Diagnostic Delay among New Smear Positive Pulmonary Tuberculosis Patients in Amhara Region, Northwest Ethiopia:
A Two-Perspective Analysis
Solomon Abebe Yimer
Supervisors :
Professor Gunnar Bjune MD, PHD CO - Supervisor
Associate Professor Getu Degu
University of Oslo Faculty of Medicine
Department of General Practice and Community Medicine Section for International Health
University of Oslo
June/2004
Thesis Submitted in Partial Fulfillment of the
Master of Philosophy Degree in International Community Health
Abstract
Delay in the diagnosis of tuberculosis (TB) causes more severe illness, more complication and an increased period of infectivity in the community. A study in Amhara region in 2001 showed that, among those who had history of cough of more than 3 weeks, only 30% visited the formal health care facilities. We hypothesized that there was a significant patients’ and health systems’ delay in the diagnosis of pulmonary TB in Amhara region, and this study was conducted to test our hypothesis.
Objectives: To determine and analyze the length and associated risk factors of patients’
health providers’ and health systems’ delay among new smear positive pulmonary TB patients in Amhara region, Northwest Ethiopia.
Methods: Within the setting of government health care facilities in Amhara region, we conducted a cross-sectional study from September 1 - December 31/2003. A total of 384 new smear positive pulmonary TB patients participated in the study. Patients were interviewed on the same date of the diagnosis using a semi-structured questionnaire.
Result: The median total delay was 80 days (IQR 44-130 days) and the median patients’
delay was 30 days (IQR 15-90 days). Forty eight percent of the subjects delayed for more than one month. The median health providers’ and health systems’ delays were 61 and 21 days, respectively. In logistics regression, home distance >10 Km to a medical provider (adjusted odds ratio [ORadj] 3.81, 95% confidence interval [CI] 2.21-6.57) and self- treatment (adjusted odds ratio [ORadj] 1.69, 95% confidence interval [CI] 1.86-6.57)
were associated with patients’ delay. Prior attendance to a health post/clinic (adjusted odds ratio [ORadj] 3.50, 95% confidence interval [CI] 1.86-6.57) and consulting private medical providers (adjusted odds ratio [ORadj] 2.10, 95% confidence interval [CI] 1.18- 3.71) were associated with increased health systems’ delay.
Conclusion: Delay in the diagnosis of pulmonary TB is unacceptably high in Amhara region. The delay is primarily related to the health providers. Accessing a simple and rapid diagnostic test for TB at the lowest health care facilities (health post/clinic) and encouraging a dialogue among all health providers are imperative interventions to reduce health systems’ delays. Besides these, due emphasis should be given to further decentralization of DOTS to the periphery and increasing public awareness of the disease among the population.
Acknowledgement
I would extremely like to thank the Norwegian Heart and Lung association (LHL) and the Norwegian Agency for Development Cooperation (NORAD) for providing me the financial support to conduct my study without which this project would not have been realized.
My special thanks go to my main supervisor Professor Gunnar Bjune from the University Oslo for his critical comments and supervision from developing the project proposal up to writing up the final thesis. I would also like to thank my co-supervisor associate professor Getu Degu, from the Gondar College of Medical Sciences in Ethiopia for his advice to my project.
I am grateful to the Amhara Regional State Health Bureau and the health departments and districts health offices in the region for their approval and coordination in conducting my study under their responsibilities.
I sincerely appreciate the kind cooperation and contribution of all the patients who participated in this study. I would like also to express my sincere apreciatiation to all my data collectors namely; Geletaw Ayalew, Derib Asen, Mohammed Yesuf, Temesgen
Birara Mesele Damte, Birhanun Melak, Bogale Dememe, Ayalew Asen, Mekonnen Amena, Azeb Tamirat, Abayinesh Alemu. Mahiteme Haile, Teshay Tarekegne, Asalif Demissie, Firehiwot Kassa, Betelhem, Alem Faris, Assefa Ali for their time and patience in interviewing patients.
My heartfelt thanks go to Mette Klouman and Jens Henning Rygh from Norway and Dr Mohammed A/Rahim from Sudan for sharing ideas and valuable comments. I am also proud to include the contribution Dr Fekadu Abebe, Ingvild Dalen, Dr M.G. Farah, Yosef Abate, Alemu Kebede, Tesfaye Sisay, Dr Adane Bantayehu, Ayalew Endris, Getaneh Derseh, Dr Abebe Eshetu, and Tamirat Assefa for their various supports to my project.
Finally, my deepest gratitude go to my parents, Abebe Yimer and Belayinesh Fantaw back home for taking care of my children while I was attending my study for a long time far away in Norway. I acknowledge the support and patience of my wife Engidawork Tesfaye and my children Yimrha and Natnael Solomon. I would like to thank also my brother Dereje Abebe, Biruk Haile and Birtukan Tesfaye from UK for their continuous encouragement and material support.
