Health System Delay Research Articles

The Extent of Delay in Diagnosis, Treatment and their Associated Factors among Tuberculosis Patients Attending Government Hospitals of Rishikesh, Uttarakhand: A Cross-Sectional Study.

"Tuberculosis (TB) remains a major public health problem" worldwide, affecting almost all age groups. "Early diagnosis and prompt treatment are essential to significantly reducing the TB burden." However, a significant proportion of cases remain undiagnosed and untreated, which plays a vital role in the transmission of the disease and severity of the illness in the community in most developing countries. This study aimed to assess "the extent of delay in diagnosis and treatment of TB patients" and to identify the major factors associated with such delays (whether patient or health system-related) among TB patients in Rishikesh. This descriptive cross-sectional study was conducted in Rishikesh Town, Dehradun District, Uttara khand, India. Total of 130 newly diagnosed TB patients were recruited as study participants who attended the government hospitals of Rishikesh, All India Institute of Medical Sciences, Rishikesh and S P S Government Hospital, Rishikesh. A universal sampling technique was used in this study. The mean age of the study participant was 36.75 (Standard Deviation (SD), 17.6), and the median age was 34 years. Of the patients, 64.6% were men, and 35.4% were women. The extent of various delays, such as patient delay (median 16 days), diagnostic delay (median 78.5 days), treatment delay (median 4 days), health system delay (43 days), and total delay (median 81 days). The misconception of any chronic disease may lead to a false diagnosis or long treatment for symptomatic relief; the absence of proper diagnostic tests and doctor shopping could be the reasons for the prolonged diagnostic delay. Therefore, by strengthening the collaboration between private and public practitioners in order to meet the expectations of the Government of India to achieve the goals of the "National Strategic Plan for ending TB" in India by providing good quality care for all patients.

LMIC-14. MAPPING THE REFERRAL PATH - HURDLES IN PEDIATRIC BRAIN TUMOR DIAGNOSIS: A PERSPECTIVE FROM TERTIARY CANCER CARE CENTRE IN A LOW MIDDLE-INCOME COUNTRY

Abstract BACKGROUND Delayed referral remains leads to worse outcomes for children with cancer in low- and middle-income countries (LMIC), especially for patients with brain tumors. Delay in treatment could be due to the ignorance from the families to seek health care advice or lack of awareness of primary care physician. METHODS A retrospective study was conducted to delineate the referral path of children with brain tumors who presented to our institution. Patients <18 years with brain tumors registered from June 2022-December 2023 were included. Patients with relapsed disease, second opinion, or partially treated in an outside institute prior to referral were excluded. Data were captured using a proforma after obtaining permission from Institutional ethics committee. RESULTS Thirty-one children were enrolled with a median age of 5 years (range: 0-17) with M: F ratio of 1.58:1. The most common diagnosis in this cohort was medulloblastoma in 13(42%) followed by high grade glioma in 7(22%) and low-grade glioma in 4 patients (13%). Twenty-four (77%) belonged to low socio-economic strata defined by Modified Kuppuswamy classification, of which 22 (71%) were hailing from rural area with median distance from cancer center being 121 miles (range: 4.34 -242). Median of 3 (range: 1-6) consultations were sought prior to being referred to us and about 11 (35%) had visited alternative system of medicine before consulting us. Mean delay from symptom onset to diagnosis was 52 days (range: 2-530) with healthcare seeking delay of 5.4 days (Range: 0-30) and health system delay of 46 days (range: 1-500). The factors influencing delay included rural background (p=0.04) and lower socioeconomic strata (p=0.03). CONCLUSIONS Health system delay was a major cause of delayed referral in our study. By improving awareness of the primary care physicians about symptomatology of pediatric brain tumors, the referral pathway can be expedited thereby improving the outcomes of these children.

