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Sociocultural aspects of delays in diagnosis among Tuberculosis-Diabetes Comorbid patients in Satara, India: Its implications for the implementation of the National Framework for Joint Tuberculosis-Diabetes Collaborative Activities
... In contrast, this study highlights the continuity and adaptation of the caliphate concept, showing that it has not remained fixed but rather evolved in response to changing political and social needs. This broader historical approach sets it apart from research that treats the caliphate as a uniform or unchanging institution (Phutane et al., 2024). ...
The concept of the caliphate has played a central role in Islamic political history, evolving significantly from the early classical period to contemporary times. Throughout Islamic history, the notion of the caliphate has shifted, reflecting the political, social, and cultural contexts of different eras. This evolution has sparked debate and differing interpretations among scholars, political leaders, and communities across the Muslim world. This study aims to explore the evolution of the concept of the caliphate, analyzing key case studies from classical Islamic history through to contemporary movements. The research seeks to understand how the concept has transformed over time and how these changes have influenced political thought in the Muslim world. The research utilizes a historical comparative approach, examining primary texts, political documents, and scholarly interpretations of the caliphate across different time periods. Case studies include the early Rashidun Caliphate, the Abbasid Caliphate, the Ottoman Caliphate, and modern interpretations by groups such as ISIS. A combination of qualitative content analysis and historical contextualization was applied. The study reveals that the concept of the caliphate has undergone significant ideological transformations, moving from a unifying political and religious institution in the classical period to more fragmented and symbolic representations in the modern era. Contemporary movements have reinterpreted the caliphate for political purposes, often deviating from classical principles. The evolution of the caliphate reflects broader changes in Islamic political thought, adapting to different historical and cultural contexts. This research highlights the complexity and diversity of interpretations surrounding the caliphate, emphasizing the need for nuanced understanding in contemporary discussions.
Background:
Tuberculosis (TB)-diabetes comorbid cases have increased in India with Karnataka among the states with the highest numbers. The comorbidity adversely affects the prognosis of individual diseases. Diabetes management is crucial to the management of TB.
Aim:
This study aims to understand the factors influencing diabetes management, and the barriers and challenges affecting the management of diabetes in TB-Diabetes comorbid patients in Udupi district.
Materials and methods:
For this mixed-method, cross-sectional study, TB-Diabetes comorbid patients, registered under the NIKSHAY in 2018 and 2019, and government Medical Officers were included in the study. Data were analyzed using SPSS. For the qualitative study, thematic analysis was done.
Results:
A total of 154 participants were included in the study. The disease the participant developed first, the place of diabetes diagnosis, person initiating diabetes treatment, and counseling (P < 0.05), were some of the factors affecting diabetes management. In addition, alcoholism, migrant status, and old age were some of the barriers in the management of diabetes among comorbid patients.
Conclusion:
Diabetes management of alcoholics, migrants, elderly patients, and patients without a family needs special consideration for the successful management of TB-Diabetes comorbidity.
Background
Unrecognised transmission of tuberculosis is a main contributor of high epidemic of tuberculosis in low-income countries. Studies done in Ethiopia showed that delay in tuberculosis diagnosis and treatment is one of the major challenges to tuberculosis control programmes in the country. This study assessed factors which predict health system diagnostic delay of new pulmonary tuberculosis in Gurage and Siltie zones, South Ethiopia.
Methods
A health facility-based cross-sectional study was conducted among 204 adult patients with new pulmonary tuberculosis in Gurage and Siltie zones. Consecutive sampling technique was used to recruit participants. Data were collected by using a structured and pretested Amharic questionnaire. Data were entered into Epi-info V.7, processed and analysed by SPSS V.20. Health system diagnostic delay was dichotomised as either long or acceptable delay using median delay.
Results
Median (IQR) patient and health system diagnostic delays are almost equal which are 20 (10–34.5) and 20.5 (8.2–56.2) days, respectively. Results from logistic regression show that presence of long patient delays (adjusted OR (AOR)=2.85, 95% CI: 1.44 to 5.62; p=0.003) in seeking care, presence of sputum smear examination (AOR=0.37, 95% CI: 0.19 to 0.75; p=0.005) at the first visit to a health facility and multiple heath facility visit before diagnosis of tuberculosis (AOR=4.95, 95% CI: 1.98 to 12.40; p=0.001) were factors significantly associated with long health system diagnostic delay.
Conclusions
Long patient delay and multiple health facility visits are positively associated with long health system diagnostic delay; whereas sputum smear examination at the first contact with a health facility is negatively associated with long health system tuberculosis diagnostic delay.
Objective
Tuberculosis (TB) and diabetes mellitus (DM) are both significant public health problems in China. Results of previous studies on the prevalence of DM among TB patients in China are inconsistent. We conducted this systematic review and meta‐analysis to estimate the overall prevalence of DM among TB patients in China.
Methods
We systematically searched Excerpta Medica Database, PubMed, Global Health, Ovid MEDLINE(R), Chinese Biomedical Literature Service System, and China Online Journals −Health & Medicine and included all observational studies reporting prevalence of DM among TB patients in China. The Cochran's Q‐statistic and I2 were used to test heterogeneity. Finally, a random‐effect model meta‐analysis was conducted to estimate the pooled prevalence of DM among TB patients in China using R studio.
Results
We screened 7043 articles and identified 43 eligible studies. The pooled prevalence was 7.8% (95% prediction interval 1.6–30.5, I2 = 99.2%). The highest prevalence was observed in Northeast China (21.9%) among four economic regions of China, followed by East Coast (8.3%), Western China (5.9%), with Central China having the lowest prevalence (5.1%). Higher prevalence was observed in urban (10.1%) than in rural (7.8%) areas, and in hospital‐based (9.0%) than in population‐based studies (6.9%).
Conclusions
This study suggests that the prevalence of DM among TB patients in China aligns with the overall DM prevalence among the public in China. Public health strategies to reduce the burden of TB‐DM comorbidity and inequity are needed.