Table of contents
Chapter one: Introduction
1.1 Country profile 1.1.1
Ethiopia……….1 1 1.2 Tuberculosis in
Ethiopia………...7 1.1.3 Background of the study area/Amhara
region………..8
1.1.4 Tuberculosis in Amhara
region………...10
1.2 Back-ground and statement of the problem……….13 1.3 Literature
Review……….15 1.3.1 Global burden of
tuberculosis………...15
1.3.3 Reasons for global tuberculosis
increase………....17
1.3.4 The global tuberculosis
control………...21
1.3.4.1 What is DOTS strategy?
………..21
1.3.4.2 Tuberculosis case
detection………..23
1.3.4.3 Tuberculosis suspects and case
finding………22
1.3.5 The importance of diagnostic delay in tuberculosis control………....24
1.3.6 What do we know about diagnostic delays?
………...25
1.3.6.1 Differences in the definition of diagnostic delay……….25
1.3.6.2 Lengths of diagnostic
delays………26
1.3.6.3 Reasons behind diagnostic
delays………26
1.4 Research questions, hypothesis and objectives of the study……….32
Chapter two: Subjects and methods
2.1 Study
area/setting………...34
2.2 Study
design………...34 2.2
Population………..34 2.3 Sampling procedure and sample
size……….35 2.4 Data collection
procedure………..35 2.4.1 Preparation for data
collection………36 2.4.2 Data collection
method………...36 2.4.2 Description of
data………..37 2.5.3
Variables……….37 2.4.3.1. Definitions of main
variables………..38 2.4.4 Data
quality……….40 2.5 Data
analysis………..40 2.6 Communication of
results………..41 2.7 Ethical
considerations………42
Chapter three: The study results
3.1 Socio-demographic
characteristics………...43 3.2 Initial symptoms, perception of illness and first
action………47
3.3 Lengths and Associated risk factors of the different delays……….49
3.3.1. A. All health providers considered as a reference point………..
50
3.3.1. A.1 The first health provider and the period of health seeking………50
3.3.1. A. 2 Health providers’
delay……….51 3.3.1. B. Only medical providers considered as a reference point……….54
3.3.1. B.1 Patients’
delay………54 3.3.1. B.2 Medical providers’
delay………...59 3.3.1. B.3 Health systems’ delay
………...63 3.3.6. B.4 Diagnosing facility’s delay
………...68 3.3.7 Total
delay……….69 3.3.8 TB diagnosis in medical private
providers………75 3.3.9
Stigma……….75
Chapter four: Discussion
4.1 The distribution of the sample
population………...77 4.2 The health seeking period and the health providers’
delay………..77 4.3 Patients’
delay………..78
4.4. Health systems’
delay………..81 4.5 Diagnosing facilitys’
delay………...83 4.6 Total
delay………84 4. 7 The role of knowledge, perception and behavior in diagnostic
delay……….88
4.8 The contribution of the different health providers in diagnostic delay………
88
4.8.1 Drug retail
outlets………..88 4.8.2 Traditional health care
providers………...89 4.8.3 Private medical
providers………..90 4.8.4 Local
injectors………...91 4.9 Strengths, weaknesses and limitations of the
study………..92
Chapter five: Conclusions and Recommendations
4.10
Conclusion……….. 94 4.11
Recommendations………...94 4.12 Further research
implications………..96
References
List of references
Appendices
List of appendices
Appendix 1.Questionnaire for patients
Appendix 2 Information about the research project Appendix 3 Declaration of consent for the study
Appendix 4. Ethical approval document from the Regional Committee for Medical Research
Ethics in Western Norway
Appendix 5. Ethical approval document from the National Ethical clearance Committee in
Ethiopia.
Abbreviations
AFB Acid fast bacilli
AIDS Acquired immune deficiency syndrome ANC Ante-natal care
ANRNHRB Amhara National Regional State Health Bureau
BZHD Bahirdar Zonal Health Department
CO Central office
DOTS Directly observed treatment short-course
Epi Info Epidemiology Program Office
GNP Gross national product
HIV Human immunodeficiency virus
HIV/AIDS Human immunodeficiency virus/acquired immunodeficiency syndrome
IMR Infant mortality rate
IEC Information education communication
IUATLD International Union Against Tuberculosis and Lung Disease
MDT/DOT Multi-drug therapy/directly observed therapy
MDR-TB Multi drug resistance tuberculosis
MOH Ministry of Health
MMR Maternal mortality rate
NTLCP National Tuberculosis and Leprosy control Program
PLHW People living with HIV
RTLCP Regional Tuberculosis and Leprosy control Program
SPSS Statistical package for the social sciences TB Tuberculosis
TBMU Tuberculosis management units
TLCP Tuberculosis and Leprosy Control Program
U5MR Under five mortality rate
UNESCO United Nations Educational Scientific and Cultural Organization
UNHCR United Nations Higher Commission for refugees
UNICEF United Nations Children Fund
WTLCP Wereda Tuberculosis and Leprosy Control
Program
WHO World Health Organization
ZTLCP Zonal Tuberculosis and Leprosy Control
Program
Explanations of words with specific meanings and written version of
“Amharic “words frequently used in the text
Birr: The Ethiopian national currency. At present, 1 Birr is equivalent to USD 0.12 or NOK 0.90
Debtera: An indigenous healer who receives his training from within the church (only men can become debtera).
Dergue: The former military government of Ethiopia that ruled the country from
1974-1993.
Kebele: The lowest administrative unit next to the woreda in the region with
a population 3-5000.
Local injector: An individual who practices administering injections to patients presenting to him/her without prescription from a formal medical provider. The procedure is usually performed behind closed door.
Nefas/Bird: It is the” wind” which is believed to causes tuberculosis if one is exposed to it.
Region: A semi-autonomous state (political administrative body) next to the central government of Ethiopia.
Sanba-nekersa: Ethiopian word describing pulmonary tuberculosis.
Tsebel Tsebel (holy water) are substances such as water, soil or ash, which are blessed in the name of a particular saint
Woreda: It is more or less equivalent to a district with a population ranging from 90000-300000.
Zone The second political administrative body next to the region with a population ranging from 500,000-3, 000,000.
Chapter one: Introduction
1.1 Country profile (Ethiopia) A. Demography
Ethiopia has an area of about 1 million square kilometers. The altitudinal variation in Ethiopia ranges from below sea level to 4300m above sea level. This offers numerous micro-climatic habitats ranging from tropical to near temperate zones. This coupled with the fact that man has inhabited the Nile valley for millennia could very well be the reason for the existence of several cultivated plants whose origin is believed to be Ethiopia. These plants include the cereals:
Avena abyssinica (Ethiopian Oats) Elusine coracana (finger millets) and Eragrostis tef (teff), the oil crops: Guizota abyssinica (noog), Ricinus cummis (Castor oil plant), the starch plant: Enset ventricosum and the forage crop:
Cynods aethiopicum (star grass) and the drug and fatigue plant: Catha edulis (chat) and Caffea arbica (coffee) (1).
Ethiopia is a country with a current population estimated at 67 million of which more than 54 million (85.1%) live in rural areas. Ethiopia is one of the most populous countries in Africa ranking third after Nigeria and Egypt. It is a multi- ethnic society with approximately 100 ethnic groups contributing their own cultures and languages. The constitution of the Federal Democratic Republic of Ethiopia established a federal system of government with nine regional states and two city administrative councils. The role of the federal government is limited to directing the countries fiscal, defense, and foreign affairs and articulating economic and social policies and normative role in sectors of public services.
The state governments are empowered to design and operate region specific programs and policies in the management of natural resources, primary and secondary education, health services and the maintenance of internal law and order (2).
B. Economy
The Ethiopian economy is classified into three categories: the agricultural sector dominated by peasant agriculture, the live stock sector dominated by nomadic pastorals and the modern sector which is in the process of coming into its own.
Over 85% of the labor force is engaged in the first two sectors. With rapid population growth and the consequent rise of the population /land ratio, farm size per household has been declining over the years. Thus landlessness, particularly among the rural youth is becoming a serious problem. In fact, landlessness, which is a function of demographic and environmental factors is the major determinant of rural poverty. Among the consequences of landlessness is increased migration of landless youth into nearby cities, placing considerable pressure on urban social and economic services.
