title: Tuberculosis treatment delays and associated factors within the Zimbabwe national tuberculosis programme.
abstract: BACKGROUND
  Delayed presentation of pulmonary TB (PTB) patients for treatment from onset of symptoms remains a threat to controlling individual disease progression and TB transmission in the community. Currently, there is insufficient information about treatment delays in Zimbabwe, and we therefore determined the extent of patient and health systems delays and their associated factors in patients with microbiologically confirmed PTB.
  
  
  METHODS
  A structured questionnaire was administered at 47 randomly selected health facilities in Zimbabwe by trained health workers to all patients aged ≥18 years with microbiologically confirmed PTB who were started on TB treatment and entered in the health facility TB registers between 01 January and 31 March 2013. Multivariate logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for associations between patient/health system characteristics and patient delay >30 days or health system delay >4 days.
  
  
  RESULTS
  Of the 383 recruited patients, 211(55%) were male with an overall median age of 34 years (IQR, 28-43). There was a median of 28 days (IQR, 21-63) for patient delays and 2 days (IQR, 1-5) for health system delays with 184 (48%) and 118 (31%) TB patients experiencing health system delays >30 days and health system delays >4 days respectively. Starting TB treatment at rural primary healthcare vs district/mission facilities [aOR 2.70, 95% CI 1.27-5.75, p = 0.01] and taking self-medication [aOR 2.33, 95% CI 1.23-4.43, p = 0.01] were associated with encountering patient delays. Associated with health system delays were accessing treatment from lower level facilities [aOR 2.67, 95% CI 1.18-6.07, p = 0.019], having a Gene Xpert TB diagnosis [aOR 0.21, 95% CI 0.07-0.66, p = 0.008] and >4 health facility visits prior to TB diagnosis [(aOR) 3.34, 95% CI 1.11-10.03, p = 0.045].
  
  
  CONCLUSIONS
  Patient delays were longer and more prevalent, suggesting the need for strategies aimed at promoting timely seeking of appropriate medical consultation among presumptive TB patients. Health system delays were uncommon, suggesting a fairly efficient response to microbiologically confirmed PTB cases. Identified risk factors should be explored further and specific strategies aimed at addressing these factors should be identified in order to lessen patient and health system delays.
authors: AIDS and TB Department, Zimbabwe Ministry of Health and Child Care, P. O Box CY 1122, Causeway, Harare, Zimbabwe. ktakarinda@theunion.org.|International Union Against Tuberculosis and Lung Disease, Paris, France. ktakarinda@theunion.org.
authors: Kudakwashe C
authors: KC
authors: Takarinda
authors: International Union Against Tuberculosis and Lung Disease, Paris, France. adharries@theunion.org.|Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK. adharries@theunion.org.
authors: Anthony D
authors: AD
authors: Harries
authors: TB CARE Project, International Union Against Tuberculosis and Lung Disease, Harare, Zimbabwe. bnyathi@mweb.co.zw.
authors: Barnet
authors: B
authors: Nyathi
authors: AIDS and TB Department, Zimbabwe Ministry of Health and Child Care, P. O Box CY 1122, Causeway, Harare, Zimbabwe. mkhongwenya@gmail.com.
authors: Mkhokheli
authors: M
authors: Ngwenya
authors: AIDS and TB Department, Zimbabwe Ministry of Health and Child Care, P. O Box CY 1122, Causeway, Harare, Zimbabwe. tsitsiapollo@gmail.com.
authors: Tsitsi
authors: T
authors: Mutasa-Apollo
authors: AIDS and TB Department, Zimbabwe Ministry of Health and Child Care, P. O Box CY 1122, Causeway, Harare, Zimbabwe. dr.c.sandy@gmail.com.
authors: Charles
authors: C
authors: Sandy
mesh_terms: D000328:Adult; D000367:Age Factors; D000995:Antitubercular Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D003430:Cross-Sectional Studies; D018450:Disease Progression; D005260:Female; D058016:Health Facility Administration; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D015995:Prevalence; D012424:Rural Population; D012737:Sex Factors; D013997:Time Factors; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000188:drug therapy*; D055815:Young Adult; D015030:Zimbabwe / Q000453:epidemiology
chemical_list: D000995:Antitubercular Agents
references: Tuber Lung Dis. 1996 Oct;77(5):401-6
references: 8959142
references: Trop Med Int Health. 2001 Apr;6(4):256-9
references: 11348515
references: JAMA. 1996 Oct 16;276(15):1223-8
references: 8849749
references: BMC Health Serv Res. 2013;13:25
references: 23327613
references: BMC Public Health. 2008;8:15
references: 18194573
references: BMC Public Health. 2005;5:122
references: 16307685
references: Can Respir J. 2008 Jul-Aug;15(5):244-8
references: 18716685
references: BMC Infect Dis. 2009;9:91
references: 19519917
references: Int Health. 2012 Dec;4(4):320-2
references: 24029680
references: Trop Med Int Health. 2005 Apr;10(4):330-5
references: 15807796
references: Cochrane Database Syst Rev. 2013;1:CD009593
references: 23440842
references: Trop Med Int Health. 2011 Apr;16(4):394-411
references: 21320240
references: Arch Intern Med. 2003 May 12;163(9):1009-21
references: 12742798
references: BMC Public Health. 2004 May 29;4:18
references: 15169548
references: Int J Tuberc Lung Dis. 1998 Aug;2(8):635-40
references: 9712277
references: BMC Infect Dis. 2005;5:112
references: 16343350
references: Int J Tuberc Lung Dis. 2001 Jul;5(7):619-27
references: 11467368
references: Int J Tuberc Lung Dis. 1999 May;3(5):388-93
references: 10331727
references: Int J Tuberc Lung Dis. 2006 Apr;10(4):422-8
references: 16602407
references: Int J Tuberc Lung Dis. 2000 Feb;4(2):133-8
references: 10694091
references: Med Sci Monit. 2004 Feb;10(2):CR62-7
references: 14737045
references: Int J Tuberc Lung Dis. 1997 Aug;1(4):326-32
references: 9432388
references: BMC Infect Dis. 2013;13:168
references: 23566166
references: PLoS One. 2006;1:e121
references: 17205125
references: Int J Tuberc Lung Dis. 2001 Nov;5(11):1013-20
references: 11716337
references: Int J Tuberc Lung Dis. 2001 Mar;5(3):233-9
references: 11326822
references: Int J Tuberc Lung Dis. 2013 May;17(5):615-20
references: 23575326
references: BMC Public Health. 2002 Sep 25;2:23
references: 12296975
references: BMC Public Health. 2013;13:250
references: 23517315