Diagnosis Delay and Factors Associated with Delay Among Tuberculosis Patients in Mombasa County, Kenya

doi:10.21203/rs.3.rs-2347458/v1

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Diagnosis Delay and Factors Associated with Delay Among Tuberculosis Patients in Mombasa County, Kenya

https://doi.org/10.21203/rs.3.rs-2347458/v1

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Background: Tuberculosis (TB) transmissions most occur between the onset of symptoms and initiation of treatment. Early identification of cases and commencement of treatment is an effective method to control the spread of TB, but lack of clear understanding on the extent of TB diagnosis delay and factors contributing to delay continue to derail progress in combating the disease. The current agenda in global TB control is to develop better and faster tools for diagnosing TB once a symptomatic patient is found or presents to the health care system, and to provide appropriate therapy [1]. The purpose of this study was to determine the extent of diagnosis delay and factors associated with delay among tuberculosis patients in one of the high TB burdened county in Kenya (Mombasa). Calculating a reliable estimate of the TB diagnosis delay and identifying the factors affecting TB diagnostic delay provides insights into better TB management. Method: Analytic cross-sectional survey of 302 TB patients on intensive phase of treatment was carried out to determine the diagnostic delay period among tuberculosis patients. Data collected using a semi- structured questionnaire were analyzed using SPSS and Microsoft excel. The mean patient delay and associations between length of patient delay and the various independent variables was determined. Multiple logistic regression was performed to determine the factors independently associated with patient delay. Results: The mean patient delay was 47 days; 34 days patient delay and 13 days health system delay. Patient with extra pulmonary tuberculosis (EPTB) took long to seek medical attention (average of 81 days), while those with pulmonary positive (PTB+) sought medical attention early (average of 22 days). Patients who had loss of weight as their first symptom took average of 62 days before seeking medical attention, while patients who had hemoptysis sought attention early within 14 days. 43% of the patients sought medical care at chemists/pharmacies as their first point of care. Long delay was associated with low TB awareness; 84.2% of the patients delayed due to either stigma/fear and lack of adequate knowledge on TB, 12.3% delayed due to economic constraints. Distance to the health facilities was not associated with diagnostic delay. Conclusions: The findings of this study underscore the need for TB stakeholders to improve the quality of TB awareness in the community; educational campaigns should go beyond providing general information about TB to emphasize on embracing early seeking of care and prevention of transmission through early diagnosis and treatment.

Tuberculosis

Diagnosis

Delay

Tuberculosis care and control is still facing major challenges globally, one of the key challenges is diagnosis delay which can lead to several complications, mortality, and TB contamination in the community. It is still a great challenge to public health in sub-Saharan Africa and major public health concern in Kenya. It is the fourth leading cause of death in Kenya, presenting an enormous economic burden to the nation and negatively impacting the lives of its citizens. Despite Kenya having a well-organized National Tuberculosis Control Program (NTP) which provides easy access and free-of-charge services in the public health facilities the ministry of health still estimates that about 40% of TB cases in Kenya remain undiagnosed in the population. These cases contribute to increase transmission, mortality and morbidity and the effects are severe in TB patients co-infected with HIV ^[2].

The most essential components of TB control are early diagnosis and adequate treatment. Delay in the diagnosis and treatment of tuberculosis may result in more extensive disease and more complications, increase severity of the disease and is associated with higher risk of mortality. Factors contributing to delay in diagnosis and treatment of tuberculosis are likely to vary depending on the populations in their local settings ^[3]. In a recent review focusing on sub-Saharan Africa, the majority of associations were related to knowledge or enabling factors describing the place of first consultation and travel time and distance from the health facility. Consulting a traditional healer was associated with patient delay ^[4].

Studies in all regions of the world have investigated patient and health care delays for TB diagnosis, and findings differ by country, setting and population. Therefore, each region needs to identify the extend and reasons for delay in diagnosis of tuberculosis for the health system to find ways to diagnose and treat patients as early as possible, and hence reduce the suffering of patients and transmission of the disease ^[5].

