom) to 4+ burden (>4 symptoms)-and decomposed by observable covariates based on logit models with 95% CIs. Of the 130 932 individuals surveyed, 9540 (7.3%) reported at least 1 recent TB symptom, of whom 2678 (28.1%; 95% CI, 27.1%-28.9%) reportedly sought health care. The net differences in health care seeking among persons with symptom burden 1+ to 4+ ranged from 6.6 percentage points (95% CI, 4.8-8.4) to 7.7 (95% CI, 5.2-10.2) as compared with persons with less symptom burden. The presence of expectoration, fatigue, and loss of appetite largely explained health care seeking (range, 0.9-3.1 percentage points [42.89%-151.9%]). The presence of fever, cough, past TB care seeking, weight loss, and chest pain moderately explained (range, 5.3%-25.3%) health care seeking. Increased symptom burden and symptoms other than the commonly emphasized cough and fever largely explained health care seeking. Orienting TB awareness and risk communications toward symptom burden and illness perceptions could help address population gaps in health care seeking for TB.

Sociocultural understanding of Tuberculosis and implications for care-seeking among adults in the province of Zambezia, Mozambique: Qualitative research.

Mozambique has a high burden of Tuberculosis (TB) with an incidence of 368 per 100,000 population in 2020, coupled with a low all-form TB detection rate. The COVID-19 pandemic has exacerbated delays in timely diagnosis and treatment of new TB cases. Promoting active TB case finding is a national priority in Mozambique. We conducted qualitative research to explore factors influencing TB testing in Zambezia province in Mozambique. One-to-one, semi-structured, audio-recorded telephone interviews were conducted to explore TB-related knowledge, and barriers and facilitators to TB testing. A sample of two TB Program staff, two community providers of TB services, and 19 community members (10 women and 9 men) was recruited, with support from provincial government TB staff, from four districts in Zambezia with a high TB burden. Interviews were transcribed verbatim, and thematic analysis was conducted. The Mozambican National Bioethics Committee for Health approved the study protocol. Our study highlights that knowledge about TB symptoms and its causes is low, which could delay timely TB testing. Sociocultural beliefs often implicate certain types of sexual activity and women as causes of TB symptoms; for example, having sex with a widow who has not been traditionally purified, or with a woman who has had an abortion. Therefore, people usually tend to first seek care from traditional healers instead of going to a health facility. Additionally, stigma associated with HIV and TB also delays care seeking. Gender-related disparities in TB care seeking were also evident. This study provides valuable insights into how healthcare seeking for TB is influenced by sociocultural understanding of symptoms and gender dynamics. Therefore, interventions to promote timely and appropriate care seeking for TB should be contextually tailored, culturally appropriate, and gender sensitive.

The Prevalence of Self-Reported Tuberculosis in the Andaman and Nicobar Islands, India: Evidence from the NFHS-IV and V.

Since 1992, many rounds of the National Family Health Surveys have produced a significant quantity of data in India. The magnitude of the tuberculosis (TB) burden in Andaman and Nicobar Island can be better understood with this data. The household-level information on self-reported TB may provide useful information on the prevalence and distribution of TB as well as care-seeking behaviour. The primary objective is to analyse the data from the NFHS-IV and NFHS-V to understand the prevalence of self-reported TB as well as healthcare-seeking patterns for TB in the Andaman and Nicobar Islands. We performed secondary data analysis of NFHS-IV and NFHS-V data. After taking into consideration the survey's cluster design and sampling weights, the prevalence was estimated. The association of identified factors with self-reported TB was investigated using the chi-square and logistic regression models. The point prevalence of self-reported TB was 615 (418, 873) and 221 (122, 367) in the NFHS-IV and NFHS-V, respectively (p = 0.012). The elderly, those from rural areas, those belonging to a tribe, and those with a poor wealth index were more likely to report TB. Self-reported TB prevalence was higher in the Nicobar district. There is an increase in a significant proportion of individuals not seeking care. The NFHS-IV and NFHS-V show a decline in self-reported TB, which is consistent with national estimates. However, the enhanced TB case detection in individuals at high risk of TB among the Nicobar districts and tribal communities could significantly contribute to the fight against tuberculosis. Improved awareness of TB could improve care seeking for TB.