Advanced-stage breast cancer diagnosis and its determinants in Ethiopia: a systematic review and meta-analysis

IntroductionWorldwide, breast cancer is the primary cause of illness and death. Unless early detected and treated breast cancer is a life-threatening tumor. Advanced-stage presentation is greatly linked with short survival time and increased mortality rates. In Ethiopia nationally summarized evidence on the level of advanced-stage breast cancer diagnosis is scarce. Therefore, this systematic review and meta-analysis aimed to determine the pooled prevalence of advanced-stage breast cancer diagnosis and its determinants in Ethiopia.MethodBy following PRISMA guidelines, a systematic review and meta-analysis were carried out. To include relevant publications, a broad literature search was conducted in the African Online Journal, PubMed, Google Scholar, and Embase which are published until last search date; June 15, 2023. To prevent further duplication this review was registered in PROSPERO database with ID no of CRD42023435096. To determine the pooled prevalence, a weighted inverse variance random effect model was applied. I2 statistics and the Cochrane Q-test were computed to determine heterogeneity. To evaluate publication bias, a funnel plot, and Egger’s regression test were used.ResultA total of 924 articles were sought and finally 20 articles were included in this review. The pooled prevalence of advanced-stage breast cancer diagnosis in Ethiopia was 72.56% (95%CI; 68.46-76.65%). Use of traditional medicine as first choice (AOR = 1.32, 95% CI: (1.13–1.55)), delay of > 3 months in seeking care (AOR = 1.24, 95% CI: (1.09–1.41)), diagnosis or health system delay of > 2 months (AOR = 1.27, 95% CI: (1.11–1.46)), rural residence (AOR = 2.04, 95% CI: (1.42 − 2.92)), and chief complaint of a painless breast lump (AOR = 2.67, 95% CI: (1.76–4.06)) were significantly associated to advanced-stage diagnosis.ConclusionIn Ethiopia, more than two-thirds of breast cancer cases are diagnosed at an advanced stage. Use of traditional medicine before diagnostic confirmation, delay in seeking care, health system delay, rural residence, and chief complaint of painless breast lump were positively associated with an advanced-stage diagnosis. Policymakers and program designers give great focus to those delays so as to seek and access modern diagnosis and treatment as early as possible specifically focusing on those who are rurally residing.

Association between TB delay and TB treatment outcomes in HIV-TB co-infected patients: a study based on the multilevel propensity score method.

HIV-tuberculosis (HIV-TB) co-infection is a significant public health concern worldwide. TB delay, consisting of patient delay, diagnostic delay, treatment delay, increases the risk of adverse anti-TB treatment (ATT) outcomes. Except for individual level variables, differences in regional levels have been shown to impact the ATT outcomes. However, few studies appropriately considered possible individual and regional level confounding variables. In this study, we aimed to assess the association of TB delay on treatment outcomes in HIV-TB co-infected patients in Liangshan Yi Autonomous Prefecture (Liangshan Prefecture) of China, using a causal inference framework while taking into account individual and regional level factors. We conducted a study to analyze data from 2068 patients with HIV-TB co-infection in Liangshan Prefecture from 2019 to 2022. To address potential confounding bias, we used a causal directed acyclic graph (DAG) to select appropriate confounding variables. Further, we controlled for these confounders through multilevel propensity score and inverse probability weighting (IPW). The successful rate of ATT for patients with HIV-TB co-infection in Liangshan Prefecture was 91.2%. Total delay (OR = 1.411, 95% CI: 1.015, 1.962), diagnostic delay (OR = 1.778, 95% CI: 1.261, 2.508), treatment delay (OR = 1.749, 95% CI: 1.146, 2.668) and health system delay (OR = 1.480 95% CI: (1.035, 2.118) were identified as risk factors for successful ATT outcome. Sensitivity analysis demonstrated the robustness of these findings. HIV-TB co-infection prevention and control policy in Liangshan Prefecture should prioritize early treatment for diagnosed HIV-TB co-infected patients. It is urgent to improve the health system in Liangshan Prefecture to reduce delays in diagnosis and treatment.

Analysis on time delay of tuberculosis among adolescents and young adults in Eastern China.

