title: How do patients access the private sector in Chennai, India? An evaluation of delays in tuberculosis diagnosis.
abstract: METHODS
  The diagnosis and treatment of tuberculosis (TB) in India are characterized by heavy private-sector involvement. Delays in treatment remain poorly characterized among patients seeking care in the Indian private sector.
  
  
  OBJECTIVE
  To assess delays in TB diagnosis and treatment initiation among patients diagnosed in the private sector, and pathways to care in an urban setting.
  
  
  METHODS
  Cross-sectional survey of 289 consecutive patients diagnosed with TB in the private sector and referred for anti-tuberculosis treatment through a public-private mix program in Chennai from January 2014 to February 2015.
  
  
  RESULTS
  Among 212 patients with pulmonary TB, 90% first contacted a formal private provider, and 78% were diagnosed by the first or second provider seen after a median of three visits per provider. Median total delay was 51 days (mean 68). Consulting an informal (rather than formally trained) provider first was associated with significant increases in total delay (absolute increase 22.8 days, 95%CI 6.2-39.5) and in the risk of prolonged delay >90 days (aRR 2.4, 95%CI 1.3-4.4).
  
  
  CONCLUSIONS
  Even among patients seeking care in the formal (vs. informal) private sector in Chennai, diagnostic delays are substantial. Novel strategies are required to engage private providers, who often serve as the first point of contact.
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: L
authors.initials: L
authors.lastname: Bronner Murrison
authors.affiliation: REACH, Chennai, India.
authors.forename: R
authors.initials: R
authors.lastname: Ananthakrishnan
authors.affiliation: REACH, Chennai, India.
authors.forename: A
authors.initials: A
authors.lastname: Swaminathan
authors.affiliation: REACH, Chennai, India.
authors.forename: S
authors.initials: S
authors.lastname: Auguesteen
authors.affiliation: REACH, Chennai, India.
authors.forename: N
authors.initials: N
authors.lastname: Krishnan
authors.affiliation: McGill International TB Centre & Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.
authors.forename: M
authors.initials: M
authors.lastname: Pai
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, USA.
authors.forename: D W
authors.initials: DW
authors.lastname: Dowdy
mesh_terms: D000328:Adult; D000995:Antitubercular Agents / Q000627:therapeutic use; D003430:Cross-Sectional Studies; D057210:Delayed Diagnosis; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D011331:Private Practice; D017149:Private Sector; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000188:drug therapy*
chemical_list: D000995:Antitubercular Agents