The Ethiopian government has adopted an Agricultural Development led Industrialization (ADLI) policy and programs that recognize the interdependent relationship between agricultural and industrial development. The policy is directed to addressing the dual need for bringing about a relatively rapid structural differentiation of the economy and for dealing with the problem of food insecurity at both the household and societal levels. The problem of food insecurity represents a serious developmental challenge. While efforts in agricultural development are paying dividends in areas with abundant rainfall, Ethiopia has seen little progress in rain deficient areas. The strategy adopted for achieving a breakthrough in these difficult areas is to reduce dependence on rainfall and achieving acreage under irrigation, and engage in agricultural diversification (2).
C. The social sector
From the development point of view, the social sector is still week. National Health Service coverage is at 51 percent from about 30 percent a decade ago.
The accelerated training of health professionals has yielded encouraging signs of deployment of health professionals to rural areas. The health system’s weakness
lies primarily in its failure to bringing about behavioral change in the attitude of Ethiopians toward personal and environmental hygiene
The education sector is undergoing rehabilitation. During most of the last decades of the 20th century, enrollment remained practically at a standstill but it has begun to increase since the turn of the current century. The new educational policy is geared to producing an educated workforce that will forge a dynamic economy. Ethiopia’s educational reorientation has led to greater emphasis on technical and vocational education at the secondary level (2).
Table 1 Demographic and socio-economic characteristics, Ethiopia, 2002 ______________________________________________________________
Indicators Estimate
______________________________________________________________
Total population 67 million
Birth per 1,000 population 44
Deaths per 1,000 population 15
Rate of natural increase (percent) 2.9
Infant mortality rate (per 1,000 births) 97
Total fertility rate 5.9
Percent of population below age 15 44
Percent of population over age 65 3
Life expectancy at birth 52
Percent urban 15
Adult literacy rate 39.1
Percent of combined 1st, 2n and 3rd level gross enrollment (99) 27
Gross national product in US$ 102
Percent of population not using clean water sources 76 Percent of children under five who are underweight 47 Percent population living under $ 1 a day 31.2 Percent of annual population growth between 2000 and 2005 2.4
Percent of population with health service coverage 51 Percent of population with access to essential drugs 50-79
______________________________________________________________
D. Health service in Ethiopia Modern health service
More than 80% of the common diseases in Ethiopia are communicable (3). The conventional health system is underdeveloped and able to provide health service to about half of the population. Much of the rural population and a significant portion of the urban population have no access to any type of modern health care. There is an inability of the health care delivery system to respond qualitatively or quantitatively to the health needs of the population (3).
In Ethiopia, there was no enunciated health policy until the fifties. Towards the end of the imperial period a comprehensive health service policy was adopted through initiatives from the WHO. However, the downfall of the regime precluded the possibility of putting this scheme to the test (4). The Dergue regime that came into power in the mid-seventies formulated a more elaborated health policy, a policy that gave emphasis to disease prevention and control, priority to rural areas in health service and promotion of self reliance and community participation. This policy worked in a centralized system. After the over-through of the Dergue regime in 1993, the new government adopted a new health policy, which gave emphasis to decentralization and democratization of the health service system (4).
According to the recent health policy, modern health service in Ethiopia should be organized in a four-tier health care delivery system where there are primary health care units with 5-satellite health posts, each serving a population of 5000 at the periphery, and with a national referral hospital at the top meant to serve 5 million people. In the middle there are district and zonal hospitals. However, the new organization of health care delivery system is becoming hard to achieve as it
costs a lot of resources (4). Considering the overall national requirements and the standard achieved in other countries, the available health infrastructures are below the desired level. There is still only one hospital for 584,500 persons, one health center for 272,400 persons and one health station for 22,800 persons (5).
E. Health expenditure and health outcome
Ethiopia has one of the worst health statuses in the world, and this is mainly due to the deteriorating socio-economic situation resulting in a low standard of living, poor environmental condition and inadequate health services. The need for an expanded and more efficient health sector in Ethiopia is overwhelming. As a proportion of gross-national product (GNP), Ethiopia’s public sector spending in 2001 (4.7%) was below the average for lowest income in Africa. In real terms this translates into less than US$ 1 per capita, which places it near the bottom in Africa (5).
Among its health outcomes, Ethiopia stands out as having some of the highest levels of malnutrition (48% of children are underweight, 8% stunted, and 14%
wasted). The infant mortality rate is a valuable indicator of health and development. Between 1998 and 2000, the infant mortality rate (IMR) reached 105/1000 live births and the under- five mortality rate (U5MR) accounted for 161/1000 live births. These figures are very high by world standards and Ethiopia remains among the countries in the world continuously classified as very high IMR and U5MR countries by United Nations Children’s Fund (UNICEF).
Ethiopia’s maternal mortality rate (MMR) estimated at 5.82 per 1000 live births is significantly higher than all other developing countries (4).The present health status of the Ethiopian population has generally been aggravated by a low per- capita share of public health expenditure, thus, low absolute level of health expenditure is clearly a constraint on health service delivery and in Ethiopia is far below estimates of what a basic package of health services would cost (less than US$ 13) (6).
F. Traditional medicine in Ethiopia
Traditional medicine is an age-old medical system practiced in all societies differing in level of usage. For centuries Ethiopians relied heavily on a system of health care containing both emperico-magical and magico-religious elements (1).
The indigenous health care system is as diverse as the cultural diversity and as varied as the physical environment, which fosters unique flora, and fauna that are often used as prime tools of the trade in the struggle against a variety of health problems (1).
Indigenous medicine in Ethiopia is heavily influenced by religious beliefs. Many of the cures that are used are derived from the Ethiopian Orthodox Church. While most of the saints in the church have specific healing practices associated with them, Mikael (for both men and women) and Mariam (for women) are probably most famous for their power to heal. When a person becomes sick, his friends and relatives may say to him, "Mikael must be with you. Mikael will protect you."
Likewise, Mariam is said to protect the health of women, especially during childbirth. Even in cases where people seek bio-medical treatment, the eventual outcome of the treatment, whether complete recovery, continued illness or death, is often attributed to the will of the saint (7).
Religious basis of indigenous medicine uses tsebel (holy water) as a treatment for various illnesses. Tsebel are substances such as water, soil or ash, which are blessed in the name of a particular saint. They are used as prophylaxes and treatments for a wide range of illnesses. In order for a tsebel to work, the sick person must be a devout believer in its effectiveness. If the tsebel fails to cure or protect against illness, the integrity of the patient's belief is challenged rather than the efficiency of the tsebel.