Background and objective
Diabetes mellitus is a complex chronic disease requiring appropriate continuous medical care and delayed, or forgone care may exacerbate the severity of the disease. This study aimed to investigate the factors affecting forgone care in patients with type2 diabetes.
Materials and methods
This was a cross-sectional study involving 1139 patients with type 2 diabetes aged> 18 years in 2019 in Tabriz, Iran. The researcher-made questionnaire was used for data collection. Data were analyzed using IBM SPSS software version 22 and IBM AMOS 22. Exploratory Factor Analysis (EFA) was performed for dimension reduction of the questionnaire, and Confirmatory Factor Analysis (CFA) used to verify the result of EFA. We applied the binary logistic regression model to assess the factors affecting forgone care.
Results
Of the 1139 patients, 510 patients (45%) reported forgone care during the last year. The percentage of forgoing care was higher in patients without supplementary insurance coverage ( P = 0.01), those with complications (P = 0.01) and those with a history of hospitalization ( P = 0.006). The majority of patients (41.5%) reported that the most important reason for forgoing care is financial barriers resulting from disease treatment costs. Of the main four factors affecting, quality of care had the highest impact on forgone care at 61.28 (of 100), followed by accessibility (37.01 of 100), awareness and attitude towards disease (18.52 of 100) and social support (17.22 of 100).
Conclusion
The results showed that, despite the implementation of the Islamic Republic of Iran on a fast-track to beating non-communicable diseases (IraPEN), a considerable number of patients with type2 diabetes had a history of forgoing care, and the most important reasons for forgoing care were related to the financial pressure and dissatisfaction with the quality of care. Therefore, not only more financial support programs should be carried out, but the quality of care should be improved.
Objectives:
to identify the trend and factors associated with Tuberculosis-Diabetes Mellitus comorbidity in Imperatriz, Maranhão.
Methods:
epidemiological temporal-series study, conducted in a Northeastern Brazilian municipality. The population consisted of Tuberculosis cases with Diabetes Mellitus-associated aggravation notified in the Notifiable Diseases Information System (SINAN) between 2009 and 2018. We determined the prevalence and trend of comorbidity using Prais-Winsten regressions and to identify associated factors employed Poisson regression.
Results:
prevalence ranged from 3.23% in 2014 to 19.51% in 2018, with a mean of 11.5% for the period, showing an increasing trend. Age groups 30 to 59 years and ≥ 60 years, education < 8 years, and clinical form of pulmonary Tuberculosis were risk factors for comorbidity.
Conclusions:
The increasing trend of comorbidity and its associated factors alert us to the need to improve customer service at all levels of health care.
Introduction
Mortality and morbidity from Non-Communicable Diseases (NCDs) in Africa are expected to worsen if the status quo is maintained. Emergency care settings act as a primary point of entry into the health system for a spectrum of NCD-related illnesses, however, there is a dearth of literature on this population. We conducted a systematic review assessing available evidence on epidemiology, interventions and management of NCDs in acute and emergency care settings in Kenya, the largest economy in East Africa and a medical hub for the continent.
Methods
All searches were run on July 15, 2015 and updated on December 11, 2020, capturing concepts of NCDs, and acute and emergency care. The study is registered at PROSPERO (CRD42018088621).
Results
We retrieved a total of 461 references, and an additional 23 articles in grey literature. 391 studies were excluded by title or abstract, and 93 articles read in full. We included 10 articles in final thematic analysis. The majority of studies were conducted in tertiary referral or private/mission hospitals. Cancer, diabetes, cardiovascular disease and renal disease were addressed. Majority of the studies were retrospective, cross-sectional in design; no interventions or clinical trials were identified. There was a lack of access to basic diagnostic tools, and management of NCDs and their complications was limited.
Conclusion
There is a paucity of literature on NCDs in Kenyan emergency care settings, with particular gaps on interventions and management. Opportunities include nationally representative, longitudinal research such as surveillance and registries, as well as clinical trials and implementation science to advance evidence-based, context-specific care.
Background
Tuberculosis (TB) remains a significant global public health problem. China has the second highest TB burden in the world. With a growing TB population with diabetes mellitus (DM), the TB control system faces mounting challenges. To date, evidence remains inconclusive regarding the association between TB-DM co-morbidity and delayed diagnosis of TB patients. This study aims to assess the diagnostic delay of TB patients with known DM and identify the factors associated with this delay.
Methods
Data was collected from China’s Tuberculosis information management system in two counties of Zhejiang province, China. Patient delay, health system delay and total diagnostic delay are defined as follows: 1) the interval between the onset of TB symptoms and first visit to any health facility; 2) from the first visit to the health facility to the confirmed TB diagnosis in the designated hospital; 3) the sum of patient and health system’s respective delays. Comparison of these delays was made between TB patients with and without DM using Mann-Whitney U test and Chi-square test. Univariate and multivariate regression analysis was used to identify factors influencing delays among TB patients with DM.
Results
Of 969 TB patients, 67 (7%) TB patients had DM co-morbidity. Compared with TB patients without DM, TB patients with DM experienced significantly shorter health system delays ( p < 0.05), and there was a significantly lower proportion of patients whose health system delayed> 14 days (7.0% vs. 18%, p < 0.05). However, no significant difference was observed between both patient categories regarding patient delay and total diagnostic delay. The multivariate regression analysis suggested that TB patients with DM who were aged < 60 years (AOR = 3.424, 95%CI: 1.008–11.627, p < 0.05) and non-severe cases (AOR = 9.725, 95%CI: 2.582–36.626, p < 0.05) were more likely to have a total diagnostic delay of> 14 days.
Conclusions
Our study suggests that DM does not contribute to further diagnostic delay as expected. Instead, we observed significantly improved health system delay among TB patients with DM. The findings indicate the importance of early screening and diagnosis for TB among diabetic patients and of strengthening the integrated control and management of TB and diabetic programs.
