http://www.loc.gov/mods/v3 http://www.loc.gov/standards/mods/v3/mods-3-2.xsd
Delay in tuberculosis treatment in Kathmandu valley, Nepal
SUMMARY: Tuberculosis (TB) is an infectious disease which spreads through the air from one person to another, it has a devastating impact on the economic well-being of families and entire communities. Early diagnosis of disease and prompt initiation of treatment is essential for an effective tuberculosis control programme, especially in areas with mobile and dense population, increasing HIV/AIDS threats, and poorly regulated private sector. Delay in diagnosis may worsen the disease, increase risk of poor clinical outcome, including death and enhance transmission of TB in the community. Tuberculosis is one of the major public health problems in Nepal. About 45% of the total population is infected with TB, out of which 60% are in the productive age group. Controlling TB in an big area like Kathmandu valley, which has the highest number of TB cases in any urban area in the country characterized by its diversified health care setting, mobile population, and increasing HIV/AIDS threats is a huge challenge. Understanding the magnitude of delay for getting appropriate treatment under the health care system, and it contextual factors associated for making such delays is very important work for making polices, programmes, and strategic aimed at reducing delay and improving TB programmes which will ultimately benefit the society at large. This is cross-sectional study conducted in the urban areas of both Kathmandu and Lalitpur districts, where there is already an urban TB control programme under the National Tuberculosis Control Programme (NTP). Altogether 140 new smear positive pulmonary TB patients, who were registered in the period between November 1, 2003 and January 15, 2004 in the NTP recognized TB treatment centers (DOTS centers) in Kathmandu Valley (who were in their first two months of intensive phase of treatment) were interviewed for the information required for this study. Pre-tested interview guidelines using semi-structured forms were administered. Data entry and analysis was done using SPSS 11.5 for Windows. Categorical data were compared by x2, logistic regression analysis was performed to obtain odds ratios for covariates with 95% confidence intervals. A p value of less than 0.05 was statistically significant. This research work obtained the ethical approval from Institute of Medicine that followed the ethical norms as per the National Ethical Guidelines for Health Research in Nepal 2001. Almost five of every six new smear positive tuberculosis cases were of economically productive age group of 15-45 years. Sex ratio (male/female) was 3:2. Most of them were married (62.1%) with various educational level and living in the Kathmandu valley temporarily (77.1%).One in every two cases (51.4%) had coughing for two weeks or more as the first reason for seeking medical care, and for 21.4% of the cases it was the second reason. Fever in the evenings and nights was mentioned as the first reason for seeking care by 28.6% of cases and 32.1% said it was their second reason. It was found that almost half (47.1%) of the new smear positive pulmonary TB cases in Kathmandu valley were delayed by 30 days or more in seeking care for their illness. The median patient delay was found 27 days (mean 53.0 days). Almost five of every seven cases (72.1%) were found delayed of more than 15 days in the current health care system with median health system delay of 39 days (mean 72.7 days) that comprised of median diagnosis delay of 37 days (mean 69.6 days) and median treatment delay of 2 days (mean 3.1 days). And, thus the median total delay was found 86 days (mean 125.7 days). The median patient delay was longer among female (37 days) as compared to male (20 days). Whereas, median health system delay was found 1.4 times higher in male (46 days) as compare to female (34 days). In overall, the total delay was higher in female (median 108 days) as compared to male (median 79 days). Women were found at 2 times higher risk of making longer patient delay than men (p<0.05). The study found that it is not the knowledge about the disease, however, the perception of the patient about the causes of disease. its social and economic impact was significantly associated for making longer patient delay (p<0.05).And stigma attached at high level showed the risk of 4 times longer delayed health seeking of illness of TB compared to less or non-stigmatized (p<0.01). This study found that 69% of the TB patients had visited private health care providers as the very first contact for seeking health care. Those seeking first care in the private sector was led by private pharmacies (31%), doctor's private clinics (17.9%), poly clinics 5.7%), private teaching hospitals (4.3%), nursing homes (2.9%), and 31% went to the public health facilities. Patient delay was found longer for those going to the public providers (median 35.5 days) than those going to the private sector (median 22 days), whereas health system delay system delay was greater for those patients going to the private health care providers. Nearly 80% of the patients visiting the private sector first, had a delay of more than 15 days for diagnosis and starting of treatment. This showed a significant association of longer health system delay in the private sector in comparison to the public sector (p<0.01). Nearly half of the patients (45.7%) had consulted two types of health care providers in the course of health seeking for illness, whereas one-third of patients (32.9%) had consulted three or more health care providers. The risk of longer system delay was 16 times when 3 or more types of consultations were provided as compared to only one type of consultation (p<0.01). It was found that almost half of the patients (47.1%) had made more than 41 visits to providers, 27.1% had made 3 - 4 visits. Significant association was observed between longer provider delay with the number of visits to the health care providers, as the risk of longer health system delay was estimated 7 times higher among those who had made 3 - 4 visits with the providers, risk increased to 13 times when the number of visits were increased to more than 4, as compared to those who had not made more than 2 visits (p<0.001). Longer patient delay had observed no association with the knowledge about the availability of the sputum microscopic diagnostic health facilities, and accessibility to the facilities. The findings of this study suggest adopting gender-sensitive strategic for TB control, especially targeting on improving case-detection, and educational programmes focusing on reducing stigma and improving good perception and correcting the wrong ones. As the main problem of delay is in the provider's side, particularly the private sector, it is crucial to educate and sensitize the private health care providers (physicians and paramedics) working at different private pharmacies, private clinics, nursing homes, and polyclinics about the possibility of TB when examining patients. High emphasis should be given to developing an effective mechanism for early sputum microscopy with good referral systems between the private and public providers with a built-in quality control mechanisms. Greater partnerships need to be established between the public and the private sectors to reduce the delays in diagnosis and treatment for the effective control of TB in Kathmandu Valley.