One of the most powerful types of healers is the debtera, who receives his training (for only men can become debtera) from within the church. Whereas most indigenous healers' treatments are orally learned, practiced, and passed on, the debtera's knowledge is derived from a series of texts written for the most
part in Ge'ez. These texts and the training that is necessary for their proper use are accessible only to selected men who have already completed their training for the priesthood (7).
The other categories of traditional healers include herbalists. These groups of healers use plants to regulate organs, separate or expel the causative agents. More than 50% of the healers are herbalists. There are also other categories of healers including bone setters, uvula, and tonsil cutters, tooth extractors traditional birth attendants, cuppers and tattooists (7).
As part of the community, traditional practitioners have over time developed very close relationships with the population in which they live. Their communication skills, easy access and spiritual healing have earned them respect and dignity (7).
F. Traditional medicine and policy framework
The first recognition of the practice of traditional medicine in Ethiopia was made in 1948 under the Medical Practitioners’ Registration Act (4). Recent policy guidelines prepared by the government include the drug policy. According to the guidelines of the policy (4):
1. Due attention shall be given to the development of beneficial aspects of traditional medicine including related research and its gradual integration into modern medicine
2. Traditional medicine shall be accorded appropriate attention by: Identifying and encouraging utilization of its beneficial aspects, coordinating and encouraging research including its linkage with modern medicine, developing appropriate regulations and registration for its practice.
3. Facilitate the gradual integration of traditional drugs with modern medicine by giving due attention to the traditional practices and identifying the beneficial and harmful aspects through investigation and research.
4. Attention shall be given to strengthening the sector through research and development. Research priorities shall be given to those traditional drugs which are in wide use.
G. Integration of traditional medicine with bio-medicine
In Ethiopia, both indigenous traditional medical practice and conventional medical practice are in operation and in most cases they conflict openly or covertly. Biomedical professionals have been known to be among the people who are very prejudiced against traditional healers and their medicine. There is also unwillingness on the part of the traditional medical practitioners to share their knowledge. Lack of recognition of traditional healers by the modern health care providers creates resentment and insecurity in the traditional healers leading to their alienation and isolation (9).
1.2 Tuberculosis (TB) in Ethiopia
According to the Ministry of health (MOH) hospital statistics data, TB is the leading cause of morbidity, the third cause of hospital admission and the first cause of hospital death in the country. It is estimated that there are about a quarter of a million cases in the country and more than 40,000 persons die of TB every year (3).
In Ethiopia, even though the effort to control TB was started in the early 1960s with the establishment of TB centers and sanatoriums in three major urban areas, there was practically no impact in reducing the toll of TB (10).
After the introduction of the concept of National TB Control Programs (NTCP) by the World Health Organization (WHO), the MOH adopted this concept and subsequently opened the central office (CO) of the NTCP in 1976. From its conception, the CO had received neither sufficient budgetary nor manpower allocations and thus remained virtually non-functional. It was in 1992 that a standardized and well-organized TB control program incorporating Directly Observed Treatment Short-course (DOTS) was implemented in a few areas of
the country. It has now reached a geographical coverage of 76 % of the entire country (10)
In view of the remarkable achievements of the combined TB and Leprosy Control Program (TLCP) achievements in other countries, it was decided to combine the two programs in Ethiopia into the National TB and Leprosy Control Programs (NTLCP). The combined program under the coordination and technical leadership of the CO came into effect in 1994. The implementation of the combined TLCP began in 1997 with the development of TLCP manual. Before the inception of a TLCP in Ethiopia, little information was available about the extent of the TB epidemic. A national survey which was conducted from 1987- 1990 estimated the annual risk of infection to be 1.5% (10).
Currently, Ethiopia is one of the twenty-two high burden countries in the world and the second to the top in Africa (10). In the year 2001, the TLCP registered 94,957 cases of TB from the DOTS implementing areas, among which 33,028 were new smear positive pulmonary TB cases (36% of the total new cases). This represents a case notification rate of 173 and 60 per 100,000 populations for all forms of TB and new smear-positive cases, respectively. The increase is attributed to the expansion of DOTS in the country. By the end of the year 2001, the DOTS program covered 56 zones in nine regions and two administrative councils. Geographically, these zones represent 76% of the country, in which about 55 million (85%) people live (10)
1.1.3 The study Area (Amhara region)
A. Demography
The Amhara regional state is the second largest region of the country. It is located in the Northwestern part of the country and has a total surface area of 161, 828.4 Sq. kms (16% of the area of the country). The region shares boundaries with Tigray in the north, Oromyia in the south and Benishanngul
Gumez in the west and Afar in the east. The topography of the region can be divided into two main parts namely the low- land and the high-lands (1500 meter above sea level). The highlands comprise the northern and eastern part of the region while the low land is mainly located in the Northwestern part of the region (11).
Based on the 1994 population census of the region, the population in 2003 was estimated to be 17,740,521, out of which 8,880,262 (50.1%) were males and 8,860,259 (49.9%) were females. Among the total population of the region, 15,792,698 (89.02%) live in rural areas whereas the remaining 1,947,823 (10.98%) live in urban and suburban areas. Administratively, the region is divided into 11 zones, 113 woredas and 3500 kebeles. The kebeles constitute the lowest administrative unit within the woreda comprising an average population of 5000 inhabitants (11).
B. Socio-economic characteristics
The majority of the population lives below the poverty line. The housing condition in the region is very poor. In most cases a single room is used for dwelling for the entire family. Especially in rural areas, people share the same room with animals. The average household for rural areas is 5.5 and for urban areas is 4.5 while the total average household size for both areas is around 5. The dependency ratio among the age group 15-64 years of age is found to be 110 dependents per 100 persons. There are significant numbers of homeless people and street children. Currently their number is increasing at an alarming rate (11).
Subsistence agriculture is the backbone of the region’s rural economy. Crop and live stock production are the major components of the agricultural sector.
Farming is mainly rain fed and undertaken by traditional methods. The region has been exposed to repeated drought. On the other hand, the region possesses many tourist attractions like the rock-hewn Churches in Lalibela, the castles of Fasilledes and the Semein Mountains with its wild life. The United Nations
Educational, Scientific and Cultural Organization (UNESCO) as parts of the world heritage has registered all of these. Moreover Lake Tana with its historical monasteries and churches, the Tisabay waterfall in the Blue-Nile are other tourist attractions in the region (11). With regards to communications, roads and air travel are the main means of transportation. There is one international airport at Bahirdar, which is the capital of the region. All weather roads cover approximately 10.2 km per 1000 sq km. Telephone, postal services and electricity are limited to the major towns of the region. The region has its own regional radio station and a weekly newspaper. There are also additional educational radio stations in 6 zones of the region (11).
