title: Four Degrees of Separation: Social Contacts and Health Providers Influence the Steps to Final Diagnosis of Active Tuberculosis Patients in Urban Uganda.
abstract: BACKGROUND
  Delay in tuberculosis (TB) diagnosis adversely affects patients' outcomes and prolongs transmission in the community. The influence of social contacts on steps taken by active pulmonary TB patients to seek a diagnosis has not been well examined.
  
  
  METHODS
  A retrospective study design was use to enroll TB patients on treatment for 3 months or less and aged ≥18 years from 3 public clinics in Kampala, Uganda, from March to July 2014. Social network analysis was used to collect information about social contacts and health providers visited by patients to measure the number of steps and time between onset of symptoms and final diagnosis of TB.
  
  
  RESULTS
  Of 294 TB patients, 58 % were male and median age was 30 (IQR: 24-38) years. The median number of steps was 4 (IQR: 3, 7) corresponding to 70 (IQR: 28,140) days to diagnosis. New patients had more steps and time to diagnosis compared retreatment patients (5 vs. 3, P < 0.0001; 84 vs. 46 days P < 0.0001). Fifty-eight percent of patients first contacted persons in their social network. The first step to initiate seeking care accounted for 41 % of the patients' time to diagnosis while visits to non-TB providers and TB providers (without a TB diagnosis) accounted for 34 % and 11 % respectively. New TB patients vs. retreatment (HR: 0.66, 95 % CI; 1.11, 1.99), those who first contacted a non-TB health provider vs. contacting social network (HR: 0.72 95 % CI; 0.55, 0.95) and HIV seronegative vs. seropositive patients (HR: 0.70, 95 % CI; 0.53, 0.92) had a significantly lower likelihood of a timely final diagnosis.
  
  
  CONCLUSIONS
  There were four degrees of separation between the onset of symptoms in a TB patient and a final diagnosis. Both social and provider networks of patients influenced the diagnostic pathways. Most delays occurred in the first step which represents decisions to seek help, and through interactions with non-TB health providers. TB control programs should strengthen education and active screening in the community and in health care settings to ensure timely diagnosis of TB.
authors: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, B.S. Miller Hall, 101 Buck Rd, Athens, GA, 30602, USA. juliet.sekandi5@gmail.com.|Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda. juliet.sekandi5@gmail.com.|Makerere University College of Health Sciences, School of Medicine, National TB Treatment Center, Mulago Referral and Teaching Hospital, Mulago, Uganda. juliet.sekandi5@gmail.com.
authors: Juliet N
authors: JN
authors: Sekandi
authors: Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda. skzalwango@gmail.com.|Department of Health Services, Kampala City Council Authority, Kampala, Uganda. skzalwango@gmail.com.
authors: Sarah
authors: S
authors: Zalwango
authors: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, B.S. Miller Hall, 101 Buck Rd, Athens, GA, 30602, USA. Leomarti@uga.edu.
authors: Leonardo
authors: L
authors: Martinez
authors: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, B.S. Miller Hall, 101 Buck Rd, Athens, GA, 30602, USA. ahandel@uga.edu.
authors: Andreas
authors: A
authors: Handel
authors: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, B.S. Miller Hall, 101 Buck Rd, Athens, GA, 30602, USA. Kakaire@uga.edu.
authors: Robert
authors: R
authors: Kakaire
authors: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, B.S. Miller Hall, 101 Buck Rd, Athens, GA, 30602, USA. kizzalan@uga.edu.
authors: Allan K
authors: AK
authors: Nkwata
authors: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, B.S. Miller Hall, 101 Buck Rd, Athens, GA, 30602, USA. aezeamam@uga.edu.
authors: Amara E
authors: AE
authors: Ezeamama
authors: Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda. nkiwanuka@gmail.com.
authors: Noah
authors: N
authors: Kiwanuka
authors: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, B.S. Miller Hall, 101 Buck Rd, Athens, GA, 30602, USA. ccwhalen@uga.edu.
authors: Christopher C
authors: CC
authors: Whalen
mesh_terms: D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D016358:Contact Tracing; D003430:Cross-Sectional Studies; D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation; D012189:Retrospective Studies; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis / Q000453:epidemiology*; D014454:Uganda / Q000453:epidemiology; D014505:Urban Population; D055815:Young Adult