title: Barriers to completing TB diagnosis in Yemen: services should respond to patients' needs.
abstract: OBJECTIVE
  Obtaining a diagnosis of tuberculosis (TB) is a prerequisite for accessing specific treatment, yet one third of estimated new cases are missed worldwide by National Programmes. This study investigated economic, geographical, socio-cultural and health system factors hindering adults' attendance and completion of the TB diagnostic process in Yemen, to inform interventions designed to improve patient access to services.
  
  
  METHODS
  The study employed a mixed methods design comprising a cross-sectional survey and In-Depth-Interviews (IDIs) and Focus Group Discussions (FGDs) among patients abandoning the diagnosis or registering for treatment. Adults with cough of ≥ 2 weeks attending a large governmental referral centre in Sana'a, Yemen, between 2009 and 2010, were eligible to participate.
  
  
  RESULTS
  497 and 446 (89.7%) participants were surveyed the first and second day of attending the services and 48 IDIs and 12 FGDs were also conducted. The majority of patients were disadvantaged and had poor literacy (61% illiterate), had travelled from rural areas (47%) and attended with companions (84%). Key barriers for attendance identified were clinic and transport costs (augmented by companions), distance from home, a preference for private services, strong social stigma and a lack of understanding of the diagnostic process. There were discrepancies between patient- and doctor-reported diagnosis and 46% of patients were unaware that TB treatment is free. Females faced more difficulties to attend than men. The laboratory practice of providing first-day negative smear results and making referrals to the private sector also discouraged patients from returning. Strategies to bring TB diagnostic services closer to communities and address the multiple barriers patients face to attend, will be important to increase access to TB diagnosis and care.
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Anderson de Cuevas
authors.affiliation: Medical Faculty, Sana'a University, Sana'a, Yemen.
authors.forename: Najla
authors.initials: N
authors.lastname: Al-Sonboli
authors.affiliation: Medical Faculty, Sana'a University, Sana'a, Yemen.
authors.forename: Nasher
authors.initials: N
authors.lastname: Al-Aghbari
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Mohammed A
authors.initials: MA
authors.lastname: Yassin
authors.affiliation: Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Luis E
authors.initials: LE
authors.lastname: Cuevas
authors.affiliation: Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: Sally J
authors.initials: SJ
authors.lastname: Theobald
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D057545:Social Stigma; D011795:Surveys and Questionnaires; D014376:Tuberculosis / Q000175:diagnosis*; D015006:Yemen; D055815:Young Adult