C. Health services
More than 80% of the region’s health problems are attributed to communicable diseases. According to the health and health related indicators of the region (11, 12), malaria, HIV/AIDS and TB are the major deadly diseases in the region. The health service coverage is 41.1%, crude birth and death rates are estimated at 27.9 and18 /1000 live births, respectively. The prevalence of HIV among ANC attendants in the year 2001 was 24%. There are 14 hospitals, 78 health centers and 519 health posts currently active for the provision of health care to the population. The private sector is also actively engaged in rendering health care.
In the region, there are 130 privately owned clinics with different levels, 40 drug stores, and 256 rural drug venders. TB patients are diagnosed at private clinics and referred to the government TB management units (TBMU) for the initiation of anti -TB chemotherapy (11).
1.1.4 TB control program in Amhara region A. Organization
Structurally, until the year 2000, the regional TB and leprosy control program (RTLCP) was organized in the regional health bureau as a unit/section under the communicable disease control team within the former health programs department currently called as the disease prevention and control department. In 2001, the unit was upgraded to TB & Leprosy control and prevention team within
diseases prevention and control department. The team comprises 3 health workers one team leader, senior expert (MD) and one RTLCP junior expert (nurse). Currently the team has two health workers, namely one team leader MD/MPH and one senior expert (MD) (13).
The regional health bureau has a responsibility to control and supervise the Zonal Tuberculosis and Leprosy Control Program (ZTLCP) at zonal level, and the ZTLC is at the same time responsible for controlling TB and all other communicable diseases at the district level. Health officers in 72% of the zones staff the ZTLCP. At woreda level, there is one woreda TB and leprosy control (WTLC) expert on the malaria and other communicable diseases desk. However, the position is filled in only some woredas. In the majority of the woredas, nurses working at the TBMU in the health centers cover the position of the woreda TBLC coordination work.
In 2002, TB was among the leading causes of morbidity and mortality in the region. A total of 6553 smear positive new cases were diagnosed. And the case detection rate was 41%. This was far less than the intended target of 70 %( 13).
The TB and Leprosy control team in the MOH supports the TB control program in Amhara region technically and financially. The support includes among other things, anti-TB drugs, laboratory supplies and other expenses for training and review meetings. The regional health bureau also allocates budget for purchase of supplementary drugs at regular bases.
B. Decentralization of DOTS in Amhara region
DOTS strategy is being implemented in the region. Health centers and hospitals are serving as diagnostic and treatment units while clinics and health posts serve as treatment units (13). According to the regional health bureau, in 2002, there was a plan to decentralize the service to 65% of health units of the region. Each woreda and zonal administration was expected to reach the target set by the bureau by the end of the year. Accordingly, 4 zones achieved DOTS service decentralization to >65% of health units. These zones were namely Waghemera
and Bahirdar 100% Oromia 75% and North Shewa 67%. However, the remaining 7 zones fail to achieve the target. Namely south Wollo 7.4%, north-Wollo 37%, west-Gojjam 41%, south Gondar 44%, north Gondar 46%, east Gojjam 49.5%, and Awie 52%.
The reasons, for not achieving the planned target at a regional level in 2002 and in the above mentioned zones in particular were: the delay in releasing the budget from the MOH, time limits due to different campaigns (polio, and measles) and high turnover of health workers at different levels. Most importantly among the 11 zonal coordinators, 8 of them either moved to other position or began their postgraduate studies. The only 3 zones not affected were east Gojjam, Awi, and north Gondar zones. But these zones were among the campaign areas of the region. The bureau believed that, a combination of one or more factors as stated above has resulted in inhibiting the decentralization process as it was planned to achieve the target at district and zonal levels (10).
For 2004 the regional health bureau’s plan is to reach an overall DOTS coverage of >85%. However, the bureau fears that the plan might not be achieved if adequate resources are not released on time from the MOH to the region (10).
The regional health bureau also reported that it had encountered problems in the already decentralized areas. The major problems encountered according to the bureau were; poor recording and reporting, failure to send smear positive pulmonary patients for follow up sputum examination, failure to send feedback on the outcome of patients, directly observed treatment is not strictly observed as health workers may at times leave for some days closing the clinic, shortage of budget for collecting drugs/supplies from the WHO, lack of drugs monitoring and management system, high turn over of staff and related consequences (13).
Quality control
The regional health bureau started quality control on AFB direct microscopy in 1998. However, due to several limitations the activity was on and off until 2000.
Since 2000 the regional health bureau has regularly been collecting slides from 6
zones. After 2nd rereading by the regional health and research laboratory, discrepant slides are submitted to the central reference laboratory for the third re- reading. During 1996 only one discrepant slide was sent to the central reference laboratory. Based on the findings of the quality control on the slide, corrective measures were taken by the regional health bureau (13).
1.2 Background information and statement of the problem
TB is a chronic infectious disease caused in most cases by Mycobacterium tuberculosis, an acid-fast rod-shaped bacillus. Occasionally, it can also be caused by Mycobacterium bovis and Mycobacterium africanum. It is transmitted by air and mainly affects the lungs (10).
TB is a leading public health problem worldwide particularly in the developing countries. In view of the seriousness of the problem, WHO in 1993 declared it to be a Global emergency. Of the 1.7 billion people estimated to be infected with the TB bacillus, 1.3 billion live in developing countries. At the present time, it is estimated that there are 16 to 20 million cases worldwide with 8.74 million new
cases every year. Two million of these people die every year. These constitute 26% of avoidable adult deaths worldwide (14).
Globally, the burden of TB is increasing at an alarming rate. Various factors including poverty, population growth, migration and HIV/AIDS could be contributing to maintaining for the continued threat of TB in the world. But a significant problem lies with the fact that many cases remain undiagnosed (15).
This could be due to various factors, principally found within the categories:
patients delaying seeking health care or failure of the health care systems to timely diagnose patients.
Delays in the diagnosis lead to an increased period of infectivity in the community. It is estimated that an untreated smear positive patient may infect on average more than 10 contacts annually and over 20 during the natural history of the disease until death (16). Delayed diagnosis also causes patients to have more severe disease, more complications and lead to higher mortality (16). This hits families in the developing world very hard, particularly because younger active productive age groups are the chief victims of the disease.
Delays in the diagnosis of TB have been reported in both industrialized and developing countries and vary considerably, from 6.2 weeks in Australia (17) to 12 weeks in Botswana (18) and 16 weeks in Ghana (16). A number of factors have been identified that appear to influence delay in diagnosis and commencement of treatment. These include the individual’s perception of the disease, the severity of the disease, access to health services, and the expertise of health personnel (19).