Importance
The coronavirus disease 2019 (COVID-19) pandemic has led to treatment delays for many patients with cancer. While published guidelines provide suggestions on which cases are appropriate for treatment delay, there are no good quantitative estimates on the association of delays with tumor control or risk of new metastases.
Objectives
To develop a simplified mathematical model of tumor growth, control, and new metastases for cancers with varying doubling times and metastatic potential and to estimate tumor control probability (TCP) and metastases risk as a function of treatment delay interval.
Design, Setting, and Participants
This decision analytical model describes a quantitative model for 3 tumors (ie, head and neck, colorectal, and non–small cell lung cancers). Using accepted ranges of tumor doubling times and metastatic development from the clinical literature from 2001 to 2020, estimates of tumor growth, TCP, and new metastases were analyzed for various treatment delay intervals.
Main Outcomes and Measures
Risk estimates for potential decreases in local TCP and increases in new metastases with each interval of treatment delay.
Results
For fast-growing head and neck tumors with a 2-month treatment delay, there was an estimated 4.8% (95% CI, 3.4%-6.4%) increase in local tumor control risk and a 0.49% (0.47%-0.51%) increase in new distal metastases risk. A 6-month delay was associated with an estimated 21.3% (13.4-30.4) increase in local tumor control risk and a 6.0% (5.2-6.8) increase in distal metastases risk. For intermediate-growing colorectal tumors, there was a 2.1% (0.7%-3.5%) increase in local tumor control risk and a 2.7% (2.6%-2.8%) increase in distal metastases risk at 2 months and a 7.6% (2.2%-14.2%) increase in local tumor control risk and a 24.7% (21.9%-27.8%) increase in distal metastases risk at 6 months. For slower-growing lung tumors, there was a 1.2% (0.0%-2.8%) increase in local tumor control risk and a 0.19% (0.18%-0.20%) increase in distal metastases risk at 2 months, and a 4.3% (0.0%-10.6%) increase in local tumor control risk and a 1.9% (1.6%-2.2%) increase in distal metastases risk at 6 months.
Conclusions and Relevance
This study proposed a model to quantify the association of treatment delays with local tumor control and risk of new metastases. The detrimental associations were greatest for tumors with faster rates of proliferation and metastasis. The associations were smaller, but still substantial, for slower-growing tumors.
Background
Delay in healthcare seeking and loss to diagnostic follow-up (LDFU) contribute to substantial increase in tuberculosis (TB) morbidity and mortality. We examined factors, including perceived causes and prior help seeking, contributing to delay and LDFU during referral to a TB clinic among patients with presumptive TB initially seeking help at the pharmacies in Dar es Salaam Tanzania.
Methods
In a TB clinic, a semi-structured interview based on the explanatory model interview catalogue (EMIC) framework for cultural epidemiology was administered to presumptive TB patients enrolled at pharmacies during an intervention study. We assessed delay in seeking care at any medical care provider for a period of ≥3 weeks after the onset of symptoms, LDFU during referral (not reaching the TB clinic), and LDFU for three required TB clinic visits among the presumptive and confirmed TB patients. Logistic regression models were used to assess factors associated with delay and LDFU.
Results
Among 136 interviewed patients, 86 (63.2%) were LDFU from pharmacies and TB clinic while 50 (36.8%) were non-LDFU. Out of 136 patients 88 (64.7%) delayed seeking care, of whom 59 (67%) were females. Among the 86 (63.2%) patients in LDFU group, 62 (72.1%) delayed seeking care, while among the 50 (36.8%) non-LDFU, 26 (52.0%) had also delayed seeking care. Prior consultation with a traditional healer (aOR 2.84, 95% CI 1.08–7.40), perceived causes as ingestion (water and food) (aOR 0.38 CI 0.16–0.89), and substance use (smoking and alcohol) (aOR 1.45 CI 0.98–2.14) were all associated with patient delay. Female gender was associated with LDFU (aOR 3.80, 95% CI 1.62–8.87) but not with delay. Other conditions as prior illness and heredity were also associated with LDFU but not delay (aOR 1.48 CI 1.01–2.17).
Conclusion
Delay and LDFU after referral from the pharmacies were substantial. Notable effects of diagnosis and female gender indicate a need for more attention to women’s health to promote timely and sustained TB treatment. Public awareness to counter misconceptions about the causes of TB is needed.
Cultural epidemiology is an interdisciplinary field based on principles and
methods of medical anthropology and classical epidemiology. Its contribution
to health research results from a focus on illness, distinct from the
disease orientation of classical epidemiology. Though rooted in the
influential illness explanatory model framework, current developments in the
field of cultural epidemiology refer more explicitly to determinants of
health and illness beyond explanatory models based on frameworks of critical
medical anthropology. This rethinking of cultural epidemiology acknowledges
the need for research to consider domains of a revised Outline for Cultural
Formulation referring to cultural identity, key social relations, and the
impact of political economy and other structural features of society. In
addition to this current work in cultural psychiatry, two other areas of
research remain active: public health studies of professional and community
determinants of vaccine acceptance and research on assessment and study of
stigma as a clinically significant feature of illness experience, providing
a clinical complement to more mainstream community studies of stigma.
Objectives
The aim of this cross-sectional study was to identify key factors associated with patient delay (PD), health system delay (HSD) and total delay (TOTD) in patients with tuberculosis (TB) to inform control programmes.
Setting
The study was conducted in four Italian regions in 2014–2016. Data were obtained using a questionnaire including: sociodemographic and lifestyle data, TB comorbidities, patient knowledge and attitudes towards TB, stigma, access to TB care and health-seeking behaviours.
Participants
Patients’ inclusion criteria were being diagnosed as a new smear positive pulmonary TB case and living in one of the participating Italian regions. Overall, 344 patients from 30 healthcare centres were invited to participate and 253 patients were included in the analysis (26.5% non-response rate); 63.6% were males and 55.7% were non-Italian born.
