Determinants of delayed diagnosis and treatment of tuberculosis in Cambodia: a mixed-methods study

Teo, Alvin Kuo Jing; Ork, Chetra; Eng, Sothearith; Sok, Ngovlyly; Tuot, Sovannary; Hsu, Li Yang; Yi, Siyan

doi:10.1186/s40249-020-00665-8

Cited by 23 publications

(26 citation statements)

References 39 publications

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“…The generalizability of our findings was limited, because not all ODs in Cambodia were included in the sampling frame. However, the sex ratio and the trends in the proportion of bacteriologically confirmed TB by age groups [ 10 ] were comparable to the most recent national TB prevalence survey [ 39 ]. In comparison with the cases notified to the NTP in 2018 [ 40 ], the age and sex distribution of our sample also reflected a similar trend.…”

Section: Discussionmentioning

confidence: 67%

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Characterizing and Measuring Tuberculosis Stigma in the Community: A Mixed-Methods Study in Cambodia

Teo

Tan

Smyth³

et al. 2020

Open Forum Infectious Diseases

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Background Stigma is a significant barrier to healthcare and a factor that drives the global burden of tuberculosis (TB). However, there is a scarcity of information on TB stigma in developing countries. We aimed to characterize, measure, and explore the determinants of TB stigma among people with TB in Cambodia. Methods We conducted a mixed-methods study between February and August 2019 using a triangulation convergent design—a cross-sectional survey (n = 730) and nested in-depth interviews (n = 31) among people with TB. Quantitative data were analyzed using descriptive statistics and generalized linear regression models. Qualitative transcripts were thematically analyzed. Results A total of 56% and 51% of participants experienced self-stigma and perceived stigma by the community, respectively. We found rural dwellers, knowledge of how TB is transmitted, and knowledge that anybody can get TB were associated with higher levels of self-stigma and perceived stigma by the community. Higher scores on knowledge of TB symptoms were inversely associated with both self-stigma and community stigma. Thematic analyses revealed accounts of experienced stigma, acts of intentional distancing and hiding TB diagnosis from others, and feelings of embarrassment and shame. Conclusions Tuberculosis stigma was prevalent, suggesting a need for the incorporation of stigma-reduction strategies in the national TB responses. These strategies should be contextualized and developed through community engagement. Future research should continue to measure the levels and dimensions of TB stigma among people with TB through behavioral surveillance using standardized tools.

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Section: Discussionmentioning

confidence: 67%

“…Missing TB cases or delayed diagnosis is an issue affected by various factors, including stigma. In Cambodia, TB stigma, rural dwellers, seeking private healthcare, and self-medication before TB diagnosis were found to be associated with delayed TB diagnosis [ 10 ]. The effects of stigma, by and large, on health are deleterious.…”

mentioning

confidence: 99%

Characterizing and Measuring Tuberculosis Stigma in the Community: A Mixed-Methods Study in Cambodia

Teo

Tan

Smyth³

et al. 2020

Open Forum Infectious Diseases

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“…The private sector relatively outperformed the public sector regarding the delivery of care and medicines availability [ 178 ]. The discrepancies in effectiveness and efficiency were highlighted as a facilitator to seek private healthcare, which eventually leads to a delay in TB diagnosis in a high TB burden setting like Cambodia[ 179 ]. Narrowing down to high TB-burden countries, the quality of public and private healthcare was also found to be below par, and systematic evaluations are needed to identify gaps in the TB care pathway [ 157 ].…”