Barriers to childhood tuberculosis case detection and management in Cambodia: the perspectives of healthcare providers and caregivers

BackgroundDiagnosis and treatment of tuberculosis (TB) in children remain challenging, particularly in resource-limited settings. Healthcare providers and caregivers are critical in improving childhood TB screening and treatment. This study aimed to determine the barriers to childhood TB detection and management from the perspectives of healthcare providers and caregivers in Cambodia.MethodWe conducted this qualitative study between November and December 2020. Data collection included in-depth interviews with 16 healthcare providers purposively selected from four operational districts and 28 caregivers of children with TB and children in close contact with bacteriologically confirmed pulmonary TB residing in the catchment areas of the selected health centers. Data were analyzed using thematic analyses.ResultsMean ages of healthcare providers and caregivers were 40.2 years (standard deviation [SD] 11.9) and 47.9 years (SD 14.6), respectively. Male was predominant among healthcare providers (93.8%). Three-fourths of caregivers were female, and 28.6% were grandparents. Inadequate TB staff, limited knowledge on childhood TB, poor collaboration among healthcare providers in different units on TB screening and management, limited quality of TB diagnostic tools, and interruption of supplies of childhood TB medicines due to maldistribution from higher levels to health facilities were the key barriers to childhood TB case detection and management. Caregivers reported transportation costs to and from health facilities, out-of-pocket expenditure, time-consuming, and no clear explanation from healthcare providers as barriers to childhood TB care-seeking. Aging caregivers with poor physical conditions, lack of collaboration from caregivers, ignorance of healthcare provider's advice, and parent movement were also identified as barriers to childhood TB case detection and management.ConclusionsThe national TB program should further invest in staff development for TB, scale-up appropriate TB diagnostic tools and ensure its functionalities, such as rapid molecular diagnostic systems and X-ray machines, and strengthen childhood TB drug management at all levels. These may include drug forecasting, precise drug distribution and monitoring mechanism, and increasing community awareness about TB to increase community engagement.

Adaptations to the first wave of the COVID-19 pandemic by private sector tuberculosis care providers in India

BackgroundIndia’s dominant private healthcare sector is the destination for 60–85% of initial tuberculosis care-seeking. The COVID-19 pandemic in India drastically affected TB case notifications in the first half of 2020. In this survey, we assessed the impact of the first wave of COVID-19 in India on private providers, and changes they adopted in their practice due to the pandemic. MethodsThe Joint Effort for Elimination of TB (JEET) is a nationwide Global Fund project implemented across 406 districts in 23 states to extend quality TB services to patients seeking care in private sector. We conducted a rapid survey of 11% (2,750) of active providers engaged under JEET’s intense Patient Provider Support Agency (PPSA) model across 15 Indian states in Q1 (February–March) of 2021. Providers were contacted in person or telephonically, and consenting participants were interviewed using a web-based survey tool. Responses from participants were elicited on their practice before COVID-19, during the 2020 lockdowns (March–April 2020) and currently (Q1 2021). Data were adjusted for survey design and non-response, and results were summarised using descriptive statistics and logistic regression. ResultsOf the 2,750 providers sampled, 2,011 consented and were surveyed (73 % response). Nearly 50 % were between 30 and 45 years of age, and 51 % were from Uttar Pradesh, Maharashtra and Gujarat. Seventy percent of providers reported reduced daily out-patient numbers in Q1 2021 compared to pre-COVID times. During the lockdown, 898 (40 %) of providers said their facilities were closed, while 323 (11 %) offered limited services including teleconsultation. In Q1 2021, 88 % of provider facilities were fully open, with 10 % providing adjusted services, and 4 % using teleconsultation. Only 2 % remained completely closed. Majority of the providers (92 %) reported not experiencing any delays in TB testing in Q1 2021 compared to pre-COVID times. Only 6 % reported raising costs at their clinic, mostly to cover personal protective equipment (PPE) and other infection control measures, although 60–90 % implemented various infection control measures. Thirty-three percent of TB providers were ordering COVID-19 testing, in addition to TB testing.To adapt, 82% of survey providers implemented social distancing and increased timing between appointments and 83% started conducting temperature checks, with variation by state and provider type, while 89% adopted additional sanitation measures in their facilities. Furthermore, 62% of providers started using PPE, and 13% made physical changes (air filters, isolation of patient areas) to their clinic to prevent infection. Seventy percent of providers stated that infection control measures could decrease TB transmission. ConclusionAlthough COVID-19 restrictions resulted in significant declines in patient turn-out at private facilities, our analysis showed that most providers were open and costs for TB care remained mostly the same in Q1 2021. As result of the COVID-19 pandemic, several positive strategies have been adapted by the private sector TB care providers. Since the subsequent COVID-19 waves were more severe or widespread, additional work is needed to assess the impact of the pandemic on the private health sector.