Outcome measures
Risk factors for PD, HSD and TOTD in patients with TB were assessed by multivariable analysis. Adjusted ORs (aOR) and 95% CIs were calculated.
Results
Median PD, HSD and TOTD were 30, 11 and 45 days, respectively. Factors associated with longer PD were: stigma (aOR 2.30; 95% CI 1.06 to 4.98), chest pain (aOR 2.67; 95% CI 1.24 to 6.49), weight loss (aOR 4.66; 95% CI 2.16 to 10.05), paying for transportation (aOR 2.66; 95% CI 1.24 to 5.74) and distance to the health centre (aOR 2.46; 95% CI 1.05 to 5.74) (the latter three were also associated with TOTD). Shorter HSD was associated with foreign-born and female status (aOR 0.50; 95% CI 0.27 to 0.91; aOR 0.28; 95% CI 0.15 to 0.53, respectively), dizziness (aOR 0.18, 95% CI 0.04 to 0.78) and seeking care at hospital (aOR 0.35; 95% CI 0.18 to 0.66). Prior unspecific treatment was associated with longer HSD (aOR 2.25; 95% CI 1.19 to 4.25) and TOTD (aOR 2.55; 95% CI 1.18 to 5.82). Haemoptysis (aOR 0.12; 95% CI 0.03 to 0.43) and repeated visits with the same provider (aOR 0.29; 95% CI 0.11 to 0.76) showed shorter TOTD.
Conclusions
This study identifies several determinants of delays associated with patient’s behaviours and healthcare qualities. Tackling TB effectively requires addressing key risk factors that make individuals more vulnerable by the means of public health policy, cooperation and advocacy to ensure that all patients have easy access to care and receive high-quality healthcare.
Background: Depending on a country’s diagnostic infrastructure, patients and providers play different roles in ensuring that correct and timely diagnosis is made. However, little is known about the work done by patients in accessing diagnostic services and completing the ‘test and treat’ loop.
Objective: To address this knowledge gap, we traced the diagnostic journeys of patients with tuberculosis, diabetes, hypertension and typhoid, and examined the work they had to do to arrive at a diagnosis.
Methods: This paper draws on a qualitative study, which included 78 semi-structured interviews and 13 focus group discussions with patients, public and private healthcare providers, community health workers, test manufacturers, laboratory technicians, program managers and policymakers. Data were collected between January and June 2013 in rural and urban Karnataka, South India, as part of a larger project on barriers to point-of-care testing. We reconstructed patient diagnostic processes retrospectively and analyzed emerging themes and patterns.
Results: The journey to access diagnostic services requires a high level of involvement and immense work from patients and/or their caretakers. This process entails overcoming cost and distance, negotiating social relations, continuously making sense of their illness and diagnosis, producing and transporting samples, dealing with the social consequences of diagnosis, and returning results to the treating provider. The quality and content of interactions with providers were crucial for completion of test and treat loops. If the tasks became overwhelming, patients opted out, delayed being tested, switched providers and/or reverted to self-testing or self-treatment practices.
Conclusion: Our study demonstrated how difficult it can be for patients to complete diagnostic journeys and how the health system works as far as diagnostics are concerned. If new point-of-care tests are to be implemented successfully, policymakers, program officers and test developers need to find ways to ease patient navigation through diagnostic services.
Introduction
The dual burden of tuberculosis (TB) and diabetes mellitus (DM) has become a major global public health concern. There is mounting evidence from different countries on the burden of TB and DM comorbidity. The objective of this systematic review was to summarize the existing evidence on prevalence and associated/risk factors of TBDM comorbidity at global and regional levels.
Methods
Ovid Medline, Embase, Global health, Cochrane library, Web of science and Scopus Elsevier databases were searched to identify eligible articles for the systematic review. Data were extracted using standardized excel form and pilot tested. Median with interquartile range (IQR) was used to estimate prevalence of TBDM comorbidity. Associated/risk factors that were identified from individual studies were thematically analyzed and described.
Results
The prevalence of DM among TB patients ranged from 1.9% to 45%. The overall median global prevalence was 16% (IQR 9.0%-25.3%) Similarly, the prevalence of TB among DM patients ranged from 0.38% to 14% and the overall median global prevalence was 4.1% (IQR 1.8%-6.2%). The highest prevalence of DM among TB patients is observed in the studied countries of Asia, North America and Oceania. On the contrary, the prevalence of TB among DM patients is low globally, but relatively higher in the studied countries of Asia and the African continents. Sex, older age, urban residence, tobacco smoking, sedentary lifestyle, poor glycemic control, having family history of DM and TB illness were among the variables identified as associated/risk factors for TBDM comorbidity.
Conclusion
This systematic review revealed that there is a high burden of DM among TB patients at global level. On the contrary, the global prevalence of TB among DM patients is low. Assessing the magnitude and risk/associated factors of TBDM comorbidity at country/local level is crucial before making decisions to undertake TBDM integrated services.
Background: The double burden of tuberculosis (TB) and diabetes mellitus (DM) is hitting certain Asian countries harder than other areas. In a global estimate, 15% of all TB cases could be attributable to DM, with 40% of those cases coming from India and China. Many other countries of South, East, and South-East Asia are of particular concern given their TB burdens, large projected increases in DM prevalence, and population size.
Objective: In this narrative review, we aimed to: (i) give an overall insight into the evidence on TB-DM epidemiology from high double burden Asian countries, (ii) present the evidence on bi-directional screening implementation in this region, (iii) discuss possible factors related to higher TB susceptibility of Asian diabetic patients, and (iv) identify TB-DM comorbidity treatment challenges.
Methods: The PubMed and Google Scholar databases were searched for all studies addressing DM/TB epidemiology, bi-directional screening and management in South, East and South-East Asia.
