Longer Delays in Diagnosis and Treatment of Pulmonary Tuberculosis in Pastoralist Setting, Eastern Ethiopia

Abstract

Purpose

This study aimed to assess the extent of patient, health system and total delays in diagnosis and treatment of pulmonary tuberculosis (TB) in Somali pastoralist setting, Ethiopia.

Patients and Methods

A cross-sectional study among 444 confirmed new pulmonary TB patients aged ≥15 years in 5 TB care units was conducted between December 2017 and October 2018. Data were collected using a structured questionnaire and record review. We measured delays from symptom onset to provider visit, provider visit to diagnosis and diagnosis to treatment initiation. Delays were summarized using median days. Mann–Whitney and Kruskal–Wallis tests were used to compare delays between categories of explanatory variables. The Log-binomial regression model was used to reveal factors associated with health system delay ≥15 days, presented in adjusted prevalence ratio (APR) with 95% confidence interval (CI).

Results

The median age of patients was 30 years, ranged from 15 to 82. The majority (62.4%) were male, and nearly half (46.4%) were pastoralists. The median patient, health system and total delays were 30 (19–48.5), 14 (4.5–29.5) and 50 (35–73.5) days, respectively. The median patient delay (35.5 days) and total delay (58.5 days) among pastoralists were substantially higher than the equivalent delays among non-pastoralists [p<0.001]. Of all, 3.8% of patients (16 of 18 were pastoralists) delayed longer than 6 months without initiating treatment. Factors associated with health system delay ≥15 days were mild symptoms [APR (95% CI) = 1.4 (1.1–1.7)], smear-negativity [APR (95% CI) = 1.2 (1.01–1.5)], first visit to health centers [APR (95% CI) = 1.6 (1.3–2.0)] and multiple provider contacts [APR (95% CI) = 5.8 (3.5–9.6)].

Conclusion

Delay in diagnosis and treatment remains a major challenge of tuberculosis control targets in pastoralist settings of Ethiopia. Efforts to expand services tailored to transhumance patterns and diagnostic capacity of primary healthcare units need to be prioritized.

Keywords:

• patient delay
• health system delay
• total delay
• tuberculosis
• pastoralist

Acknowledgment

We are very thankful to Haramaya University and AHRI for protocol evaluation and ethical approval. Our special gratitude goes to Somali Regional Health Bureau and the respective study facilities for their support during data collection including transport and logistic support and permitting TB care providers’ engagement in data collection. Our sincere gratefulness also goes to TB care for their vigilant effort in the data collection process.

Abbreviations

AFB, acid-fast bacilli; AHRI, Armauer Hansen Research Institute; APR, adjusted prevalence ratio; CI, confidence interval; DOTS, Directly Observed Therapy-Short Course; FMOH, Federal Ministry of Health; HIV, human immunodeficiency virus; IQR, inter-quartile range; MDR, multi-drug resistant; NTP, national TB control program; PR, Prevalence Ratio; PTB, pulmonary tuberculosis; TB, tuberculosis; WHO, World Health Organization.

Data Sharing Statement

The data supporting the conclusions of this article are included in the article. The collected data contain confidential information, and consent has not been obtained for public sharing of raw data with identifiers. However, the datasets analyzed are available at the hands of the corresponding author and can be shared upon reasonable requests.

Ethical Approval and Informed Consent

This study was conducted in accordance with the Declaration of Helsinki. The protocol was approved by Institutional Health Research Ethics Review Committee (IHRERC) of Haramaya University (Ref.No: IHRERC/009/2016), and AHRI/ALERT Ethical Review Committee (Ref.No: P001/17). Written consent was obtained after appropriate information was provided for participants and parents/guardians of 15–17 years old participants. Participation was voluntarily and withdrawal was guaranteed.

Author Contributions

All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

Disclosure

None of the authors have any competing interests.

Additional information

Funding

This study was funded by the Swiss Agency for Development and Cooperation (SDC) in the frame of the Jigjiga One Health Initiative (JOHI) and Jigjiga University. Swiss Tropical and Public Health Institute and Armauer Hansen Research Institute also provided logistic support. Funding bodies had no role in the design, collection, analysis, and interpretation of findings.