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

Teo, Alvin Kuo Jing; Singh, Seema; Prem, Kiesha; Hsu, Li Yang; Yi, Siyan

doi:10.21203/rs.2.24605/v1

Cited by 3 publications

(3 citation statements)

References 119 publications

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“…Despite the effect of stigma on delayed TB diagnosis [ 7 ], IDI participants also reported that encouragements from family members, friends, and notably TB survivors were instrumental in facilitating TB care-seeking. One apparent link to the current TB policy in Cambodia was the implementation of the community directly observed treatment, short-course (C-DOTS).…”

Section: Discussionmentioning

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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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: 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

Self Cite

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“…Therefore, understanding the specific determinants of delayed diagnosis can be used as a practical guide to enhance outreach programs, increase community engagement to reach missing cases, and to improve TB control strategies. Recent systematic reviews have reported empirical evidence associating socio-demographic, clinical, health system, and economic factors with delayed diagnosis and treatment of TB [8][9][10]. In Cambodia, Sundaram and colleagues have reported that strong preference for private healthcare services, lack of awareness of TB symptoms, and misbeliefs regarding TB (such as TB is a hereditary disease and the ability to recover without treatment) may delay seeking TB diagnosis [11].…”

Section: Introductionmentioning

confidence: 99%

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

Teo

Ork²,

Eng³

et al. 2020

Infect Dis Poverty

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Background Cambodia is among the 30 countries in the world with the highest burden of tuberculosis (TB), and it is estimated that 40% of people with TB remain undiagnosed. In this study, we aimed to investigate the determinants of delayed diagnosis and treatment of TB in Cambodia. Methods This mixed-method explanatory sequential study was conducted between February and September 2019 in 12 operational districts in Cambodia. It comprised of a retrospective cohort study of 721 people with TB, followed by a series of in-depth interviews. We assessed factors associated with time to TB diagnosis and treatment initiation using Cox proportional hazards model. Subsequently, we conducted in-depth interviews with 31 people with TB purposively selected based on the time taken to reach TB diagnosis, sex, and residence. Transcripts were coded, and thematic analyses were performed. Results The median time from the onset of symptoms to TB diagnosis was 49 days (Interquartile range [IQR]: 21–112). We found that longer time to diagnosis was significantly associated with living in rural area (Adjusted hazards ratio [aHR] = 1.25; 95% confidence interval [CI]: 1.06–1.48); TB symptoms—cough (aHR: 1.52; 95% CI: 1.18–1.94), hemoptysis (aHR 1.32; 95% CI: 1.07–1.63), and night sweats (aHR: 1.24; 95% CI: 1.05–1.46); seeking private health care/self-medication (aHR: 1.23; 95% CI: 1.04–1.45); and higher self-stigma (aHR: 1.02; 95% CI: 1.01–1.03). Participants who received education level above the primary level were inversely associated with longer time to diagnosis (aHR: 0.78; 95% CI: 0.62–0.97). The median time from TB diagnosis to the initiation of treatment was two days (IQR: 1–3). The use of smear microscopy for TB diagnosis (aHR: 1.50; 95% CI: 1.16–1.95) was associated with longer time to treatment initiation. Seeking private health care and self-medication before TB diagnosis, lack of perceived risk, threat, susceptibility, and stigma derived qualitatively further explained the quantitative findings. Conclusions TB diagnostic delay was substantial. Increasing public awareness about TB and consciousness regarding stigma, engaging the private healthcare providers, and tailoring approaches targeting the rural areas could further improve early detection of TB and narrowing the gap of missing cases in Cambodia.

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“…6 However, many newly diagnosed TB cases face not only financial difficulties but also a lack of poor awareness about TB prevention and treatment. 7,8 For example, two surveys showed that only 16% and 26.9% of adults had accurate knowledge of TB symptoms in two Chinese provinces, 9,10 and another survey showed that the total mean percentage of correct answers for TB diagnosis knowledge was 35.7% (SD: 16.1%) among medical students in Hunan, China. 11 Many people do not have sufficient knowledge to recognize TB and treat TB as a cold or pneumonia and initially go to drugstores or village clinics to buy cold medicines or antibiotics to relieve the disease when they develop TB symptoms.…”

Section: Introductionmentioning

confidence: 99%

Cut-off Points of Treatment Delay to Predict Poor Outcomes Among New Pulmonary Tuberculosis Cases in Dalian, China: A Cohort Study

Ji¹,

Xu²,

Wu³

et al. 2021

IDR

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Purpose: Despite increasing literature on the association between treatment delay and outcomes, cut-off point (1 month or median) selection in almost all studies for treatment delay is too subjective. This study explored more scientific cut-off points of treatment delay for poor treatment outcomes and death at the clinical level. Patients and Methods: A total of 18,100 newly confirmed pulmonary tuberculosis (TB) cases in Dalian, China were used in the final analysis. A 3-knotted restricted cubic spline (RCS) fitted for Cox proportional hazard regression models is used to analyse the effects of cut-off points of treatment delay on incident poor treatment outcomes. To explore the moderating effects of age, gender and diabetes, we added the interaction terms of these moderating variables and treatment delay to Cox proportional hazard regression models. Results:The median time of treatment initiation was 30 days (IQR: 14-59 days). The risk of incident poor treatment outcomes increased when the time was greater than cut-off point 1 (53 days; adjusted HR: 1.26; 95% CI: 1.00-1.60) of treatment delay, and the risk of incident death events increased when the time was greater than cut-off point 2 (103 days; adjusted HR: 1.56; 95% CI: 1.00-2.44) of delay. In addition, treatment delay was associated with an increased risk of incident poor treatment outcomes and death, and older age, male sex, and diabetes may increase the risk of treatment delay for poor outcomes. Conclusion:This study is the first to identify scientific cut-off points of treatment delay for poor treatment outcomes and death, and this method of exploration should be popularized. In addition, the knowledge of tuberculosis must be spread to every adult. Moreover, the tuberculosis diagnosis level of community level health workers should be enhanced.

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

Cited by 3 publications

References 119 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

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

Cut-off Points of Treatment Delay to Predict Poor Outcomes Among New Pulmonary Tuberculosis Cases in Dalian, China: A Cohort Study

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