Results: We identified the DM prevalences among TB patients as ranging from approximately 5% to more than 50%, whereas TB prevalences among diabetic patients were 1.8–9.5 times higher than in the general population in developing Asian countries. Evidence from studies designed to address diagnosis and treatment of the dual disease in these critical regions is scarce as well as the evidence related to possible DM patients’ genetic and acquired predisposition for TB.
Conclusion: More prospective studies specifically designed to address adequate screening techniques, identify patients at risk, and define an adequate treatment of dual disease in this region are needed without delay.
Background:
India accounts for more than one-fifth of the world's tuberculosis (TB) burden. In spite of efforts taken by the Revised National Tuberculosis Control Programme, tribal areas of the state of Odisha report a high TB incidence over the years. One of the reasons could be delay in reporting to health facilities by the symptomatic patients. During such delays an active case may infect numerous susceptible people thereby contributing to the perpetuation of the infection. The delay in diagnosis may be as long as 2-3months and even more in hard-to-reach areas.
Objective:
The present study aims to find out the extent of delay in diagnosis among pulmonary TB patients of a tribal dominated district that may help in planning effective control strategies for similar situations.
Methods:
The information on delay in diagnosis is part of a cross-sectional drug resistance study carried out from June 2011 to May, 2013 in 20 Designated Microscopy Centres (DMCs) of Rayagada district of Odisha, India. Out of 634 smear positive pulmonary TB patients enrolled in this study, information on health seeking by the patients were available for 580 patients. The patients included had clinical signs and symptoms suggestive of pulmonary TB (cough, chest pain, and hemoptysis), with/without radiological evidence. Patients found smear positive by Ziehl-Neelsen microscopy were requested to take part in the study and accordingly a written questionnaire including history of: TB treatment; symptoms experienced by the patient and duration of suffering; and radiological examination was completed. The delay in diagnosis at the DMCs due to delay in health seeking by the symptomatic TB patients was evident as only 5.2% patients reported within 2weeks and 62.6% up to 1month of onset of symptoms.
Results:
The delay in health seeking by the patients was not differentiated by sex or resistance profile, although more men attended the DMC for diagnosis. The present study is the first of its kind to report diagnostic delay of TB among smear-positive TB patients of Rayagada, a tribal-dominated district of Odisha, India and it reveals an extremely long diagnostic delay of TB in this area. We found that 12.9% of patients had a delay exceeding 2months, and 50% of them had high sputum grade. This is a serious concern due to the fact that each of these patients dispenses up to 3500 bacilli in each cough, and may infect 10-15 people each year, eventually creating a public health problem.
Conclusion:
Poor awareness of patients about the disease and limited access to health care are the bottom-line in apparent diagnostic delay of TB patients. This substantial patient delay to diagnosis is a major contributing factor for increasing transmission of TB in tribal districts of Odisha. Increased awareness of the disease is crucial in improving health-seeking behavior in these areas.
As we enter the new era of Sustainable Development Goals, the international community has committed to ending the TB epidemic
by 2030 through implementation of an ambitious strategy to reduce TB-incidence and TB-related mortality and avoiding catastrophic
costs for TB-affected families. Diabetes mellitus (DM) triples the risk of TB and increases the probability of adverse TB
treatment outcomes such as failure, death and recurrent TB. The rapidly escalating global epidemic of DM means that DM needs
to be addressed if TB-related milestones and targets are to be achieved. WHO and the International Union Against Tuberculosis
and Lung Disease's Collaborative Framework for Care and Control of Tuberculosis and Diabetes, launched in 2011, provides a template to guide policy makers and implementers to combat the epidemics of both diseases.
However, more evidence is required to answer important questions about bi-directional screening, optimal ways of delivering
treatment, integration of DM and TB services, and infection control. This should in turn contribute to better and earlier
TB case detection, and improved TB treatment outcomes and prevention. DM and TB collaborative care can also help guide the
development of a more effective and integrated public health approach for managing non-communicable diseases.
Delays in tuberculosis (TB) diagnosis and treatment is a major barrier to effective management of the disease. Determining the factors associated with patient and provider delay of TB diagnosis and treatment in Asia may contribute to TB prevention and control.
We searched the PubMed, EMBASE and Web of Science for studies that assessed factors associated with delays in care-seeking, diagnosis, or at the beginning of treatment, which were published from January 1992 to September 2014. Two reviewers independently identified studies that were related to our meta-analysis and extracted data from each study. Independent variables were categorized in separate tables for patient and provider delays.
Among 45 eligible studies, 40 studies assessed patient delay whereas 30 assessed provider delay. Cross-sectional surveys were used in all but two articles, which included 17 countries and regions. Socio-demographic characteristics, TB-related symptoms and medical examination, and conditions of seeking medical care in TB patients were frequently reported. Male patients and long travel time/distance to the first healthcare provider led to both shorter patient delays [odds ratio (OR) (95% confidence intervals, CI) = 0.85 (0.78, 0.92); 1.39 (1.08, 1.78)] and shorter provider delays [OR (95%CI) = 0.96 (0.93, 1.00); 1.68 (1.12, 2.51)]. Unemployment, low income, hemoptysis, and positive sputum smears were consistently associated with patient delay [ORs (95%CI) = 1.18 (1.07, 1.30), 1.23 (1.02, 1.49), 0.64 (0.40, 1.00), 1.77 (1.07, 2.94), respectively]. Additionally, consultation at a public hospital was associated with provider delay [OR (95%CI) = 0.43 (0.20, 0.91)].
We propose that the major opportunities to reduce delays involve enabling socio-demographic factors and medical conditions. Male, unemployed, rural residence, low income, hemoptysis, positive sputum smear, and long travel time/distance significantly correlated with patient delay. Male, long travel time/distance and consultation at a public hospital were related to provider delay.