Improving pathways to care through interventions cocreated with communities: a qualitative investigation of men’s barriers to tuberculosis care-seeking in an informal settlement in Blantyre, Malawi

IntroductionMen have a higher prevalence of undiagnosed tuberculosis (TB) than women and can spend up to a year longer contributing to ongoing transmission in the community before receiving treatment. Health...

Behavioural barriers and perceived trade-offs to care-seeking for tuberculosis in the Philippines

ABSTRACT Effective tuberculosis (TB) treatment has existed for more than 50 years, but TB remains a leading cause of death worldwide and in the Philippines, in part because symptomatic individuals delay or avoid seeking care. Through qualitative interviews in Pampanga, Philippines, we investigated barriers to care-seeking using a behavioural science lens. We found barriers to TB care-seeking to be shaped by: (1) ambiguous symptoms; (2) association of TB risk with lifestyle and habits; (3) expectations of stigma, discrimination, and isolation; (4) short-term costs and long-term financial burden of TB; and (5) visibility of care in public sector facilities. Findings suggest that these barriers are deeply intertwined and that, typically, it is a combination of barriers that holds back a particular symptomatic individual from seeking care, as the barriers influence implicit trade-offs related to health, social, and financial consequences of having TB or another serious illness and of seeking care or not seeking care. The findings suggest avenues for more effectively reaching those with symptoms and their family members to encourage care-seeking by elevating the perceived benefits and putting perceived costs in proper perspective.

Understanding why at-risk population segments do not seek care for tuberculosis: a precision public health approach in South India

IntroductionDelaying care-seeking for tuberculosis (TB) symptoms is a major contributor to mortality, leading to worse outcomes and spread. To reduce delays, it is essential to identify barriers to care-seeking and...

Patient pathways of tuberculosis care-seeking and treatment: an individual-level analysis of National Health Insurance data in Taiwan

IntroductionPatients with tuberculosis (TB) often experience difficulties in accessing diagnosis and treatment. Patient pathway analysis identifies mismatches between TB patient care-seeking patterns and service coverage, but to date, studies have...

Patient Pathways of Tuberculosis Care-Seeking and Treatment: An Individual-Level Analysis of National Health Insurance Data

