|BRIEF RESEARCH ARTICLE
|Year : 2016 | Volume
| Issue : 1 | Page : 77-80
Patient and health system delays among adult smear-positive tuberculosis patients diagnosed at medical colleges of Puducherry in south India
Anil Jacob Purty1, Ramesh Chand Chauhan2, Murugan Natesan3, Johnson Cherian4, Zile Singh5, Yogesh Sharma6
1 Professor, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Assistant Professor, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
3 Associate Professor, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
4 Assistant Professor, Department of Community Medicine, Indira Gandhi Medical College & Research Institute, Puducherry, India
5 Professor and Head, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
6 Tutor, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
|Date of Web Publication||23-Feb-2016|
Ramesh Chand Chauhan
Assistant Professor, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry - 605 014
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Early diagnosis and prompt initiation of treatment are essential for an effective tuberculosis (TB) control program. This study was done to assess the extent of various delays among TB patients diagnosed at medical colleges of Puducherry. A cross-sectional study involving retrospective medical record review and prospective patient interviews was conducted in and around the union territory of Puducherry during the period 2009-10. Various delays and adjusted odds ratios (ORs) were calculated. Level of significance was determined at 95% confidence interval (CI) (P value <0.05) and all tests were two-sided. Among 216 new sputum smear-positive TB patients, 11.1% and 10.6% were smokers and alcohol users, respectively. The median patient delay, health system delay, and total delay was 37 days, 28 days, and 65 days respectively. Being a resident of Puducherry (OR = 0.39, 95% CI = 0.18-0.87) and family size of ≤5 (OR = 0.45, 95% CI = 0.21-0.97) were found as the determinants of patient delays and total delays, respectively.
Keywords: Health system delay, India, patient delay, tuberculosis (TB)
|How to cite this article:|
Purty AJ, Chauhan RC, Natesan M, Cherian J, Singh Z, Sharma Y. Patient and health system delays among adult smear-positive tuberculosis patients diagnosed at medical colleges of Puducherry in south India. Indian J Public Health 2016;60:77-80
|How to cite this URL:|
Purty AJ, Chauhan RC, Natesan M, Cherian J, Singh Z, Sharma Y. Patient and health system delays among adult smear-positive tuberculosis patients diagnosed at medical colleges of Puducherry in south India. Indian J Public Health [serial online] 2016 [cited 2019 Dec 10];60:77-80. Available from: http://www.ijph.in/text.asp?2016/60/1/77/177349
Early diagnosis of the disease and prompt initiation of treatment are essential for an effective tuberculosis (TB) control program.  Delay in diagnosis of TB may worsen the disease; it also both increases the risk of poor treatment outcomes, including death, and enhances transmission of disease in the community. 
Private and informal health care providers (HCPs) are often the first source of care for TB, like any other illness. A patient moves from one HCP to another before he/she is finally diagnosed and started on anti-TB treatment.  Several factors have been identified as influencing delay in diagnosis and start of treatment, including the individual's perception of disease, socioeconomic level, extent of awareness about the disease, the severity of the disease, distance between the patient's residence and health services, and expertise of health personnel.  Such reasons for overall delay have been attributed to both patients and the health system. Since the involvement of medical colleges in the Revised National Tuberculosis Control Programme (RNTCP), a large number of patients are diagnosed and treated at medical college Designated Microscopy Centres (DMC). As there was no study on various delays for TB cases diagnosed at the medical colleges, this study was done to assess the extent and the determinants of delay in the diagnosis and treatment of TB patients at medical college hospitals.
A community-based descriptive study was done in and around the union territory of Puducherry during the period 2009-2010. All TB patients diagnosed at the medical college hospitals were registered and started on Directly Observed Treatment Short course (DOTS) or directly referred to Peripheral Health Institutions (PHIs) for starting anti-TB treatment. At the time of this study, RNTCP was implemented in only four medical colleges of Puducherry. All new sputum-positive TB patients diagnosed at these medical colleges during the period January to December, 2009 were included in the study.
A sample size of 282 was calculated using Epi info version 6 (Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, USA), taking absolute precision of 5%, 40% prevalence of delay, and confidence level 95%. To compensate for wrong addresses and refusal to participate, another 35 patients (~10%) were recruited.