Tuberculosis (TB) is recognized as a significant global public health concern. Still, there remains a dearth of comprehensive evaluation regarding the specific indicators and their influencing factors of delay for adolescents and young adults. All notified pulmonary TB (PTB) patients in Jiaxing City were collected between 2005 and 2022 from China's TB Information Management System. Logistic regression models were conducted to ascertain the factors that influenced patient and health system delays for PTB cases, respectively. Furthermore, the impact of the COVID-19 pandemic on local delays has been explored. From January 1, 2005 to December 31, 2022, a total of 5,282 PTB cases were notified in Jiaxing City, including 1,678 adolescents and 3,604 young adults. For patient delay, female (AOR: 1.18, 95%CI: 1.05-1.32), PTB complicated with extra-pulmonary TB (AOR: 1.70, 95% CI: 1.28-2.26), passive case finding (AOR: 1.46, 95% CI: 1.07-1.98) and retreatment (AOR: 1.52, 95% CI: 1.11-2.09) showed a higher risk of delay. For health system delay, minorities (AOR: 0.69, 95% CI: 0.53-0.90) and non-students (AOR: 0.83, 95% CI: 0.71-0.98) experienced a lower delay. Referral (AOR: 1.46, 95% CI: 1.29-1.65) had a higher health system delay compared with clinical consultation. Furthermore, county hospitals (AOR: 1.47, 95% CI: 1.32-1.65) and etiological positive results (AOR: 1.46, 95% CI: 1.30-1.63) were associated with comparatively high odds of patient delay. Contrarily, county hospitals (AOR: 0.88, 95% CI: 0.78-1.00) and etiological positive results (AOR: 0.67, 95% CI: 0.59-0.74) experienced a lower health system delay. Besides, the median of patient delay, health system delay, and total delay during the COVID-19 pandemic were significantly lower than that before. In general, there has been a noteworthy decline in the notification rate of PTB among adolescents and young adults in Jiaxing City while the declining trend was not obvious in patient delay, health system delay, and total delay, respectively. It also found factors such as gender, case-finding method, and the hospital level might influence the times of seeking health care and diagnosis in health agencies. These findings will provide valuable insights for refining preventive and treatment strategies for TB among adolescents and young adults.

Diagnosis delay and factors associated with delay among tuberculosis patients in Mombasa County, Kenya

Background: Most tuberculosis (TB) transmissions occur between the onset of symptoms and treatment initiation. Early case identification and treatment initiation is an effective method to control the spread of TB, but the lack of a clear understanding about the extent of TB diagnostic delay and the factors contributing to delay continue to derail progress in combating the disease. The purpose of this study was to determine the extent of diagnostic delay and factors associated with delay among TB patients. Methods: An analytic cross-sectional survey of 302 TB patients on the intensive phase of treatment was carried out to determine the diagnostic delay period among TB patients. Data were collected using a semi-structured questionnaire. The mean patient delay and associations between the length of patient delay and the various independent variables were determined. Results: The mean diagnostic delay was 47 days, patient delay was 34 days and health system delay was 13 days. Patients with extrapulmonary TB had lengthy diagnostic delay of 81 days. Prolonged delay was associated with low TB awareness. Conclusions: The study findings underscore the need to improve the quality of TB awareness in the community; campaigns should go beyond providing general information about TB to emphasize on early care-seeking.

Total Patient Delay: A Comparison of Patient and Clinician/Health System Delays in the Diagnosis of Progressive Supranuclear Palsy and Corticobasal Syndrome.

Early diagnosis in progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS) is important for clinical care and key to developing successful disease-modifying agents. The patient-dependent phases of decision-making made before contact with a healthcare professional have been inadequately studied. To evaluate the patient-dependent phases of decision-making from symptom onset, comparing this to clinician and/or health system delays within the overall diagnostic pathway. Using the Anderson General Model of Total Patient Delay and a mixed-methods approach in participants with PSP/CBS and their caregivers recruited to the Scottish PSP and CBS cohort, we quantified and evaluated the determinants of "appraisal", "illness," and "behavioral" delay, comparing this to the clinician and/or health system delays ("treatment" delay) within the overall time from symptom onset to diagnosis. The time from index symptom onset to diagnosis was 3.26 (interquartile range [IQR] = 2.42, 4.75) years in PSP and 2.58 (IQR = 1.69, 4.08) years in CBS. Patient appraisal delay was 24 (IQR = 6, 60) weeks in PSP and 8 (IQR = 5, 24) weeks in CBS, illness delay 0 (IQR = -14, 0) weeks in PSP and 0 (IQR = -4, 0) weeks in CBS, with little perceived behavioral delay. Determinants of delay included the non-specificity of symptoms, normalization of symptoms within the context of age or normal physiological variability, and the extent of insight into new somatic symptoms. Although patient appraisal delay contributes to overall diagnostic delay in PSP/CBS, the greater proportion of overall diagnostic delay arises after contact with a healthcare professional (treatment delay).