Background: Tuberculosis patients often experience difficulties in accessing diagnosis and treatment. Patient Pathway Analysis provides a tool to identify mismatches between provision of, and patient demand for, tuberculosis care, but was developed using cross-sectional, aggregate data. Methods: We developed an algorithmic approach to analyse and interpret patient-level routine data on healthcare utilisation and construct patients' pathways from initial care-seeking to treatment outcome. We applied this to tuberculosis patients in a simple random sample of one million patients' records in the Taiwan National Health Insurance database. We analysed heterogeneity in pathway patterns, delays, service coverage, and patient flows between different health system levels. Findings: We constructed 7,255 pathways for 6,258 patients. Patients most commonly initially sought care at the primary clinic level, where the capacity for diagnosing tuberculosis was 12%, before eventually initiating treatment at higher levels. Patient pathways are extremely heterogeneous prior to diagnosis, with the 10% most complex pathways accounting for 48% of all clinical encounters, and 55% of those pathways yet to initiate treatment after a year. Extended consideration of alternative diagnoses was more common for patients aged 65 or older and for patients with chronic lung disease. Interpretation: Patient-level routine healthcare data can be analysed to generate individual patient tuberculosis care-seeking pathways. Improving tuberculosis awareness and specimen-handling capacity at primary care level may improve patient experience of accessing tuberculosis care in Taiwan. Funding Statement: PJD was supported by a fellowship from the UK MRC (MR/P022081/1). HHL was supported by the Taiwan MoST, (101-2314-B-002-124) and the Taiwan NHRI (NHRI-EX105- 10228PC). Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: The study was approved by the ethics committee of the University of Sheffield (Reference Number 017693).

How tuberculosis programs can navigate the world of social health insurance.

Many countries with a high tuberculosis (TB) burden are adopting social health insurance (SHI) schemes. However, the national TB programs (NTPs) of these countries are only just starting to grapple with the effects of SHI on their operations. Here, we review the rationale for analyzing TB programs in light of the changes brought by SHI. We consider the influence of certain purchasing decisions on TB care and prevention, and the opportunities that SHI may present for NTPs to broaden private sector engagement, extract TB data across the health sector, and facilitate quality improvement efforts. We also explore which functions are likely to be performed by SHI systems, which require special attention with the advent of SHI, and the metrics that indicate how much of TB care seeking and treatment can be reached and influenced by SHI. SHI presents certain risks for TB programs, but also opportunities to adapt to a more modern health system and to bring quality TB care and treatment to more people.

Finding the Missing Patients With Tuberculosis: Lessons Learned From Patient-Pathway Analyses in 5 Countries.

BackgroundDespite significant progress in diagnosis and treatment of tuberculosis over the past 2 decades, millions of patients with tuberculosis go unreported every year. The patient-pathway analysis (PPA) is designed to assess the alignment between tuberculosis care-seeking patterns and the availability of tuberculosis services. The PPA can help programs understand where they might find the missing patients with tuberculosis.MethodsThis analysis aggregates and compares the PPAs from case studies in Kenya, Ethiopia, Indonesia, the Philippines, and Pakistan.ResultsAcross the 5 countries, 24% of patients with tuberculosis initiated care seeking in a facility with tuberculosis diagnostic capacity. Forty-two percent of patients sought care at level 0 facilities, where there was generally no tuberculosis diagnostic capacity; another 42% of patients sought care at level 1 facilities, of which 39% had diagnostic capacity. Sixty-six percent of patients initially sought care in private facilities, which had considerably less tuberculosis diagnostic capacity than public facilities; only 7% of notified cases were from the private sector. The GeneXpert system was available in 14%–41% of level 2 facilities in the 3 countries for which there were data. Tuberculosis treatment capacity tracked closely with the availability of diagnostic capacity. There were substantial subnational differences in care-seeking patterns and service availability.DiscussionThe PPA can be a valuable planning and programming tool to ensure that diagnostic and treatment services are available to patients where they seek care. Patient-centered care will require closing the diagnostic gap and engaging the private sector. Extensive subnational differences in patient pathways to care call for differentiated approaches to patient-centered care.