A list of all new pulmonary sputum-positive TB patients of 15 years and above diagnosed under the RNTCP at the DMCs of four selected medical colleges during the year 2009 was prepared. A total of 849 sputum smear-positive adult TB patients were diagnosed during the year 2009 [Figure 1]. Using simple random sampling, from the list of all new adult smear-positive TB patients, 317 patients were selected. As these patients were started on treatment or referred to PHIs, their contact details were cross-checked with the referral register and treatment cards maintained at the District Tuberculosis Centre, Puducherry.
The study protocol was approved by the Institute Ethics Committee of the Pondicherry Institute of Medical Science, Puducherry. Permission for this study to be conducted was obtained from the Department of Health, Government of Puducherry.
The questionnaire used in the World Health Organization (WHO) multicountry study to estimate the diagnostic and treatment delay in TB were used.  The questionnaire was translated into the local language and then retranslated into English. The questionnaire was pilot-tested on 4 TB patients and based on the results of pilot testing, it was suitably modified. The patients on whom pilot testing was done were not included in the final analysis. The selected TB patients were contacted at their home and written informed consent was obtained from them before the interview. The questionnaire included information on sociodemographic profiles, major presenting symptoms, duration of major presenting symptoms, and the date of first visit to a health facility, etc. The duration of symptoms, date of diagnosis, date of treatment, and regularity with DOTS were also cross-checked from the available RNTCP records.
The total delay is the sum of patient delay and health care system delay, as it can be attributed to the types of delay that are defined as follows [Figure 2]:
|Figure 2: Flow-diagram of TB patients diagnosed at the selected medical colleges|
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- Patient delay: Time interval between the onset of symptoms and presentation to a HCP.
- Health system delay: Time interval between the date of presentation to a HCP and the initiation of anti-TB treatment.
- Diagnosis delay: Time interval between the date of presentation to a HCP and the diagnosis of TB.
- Treatment delay: Time interval between the diagnosis of TB and the initiation of anti-TB treatment.
Data analysis was performed using the statistical package SPSS for Windows version 16.0 (Chicago, SPSS Inc.). Summary output tables of frequency, mean and standard deviation (SD), and median and range were produced. A multivariate logistic regression analysis was performed to identify the determinants of diagnostic and treatment delay of TB patients based on calculated P value. For the logistic regression modeling, the outcome variables were patient delay, health system delay, and total delay. Age, sex, education, income, place of residence, and smoking and alcohol consumption were likely to influence delay. Odds ratios (ORs) were calculated. All variables in the table were adjusted for this model. Level of significance was determined at 95% (P value <0.05) and all tests were two-sided.
A total of 849 TB patients were diagnosed during the study year and 216 patients were interviewed [Figure 1].
Among 216 new sputum smear-positive TB patients interviewed, the majority (68.1%) were male and married (70.4%); one-fourth (25.0%) were in the age group of 15-24 years. The majority of the patients were literate (89.6%) and approximately two-third (67.6%) were residents of nearby districts of Tamil Nadu. The family size was ≤5 in the majority of the cases (77.8%). Most patients (40.7%) were earning INR ≤2000 per month and another 35.2% did not have a steady source of income. Among TB patients, 11.1% and 10.6% were smokers and alcohol users, respectively.
Delay in diagnosis and treatment of the tuberculosis patients
After the onset of symptoms, patients consulted the HCP after a median duration of 37 days, which constituted patient delay. The median duration between the first consultation and initiation of treatment, that is the health system delay, was 28 days; this included a median diagnostic delay of 12 days and a treatment delay of 16 days. The median duration between the onset of symptoms and initiation of anti-TB drugs, that is, the total delay, was 65 days [Table 1].