Assessing heterogeneity of patient and health system delay among TB in a population with internal migrants in China.

The diagnostic delay of tuberculosis (TB) contributes to further transmission and impedes the implementation of the End TB Strategy. Therefore, we aimed to describe the characteristics of patient delay, health system delay, and total delay among TB patients in Shanghai, identify areas at high risk for delay, and explore the potential factors of long delay at individual and spatial levels. The study included TB patients among migrants and residents in Shanghai between January 2010 and December 2018. Patient and health system delays exceeding 14 days and total delays exceeding 28 days were defined as long delays. Time trends of long delays were evaluated by Joinpoint regression. Multivariable logistic regression analysis was employed to analyze influencing factors of long delays. Spatial analysis of delays was conducted using ArcGIS, and the hierarchical Bayesian spatial model was utilized to explore associated spatial factors. Overall, 61,050 TB patients were notified during the study period. Median patient, health system, and total delays were 12 days (IQR: 3-26), 9 days (IQR: 4-18), and 27 days (IQR: 15-43), respectively. Migrants, females, older adults, symptomatic visits to TB-designated facilities, and pathogen-positive were associated with longer patient delays, while pathogen-negative, active case findings and symptomatic visits to non-TB-designated facilities were associated with long health system delays (LHD). Spatial analysis revealed Chongming Island was a hotspot for patient delay, while western areas of Shanghai, with a high proportion of internal migrants and industrial parks, were at high risk for LHD. The application of rapid molecular diagnostic methods was associated with reduced health system delays. Despite a relatively shorter diagnostic delay of TB than in the other regions in China, there was vital social-demographic and spatial heterogeneity in the occurrence of long delays in Shanghai. While the active case finding and rapid molecular diagnosis reduced the delay, novel targeted interventions are still required to address the challenges of TB diagnosis among both migrants and residents in this urban setting.

Measuring and Comparing Health System Delays in Leprosy Detection Based on the First Healthcare Service Visit in Tegal Regency, Indonesia

The prevalence of leprosy patients with disabilities among new cases in Tegal Regency was high in 2021, reaching 10%. This problem is due to the delays in the diagnosis and treatment of leprosy, including health system delays associated with patients’ visits to healthcare services. This study aims to measure and compare health system delays based on the types of healthcare service first visited by leprosy patients. This study employed a cross-sectional design involving a sample of 125 leprosy patients recruited in 2022. Data were collected through interviews with leprosy patients using a validated case detection delay questionnaire. Descriptive and inferential statistics were performed using Kruskal-Wallis test. Among the respondents, 67% were male. Patients sought initial care at various types of healthcare services, with community health centers being the most frequently visited (53%). The average health system delay was 3.3 months, with the longest delay observed when the first visit was to a medical doctor (5.4 months). A significant difference in health system delays was found across the types of healthcare services first visited by leprosy patients (p = 0.001). Further research is recommended to enhance the leprosy detection capacity of healthcare staff in Tegal Regency.

