title: Tuberculosis patients' pre-hospital delay and non-compliance with a longstanding DOT programme: a mixed methods study in urban Zambia.
abstract: Tuberculosis (TB) remains a major health problem in Zambia, despite considerable efforts to control and prevent it. With this study, we aim to understand how perceptions and cultural, social, economic, and organisational factors influence TB patients' pre-hospital delay and non-compliance with care provided by the National Tuberculosis Programme (NTP).
  
  
  
  A mixed methods study was conducted with 300 TB patients recruited at Kanyama clinic for structured interviews. Thirty were followed-up for multiple in-depth interviews. Six focus group discussions were organised and participant observation was conducted. Ten biomedical care providers, 10 traditional healers, and 10 faith healers were interviewed. Factors associated with non-compliance (disruption of treatment > one week) were assessed by applying logistic regression analyses; qualitative analysis was used to additionally assess factors influencing pre-hospital delay and for triangulation of study findings.
  
  
  
  TB treatment non-compliance was low (10 %), no association of outcome with cultural or socio-economic factors was found. Only patients' time constraints and long distance to the clinic indicated a possible association with a higher risk of non-compliance (OR 0.52; 95 % CI 0.25, 1.10, p = 0.086). Qualitative data showed that most TB patients combined understandings of biomedical and traditional TB knowledge, used herbal, traditional and/or faith healing, suffered from stigmatizing attitudes, experienced poverty and food shortages, and faced several organisational obstacles while being on treatment. This led in some cases to pre-hospital delay or treatment non-compliance.
  
  
  
  Mixed methods analysis demonstrated the importance of in-depth information ascertained by qualitative approaches to understand how cultural, socio-economic and organisational factors are influencing patients' pre-hospital delay and treatment compliance. To strengthen the Zambian NTP, combating stigma is of utmost priority coupled with programmes addressing poverty. Organisational barriers and co-operation between (private) clinics and traditional/faith healers should be considered.
authors: Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. a.l.cremers@amc.uva.nl.|Faculty of Social and Behavioural Science, Department of Sociology and Anthropology, University of Amsterdam, Amsterdam, The Netherlands. a.l.cremers@amc.uva.nl.
authors: Anne Lia
authors: 0000-0002-9602-0940
authors: AL
authors: Cremers
authors: Faculty of Social and Behavioural Science, Department of Sociology and Anthropology, University of Amsterdam, Amsterdam, The Netherlands.
authors: René
authors: R
authors: Gerrets
authors: Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.|National TB and Leprosy Control programme, Lusaka, Zambia.|University of Zambia - University College London (UNZA-UCL) programme, Lusaka, Zambia.
authors: Nathan
authors: N
authors: Kapata
authors: Department of Psychology, School of Humanities and Social Sciences, The University of Zambia, Lusaka, Zambia.
authors: Austin
authors: A
authors: Kabika
authors: Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors: Emma
authors: E
authors: Birnie
authors: Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.|Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors: Kerstin
authors: K
authors: Klipstein-Grobusch
authors: Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors: Martin P
authors: MP
authors: Grobusch
mesh_terms: D000328:Adult; D003695:Delivery of Health Care / Q000592:standards; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006763:Hospitals, Chronic Disease; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D010349:Patient Compliance / Q000706:statistics & numerical data*; D057545:Social Stigma; D014376:Tuberculosis / Q000517:prevention & control / Q000628:therapy*; D055815:Young Adult; D015024:Zambia
keywords: Pre-hospital delay; Public health; Treatment compliance; Tuberculosis; Zambia