Analytic cross-sectional study design was adopted to determine the diagnostic delay period among tuberculosis patients. The study was carried out in Mombasa County, one of the high burdened counties in Kenya. The county has 51 TB diagnostic centers and 103 tuberculosis treatment centers among which 50 are public facilities while 53 are non-state facilities. Mombasa County in 2019 registered and notified a total of 3,960 cases giving a case notification rate for TB is at 469 per 100,000 which is above the national average ^[2]. All the103 tuberculosis treatment centers were included in the study but priority was given to health facilities with high number of patients on intensive phase (first 2 months) of treatment of TB.

The target population was TB patients aged 18 years and above on treatment who were attending clinic during the period of study (March- May 2016). All patients aged 18 years and above also on intensive phase of treatment (within the first 2 months) were included in the study. Those who had been on TB treatment for a period more than 2 months or not willing to participate were excluded. A desired sample size of 355 was calculated using Fisher et al 1998 formula but during the study period only 302 patients were identified for the study, these being all of those who were on intensive phase of treatment.

Purposive sampling was used to identify TB treatment health facilities in Mombasa County the health facilities without TB patients on intensive phase were skipped. A simple random sampling method was applied to obtain the 302 TB patients on intensive phase of treatment to reduce recall bias who attended TB clinic during the study period (March- May 2016). A structured questionnaire was used to collect data which was administered in a private room after the patients had been reviewed by the clinician -exit interview approach after obtaining an informed verbal consent from the patient. Computer packages (SPSS 20.0 and MS excel) were used to analyze data to obtain comparatives of mean and median of various dependent variables against the dependent variable and significance interpreted. Research ethical approval was provided by the Great Lakes University of Kisumu research ethics committee.

A total of 302 patients were studied, the majority were males, i.e., 191 (63.2%) and 111 (36.8%) were females. The mean age of the participants was 32.54 years, (range 18–81 years). Majority of the participants were from public facilities 74% while 26% were form private health facilities, most participants (57%) were receiving treatment at health centers. Majority of the respondents (43%) on their onset presentation of first symptom of TB sought attention at Chemist/pharmacy.

Extend of delay

Gender

The male respondents reported long delay of 35.47days compared to female who took an average of 32.5 days to seek for health attention following symptoms of TB.

Table 3.1

Sex distribution of respondents and relation to TB diagnosis delay
	Frequency	Percent	Time before seeking medical attention (Mean in days)
Male	191	63.2	35.47
Female	111	36.8	32.50
Total	302	100.0	34.38

Form of TB

Varied delay period were observed among the patients based on the different forms of TB. Majority of the respondents who had extra pulmonary tuberculosis (EPTB) took long to seek medical attention (average of 81 days), PTB + sought medical attention earlier (average of 22 days). The average time taken by all the respondents before seeking medical attention was 34 days.

Table 3.2

Type of TB in relation with TB diagnosis patient delay
	Frequency	Percent	Valid Percent	Time before seeking medical attention (Mean in days)
EPTB	46	15.2	15.2	81.02
PTB+	205	67.9	67.9	22.68
PTB-	51	16.9	16.9	39.33
Total	302	100.0	100.0	34.38

First TB symptom

Majority of responds presented with cough (60.6%) as the first symptom of TB, followed by chest pain (24.5%). The respondents who had loss of weight as their first symptom of TB took long (average of 62 days) before seeking medical attention, while patients who had hemoptysis sought attention early (average of 14 days).

Table 3.3

First TB symptom in relation to TB patient diagnosis delay
First TB symptom	Frequency	Percent	Time before seeking medical attention (Mean in days)
Cough	183	60.6	29
Fever	28	9.3	32
Loss of weight	14	4.6	62
Haemoptysis	2	0.7	14
Chest pain	74	24.5	45
Other signs	1	0.3	21
Total	302	100

Diagnosis delay

The average time taken by respondents before seeking medical attention was 34 days (patient delay), while the average time taken from first visit to health facility to diagnosis of TB was 13 days (health system delay) giving a total diagnosis delay of 47 days.

