Factors associated with patient and health care system delay in diagnosis and treatment for TB in sub-Saharan African countries with high burdens of TB and HIV.

OBJECTIVE: To identify factors causing delayed diagnosis and treatment for tuberculosis in high tuberculosis (TB)/HIV burden African countries. METHODS: We searched Ovid Medline, CINAHL, PsychInfo, Scopus and Sabinet-South African journals and reference lists, Google, Google Scholar and Google SA for reports in English, ≥1992, of original data from sub-Saharan countries on patient or system delay in TB diagnosis or treatment with populations ≥15 years old. Two reviewers extracted data independently for each study. We categorized independent variables as predisposing, enabling or reinforcing (PRECEDE model). Meta-analysis was conducted for factors associated with delay in ≥2 studies. RESULTS: Of 20 eligible studies, 12 assessed both sources of delay; 1, system delay; and 7, patient delay only. Most were cross-sectional surveys (k = 13) with samples of consecutive patients (k = 13) and bivariate analyses (k = 11). Starting and endpoints for patient delay were consistent, but not system delay. Patient characteristics were studied frequently; HIV stigma and enabling factors were studied infrequently, although the last were most often associated with delay. Consulting traditional healers first--usually by rural residents--consistently led to patient delay; OR = 3.45 (1.91-6.21). Travel time for the return visit was consistently associated with system delay OR = 1.87 (1.378-2.531). CONCLUSIONS: We recommend partnerships with traditional healers and research emphasizing HIV and system factors, standard definitions of delay and qualitative and cohort studies to identify enabling and reinforcing factors related to delay.

Pilot study to develop a rapid assessment of tuberculosis care-seeking and adherence practices in rural Limpopo Province, South Africa.

Studies of factors influencing tuberculosis (TB) care-seeking and treatment adherence in high TB/HIV co-burden African countries have typically surveyed urban patients' sociodemographic characteristics. To understand community perceptions and guide rapid assessment interviews, we interviewed key informants (nurses, tribal leaders, n = 9) and local researchers (n = 3) in poor, rural areas of South Africa. HIV-related stigma and misperceptions about TB causes and symptoms were cited as barriers. Key informants said older people preferred traditional healers; local researchers heard a preference for "western" care and suggested supporting clinic staff travel to remote villages with health education and diagnostic services. Key informants said not understanding the consequences of incomplete treatment and reluctance to relinquish disability grants decreased adherence. All reported that nonfamily DOTS supporters provided invaluable support. Rapid assessment should include drop-outs, re-treated, and co-infected patients and ask questions examining origins of misperceptions, stigma of testing, and pre-test messages to improve community perceptions about TB care-seeking and treatment adherence.