Pathways to care and preferences for improving tuberculosis services among tuberculosis patients in Zambia: A discrete choice experiment

Abstract

Background Delays in the diagnosis of tuberculosis (TB) contribute to a substantial proportion of TB-related mortality, especially among people living with HIV (PLHIV). We sought to characterize the diagnostic journey for HIV-positive and HIV-negative patients with a new TB diagnosis in Zambia, to understand drivers of delay, and characterize their preferences for service characteristics to inform improvements in TB services. Methods We assessed consecutive adults with newly microbiologically-confirmed TB at two public health treatment facilities in Lusaka, Zambia. We administered a survey to document critical intervals in the TB care pathway (time to initial care-seeking, diagnosis and treatment initiation), identify bottlenecks and their reasons. We quantified patient preferences for a range of characteristics of health services using a discrete choice experiment (DCE) that assessed 7 attributes (distance, wait times, hours of operation, confidentiality, sex of provider, testing incentive, TB test speed and notification method). Results Among 401 patients enrolled (median age of 34 years, 68.7% male, 46.6% HIV-positive), 60.9% and 39.1% were from a first-level and tertiary hospital, respectively. The median time from symptom onset to receipt of TB treatment was 5.0 weeks (IQR: 3.6–8.0) and was longer among HIV-positive patients seeking care at a tertiary hospital than HIV-negative patients (6.4 vs. 4.9 weeks, p = 0.002). The time from symptom onset to initial presentation for evaluation accounted for the majority of time until treatment initiation (median 3.0 weeks, IQR: 1.0–5.0)–an important minority of 11.0% of patients delayed care-seeking ≥8 weeks. The DCE found that patients strongly preferred same-day TB test results (relative importance, 37.2%), facilities close to home (18.0%), and facilities with short wait times (16.9%). Patients were willing to travel to a facility up to 7.6 kilometers further away in order to access same-day TB test results. Preferences for improving current TB services did not differ according to HIV status. Conclusions Prolonged intervals from TB symptom onset to treatment initiation were common, especially among PLHIV, and were driven by delayed health-seeking. Addressing known barriers to timely diagnosis and incorporating patients’ preferences into TB services, including same-day TB test results, may facilitate earlier TB care engagement in high burden settings.

Impact of early chest radiography on delay in pulmonary tuberculosis case notification in Ethiopia

“…[ 18 ] The diagnostic delay in the current study was lower than a study done in sub-Saharan Africa countries and other countries. In Uganda, median of 1 week among 44%, [ 32 ] median of 1.7 weeks in Zambia, [ 33 ] and at China diagnostic delay more than 2 weeks among 23.6%. [ 34 ] Indeed, about a third (27.8%) patients were diagnosed in same-day in the current study that patients were very strongly favored in a study at Zambia.…”

“…[ 34 ] Indeed, about a third (27.8%) patients were diagnosed in same-day in the current study that patients were very strongly favored in a study at Zambia. [ 33 ] This very low diagnostic delay, as low as 2.6% with median of 1 day, in the current study might be related to the screening methods we used cough of any duration among people who sought health care for any reason, which was consistent with a study at Ethiopia, [ 24 ] a study at Kenya, [ 23 ] and the World Health Organization indicated as cough screening could reduce the delay [ 17 , 24 ] but in our current study in addition to cough screening, among eligible it was followed by chest X-ray screening that is sensitive and can be detected TB before patients recognized the symptom. [ 35 ]…”

“…This finding corroborated with the finding of systemic review and meta-analysis indicated as the use of CXR in reducing the diagnosis delay might vary by presence or absence of expert at the facility [ 14 ] and the diagnosis delay was lower at a tertiary hospital in a study at Zambia. [ 33 ] Patients visiting health center, reduced the patient’s delay as it has been accessible in the community but the diagnostic delay increased for the patients. This finding was similar to a study from the Somali region, Ethiopia [ 30 ] and at the national level.…”

Patient Preferences for Strategies to Improve Tuberculosis Diagnostic Services in Zambia

“…A prospective cross-sectional study of 401 patients with TB was undertaken between September 18, 2019, and January 17, 2020, at 2 public health facilities in Lusaka, Zambia. 8 Individuals eligible for study inclusion were those 18 years or older, who had microbiologically confirmed TB, who had their TB episode classified as a new or relapse case, and who began anti-TB therapy within the prior 2 weeks. 8 Ethical approval was obtained from the University of Zambia Biomedical Research Ethics Committee and the institutional review board of the University of California, San Francisco.…”

“…8 Individuals eligible for study inclusion were those 18 years or older, who had microbiologically confirmed TB, who had their TB episode classified as a new or relapse case, and who began anti-TB therapy within the prior 2 weeks. 8 Ethical approval was obtained from the University of Zambia Biomedical Research Ethics Committee and the institutional review board of the University of California, San Francisco. All participants provided written informed consent in their preferred language.…”