Mathematical modeling and optimal control of tuberculosis spread among smokers with case detection

<p>Tuberculosis (TB) remains one of deadly infectious diseases worldwide. Smoking habits are a significant factor that can increase TB transmission rates, as smokers are more susceptible to contracting TB than nonsmokers. Therefore, a control strategy that focused on minimizing TB transmission among smokers was essential. The control of TB transmission was evaluated based on the case detection rate. Undetected TB cases often resulted from economic challenges, low awareness, negative stigma toward TB patients, and health system delay (HSD). In this study, we developed a mathematical model that captured the dynamics of TB transmission specifically among smokers, incorporating the effects of case detection. Our innovative approach lied in the integration of smoking behavior as a key factor in TB transmission dynamics, which has been underexplored in previous models. We analyzed the existence and stability of the TB model equilibrium based on the basic reproduction number. Additionally, parameter sensitivity analysis was conducted to identify the most influential factors in the spread of the disease. Furthermore, this study investigated the effectiveness of various control strategies, including social distancing for smokers, TB screening in high-risk populations, and TB treatment in low-income communities. By employing the Pontryagin maximum principle, we solved optimal control problems to determine the most effective combination of interventions. Simulation results demonstrated that a targeted combination of control measures can effectively reduce the number of TB-infected individuals.</p>

Care-seeking pathways and diagnostic delays in extrapulmonary TB patients

SETTING: This study was conducted at a private tertiary hospital engaged with the TB control programme in the city of Lahore, Pakistan.OBJECTIVE: To assess the healthcare-seeking pathways, different delays and factors associated with delays among the patients who presented in the outpatient department with tuberculous lymphadenitis and pleuritis, the most common manifestations of extrapulmonary TB.DESIGN: This cross-sectional study was conducted prospectively from April 2016 to August 2017.RESULTS: The median age of the 339 patients analysed was 22 years (IQR 17–30); tuberculous lymphadenitis was predominant in females (63%), while pleuritis affected more males (64%). Overall, 62% reported seeking care from healthcare providers before diagnosis, of whom 62% sought care from private facilities, 32% visited facilities >2 times and 8% visited traditional healers. Diagnostic delay was associated with tuberculous lymphadenitis, age 15–44 years, poor socio-economic status and poor TB knowledge.CONCLUSION: There was considerable delay in the management of extrapulmonary TB patients, and the health-system delay was the major contributor, leading to increased patient suffering. Efforts towards minimising health-system delay need to be prioritised for patient screening and diagnosis, with a feasible algorithm that is workable in resource-limited settings.

Diagnostic delay, treatment duration and outcomes since the implementation of integrated model of tuberculosis control and their associated factors in a county in East China

ObjectiveThis study assesses the diagnostic delay, treatment duration and treatment outcomes of tuberculosis (TB) patients since the implementation of the integrated model of TB control in a county in eastern China. It further identifies factors associated with diagnostic delay and treatment duration in the integrated model.MethodsWe collected data through the Chinese Tuberculosis Information Management System (TBIMS) for Cangnan County in Zhejiang Province. Chi-square and Mann-Whitney tests were adopted to identify factors associated with duration of treatment and treatment delay for TB patients within the integrated model. Multiple regression analysis was subsequently performed to confirm the identified factors.ResultsIn the integrated model from 2012 to 2018, the median health system delay was maintained at 1 day, and the median patient delay decreased from 14 to 9 days and the median total delay decreased from 15 to 11 days. In addition, the proportion of patients who experienced patient delay > 14 days and total delay > 28 days decreased from 49% to 35% and from 32% to 29% respectively. However, the proportion of patients who had health system delay > 14 days increased from 0.2% to 13% from 2012 to 2018. The median treatment duration increased from 199 to 366 days and the number of TB patients lost to follow-up showed an overall upward trend from 2012 to 2018. The multivariable regression analysis indicated that migrant TB patients and TB patients initially diagnosed in hospitals at the prefectural level and above tended to experience total delay > 28 days (p < 0.001). Linear regression analysis confirmed that new TB patients>60 years tended to have longer treatment duration (p < 0.05).ConclusionsWhile our study may suggest the potential of the integrated model in early detection and diagnosis of TB, it also suggests the importance of strengthening supervision and management of designated hospitals to optimize the treatment duration and improve retention of patients in TB care. Enhancing health education for TB patients, especially amongst migrant patients, and training in TB identification and referral for non-TB doctors are also key for early TB detection and diagnosis in the integrated model.

Wilms tumor treatment protocol compliance and the influence on outcomes for children in Tanzania.