Predictors of delayed care seeking for tuberculosis in southern India: an observational study

BackgroundReducing delay to accessing care is necessary to reduce the Tuberculosis (TB) burden in high incidence countries such as India. This study aimed to identify factors associated with delays in seeking care for TB in Southern India.MethodsWe analyzed data from newly diagnosed, smear-positive, culture-confirmed, pulmonary TB patients in the Regional Prospective Observational Research for TB (RePORT) cohort in Puducherry and Tamil Nadu, India. Data were collected on demographic characteristics, symptom duration, and TB knowledge, among other factors. Delay was defined as cough ≥4 weeks before treatment initiation. Risky alcohol use was defined by the AUDIT-C score which incorporates information about regular alcohol use and binge drinking. TB knowledge was assessed by knowing transmission mode or potential curability.ResultsOf 501 TB patients, 369 (73.7%) subjects delayed seeking care. In multivariable analysis, risky alcohol use was significantly associated with delay (aOR 2.20, 95% CI: 1.31, 3.68). Delay was less likely in lower versus higher income groups (<3000 versus >10,000 rupees/month, aOR 0.31, 95% CI: 0.12, 0.78). TB knowledge was not significantly associated with delay.ConclusionsLocal TB programs should consider that risky alcohol users may delay seeking care for TB. Further studies will be needed to determine why patients with higher income delay in seeking care.

Complex relation among Health Belief Model components in TB prevention and care

ObjectivesThis study aims to explore the relationships among components of the Health Belief Model, tuberculosis (TB) preventive behavior, and intention of seeking TB care. Study designCross section study. MethodsUsing convenience sampling, 1154 rural-to-urban migrant workers were selected between the ages of 18–50 years in six urban areas of three provinces in China. The survey was conducted by individual, face-to-face interviews with a standardized questionnaire. Lisrel 8.7 was used to conduct path analysis. ResultsThe knowledge and benefits components of the Health Belief Model predicted preventive behaviors: cover nose/mouth when coughing or sneezing (β = 0.24, 0.33 respectively), evade others' coughs (β = 0.13, 0.25) and also predicted seeking TB care (β = 0.27, 0.19). Susceptibility and severity also predicted seeking TB care (β = 0.12, 0.16). There were also important relationships among model components. Knowledge of TB predicted both susceptibility (β = 0.32–0.60) and severity (β = 0.41–0.45). Further, each of susceptibility (β = 0.30) and severity (β = 0.41) predicted perceived benefits of preventive care. ConclusionThus, a path from knowledge, through severity and susceptibility, and then through benefits predicted prevention and TB care seeking behaviors.

‘For a mere cough, men must just chew Conjex, gain strength, and continue working’: the provider construction and tuberculosis care-seeking implications in Blantyre, Malawi

BackgroundDelay by men in seeking healthcare results in their higher mortality while on HIV or tuberculosis (TB) treatment and contributes to ongoing community-level disease transmission before going on treatment.ObjectiveTo understand masculinity's role in delay in healthcare seeking for men, with a focus on TB-suggestive symptoms.DesignData were collected between March 2011 and March 2012 in low-income suburbs in urban Blantyre using focus group discussions with community members (n=8) and health workers (n=2), in-depth interviews with 20 TB patients (female=14) and 20 uninvestigated chronic coughers (female=8), and a 3-day participatory workshop with 27 health stakeholder representatives. The research process drew to a large extent on grounded theory principles in the manner of Strauss and Corbin (1998) and also Charmaz (1995).ResultsRole descriptions by both men and women in the study universally assigned men as primary material providers for their immediate family, that is, the ones earning and bringing livelihood and additional material needs. In a context where collectivism was valued, men were also expected to lead the provision of support to wider kin. Successful role enactment was considered key to achieving recognition as an adequate man; at the same time, job scarcity and insecurity, and low earnings gravely impeded men. Pressures to generate continuing income then meant constantly looking for jobs, or working continuously to retain insecure jobs or to raise money through self-employment. All this led men to relegate their health considerations.ConclusionsEarly engagement with formal healthcare is critical to dealing with TB and HIV. However, role constructions as portrayed for men in this study, along with the opportunity costs of acknowledging illness seem, in conditions of vulnerability, important barriers to care-seeking. There is a need to address hidden care-seeking costs and to consider more complex interventions, including reducing precarity, in efforts to improve men's engagement with their health.

Assessing the economic burden of illness for tuberculosis patients in Benin: determinants and consequences of catastrophic health expenditures and inequities.