Background
Despite the growing burden of NCDs in South Africa, very little is known about how people living in urban townships manage these illnesses. In this article we expound upon the findings of a study showing that only one-third of women with an NCD participating in the Birth to Twenty (Bt20) cohort study of Soweto-Johannesburg, South Africa, had sought biomedical services in the previous six months.Methods
We evaluated quantitative data from a cross sectional health access survey conducted with adult women (mean age¿=¿44.8) and examined 25 in-depth narrative interviews with twelve women who self-reported at least one NCD from the larger study.ResultsThe qualitative findings highlight the potential role of negative experiences of healthcare services and biomedicine in delaying the seeking of healthcare. Multivariate analysis of the quantitative findings found that the possession of medical aid (OR¿=¿1.7, CI¿=¿1.01-2.84) and the self-reported use of patient strategies in negotiating healthcare access (OR¿=¿1.6, CI¿=¿1.04-2.34) were positively associated with the utilization of healthcare services. Belief in the superior efficacy of traditional healers over doctors was associated with delay of NCD treatment (OR¿=¿2.4, CI¿=¿1.14-4.18).Conclusion
Our data suggest that low healthcare utilization is due in part to low rates of expectation for consistent and high-quality care and potential mistrust of the medical system. We conclude that both demand-side and supply-side measures focusing on high trust management practices will prove essential in ensuring access to healthcare services.
To systematically review Indian literature on delays in tuberculosis (TB) diagnosis and treatment.
We searched multiple sources for studies on delays in patients with pulmonary TB and those with chest symptoms. Studies were included if numeric data on any delay were reported. Patient delay was defined as the interval between onset of symptoms and the patient's first contact with a health care provider. Diagnostic delay was defined as the interval between the first consultation with a health care provider and diagnosis. Treatment delay was defined as the interval between diagnosis and initiation of anti-tuberculosis treatment. Total delay was defined as time interval from the onset of symptoms until treatment initiation.
Among 541 potential citations identified, 23 studies met the inclusion criteria. Included studies used a variety of definitions for onset of symptoms and delays. Median estimates of patient, diagnostic and treatment delay were respectively 18.4 (IQR 14.3-27.0), 31.0 (IQR 24.5-35.4) and 2.5 days (IQR 1.9-3.6) for patients with TB and those with chest symptoms combined. The median total delay was 55.3 days (IQR 46.5-61.5). About 48% of all patients first consulted private providers; an average of 2.7 health care providers were consulted before diagnosis. Number and type of provider first consulted were the most important risk factors for delay.
These findings underscore the need to develop novel strategies for reducing patient and diagnostic delays and engaging first-contact health care providers.
Since the mid-1980ies the world has witnessed a dramatic increase in tuberculosis. Our knowledge of tuberculosis epidemiology was established during the previous epidemic that, at least in Europe, took two hundred years from rise to fall. It is difficult to understand the new epidemic if we assume that the genetics of the host-parasite relationship is unchanged from the previous epidemic.
The paper discusses how both host and parasite genetics may have changed. Molecular epidemiology done in Archangel, Russia, where most of the classical reasons for increase in tuberculosis were absent, indicated that strains of Mycobacterium tuberculosis with changed biological properties could be responsible. Strains belonging to the so-called Beijing family were strongly associated with primary drug resistance and caused clusters ten times as big as “traditional” strains.
The paper describes how the research consortium takes these observations further to explore the importance of “new” strains of tubercle bacilli in the on-going pandemic. What are the changes in biological properties and what genetic changes do they reflect? The previous epidemic may have changed the genetic susceptibility of the human host by selection, but what has constituted a selective pressure for the bacillary population? The two most dramatic changes in the environment of M. tuberculosis are mass introduction of chemotherapy and BCG vaccination. We explore further the nature of drug resistance in these strains and the possibility that BCG may fail to protect against bacilli of the new pandemic.
Lastly the paper points at some action that can be taken instantly and that may have a major impact on transmission, even before the questions mentioned above are answered. The clue here is to shorten the time of transmission by a rapid test to secure early diagnosis and treatment. What is needed, however, is not a diagnostic test for tuberculosis, but a simple screening test with high sensitivity that could tell us whom among the numerous people who have a chronic cough and systemic symptoms who are the true “tuberculosis suspects” eligible for rapid examination of sputum by smear microscopy
Delay in diagnosis of pulmonary tuberculosis results in increasing severity, mortality and transmission. Various investigators have reported about delays in diagnosis of tuberculosis. We aimed at summarizing the data on these delays in diagnosis of tuberculosis.
A systematic review of literature was carried out. Literature search was done in Medline and EMBASE from 1990 to 2008. We used the following search terms: delay, tuberculosis, diagnosis, and help-seeking/health-seeking behavior without language restrictions. In addition, indices of four major tuberculosis journals were hand-searched. Subject experts in tuberculosis and authors of primary studies were contacted. Reference lists, review articles and text book chapters were also searched. All the studies were assessed for methodological quality. Only studies carried out on smear/culture-positive tuberculosis patients and reporting about total, patient and health-care system delays were included.
A total of 419 potential studies were identified by the search. Fifty two studies qualified for the review. The reported ranges of average (median or mean) total delay, patient delay, health system delay were 25-185 days, 4.9-162 days and 2-87 days respectively for both low and high income countries. Average patient delay was similar to health system delay (28.7 versus 25 days). Both patient delay and health system delay in low income countries (31.7 days and 28.5 days) were similar to those reported in high income countries (25.8 days and 21.5 days).
The results of this review suggest that there is a need for revising case-finding strategies. The reported high treatment success rate of directly observed treatment may be supplemented by measures to shorten the delay in diagnosis. This may result in reduction of infectious cases and better tuberculosis control.
The 1998 Canadian clinical practice guidelines for the management of diabetes lowered the cutoff point for diagnosing diabetes mellitus from a fasting plasma glucose (FPG) level of 7.8 to 7.0 mmol/L. We studied the prevalence and clinical outcomes of undiagnosed and diagnosed diabetes within specific ranges of FPG among a cohort of subjects recruited in 1990.