In all delay studies conducted so far, conflicting reports exist on how patient socio- economic characteristics, gender and the health services affect diagnostic delay. Besides this, the already available information regarding diagnostic delay
has been evaluated to be inadequate at a consultative meeting that was held in Geneva in 2000 (20).
Delay in diagnosis has been observed in Amhara region, North West Ethiopia.
An unpublished community based survey which was conducted in 2001, revealed that, among those who showed the main symptoms of TB for more than 3 weeks, only 30% visited the formal health care facilities (21). This might show that a significant number of patients are not correctly diagnosed, or prefer to go to other health providers, or fail to seek appropriate health care at an early stage of the disease. Therefore, there was an urgent need to investigate this problem so as to improve the case finding activities in the region. And hence the current study was conducted.
In Ethiopia, two studies were conducted on delay in TB. One was conducted in southern Ethiopia in a hospital setting (22) and another one in 1998, in the capital city in a health center setting (23). Both studies assessed patients’ and health system’s delays by taking diagnosing facilities as the first level of health care contact for patients seeking health. The roles of other health providers were not included in their studies. As the health service coverage in the country is very low (<50%), a number of people use other options to get health care for their health problems (3). These include the various categories of traditional health care practitioners and others. Taking this reality into account, the current study has managed to incorporate all health providers known to be potential venues for patients seeking health. Therefore, considering the importance of implementation research, which has an important role in increasing our knowledge of the factors affecting diagnostic delay, this study was conducted to examine diagnostic delay among smear positive pulmonary TB patients in Amhara region, Northwest Ethiopia.
The researcher believes that, this study, by including all health providers as potential venues for seeking health care has managed to collect relevant
information regarding the health seeking behavior, lengths and risk factors of delay both from the patient and the provider side. It is hoped that, the regional TB control program will use this information to improve the current low case detection rate in the region.
1.3 Literature Review
1.3.1 Global burden of TB
Despite effective treatment, TB remains a major public health problem on a global scale. Due to its frequency, its transmission pattern and its potential effects, TB has significance to public health that exceeds most other diseases.
TB today may infect anyone by breathing in the air where a TB patient has coughed, sneezed, talked or spat. Left untreated, each person with active TB will infect on average between 10-15 people every year (24).
From the global perspective, TB is perhaps the greatest infectious killer of all time. It is the seventh most important cause of mortality worldwide and the fourth most important cause of death in developing regions. Over centuries, it has taken over one billion lives (25). TB today is estimated to cause about 2 million deaths and 8.74 million new cases yearly (26). TB causes more than 26% avoidable adult (15-59 years of age) deaths in the developing world, which results in tremendous social and economic costs. The WHO has identified 22 high burden countries that account for 79% of all TB cases worldwide, and all of them are low or middle-income countries (25).
According to the WHO, the NTCPs reported that, by the end of 2002, 69% of the world’s population lived in countries, or parts of countries, covered by DOTS.
DOTS programs notified 3.0 million new cases, of which 1.4 million were smear positive. A total of 13.3 million TB patients and 6.8 million smear-positive patients were in DOTS programs between 1995 and 2002 (26).
The distribution of TB is very uneven in the world. Of the estimated 8.74 million cases emerging globally each year, only 5 percent occur in the industrialized countries. In these countries, the bulk of infected persons are found among the elderly, while in most low-income countries, the large majority of infected persons are in the economically most productive and reproductive age groups (27).
TB accounts for 8.4% of healthy years of life being lost among men and 7%
among women. The economic costs of TB in terms of lost production are therefore considerable. Further studies show that TB is concentrated in lower socio-economic groups, in households least able to cope with the burden (25).
Globally, the prevalence of infection is thought to be similar in males and females. There is an estimated 2:1.1 male to female ratio of cases notified to public health authority worldwide. However, the rate of developing active disease from a primary infection with M. tuberculosis (progression rate) may be greater among women of reproductive age than men of the same age (25). As the leading infectious killer of youth and adults, TB kills more women than all causes of maternal mortality combined (15).
From a public health perspective, TB is a high priority disease because of the tremendous burden it imparts and the existence of interventions of proven efficacy that are some of the most cost effective we have (28). Since 1994, WHO has recommended and scaled up the TB control strategy, brand named as DOTS (directly observed treatment short course). Other global initiatives, which have recently emerged in response to the global TB crisis are stop TB, the Global Alliance for TB Drug Development, the TB Diagnostic Initiative and the TB Vaccine Initiative (25).
The goals of TB control are to reduce mortality, morbidity and transmission of the disease, while preventing drug resistance, until TB no longer poses a threat to public health. It also aims to reduce human suffering and the social and economic burden families and communities have to bear as a consequence. To
achieve this, it is necessary to ensure access to diagnosis, treatment and cure for each TB patient and to protect vulnerable populations from TB and its drug- resistant forms (29).
2.2.2 Reasons for Global TB increase A. Demography
TB is a disease concentrated in lower socio-economic groups, and increasing economic inequalities together with population growth creates an increase in TB cases. People’s life expectancy is also increasing and as a result, any increase in resources has been absorbed by an increase in cases (30). Demographic factors have played a major role in the global re-emergence of TB. Childhood mortality rates have declined much more rapidly than birth rates over the past 30 years, resulting in dramatic increase in the size of adolescents and young adult population in the world. The population mostly of poor countries has increased.
The highest incidence of TB across the world is in central Africa and southern Asia, particularly in India, where the population increase is known to be the most rapid. Current annual population growth in these countries is about 100 million, which means that global TB incidence in absolute numbers will continue to increase by around 100.000 cases every year. In Ethiopia, the population is rapidly increasing at a rate of 2.9% every year (31). This contributes to the increased incidence of TB in the country.
B. TB and HIV
Factors associated with resurgence of TB in many countries include HIV epidemic. Infection with HIV leads to extensive destruction of the immune defense mechanisms of the body. As a result, those infected with HIV become ill with severe and often deadly diseases to which persons without HIV infection would not usually be susceptible (24). Throughout the industrialized and the developing world, TB and HIV are closely linked in mutually disadvantageous synergy: HIV infection promotes the progression of TB infection to disease, and TB accelerates the course of HIV. HIV infection greatly increases the likelihood
that infection with M. tuberculosis, either recent or latent, will progress to active TB. In fact, HIV infection may be the most potent risk factor for TB yet identified.
Conversely, TB is the most common cause of death in persons with HIV infection in the world (24).