Standardized Wilms tumor treatment protocols exist for low- and middle-income countries, but outcomes equivalent to high-income countries are not achieved outside of clinical trials. As Wilms tumor treatment protocols in Africa shift with increasing resource capacity, it is not known how treatment compliance to each stage of therapy affects outcomes and where the critical breakpoints are for protocol adherence in clinical practice. We describe both treatment outcomes and treatment protocol adherence in a retrospective single-center cohort study of pediatric Wilms tumor patients at a zonal cancer referral hospital in Tanzania from 2016 to 2019, treated per the International Society of Paediatric Oncology standard (2016-2017) or Tanzania adapted (2018-2019) therapy protocols. A total of 69 patients were evaluated. The two-year overall survival and event-free survival rates were 40% and 29%, respectively. Only 29% of patients completed recommended chemotherapy per protocol, and completion of preoperative and postoperative chemotherapy was predictive of two-year overall survival (odds ratio [OR] 14.4, p<.001). There were delays at almost every stage of treatment, especially time from preoperative chemotherapy to surgery (56days), from surgery to pathology report (30days), and from surgery to initiation of postoperative chemotherapy (38days). Nonadherence with recommended Wilms tumor treatment guidelines due to key health system delays correlated to reduced overall survival rates, with chemotherapy nonadherence due to abandonment, lack of surgery, and deaths on therapy as the strongest contributors. Future interventions targeting health system delays and reducing deaths during therapy are critical to improving protocol compliance and increasing overall survival for pediatric Wilms tumor patients in low-resource settings.

Geographic distribution and predictors of diagnostic delays among possible TB patients in Uganda.

Understanding the geographic distribution and factors associated with delayed TB diagnosis may help target interventions to reduce delays and improve patient outcomes. We conducted a secondary analysis of adults undergoing TB evaluation within a public health demonstration project in Uganda. Using Global Moran's I (GMI) and Getis-Ord GI* statistics, we evaluated for residential clustering and hotspots associated with patient-related and health system-related delays. We performed multivariate logistic regression to identify individual predictors of both types of delays. Of 996 adults undergoing TB evaluation (median age: 37 years, IQR 28-49), 333 (33%) experienced patient delays, and 568 (57%) experienced health system delays. Participants were clustered (GMI 0.47-0.64, P ⩽ 0.001) at the sub-county level, but there were no statistically significant hotspots for patient or health system delays. Married individuals were less likely to experience patient delays (OR 0.6, 95% CI 0.48-0.75; P < 0.001). Those aged 38-57 years (OR 1.2, 95% CI 1.07-1.38; P = 0.002) were more likely than those aged ⩾58 years to experience patient delays. Knowledge about TB (OR 0.8, 95% CI 0.63-0.98; P = 0.03) protected against health system delays. We did not identify geographic hotspots for TB diagnostic delays. Instead, delays were associated with individual factors such as age, marital status and TB knowledge.

Factors leading to diagnostic delay in tuberculosis in the tropical north of Australia.

Tuberculosis (TB) incidence is decreasing in the Northern Territory (NT) but still exceeds rates elsewhere in Australia. Deaths and morbidity from advanced TB continue, with delay in diagnosis a contributor to adverse outcomes. We aimed to describe the delay in diagnosis of TB, identify risk factors for delay and examine the associations between delay and clinical outcomes. We conducted a historical cohort analysis which included adult inpatients diagnosed with TB at the Royal Darwin Hospital from 2010 to 2020. Patient delay was measured as time from symptom onset to first seeking care, and health system delay was quantified as time from first relevant clinical contact to diagnosis. The sum of these two periods was the total delay. Ethics approval was granted by NT HREC (2020-3852). Eighty-four cases were included; the median total delay was 90 days (interquartile range (IQR): 60-121), patient delay was 53 days (IQR: 30-90), and health system delay was 21 days (IQR: 12-45). Patient delay was longer among patients with extrapulmonary (median: 100 days (IQR: 90-105) compared with pulmonary TB patients (39 days (IQR: 27-54), P < 0.0001). Health system delay was longer in those aged ≥45 years (30 days (IQR: 16-51) vs younger patients (14 days (IQR: 8-30), P = 0.007) and among non-smokers (31 days (IQR: 21-55) vs 21 days (IQR: 10-40), P = 0.048). Median delay was longer among patients with non-drug-related complications of disease (P < 0.0001), those admitted to critical care (P < 0.0001), and those with respiratory failure (P = 0.001). The patient delays we report are longer than reported elsewhere in Australia. The next steps will require concerted efforts to improve community awareness of TB and strategies to strengthen health systems through better resourcing and healthcare provider support.