In 1990 a representative sample of 2792 adult residents of Manitoba participated in the Manitoba Heart Health Survey, which included measurement of FPG and a question about each participant's past history of diabetes. Individuals who would now be classified as having undiagnosed diabetes under the new criteria were not considered as such in 1990. Through data linkage with the provincial health care utilization database, the use of health care by these individuals was tracked and compared with that of individuals whose diabetes had been diagnosed and with that of normoglycemic individuals over an 8-year period subsequent to the survey.
The prevalence of undiagnosed diabetes in the adult population of Manitoba was 2.2%. Undiagnosed cases accounted for about one-third of all diabetes cases. Individuals with undiagnosed diabetes had an unfavourable lipid profile and higher blood pressure and obesity indices than normoglycemic individuals. Individuals who satisfied the new criteria for diabetes but remained undiagnosed had an additional 1.35 physician visits per year (95% confidence interval [95% CI] 0.93-1.96) and were more likely to be admitted to hospital at least once (odds ratio 1.23, 95% CI 0.40-3.79), compared with normoglycemic individuals.
Undiagnosed cases represent the unseen but clinically important burden of diabetes, with significant concurrent metabolic derangements and a long-term impact on health care use.
Delayed diagnosis and treatment of tuberculosis (TB) results in severe disease and a higher mortality. It also leads to an increased period of infectivity in the community. The objective of this study was to determine the length of delays, and analyze the factors affecting the delay from onset of symptoms of pulmonary tuberculosis (PTB) until the commencement of treatment.
In randomly selected TB management units (TBMUs), i.e. government health institutions which have diagnosing and treatment facilities for TB in Amhara Region, we conducted a cross sectional study from September 1-December 31/2003. Delay was analyzed from two perspectives, 1. Period between onset of TB symptoms to first visit to any health provider (health seeking period), and from the first health provider visit to initiation of treatment (health providers' delay), and 2. Period between onset of TB symptoms to first visit to a medical provider (patients' delay), and from this visit to commencement of anti-TB treatment (health systems' delay). Patients were interviewed on the same date of diagnosis using a semi-structured questionnaire. Logistics regression analysis was applied to analyze the risk factors of delays.
A total of 384 new smear positive PTB patients participated in the study. The median total delay was 80 days. The median health-seeking period and health providers' delays were 15 and 61 days, respectively. Conversely, the median patients' and health systems' delays were 30 and 21 days, respectively. Taking medical providers as a reference point, we found that forty eight percent of the subjects delayed for more than one month. Patients' delays were strongly associated with first visit to non-formal health providers and self treatment (P < 0.0001). Prior attendance to a health post/clinic was associated with increased health systems' delay (p < 0.0001).
Delay in the diagnosis and treatment of PTB is unacceptably high in Amhara region. Health providers' and health systems' delays represent the major portion of the total delay. Accessing a simple and rapid diagnostic test for TB at the lowest level of health care facility and encouraging a dialogue among all health providers are imperative interventions.
Tuberculosis (TB) control programmes in Bangladesh, India and Malawi.
To compare the interval from symptom onset to diagnosis of TB for men and women, and to assess socio-cultural and gender-related features of illness explaining diagnostic delay.
Semi-structured Explanatory Model Interview Catalogue (EMIC) interviews were administered to 100 or more patients at each site, assessing categories of distress, perceived causes and help seeking. Based on time from initial symptoms to diagnosis of TB, patients were classified with problem delay (>90 days), timely diagnosis (< or =30 days) or moderate delay. EMIC interview data were analysed to explain problem delay.
The median interval from symptom onset to diagnosis was longest in India and shortest in Malawi. With adjustment for confounding, female sex (Bangladesh), and status of married woman (India) and housewife (Malawi) were associated with problem delay. Prominent non-specific symptoms--chest pain (Bangladesh) and breathlessness (Malawi)--were also significant. Cough in India, widely associated with TB, was associated with timely diagnosis. Sanitation as a perceived cause linked to poor urban conditions was associated with delayed diagnosis in India. Specific prior help seeking with circuitous referral patterns was identified.
The study identified gender- and illness-related features of diagnostic delay. Further research distinguishing patient and provider delay is needed.
Although the value of interdisciplinary collaboration between epidemiology and anthropology is both widely acknowledged and hotly contested, effective international health policy and multicultural health programmes require it. The EMIC framework for cultural studies of illness was developed in response to such needs, and a cultural epidemiology emerged from that framework as an interdisciplinary field of research on locally valid representations of illness and their distributions in cultural context. These representations are specified by variables, descriptions, and narrative accounts of illness experience, its meaning, and associated illness behaviour. Specialized interactive qualitative and quantitative research methods provide a descriptive account, facilitate comparisons, and clarify the cultural basis of risk, course, and outcomes of practical significance for clinical practice and public health. This paper discusses the theoretical underpinnings of cultural epidemiology and an operational formulation for examining patterns of distress, perceived causes, and help-seeking. Five additional papers in this special issue of Anthropology and Medicine indicate how the EMIC has been used and has engendered an ethnographically grounded cultural epidemiology. Although this overview and these papers are concerned exclusively with mental health, a complementary stream of active research on leprosy, tuberculosis, epilepsy, and other tropical infectious, neurological, and medical disorders is ongoing. Next steps for cultural epidemiology in mental health research are discussed, including (1) further clinic-based studies of psychiatric disorders, (2) studies of deliberate self-harm in clinic and community settings, (3) complementary cultural components of psychiatric epidemiological surveys, (4) baseline assessments to guide community programmes, and (5) contributions to intervention studies.