Globally, TB is the leading cause of HIV-related morbidity and mortality. In developing countries, HIV-infected people run an annual risk of 5-15% of developing TB. At least one in three people living with HIV (PLWH) will develop TB (32). The escalating TB case rate over the past decade in sub-Saharan Africa is largely attributable to the HIV epidemic (33). In 1997, the prevalence of M.
tuberculosis and HIV co-infection worldwide was 0.18% and 640,000 incident TB cases (8%) had HIV infection. It was estimated that in the year 2000, the global incidence of HIV-positive TB cases was 12 %. The number of people living with TB and HIV co-infection was 16.3 million. Of the estimated 2 million TB deaths in the world, about 0.5 million deaths were HIV- positive TB cases (32). Sub- Saharan Africa bears the highest burden of HIV positive TB cases followed by south East Asia (32).
In Ethiopia, even though there are not many studies conducted to analyze the impact of HIV on TB, few studies have documented that about 40% of adult TB cases in urban areas are HIV-positive (10).
C. Poverty
Poverty has been strongly associated with the incidence of TB. Low socio- economic indicators tend to result in crowded living conditions, conditions that are conducive to increased transmission of tubercle bacilli should a case occur, resulting thus in a generally higher prevalence of TB infection with subsequent increased incidence of the disease. Poverty may also reduce access to health care services, thus prolonging the period of infectiousness of TB patients and further increasing the risk of infection among the contacts of such a patient (34).
Social and economic trends have contributed to the spread of TB. Over the past 10 years the number of less developed countries has doubled while GNP in some middle-income countries has decreased. This has meant a decrease in the availability of resources for TB control programs. Poverty, malnutrition and overcrowding have for a long time been recognized as the main predisposing factors for TB. It is estimated that about one third of the world’s population is infected with TB but far from every body gets sick. The immune system walls off the TB bacilli, which are protected by a thick waxy coat and they can lie dormant (inactive) for years. When one’s immune system is weakened, the chances of getting sick are much greater. The strength of the immune system is related to nutritional status, hygienic conditions, susceptibility to other infection as well as access to health care and vaccination throughout a lifetime (25).
From the late 19th century, improvement of socio-economic conditions contributed more to the large decline in the prevalence of TB in industrialized countries than all the medical interventions did. In the industrialized countries today, this is again manifested through it has become a rare disease in the population in general but is getting more prevalent among certain minority groups, as well as among homeless people, alcoholics and drug abusers (34).
Even if we see an increase of TB among some groups in industrialized countries, the burden of TB is mainly carried by developing countries where 95% of all cases of the disease and 98% of all deaths due to it occur (30). In Ethiopia, majority of the population live in absolute poverty. This creates a favorable condition for the increase of TB incidence in the country. As described earlier, the burden of TB in Ethiopia is one of the highest in the world. At the center of the problem is the back ward socio-economic development resulting in one of the lowest standard of living (9).
D. Movement and migration of people
Population movement in the form of migration of labour, general migration, armed conflicts and refugee movement is more common to take place now a
days. In recent years, TB has become confined to definable population groups, such as disadvantaged populations; immigrants from countries with a high prevalence of TB, refugees, the elderly, homeless, substance abusers, persons in correctional facilities and nursing homes. A high incidence of the disease in these groups is not unexpected because the rates are higher in lower socio- economic groups. Poverty leads to bad and overcrowded housing or poor conditions. These may lower defenses as well as making infection more likely.
People living in these conditions are often badly nourished, suffer from alcohol abuse or drug addiction. The whole complex of poverty makes it easier for M.tuberculosis to cause the disease.
As a result of poverty, the actual number of refugees as well as displaced people in the world is increasing. Untreated TB spreads very easily in crowded refugee- camps, prisons or between groups of homeless living together under poor conditions. Homeless usually live in poor conditions. In addition, it is difficult to treat migratory and homeless groups, as treatment takes at least six months and close supervision. According to the WHO, as many as 50% of the world’s refugees may be infected with TB, and forced movements of immigrants and refugees contribute to the spread. The increasingly global nature of trade, air traveling and the rapid movement of people across the world represents additional risks of spreading the infection (32).
According to the United Nations Higher Commission for Refugees (UNHCR) (31), there were an estimated 20 million refugees,
displaced and needy people in 2003. Many refugees originate from countries with high TB incidence rates. Poor nutrition and health mean that refugees are at particularly high risk of developing TB. In Ethiopia, as a result of rural poverty landless people are being displaced. Due to HIV and other socio-economic factors the number of street children is increasing. Besides these, the country had been in a civil war for a number of years as a result a number of people had
been displaced. These all have created a favourable ground for the increased transmission of TB in the country.
F. TB and drug resistance
During the past 4 decades, NTCPs have failed to reduce TB transmission. Health policies in most low and middle in-come countries have not given priority to TB control. In adequately funded programs have led to an increase in the pool of chronic infectious sources. The overwhelming problem with the treatment of TB is that cure takes months of treatment. The great majority of TB patients in the world have poor health care facilities. Therefore, patients do not complete their treatment. Premature stop of the treatment for TB results in relapse and the emergence of drug resistance (34).
Poor management of TB causes resistance to anti-TB drugs. From a public health perspective, treatment poorly supervised or incomplete treatment of TB is worse than no treatment at all. Widespread occurrence of multi-drug resistance TB (MDR) would constitute a major threat to controlling TB in resource poor countries (35). This is because TB patients with resistant organisms may not respond to standard treatment; remain infectious for longer periods of time and spread resistant organisms to others. Most patients will require expensive second line drugs. And in settings where resources are already inadequate, control will be further compromised. There is no mystery about the causes of drug resistance. It is a man-made consequence of poor patient management, including improper prescription, non-compliance, lack of control of drug distribution and irregular drug supply (30).
Studies have been conducted on drug resistance in different countries of the world. In 2000, an estimated 273,000 of the 8.7 million new TB cases (3.2%) were multi drug resistant. In A drug resistance survey carried out in 64 countries the highest MDR proportions among new cases were found mostly in Eastern
Europe, Russia and china. An estimated 70% of new MDR cases were found in only 10 countries (36).
In Ethiopia, periodic surveillance of drug resistance is lacking. Few studies conducted have reported resistance to one or more anti-TB drugs that ranged from 15% to 37% (37, 38).
2. 2.3 The global TB control
2.2.3.1 What is DOTS strategy?
In 1993 the World Health Organization declared TB a global emergency, and created a framework for TB control (39). In 1994, the WHO together with the International Union against Tuberculosis and Lung Disease (IUATLD) launched the DOTS strategy to fight TB. This five-pillar strategy has been proven to be cost effective in some studies (40). And it is now recommended world wide as a solution to the “Global emergency”. From the time DOTS was introduced on a global scale, over 10 million infectious patients have been successfully treated (29).
