title: Long delays and missed opportunities in diagnosing smear-positive pulmonary tuberculosis in Kampala, Uganda: a cross-sectional study.
abstract: BACKGROUND
  Early detection and treatment of tuberculosis cases are the hallmark of successful tuberculosis control. We conducted a cross-sectional study at public primary health facilities in Kampala city, Uganda to quantify diagnostic delay among pulmonary tuberculosis (PTB) patients, assess associated factors, and describe trajectories of patients' health care seeking.
  
  
  RESULTS
  Semi-structured interviews with new smear-positive PTB patients (≥ 15 years) registered for treatment. Between April 2007 and April 2008, 253 patients were studied. The median total delay was 8 weeks (IQR 4-12), median patient delay was 4 weeks (inter-quartile range [IQR] 1-8) and median health service delay was 4 weeks (IQR 2-8). Long total delay (>14 weeks) was observed for 61/253 (24.1%) of patients, long health service delay (>6 weeks) for 71/242 (29.3%) and long patient delay (>8 weeks) for 47/242 (19.4%). Patients who knew that TB was curable were less likely to have long total delay (adjusted Odds Ratio [aOR] 0.28; 95%CI 0.11-0.73) and long patient delay (aOR 0.36; 95%CI 0.13-0.97). Being female (aOR 1.98; 95%CI 1.06-3.71), staying for more than 5 years at current residence (aOR 2.24 95%CI 1.18-4.27) and having been tested for HIV before (aOR 3.72; 95%CI 1.42-9.75) was associated with long health service delay. Health service delay contributed 50% of the total delay. Ninety-one percent (231) of patients had visited one or more health care providers before they were diagnosed, for an average (median) of 4 visits (range 1-30). All but four patients had systemic symptoms by the time the diagnosis of TB was made.
  
  
  CONCLUSIONS
  Diagnostic delay among tuberculosis patients in Kampala is common and long. This reflects patients waiting too long before seeking care and health services waiting until systemic symptoms are present before examining sputum smears; this results in missed opportunities for diagnosis.
authors.affiliation: Public Health Department, Kampala City Council, Kampala, Uganda.
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Sendagire
authors.forename: Maarten
authors.initials: M
authors.lastname: Schim Van der Loeff
authors.forename: Mesach
authors.initials: M
authors.lastname: Mubiru
authors.forename: Joseph
authors.initials: J
authors.lastname: Konde-Lule
authors.forename: Frank
authors.initials: F
authors.lastname: Cobelens
mesh_terms: D000293:Adolescent; D000328:Adult; D001294:Attitude to Health; D003140:Communicable Disease Control; D003430:Cross-Sectional Studies; D042241:Early Diagnosis; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D010358:Patient Participation; D011795:Surveys and Questionnaires; D013997:Time Factors; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000453:epidemiology*; D014454:Uganda