To inform policy-making, we measured the risk, causes and consequences of catastrophic expenditures for tuberculosis and investigated potential inequities. Between August 2008 and February 2009, a cross-sectional study was conducted among all (245) smear-positive pulmonary tuberculosis patients of six health districts from southern Benin. A standardised survey questionnaire covered the period of time elapsing from onset of tuberculosis symptoms to completion of treatment. Total direct cost exceeding the conventional 10% threshold of annual income was defined as catastrophic and used as principal outcome in a multivariable logistic regression. A sensitivity analysis was performed while varying the thresholds. A pure gradient of direct costs of tuberculosis in relation to income was observed. Incidence (78.1%) and intensity (14.8%) of catastrophic expenditure were high; varying thresholds was insensitive to the intensity. Incurring catastrophic expenditure was independently associated with lower- and middle-income quintiles (adjusted odd ratio (aOR) = 36.2, 95% CI [12.3-106.3] and aOR = 6.4 [2.8-14.6]), adverse pre-diagnosis stage (aOR = 5.4 [2.2-13.3]) and less education (aOR = 4.1[1.9-8.7]). Households incurred important days lost due to TB, indebtedness (37.1%), dissaving (51.0%) and other coping strategies (52.7%). Catastrophic direct costs and substantial indirect and coping costs may persist under the 'free' tuberculosis diagnosis and treatment strategy, as well as inequities in financial hardship.

Factors associated with patient, and diagnostic delays in Chinese TB patients: a systematic review and meta-analysis

BackgroundDelay in seeking care is a major impediment to effective management of tuberculosis (TB) in China. To elucidate factors that underpin patient and diagnostic delays in TB management, we conducted a systematic review and meta-analysis of factors that are associated with delays in TB care-seeking and diagnosis in the country.MethodsThis review was prepared following standard procedures of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and checklist. Relevant studies published up to November 2012 were identified from three major international and Chinese literature databases: Medline/PubMed, EMBASE and CNKI (China National Knowledge Infrastructure).ResultsWe included 29 studies involving 38,947 patients from 17 provinces in China. Qualitative analysis showed that key individual level determinants of delays included socio-demographic and economic factors, mostly poverty, rural residence, lack of health insurance, lower educational attainment, stigma and poor knowledge of TB. Health facility determinants included limited availability of resources to perform prompt diagnosis, lack of qualified health workers and geographical barriers.Quantitative meta-analysis indicated that living in rural areas was a risk factor for patient delays (pooled odds ratio (OR) (95% confidence interval (CI)): 1.79 (1.62, 1.98)) and diagnostic delays (pooled OR (95% CI): 1.40 (1.23, 1.59)). Female patients had higher risk of patient delay (pooled OR (95% CI): 1.94 (1.13, 3.33)). Low educational attainment (primary school and below) was also a risk factor for patient delay (pooled OR (95% CI): 2.14 (1.03, 4.47)). The practice of seeking care first from Traditional Chinese Medicine (TMC) providers was also identified as a risk factor for diagnostic delay (pooled OR (95% CI): 5.75 (3.03, 10.94)).ConclusionPatient and diagnostic delays in TB care are mediated by individual and health facility factors. Population-based interventions that seek to reduce TB stigma and raise awareness about the benefits of early diagnosis and prompt treatment are needed. Policies that remove patients’ financial barriers in access to TB care, and integration of the informal care sector into TB control in urban and rural settings are central factors in TB control.

Filipino Women's Tuberculosis Care Seeking Experience in an Urban Poor Setting: A Socioecological Perspective

Urban, poor Filipino women tend to delay seeking care for tuberculosis (TB), which increases their risk for morbidity and mortality. We interviewed 13 women and conducted three focus group discussions to characterize their TB care seeking pathways and identify the barriers and facilitators that influence care seeking at multiple levels. The quality of health services, shame associated with TB, financial insecurity, and familial responsibilities hindered care seeking, while support from community health volunteers and family members encouraged it. Strategies to improve TB control should create social support systems and improve the quality of health services to promote timely care seeking.