engleski

Determinants of delay in tuberculosis diagnosis and treatment in middle–incidence country

Early detection and treatment of tuberculosis patients have been key principles of tuberculosis control. Delayed diagnosis and treatment of tuberculosis increase both the severity of the disease and the duration of infectivity. A number of studies have addressed the issue of health system delay but mostly in high- or low- incidence countries. Our understanding of delay is quite limited in settings with intermediate tuberculosis burden. One of them is Croatia, a European country with a decreasing incidence. We explored the duration and the factors associated with delay in the Croatian health system which is characterized by free health care and sufficient network of health services providing tuberculosis diagnosis and care. Objectives were to explore both health seeking behaviour for tuberculosis symptoms and the time needed to establish the diagnosis and therapy by physicians under these particular circumstances in Croatia. A total of 241 consecutive adult cases with culture-confirmed pulmonary tuberculosis were interviewed and their medical records were evaluated. Health system delay was defined as the number of days from the first consultation with physicians to the initiation of treatment. Long delay was defined as a period exceeding the median of delay. A total of 241 consecutive adult cases with culture-confirmed pulmonary tuberculosis were interviewed in seven randomly selected Croatian counties and their medical records were evaluated. Patient delay was defined as the period from the appearance of any symptoms to the first visit to a medical provider. Health system delay was defined as the number of days from the first consultation with physicians to the initiation of anti-TB treatment. Long delay was defined as a period exceeding the median of delay. The median patient and health system delays were 38 and 15 days. Long patient delay was associated with the lowest level of education (p=0.016), current smoking (p=0.029), and coughing (p=0.022) in multivariate logistic regression. The most common reasons for delay were supposed influenza or symptoms improving over time (34.5%) and underestimated symptoms (32.9%). Almost 30 % of patients remained undiagnosed more than 30 days after the initial health care visit. Female patients (p=0.008), negative sputum smear (p=0.003) and having symptoms other than usual (0.037) were found to be significantly associated with long health system delay in multivariate analysis. People with the lowest level of education, smoking habits and health seeking behaviour which might favour advanced disease and prolonged infectiousness contributed to delay. There is a need to raise awareness of tuberculosis symptoms with emphasis on developing general health awareness, as well. Our findings also suggested that some groups of TB patients experienced a health system delay, mainly due to lack of suspicion. In such a setting where tuberculosis incidence is decreasing, which results in lack of physician experience and expertise, training in tuberculosis treatment is required. These measures may be useful in reducing the number of missed opportunities for earl tuberculosis diagnosis and treatment as one of the approaches towards tuberculosis elimination in countries with an intermediate burden.

tuberculosis; diagnosis; treatment

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