Table 3.4

TB diagnostic delay
	Respondents	Minimum	Maximum	Mean	Std. Deviation
Time before seeking medical attention	302	1	450	34.38	55.199
Time taken from first visit to TB diagnosis	302	1	46	13.2	11.58

Patient perception on causes of delay

Majority of the respondents (39.1%) perceived TB diagnosis delay to be associated with low quality TB awareness in the community among the community members. The underestimation of the disease was also perceived to contribute to delay “the hope that the symptoms would resolve on their own”.

Table 3.5

Perceived cause of TB diagnosis delay
	Frequency	Percent
Low community education/awareness	118	39.10%
Hope that the symptoms would resolve on their own	58	19.20%
Fear of what would be the diagnosis	41	13.60%
Economic constrain	37	12.30%
Stigma	37	12.30%
Poor staff attitude	8	2.60%
Poor quality health services	3	0.70%

4.1 Extent of diagnostic delay among patients with tuberculosis

The TB diagnostic delay is the time interval between the onset of TB symptoms and diagnosis of TB; this can be looked in two perspectives; patient delay or health system delay. Based on the findings of this research it was found that that patient delay contributed highly to the delay about 34 days while health system delay contributed 13 days giving a total of 47 days of TB diagnosis delay. This agreed with the study in western Kenya which found the diagnosis delay to be up to 5 weeks as well the study done in Gambia which reported a diagnosis delay of 34 days among the patients ^{[6, 7]}.

The median diagnosis delay was found to be 21 days which agreed with study done in Ethiopia which found the median patients’ delay to be 20 days among TB patients ^[8]. This was lower in comparison with same study in Nepal found the median patient delay was 50 days ^[9], which is more than double our findings. It is also lower in comparison with similar study done in Tanzania which found the mean and median time interval between onset of symptoms to initiation of treatment was 125.5 and 90.0 days respectively ^[10].

The research findings agreed with findings from similar study done in Ethiopia which found out that the type of TB had association with TB diagnostic delay ^[11]. In our study findings we noted that type of tuberculosis contributed to the delay, this is because it patients with EPTB had the longest patient delay of 81 days followed by PTB- with 39 days and PTB + with 22 days. This thus establishes association between the form of TB and diagnosis delay period, which we attribute to disease presentation and symptoms of the form of TB. Our study findings indicated that tuberculosis symptoms presentation seem to have contributed to the delay with weight loss having the highest patient delay of 62 days while hemoptysis having the least patient delay of 14 days (2 weeks).

4.2 Association between social demographic and TB diagnosis delay among TB patients

Social demographic factors played a major role in patient delay in tuberculosis diagnosis with gender being a key factor. We found that women had less delay compared to men (32.5 days and 35.47 days respectively). This agreed with finding of study done in Bangladesh where women, in comparison with men, had significantly longer mean and median delays in total delay (63.2 and 61.0 days vs. 60.3 and 53 days, respectively) ^[12]. Distance to diagnostic centre was not a factor to consider for diagnostic delay since majority of the respondents had positive response concerning access to TB diagnostic centre. Level of education seemed to have association with diagnostic delay in that most of the patients who had primary level of education had higher mean delay compared to those of tertiary (Primary, 49 days, tertiary 14 days). This concurred with findings from other similar studies ^{[11, 13]}, which showed prolonged patient delay to be significantly associated with literacy where delay was significantly higher among illiterate patients than those who literate.

4.3 Association between knowledge on TB and diagnosis delay among TB patients

In our study majority of the respondents (39%) perceived low community TB education/awareness as a major contributor to patient diagnosis delay. This agreed with finding from other studies that associated poor knowledge on TB symptoms was among the risk factors that contributed to delay in diagnosis _{[10, 11, 14]}.

4.4 Relationship between health system response and diagnosis delay among TB patients

43% of the respondents confessed to have visited a Chemist/pharmacy first for over the counter treatment at the onset of their TB symptoms. This shows that majority of the respondents did not sought treatment from a health facility with capacity to diagnose TB as first priority. This agreed with findings other similar studies ^{[6, 8]} which found that most of their despondence sought treatment from non-formal health providers resulting to long delay in TB diagnosis compared to those who had a formal provider as their first visit. The findings pointed out health seeking behavior as a big contributor to delay in relation to health system response on TB diagnosis.