SETTING: All culture-positive tuberculosis patients without previous treatment for tuberculosis (n = 184), New York City, April 1994.OBJECTIVE: To examine factors associated with delays in presenting to a health care provider (patient delay) and in starting antituberculosis treatment (health care system delay).DESIGN: Retrospective medical record review and patient interviews.RESULTS: Median total delay was 57 days (range 4764), 35 for acid-fast bacilli smear-positive patients and 79 for smear-negative patients (P < 0.001). Median patient delay was 25 (range 0731). Median health care system delay was 15 days, 6 for smear-positive patients and 31 for smear-negative patients (P < 0.001). In logistic regression, age 5564 years (adjusted odds ratio [ORadj] 10.6, 95% confidence interval [CI] 1.386.9), and primary language other than English (ORadj 2.5, 95%CI 1.05.8), were associated with longer patient delays. Homelessness (ORadj 7.1, 95%CI 1.0533.5), not having a chest radiograph at the first medical visit (ORadj 2.4, 95%CI 1.05.4), negative smear (ORadj 10.2, 95%CI 4.423.3) and absence of cough (ORadj 2.9, 95%CI 1.26.8) were associated with longer health care system delays.CONCLUSION: To reduce delays, patients should be educated to seek care more quickly, and should be provided with culturally appropriate health care and language services. Physicians should maintain a high index of suspicion for tuberculosis and perform appropriate diagnostic tests.
To investigate the factors associated with delay in 1) care-seeking (patient delay), and 2) diagnosis by health providers (health system delay), among smear-positive tuberculosis patients, before large-scale DOTS implementation in South India.
New smear-positive patients were interviewed using a structured questionnaire.
Among 531 participants, the median patient, health system and total delays were 20, 23 and 60 days, respectively. Twenty-nine per cent of patients delayed seeking care for > 1 month, of whom 40% attributed the delay to their lack of awareness about TB. Men postponed seeking care for longer periods than women (P = 0.07). In multivariate analysis, the patient delay was greater if the patient had initially consulted a government provider (adjusted odds ratio [AOR] 2.2, P < or = 0.001), resided at a distance >2 km from a health facility (AOR 1.6, P = 0.04), and was an alcoholic (AOR 1.6, P = 0.04). Health system delay was >7 days among 69% of patients. Factors associated with health system delay were: first consultation with a private provider (AOR 4.0, P < 0.001), a shorter duration of cough (AOR 2.6, P = 0.001), alcoholism (P = 0.04) and patient's residence >2 km from a health facility (AOR 1.8, P = 0.02). The total delay resulted largely from a long patient delay when government providers were consulted first, and a long health system delay when private providers were consulted first.
Public awareness about chest symptoms and the availability of free diagnostic services should be increased. Government and private physicians should be educated to be aware about the possibility of tuberculosis when examining out-patients. Effective referrals for smear microscopy should be developed between private and public providers.
Previous population-based studies have reported a proportion of undiagnosed diabetes in the range between 25% and 50%. However, data on undiagnosed diabetes in a high-risk population, such as patients scheduled for coronary angiography, are lacking. Therefore, we sought to determine prevalence, predictors, and consequences of unrecognized diabetes in patients scheduled for coronary angiography.
This analysis involved 3266 patients scheduled for coronary angiography who have been enrolled in the Ludwigshafen Risk and Cardiovascular Health study.
Five hundred fifty-six patients (17.0%) had known diabetes. Another 486 patients with previously unrecognized diabetes (17.9%) were diagnosed in the remaining 2710 presumed nondiabetic subjects. Therefore, 486 (46.6%) of a total of 1042 patients with diabetes were previously undiagnosed, raising the diabetic proportion of enrolled patients to 31.9%. In half of the newly diagnosed patients with diabetes, the disease was detectable only by use of glucose challenge. Independent predictors of unrecognized type 2 diabetes were C-reactive protein >5 mg/L, arterial hypertension, body mass index >30 kg/m(2), age >or=65 years, and a positive family history of diabetes. Compared with nondiabetic subjects, patients with unrecognized type 2 diabetes showed a significantly increased risk for coronary artery disease (odds ration [OR] 1.7, 95% CI 1.3-2.3) and multivessel disease (OR 1.4, 95% CI 1.1-1.8), and a borderline association with myocardial infarction (OR 1.2, 95% CI 1.0-1.5). Oral glucose challenge was not superior to fasting glucose in predicting this increased cardiovascular risk.
In half of the patients scheduled for coronary angiography, diabetes was previously unrecognized. In a high-risk population of patients scheduled for coronary angiography, screening for diabetes should be performed routinely to initiate timely preventive efforts.
The reduction of delay in cancer diagnosis has been targeted as a way to improve survival. We undertook a qualitative synthesis of international research evidence to provide insight into patients' experiences of recognising symptoms of cancer and seeking help.
We searched international publications (1985-2004) for delay in cancer diagnosis to identify the relevant qualitative research, and used meta-ethnography to identify the common themes across the studies. Our synthesis interpreted individual studies by identification of second-order constructs (interpretations offered by the original researchers) and third-order constructs (development of new interpretations beyond those offered in individual studies).
We identified 32 papers (>775 patients and carers) reporting help-seeking experiences for at least 20 different types of cancer. The analysis showed strong similarities in patients with different cancer types. Key concepts were recognition and interpretation of symptoms, and fear of consultation. Fear manifested as a fear of embarrassment (the feeling that symptoms were trivial or that symptoms affected a sensitive body area), or a fear of cancer (pain, suffering, and death), or both. Such analyses allowed exploration of third-order constructs. The patient's gender and the sanctioning of help-seeking were important factors in prompt consultation.
Strategies to understand and reduce patients' delay in cancer presentation can help symptom recognition but need to address patients' anxieties. The effect of the patient's sex in help-seeking also needs to be recognised, as does the important role of friends, family, and health-care professionals in the sanctioning of consultation. This meta-ethnography provides an international overview through the systematic synthesis of a diverse group of small-scale qualitative studies.
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