Section: Discussionmentioning

confidence: 99%

Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis

et al. 2021

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Background Thirty countries with the highest tuberculosis (TB) burden bear 87% of the world’s TB cases. Delayed diagnosis and treatment are detrimental to TB prognosis and sustain TB transmission in the community, making TB elimination a great challenge, especially in these countries. Our objective was to elucidate the duration and determinants of delayed diagnosis and treatment of pulmonary TB in high TB-burden countries. Methods We conducted a systematic review and meta-analysis of quantitative and qualitative studies by searching four databases for literature published between 2008 and 2018 following PRISMA guidelines. We performed a narrative synthesis of the covariates significantly associated with patient, health system, treatment, and total delays. The pooled median duration of delay and effect sizes of covariates were estimated using random-effects meta-analyses. We identified key qualitative themes using thematic analysis. Results This review included 124 articles from 14 low- and lower-middle-income countries (LIC and LMIC) and five upper-middle-income countries (UMIC). The pooled median duration of delays (in days) were—patient delay (LIC/LMIC: 28 (95% CI 20–30); UMIC: 10 (95% CI 10–20), health system delay (LIC/LMIC: 14 (95% CI 2–28); UMIC: 4 (95% CI 2–4), and treatment delay (LIC/LMIC: 14 (95% CI 3–84); UMIC: 0 (95% CI 0–1). There was consistent evidence that being female and rural residence was associated with longer patient delay. Patient delay was also associated with other individual, interpersonal, and community risk factors such as poor TB knowledge, long chains of care-seeking through private/multiple providers, perceived stigma, financial insecurities, and poor access to healthcare. Organizational and policy factors mediated health system and treatment delays. These factors included the lack of resources and complex administrative procedures and systems at the health facilities. We identified data gaps in 11 high-burden countries. Conclusions This review presented the duration of delays and detailed the determinants of delayed TB diagnosis and treatment in high-burden countries. The gaps identified could be addressed through tailored approaches, education, and at a higher level, through health system strengthening and provision of universal health coverage to reduce delays and improve access to TB diagnosis and care. PROSPERO registration: CRD42018107237.

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“…Among LIC and LMIC, a systematic review reported that the quality of health care in public and private sectors was poor, of which the private sectors relatively outperformed the public sector with regards to the delivery of care and medicines availability [175]. The discrepancies in effectiveness and efficiency were highlighted as a facilitator to seek private healthcare, which eventually leads to a delay in TB diagnosis in a high TB burden setting like Cambodia [176]. Narrowing down to high TB-burden countries, quality of both public and private healthcare were also found to be below par, and systematic evaluations are needed to identify gaps in the TB care pathway [157].…”

Section: Health System and Treatment Delaymentioning

confidence: 99%

Determinants of delayed diagnosis and treatment of tuberculosis in high-burden countries: a mixed-methods systematic review and meta-analysis

Teo¹,

Singh

Prem

et al. 2020

Preprint

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Background: Globally, 30 countries with the highest tuberculosis (TB) burden bears 87% of the world’s TB cases. Delayed diagnosis and treatment are detrimental to TB prognosis and sustain TB transmission in the community, making TB elimination a great challenge, especially in these countries. Our objective was to elucidate the determinants and duration of delayed diagnosis and treatment of pulmonary TB in high TB burden countries. Methods: We conducted a systematic review and meta-analysis of quantitative and qualitative studies by searching four databases for literature published between 2008 and 2018 following PRISMA guidelines. For quantitative studies, we performed narrative synthesis of the covariates that were significantly associated with patient, health system, treatment, and total delays. The pooled median duration of delay and effect sizes of covariates were estimated using random-effects meta-analyses. We identified key qualitative themes using thematic analysis. Results: We included 124 articles from 14 low-and lower-middle-income countries (LIC and LMIC) and five upper-middle-income countries (UMIC) in this review. The pooled median duration of patient, health system, and treatment delay were 28 days (95%CI 20–30), 11.5 days (95%CI 3.9–24.7), and six days (95%CI 1–28.4), respectively. We found that the duration of delays was consistently shorter among UMIC compared to LIC and LMIC. There was consistent evidence that being female and rural residence was associated with longer patient delay. Furthermore, patient delay was also associated with other individual, interpersonal, and community risk factors such as poor TB knowledge, long chains of care-seeking through private/multiple providers, perceived stigma, financial insecurities, and poor access to healthcare. Health system and treatment delay were mediated by organizational and policy factors. These factors included the lack of resources and complex administrative procedures and systems at the health facilities. We identified data gaps in 11 high burden countries. Conclusions: This review detailed the determinants of delayed TB diagnosis and treatment in high burden countries. The gaps identified at different socio-ecological levels could be addressed through tailored approaches, education, and at a higher level, through health system strengthening and provision of universal health coverage to reduce delays and improve access to TB diagnosis and care.

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Determinants of delayed diagnosis and treatment of tuberculosis in Cambodia: a mixed-methods study

Cited by 23 publications

References 39 publications

Characterizing and Measuring Tuberculosis Stigma in the Community: A Mixed-Methods Study in Cambodia

Characterizing and Measuring Tuberculosis Stigma in the Community: A Mixed-Methods Study in Cambodia

Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis

Determinants of delayed diagnosis and treatment of tuberculosis in high-burden countries: a mixed-methods systematic review and meta-analysis

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