Measuring leprosy case detection delay and associated factors in Indonesia: a community-based study

BackgroundLeprosy is a public health burden in Indonesia with a high number of new cases every year and a high proportion of disability among new cases. Case detection delay (CDD) can contribute to ongoing transmission and increased disability chances among leprosy patients. This study aimed to establish the CDD of leprosy and the factors associated with detection delay in Indonesia.MethodCommunity-based study with a cross-sectional design. Data were collected through interviews about sociodemographic and behavioral factors, anticipated stigma, and duration of CDD. Leprosy classification and case detection methods were obtained from health service records. A random sample was taken of 126 leprosy patients registered between 1st October 2020 and 31st March 2022 in the Tegal regency in the Central Java Province. Data were analysed by descriptive and analytical statistics using multiple linear regression.ResultsThe mean CDD, patient delay, and health system delay were 13.0 months, 9.7 months, and 3.2 months, respectively. Factors associated with longer CDD are younger age (below 35 years), male, found through passive case detection, and not having a family member with leprosy. Factors associated with longer patient delay were being younger (below 35 years), being male, not having a family member with leprosy, and anticipated stigma of leprosy. It was not possible to reliably identify factors associated with health system delay.ConclusionCDD in leprosy should be reduced in Indonesia. The Indonesian National Leprosy Control Program (NLCP) is advised to adopt an integrated intervention programme combining active case detection with targeted health education to reduce CDD and thereby preventing disabilities in people affected by leprosy.

Delay analysis of pulmonary tuberculosis in the eastern coastal county of China from 2010 to 2021: evidence from two surveillance systems.

Tuberculosis (TB) remains a major public health challenge. However, indicators of delays in assessing effective TB prevention and control and its influencing factors have not been investigated in the eastern coastal county of China. All notified pulmonary tuberculosis (PTB) cases in the Fenghua District, China were collected between 2010 and 2021 from the available TB information management system. Comparison of delays involving patient, health system, and total delays among local and migrant cases. Additionally, in correlation with available Basic Public Health Service Project system, we performed univariate and multivariate logistic regression analyses identified the influencing factors associated with patient and total delays in patients aged >60 years. In total, 3,442 PTB cases were notified, including 1,725 local and 1,717 migrant patients, with a male-to-female ratio of 2.13:1. Median patient and total delays of local TB patients were longer than those for migrant patients; the median health system delay did not show any significant difference. For patient delay among the older adult, female (cOR: 1.93, 95% CI: 1.07-3.48), educational level of elementary school and middle school (cOR: 0.23, 95% CI: 0.06-0.84) had a statistical difference from univariable analysis; however, patients without diabetes showed a higher delay for multiple-factor analysis (aOR: 2.12, 95% CI: 1.02-4.41). Furthermore, only the education level of elementary school and middle school presented a low total delay for both univariate (cOR: 0.22, 95% CI: 0.06-0.82) and multivariate analysis (aOR: 0.21, 95% CI: 0.05-0.83) in the older patients. The delay of TB cases among migrants was lower than the local population in the Fenghua District, which may be related to the "healthy migrant effect". It highlights that women, illiterate people, and people without diabetes are key groups for reducing delays among older adults. Health awareness should focus on these target populations, providing accessible health services, and reducing the time from symptom onset to diagnosis.