Majority of the respondents had their TB diagnosed the first 3 days after visiting a health facility with TB diagnostic capacity, though majority of the respondents (43.7%) sought medical attention first at a chemist/pharmacy, while only 18% sought medical attention at a health facility with TB diagnostic capacity upon presentation of the symptoms. Among those patients who sought medical attention at private and public facilities the diagnostic delay (health system delay) varied; public had 1.8 days while private had 2 days, which showed that public facilities had a slight better health system response than private did. Upon diagnosis private health facilities had a slight long delay on commencing patients on treatment 1.6 days while public had 1.5days. Health system delay on TB diagnosis was a key contributor due to vicious circle in which the patients went through before being diagnosed to have TB.

The mean patient delay was 47 days; 34 days patient delay and 13 days health system delay. Patients with extra pulmonary tuberculosis (EPTB) took long to seek medical attention (average of 81 days), while those with pulmonary positive (PTB+) sought medical attention early (average of 22 days). Sociodemographic factors were found to contribute to diagnosis delay gender being key (men delayed more than women) also level of education contributed to diagnosis delay with those with low education level having experiencing long delay compared to those with higher education level, however distance to the health facilities was found not associated with diagnostic delay. Low TB awareness among the community was found to contribute to delay in diagnosis (84.2% of patients delayed due to lack of adequate knowledge on TB, stigma and fear), also, economic constraint was associated with long delay. Health system response was found to contribute to diagnosis delay with patient visiting more than 3 times with symptoms before being diagnosed to have TB.

TB response strategies focusing on male more than women should be implemented in order to reduce the diagnosis delay among the men
There is need for national TB program (NTP) and its stakeholders to improve the quality of TB awareness in the community; educational campaigns should go beyond providing general information about TB to emphasize on embracing early seeking of care and prevention of transmission through early treatment.
Most tuberculosis sought medical attention at a chemist/pharmacy during the onset of the TB symptoms, which means, for any effective reduction of TB diagnosis delays this particular category of providers need to be incorporated in TB care and control activities.
Similar studies can be done to determine the extent and contribution of various health care providers to patient delays at a national level. Delays to diagnosis and commencement of effective treatment attributable to the health system factors can also be investigated.

Study Limitations

The length of patient delay was self-reported and thus prone to recall bias. To minimize this bias, only newly diagnosed patients and those in their first two months (intensive phase) of TB treatment were included in the study. The patients were specifically asked about the onset of major symptoms and local calendars and national holidays were used to help patients recall with a degree of accuracy.

Institutional Review Board Statement: The study protocol was approved by Great Lakes University of Kisumu, Research Ethics Committee (Protocol Ref: No. GREC/009/247/2016) approved on March 22, 2016.

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study

Acknowledgments: We acknowledge Great Lakes University of Kisumu and Mombasa County for their technical support in conducting the study. Our special thanks to all the TB patients who accepted to participate and contributed to the findings in this study.

Conflicts of Interest: The authors declare no conflict of interest

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No competing interests reported.

Download PDF

Journal Publication

published 29 Mar, 2024

Read the published version in International Journal Of Community Medicine And Public Health →

Version 1

posted

You are reading this latest preprint version

Diagnosis Delay and Factors Associated with Delay Among Tuberculosis Patients in Mombasa County, Kenya

Status:

Journal Publication

Version 1

Abstract

Figures

1. Introduction

2. Methodology

3. Results

4. Discussion

4.1 Extent of diagnostic delay among patients with tuberculosis

4.2 Association between social demographic and TB diagnosis delay among TB patients

4.3 Association between knowledge on TB and diagnosis delay among TB patients

4.4 Relationship between health system response and diagnosis delay among TB patients

5. Conclusions

Recommendations

Declarations

References

Additional Declarations

Status:

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