The targets for global TB control by the year 2000, ratified by the World Health assembly were to successfully treat 85% of the detected smear positive TB cases and to detect 70 % of all such cases (41). However, these targets were not achieved as planned and the target year has been re-set to 2005. The WHO estimates that in the year 2000, 55% of the worlds population lived in countries or parts of countries covered by DOTS. Global case detection of smear positive cases detected under DOTS calculations of the cure rate show an 80 % treatment success rate in DOTS areas and a 22% cure rate in non DOTS areas (25). A recent prediction shows that at the current pace of case detection, the TB control goals will not be reached until 2013 (42). The major challenge is for TB endemic countries to accelerate case detection, while still maintaining high cure rates.
DOTS is one of the most cost effective health interventions, compared to those available for other diseases. As part of the DOTS strategy, health workers counsel and observe their patients swallowing each dose of a powerful combination of medicines. The health system is required to observe that all patients take their medication, to monitor their progress, ensure that all bacilli are gone, and to document that they are cured. The package has other components in a five-point policy package. These components include the following (10),
1. Government commitment to sustained TB control activity
2. Case detection by sputum smear microscopy among symptomatic patients self- reporting to health services
3. Standardized treatment regimen of six to eight months with directly observed therapy (DOT)
4. A regular and un interrupted supply of all essential anti-TB drugs
5. A standardized recording and reporting system that allows assessment of treatment results for each patient and of the TB control program performance overall.
2.2.3.2 TB case detection
Case detection under DOTS refers to the proportion of TB cases that are diagnosed and reported within a DOT program divided by the assumed TB incidence. Since the true incidence of TB in a given population is rarely known, calculations of case detection are based on estimates of the true incidence of TB.
Different methods are used for estimating TB incidence, including extrapolation made from assumed annual risk of infection and information from sentinel studies (43).
The way to reach the target of 70% case detection is through passive case finding. Passive case detection refers to the absence of active initiation from health care providers i.e. the patient reports him or herself to health care providers as opposed to active case detection, where health care providers actively screen for TB in the population (44). The success of passive case
detection is thus highly dependent on both the patient health seeking behavior and the awareness among health providers of symptoms suggestive of TB and the possibility to act on them (44).
On the other hand, if increased case detection is to have an effect on the TB epidemic, high cure rates are necessary. The WHO recommends national TB control programs to first ensure a sufficiently high cure rate level and after that expanding the program in terms of case detection (45). The way to reach the set target of 85% cure rate, once adequate chemotherapy is available is according to the DOTS strategy, to ensue patient compliance by direct observed therapy. This component recommends observation of each intake of TB medication at least during the first two months of treatment (45).
2.2.3.3 TB suspects and passive case finding
The diagnostic methods recommended in the DOTS strategy focus on identifying sputum smear positive cases of pulmonary TB. The WHO and IUATLD have recommended that all individuals with cough lasting for more than three weeks should be offered TB diagnostics, i.e. a sputum smear examination when seeking health care in TB high prevalent setting (45). Thus, long-term cough together with sputum production are key features of the TB suspect case. Other general symptoms of pulmonary TB are fever, weight loss and night sweats together with additional respiratory symptoms like haemoptysis, cough, chest pain or dyspnea (45).
According to the guidelines of the national TB control program, examination of sputum by direct microscopy for the presence of acid fast bacilli (AFB) in all self presenting persons with symptoms suggestive of TB must be performed (10).
Also, an assessment of the close contacts of patients of a smear positive pulmonary case should be done. Other important activities that must be carried out to improve the effectiveness of passive case finding activity include; public education on the importance of early self-reporting for examination and treatment
whenever there are symptoms suggestive of the disease, training of general health staff on prompt recognition of the signs and symptoms of the disease &
making quality diagnostic and treatment services accessible to all communities in the country (10).
2.2.4 The importance of diagnostic delay in TB control
According to Rieder (2000), to ultimately reduce the incidence of TB in a community, the primary epidemiological aim of TB controls is to reduce the pool of persons with TB infection. Without intervention future cases of TB will emerge from this pool. Principally, there are two supplementary lines of action to accomplish this objective. The first is the interruption of transmission from newly occurring infectious cases of TB with appropriate chemotherapy as swiftly as possible after their occurrence, and the second line of action is the prevention of TB cases before they occur with preventive therapy of sub clinically infected persons. The first line of action will reduce the incidence of infection and the second will reduce the prevalence of infection (46).
Rieder further elaborated that, between the onset of transmissibility and its arrest, there could be a delay of the patient in seeking medical attention and the delay of health care provider in making the diagnosis and commencing appropriate chemotherapy. These delays are variably attributable to the patients’
attitude towards symptoms and the health care providers’ ability to rapidly diagnose TB (46). For the patient, delay can occur during the process of noticing symptoms, determining if one is ill, assessing the need of professional care and overcoming social, personal and physical barriers to obtaining that care. For the health care system, the differential diagnosis can expand or become more focused depending upon key pieces of information. For instance, a physician who has a high clinical suspicion of TB and an AFB smear positive sputum result will probably initiate treatment more quickly than one with low clinical suspicion and an AFB smear negative result. Further more, the clinician may begin by considering diagnoses other than TB (47).
Globally, delays in diagnosis have been studied in many countries in different settings and many different findings have been observed. In the following, detailed accounts of the different lengths and risk factors of diagnostic delays are presented.
2.2.5 What do we know about diagnostic delays?
2.2.5.1 Differences in the definition of diagnostic delays
According to Rieder (2000) diagnostic delays refer to the delay period related to the patient and the health care provider before diagnosis and commencement of treatment. When it comes specifically to patients’ delay, various definitions might be given (46). For example, in the study that was conducted in an urban health center setting in the Gambia (19), patients’ delay was defined as the period from onset of the major symptoms to first visit to a health provider. The delay period was divided into three. Namely, patients delay, health providers’ delay & diagnosing facilities’ delay. The health provider in this study included traditional healers, market drug sellers, pharmacists, village health workers, friends and relatives as well as medical staff. Whereas in the Ethiopian study which was conducted in a similar setting, patients’ delay was defined as the interval between the onsets of the major symptoms to the first consultation to a health care facility (23). The delay period was divided again into three namely; patients’
delay, health services’ delay and total delay. In this study, unlike the Gambian study, consultations with traditional healers and other forms of health providers were not included. In the Ethiopian study, this implies that, the delay is related to the patient unless he/she visits a modern health care facility either in the private sector or publicly owned health care facilities. From the Gambian study, the lesson is that, the patient should not be blamed as long as he/she visits anyone of the health providers based on the above definition, i.e. the delay is because of other providers not because of the patient.