As shown in [Table 2], the total delay was less among residents of Puducherry as compared to Tamil Nadu [OR = 0.39, 95% confidence interval (CI) = 0.18-0.87]. In addition, patient delay was less in patients living in families with size of less than five (OR = 0.45, 95% CI = 0.21-0.97). Patients in the younger age group seemed to have a shorter delay, but this difference was statistically nonsignificant (OR = 0.49, 95% CI = 0.19-1.24). Similarly, there was no statistically significant difference for various delays with sex, education status, occupation, and income of patients.
|Table 2: Logistic regression analysis of risk factors for various delays|
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As medical colleges contribute significantly to the RNTCP, the assessment of various delays among patients diagnosed at medical colleges is important for the control of TB. Many studies have estimated the magnitude of total, patient, and health system delays among the TB patients in India. These delays ranged 60-62 days, 6-23 days, and 9-34 days, respectively. , In the present study, the median patient delay was 37 days. This delay is similar to other community-based studies done in South India, , but some studies done in Maharashtra showed a median patient delay of 47-95 days. , The possible reason for more delay in these studies could be that these studies were done in rural areas and our study also includes the urban population.
In the present study, the median health system delay was 28 days. A similar study done in Bangalore showed a median health system delay of 18 days, but the study setting varies between the two studies.  The same study shows a total delay of 41 days, and in the present study the median total delay was 81 days, as the present study includes participants from tertiary care hospitals only. 
This study reported the long delay between onset of symptoms and treatment with anti-TB drugs in TB patients. The duration of delay ranged between 1 month and 1.5 years among various participants, during which the diseased persons were transmitting infection across the community. Although the time of diagnosis and the start of treatment were confirmed from the reports, the time of onset of symptoms suggestive of TB was reported by the patients themselves and there is a possibility of recall bias. In addition, the people who reported the wrong address or who died were not interviewed. Further, the findings of the study cannot be generalized to the patients diagnosed and treated at PHIs, as these facilities are near the residence of the patients and the probable delay is expected to be less than that observed among patients diagnosed at the medical colleges.
The diagnosis and treatment delay among adult smear-positive TB patients is significant. The study suggests that there is a need for the revision of case-finding strategies in our setting. The reported high treatment success rate of directly observed treatment may be supplemented by measures to shorten the delay in diagnosis.
The authors would like to acknowledge the support of Dr. S. Govindarajan, State TB officer, Puducherry for his continuous support throughout the study.
Financial support and sponsorship
RNTCP STF operational recearch grant was received.
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Global Tuberculosis Report, 2012. WHO/HTM/TB/2012.6. Geneva, Switzerland: World Health Organization; 2012.
Toman K. Tuberculosis Case Finding and Chemotherapy Questions and Answers. Geneva: WHO; 1979.
Hazarika I. Role of private sector in providing tuberculosis care: Evidence from a population-based survey in India. J Glob Infect Dis 2011;3:19-24.
Suganthi P, Chadha VK, Ahmed J, Umadevi G, Kumar P, Srivastava R, et al
. Health seeking and knowledge about tuberculosis among persons with pulmonary symptoms and tuberculosis cases in Bangalore slums. Int J Tuberc Lung Dis 2008;12:1268-73.
Bassili A, Seita A, Baghdadi S, AlAbsi A, Abdilai I, Agboatwalla M, et al
. Diagnostic and treatment delay in tuberculosis in 7 countries of the Eastern Mediterranean Region. Infect Dis Clin Pract 2008;16:23-35.
Selvam JM, Wares F, Perumal M, Gopi PG, Sudha G, Chandrasekaran V, et al
. Health-seeking behaviour of new smear-positive TB patients under a DOTS programme in Tamil Nadu, India, 2003. Int J Tuberc Lung Dis 2007;11:161-7.
Rajeswari R, Chandrasekaran V, Suhadev M, Sivasubramaniam S, Sudha G, Renu G. Factors associated with patient and health system delays in the diagnosis of tuberculosis in South India. Int J Tuberc Lung Dis 2002;6:789-95.
Jagadish SD, Saraswathi S, Divakar SV. A study of impact of determinants of patients and health system delay on tuberculosis diagnosis and treatment in Bangalore. Indian J Community Health 2012;24:319-24.
Dhanvij P, Joshi R, Kalantri S. Delay in diagnosis of tuberculosis in patient's presenting to a tertiary care hospital in rural central India. J MGIMS 2009;14:56-63.
Bawankule S, Quazi S, Gaidhane A, Khatib N. Delay in DOTS for new pulmonary tuberculosis patient from rural area of Wardha District, India. Online J Health Allied Scs 2010;9:5.
[Figure 1], [Figure 2]
[Table 1], [Table 2]
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