title: Factors associated with patient and health system delays in the diagnosis of tuberculosis in South India.
abstract: OBJECTIVE
  To investigate the factors associated with delay in 1) care-seeking (patient delay), and 2) diagnosis by health providers (health system delay), among smear-positive tuberculosis patients, before large-scale DOTS implementation in South India.
  
  
  METHODS
  New smear-positive patients were interviewed using a structured questionnaire.
  
  
  RESULTS
  Among 531 participants, the median patient, health system and total delays were 20, 23 and 60 days, respectively. Twenty-nine per cent of patients delayed seeking care for > 1 month, of whom 40% attributed the delay to their lack of awareness about TB. Men postponed seeking care for longer periods than women (P = 0.07). In multivariate analysis, the patient delay was greater if the patient had initially consulted a government provider (adjusted odds ratio [AOR] 2.2, P < or = 0.001), resided at a distance >2 km from a health facility (AOR 1.6, P = 0.04), and was an alcoholic (AOR 1.6, P = 0.04). Health system delay was >7 days among 69% of patients. Factors associated with health system delay were: first consultation with a private provider (AOR 4.0, P < 0.001), a shorter duration of cough (AOR 2.6, P = 0.001), alcoholism (P = 0.04) and patient's residence >2 km from a health facility (AOR 1.8, P = 0.02). The total delay resulted largely from a long patient delay when government providers were consulted first, and a long health system delay when private providers were consulted first.
  
  
  CONCLUSIONS
  Public awareness about chest symptoms and the availability of free diagnostic services should be increased. Government and private physicians should be educated to be aware about the possibility of tuberculosis when examining out-patients. Effective referrals for smear microscopy should be developed between private and public providers.
authors.affiliation: Tuberculosis Research Centre, Indian Council of Medical Research, Chetput, Chennai. icmrtrc@vsnl.com
authors.forename: R
authors.initials: R
authors.lastname: Rajeswari
authors.forename: V
authors.initials: V
authors.lastname: Chandrasekaran
authors.forename: M
authors.initials: M
authors.lastname: Suhadev
authors.forename: S
authors.initials: S
authors.lastname: Sivasubramaniam
authors.forename: G
authors.initials: G
authors.lastname: Sudha
authors.forename: G
authors.initials: G
authors.lastname: Renu
mesh_terms: D000328:Adult; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D010353:Patient Education as Topic; D012307:Risk Factors; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D013997:Time Factors; D014376:Tuberculosis / Q000175:diagnosis* / Q000453:epidemiology*