title: Delay in the treatment of pulmonary tuberculosis: a report from Afghanistan.
abstract: OBJECTIVE
  The aim of this study was to determine the length of delays and to investigate the factors associated with patient (care-seeking) and health-system (treatment initiation following care-seeking) delays, among smear-positive tuberculosis patients in Kunar province, Afghanistan, as delay in diagnosis and treatment results in more severe disease, higher mortality, and a longer period of infectivity in the community.
  
  
  METHODS
  A cross-sectional study of 122 new smear-positive pulmonary tuberculosis patients, aged ≥15 years, registered at a hospital and a clinic in Kunar province, was conducted from September 2008 to February 2009 using a structured questionnaire interview.
  
  
  RESULTS
  Among the 122 participants, the average patient, health-system, and total delays were 205.2, 150.7, and 356.0 days, respectively. Patient delay was independently associated with an increase in the household size, social stigma linked with tuberculosis (social consequences of having tuberculosis), chest pain, longer time to reach a private health-care facility, initial seeking of alternative services (self-treatment with herbs or drugs; obtaining of drugs from pharmacy or drug store; visiting traditional health provider; and visiting community health worker), and initial consultation with a private health-care facility (p < 0.05). The risk of health-system delays increased with multiple visits and with time to reach private health facilities (p < 0.05). The risk of health-system delays decreased as social stigma increased (p < 0.05).
  
  
  CONCLUSIONS
  Delays in the initiation of tuberculosis treatment in Kunar province are daunting. Efforts to reduce delays must encourage early visits, reduce tuberculosis-associated stigma, encourage a public-private health-care mix, improve health-care providers' diagnostic capabilities, and encourage active case-finding with recording of symptoms and screening of contacts.
authors: Department of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan.
authors: Wrishmeen
authors: W
authors: Sabawoon
authors: Hajime
authors: H
authors: Sato
authors: Yasuki
authors: Y
authors: Kobayashi
references: Int J Tuberc Lung Dis. 2002 Sep;6(9):796-805
references: 12234135
references: BMC Infect Dis. 2009 Jun 11;9:91
references: 19519917
references: Int J Tuberc Lung Dis. 2008 Feb;12(2):180-5
references: 18230251
references: Int J Tuberc Lung Dis. 1999 May;3(5):388-93
references: 10331727
references: MedGenMed. 1999 Jun 18;:E6
references: 11104408
references: Health Policy. 2000 May;52(1):33-51
references: 10899643
references: Public Health. 1998 May;112(3):165-8
references: 9629023
references: BMC Public Health. 2005 Nov 24;5:122
references: 16307685
references: JAMA. 1996 Oct 16;276(15):1223-8
references: 8849749
references: BMC Public Health. 2009 Feb 09;9:53
references: 19203378
references: Int J Tuberc Lung Dis. 2006 Apr;10(4):422-8
references: 16602407
references: BMC Public Health. 2008 Jan 14;8:15
references: 18194573
references: Int J Tuberc Lung Dis. 2006 Jan;10(1):24-30
references: 16466033
references: Int J Tuberc Lung Dis. 1998 Aug;2(8):635-40
references: 9712277
references: Can Med Assoc J. 1978 Jun 24;118(12):1520-2
references: 657048
references: Int J Tuberc Lung Dis. 2002 Sep;6(9):789-95
references: 12234134
references: Kekkaku. 2006 Jul;81(7):467-74
references: 16910598
references: Int J Tuberc Lung Dis. 2000 Feb;4(2):133-8
references: 10694091
references: BMC Infect Dis. 2005 Dec 12;5:112
references: 16343350