Delay in healthcare seeking, diagnosis, and treatment of patients with tuberculosis: A cross-sectional study

Background: One of the greatest challenges in the fight against tuberculosis (TB) is the delay in seeking medical care among those who are sick. This can be complemented by delays in providing prompt health-care services. Aims and Objectives: The aims of this study were to estimate the number of patients facing delays and to understand the various reasons for individual and health system delays. Materials and Methods: In this cross-sectional study, new sputum positive cases of &gt;18 years registered at the two TB Units of two community health centers of a district in Uttar Pradesh from March 2018 to April 2019 were included. The primary outcome was patient delay and health system delay. They were assessed from patient interviews as well as through records. Results: A total of 120 patients were included in the study of which, 76 had been subjected to one or the other form or a combination of delay. The factors such as age, education level, occupation, socioeconomic condition, and the walking duration to the nearest health center were found to be significantly associated with delay. The patient delay was seen in 37 (30.8%) with median delay of 45 days (interquartile range [IQR] 37–53). The health system delay was observed in 48 (40.0%) patients with median delay of 24.5 days (IQR 12.0–47.2). Conclusion: In spite of robust program implementation, patient factor delays continue to prevail which contributes to the total delay. Addressing delay in Tb is of utmost important so as to progress to TB elimination.

DELAY IN DIAGNOSIS OF TUBERCULOSIS AMONG PATIENTS ATTENDING DIFFERENT DOTS CENTRES OF BHARATPUR METROPOLITAN CITY, CHITWAN

Background: Delay in the diagnosis of tuberculosis can lead to an increased inactivity period, delayed treatment, and increased disease severity. The objective of this study was to identify the magnitude of the delay and the factors causing a delay in the diagnosis of Tuberculosis. Methods: A descriptive cross-sectional study of 216 tuberculosis patients was conducted at 29 DOTS centers in the Bharatpur metropolitan city of Nepal from November 2021 to April 2022. Data was collected by a face-to-face interview method using a Semi-structured questionnaire. Data entry and analysis were done through IBM-SPSS 20 version, and the Pearson Chi-Squared test was used to find the association between the delay status of diagnosis of Tuberculosis and some independent variables at a 5% level of significance. Results: Present study showed that median patient delay, health system delay and total delay were 21.5 days, 17 days and 40 days, respectively. Similarly, the Pearson chi-square test showed that the sex (P=0.005&lt; 0.05, df =1), level of knowledge on tuberculosis symptoms (P=0.008&lt; 0.05, df=1) and age of respondents (P=0.001&lt; 0.05, df=1) were found significant to the total delay time of tuberculosis diagnosis. Conclusions: Total median delay in diagnosing Tuberculosis was around six weeks, and the patient delay was higher than the health system delay. Interventions to improve knowledge and awareness of the disease and to increase the suspicion of chest symptoms by healthcare providers in health institutions are vital measures to reduce total delay in diagnosis.

“It Seems like it’s Helping”: Complementary and Alternative Medicine Use among Breast Cancer Patients at a South African Breast Clinic

The use of complementary and alternative medicine in the treatment of breast cancer is widely documented in low- and middle-income countries. However, there are limited data on the use of complementary and alternative medicine among breast cancer patients in South Africa. In this study, we examined the use of complementary medicine among a small sample of women attending a breast cancer clinic in a public health hospital in the Western Cape, South Africa; a context in which structural violence is rife. A convenience sample of 17 women participated in semi-structured interviews. We used an interpretative phenomenological analysis approach. We found that breast cancer patients’ use of complementary and alternative medicine was motivated by (1) pragmatic reasons related to health system delays in obtaining biopsy results, confirmation of diagnosis and between diagnosis and start of treatment, (2) psychological benefits, namely, enhancing holistic well-being and fostering a sense of hope and agency despite the physical disease, and (3) sociocultural influences. Such information was based on folk knowledge and cultural beliefs. Patient-centred care in this context may be enhanced by collaboration between biomedical and practitioners who provide complementary and alternative medicine to support transparency in patient treatment options, negotiate the various domains of patient care (physical, psychological, sociocultural) and contribute to earlier detection, diagnosis and better treatment outcomes. In addition, further research on the systemic complexities of structural violence and the way in which it shapes the illness experiences of women is necessary.