Tuberculosis Diagnosis Delays and Associated Institutional Barriers Among Tertiary Hospitals in Tharaka Nithi County, Kenya

Abstract

Globally, delayed diagnosis of Tuberculosis (TB) is a significant contributor to spread of TB despite avaiability of diagnostic aligorithm and advanced diagnostic machine. Kenya is still grouped among high TB burden nations and has the highest TB incidences in East Africa. This has been associated with delays in diagnosis, resulted to either individual or community health and economic challenges. The purpose of this study was to assess health system related factors influencing timely diagnosis of TB in Tharaka Nithi County. A descriptive crossectional survey study design was adopted among 154 randomly selected patients and 12 purposively selected key informants in selected hospitals in Tharaka Nithi County. A self administered questionaire and key informant guide were used to collect data among patients and key informants respectively. Descriptive and inferential statistics were used to analyse data. Bivariate analysis was used to test the strength of association between health system related factors and duration of TB before diagnosis. Qualitative data was analysed thematically. Study findings revealed that most (70.86%, n=107) respondents delayed in diagnosis. Bivariate regression results revealed that multiple visits (OR=3.24;95%CI:1.55-6.76,p=0.002), long turnarround time (OR=2.38 ;95% CI:1.06-5.30;p=0.035), cash payment (OR=4.53;95%CI:1.82-11.23; p= 0.001), far diagnostic centers (OR=3.86;95%CI:1.71-8.73;p=0.001),lack of prior TB health education (OR=2.71; 95%CI: 1.29-5.64;p=0.008) and long laboratory results turnarround time (OR=2.49; 95% CI: 1.29-5.64; p=0.016) as significants associated with delayed diagnosis. Machine breakdown, misdiagnosis, and inadequate counselling on TB were identified as precipitators of diagnostic delay within a hospital. The study recommends empowerment of community based-hospital referral system, strengthening of collaboration between County government and independent service providers, equipping health facility and continuous training on TB diagnosis and care.

Full text

International Journal of Health Sciences and Research
Volume14; Issue: 3; March 2024
Website: www.ijhsr.org
Original Research Article ISSN: 2249-9571
International Journal of Health Sciences and Research (www.ijhsr.org) 170
Volume 14; Issue: 3; March 2024
Tuberculosis Diagnosis Delays and Associated
Institutional Barriers Among Tertiary Hospitals in
Tharaka Nithi County, Kenya
Linda B.K1, Onchangwa T.N1, Gitonga L.K1, Mukhwana E.S1, M’Kiunga K.S1
1School of Nursing and Public Health, Chuka University, Chuka, Kenya
Corresponding Author: Linda Bonface Kivuva
DOI: https://doi.org/10.52403/ijhsr.20240325
ABSTRACT
Globally, delayed diagnosis of Tuberculosis (TB) is a significant contributor to spread of TB
despite avaiability of diagnostic aligorithm and advanced diagnostic machine. Kenya is still
grouped among high TB burden nations and has the highest TB incidences in East Africa.
This has been associated with delays in diagnosis, resulted to either individual or community
health and economic challenges. The purpose of this study was to assess health system
related factors influencing timely diagnosis of TB in Tharaka Nithi County. A descriptive
crossectional survey study design was adopted among 154 randomly selected patients and 12
purposively selected key informants in selected hospitals in Tharaka Nithi County. A self
administered questionaire and key informant guide were used to collect data among patients
and key informants respectively. Descriptive and inferential statistics were used to analyse
data. Bivariate analysis was used to test the strength of association between health system
related factors and duration of TB before diagnosis. Qualitative data was analysed
thematically. Study findings revealed that most (70.86%, n=107) respondents delayed in
diagnosis. Bivariate regression results revealed that multiple visits (OR=3.24;95%CI:1.55-
6.76,p=0.002), long turnarround time (OR=2.38 ;95% CI:1.06-5.30;p=0.035), cash payment
(OR=4.53;95%CI:1.82-11.23; p= 0.001), far diagnostic centers (OR=3.86;95%CI:1.71-
8.73;p=0.001),lack of prior TB health education (OR=2.71; 95%CI: 1.29-5.64;p=0.008) and
long laboratory results turnarround time (OR=2.49; 95% CI: 1.29-5.64; p=0.016) as
significants associated with delayed diagnosis. Machine breakdown, misdiagnosis, and
inadequate counselling on TB were identified as precipiators of diagnostic delay within a
hospital. The study recommends empowerment of community based-hospital referral system,
strengthening of collaboration between County government and independent service
providers, equiping health facility and continuous training on TB diagnosis and care.
Keywords: Timely diagnosis, Health System Related, Tuberculosis, Delay, Barriers
INTRODUCTION
Approximately over 30 years after
declaration of TB as a global emergency [1],
it still remains the leading single cause [2] of
morbidity and mortality globally [1],[3] ,
affecting approximately 30% of global
population despite provision of proper
mitigation measures by various nations [1].
In 2015, WHO member state set in motion a
plan dubbed “TB eradicate by 2030,” with a
tripple targets approach of five years apart
[4],[5]. However, an aggregated decline of 9%
on TB incidence rate was attained between
2015 and 2020, compared to set target of

Linda B.K et.al. Tuberculosis diagnosis delays and associated institutional barriers among Tertiary Hospitals in
Tharaka Nithi County, Kenya
International Journal of Health Sciences and Research (www.ijhsr.org) 171
Volume 14; Issue: 3; March 2024
20% [4]. The decimal decline poses a greater
challenge on TB control. Thus resulting to
continued disease spread and advancement
within the community. Delayed diagnosis
of tuberculosis has been reported to
significantly perpertuate TB spread and
inhibit its eradication [6]. Thus the need to
identify the gap in tuberculosis diagnosis.
Literature on prevention and control of TB
has revealed that the rising number of
tuberculosis undiagnosed cases as
alarming[7]. In 2019 alone, approximately
three million TB case were believed not to
be diagnosed or reported[5]. This may be
associated with either patients or hospital
barriers. Among developing nations, many
studies conducted are on patients related
delay in TB diagosis. Thus the need to
investigate and address the gaps within
health care system. A study in Ethiopia
revealed that hospital delays in timely TB
diagnosis as contributor to high TB burden
in subsaharan region[8]. However, it has
been established that delays in diagnosis
differ greaterly among nations[9]. Some of
reported health factors include distance to
diagnostic center[7]; [8];[10]; [11],
misdiagnosis[2];[12], clinical inertia[13], high
workload[2], multiple visits to hospital[1]; [3];
[14], cash payment[2]; [3]; [7], machine
breakdown [15] and inadequate health
education[15];[16].
In 2021, the prevalence of TB in Kenya was
reported as 426 per 100,000
population[17];[18]. Inaddition, 40% and 52%
of TB cases were reported to be missing and
not diagnosed on time respectively[17]. This
poses a public health challenge to Kenya
population. Thus the need to investigate
hospital factors delaying diagnosis of TB.
This will provide useful information to aid
in setting policies and stratergies of TB
control in the county.
MATERIALS & METHODS
A hospital based descriptive crossectional
survery research design was adopted among
154 randomly selected patients and 12
purposively selected key informant in
Chuka and Chogoria Hospitals in Tharaka
Nithi County. A self administered pre-
design and pre-tested modified WHO
questionnaire was used to collect data
among patients respondents while a key
informant guide was adopted among the key
informants. Data was code and analysed
using MS Exel and SPSS v26 respectively.
Patients characteristics were presented using
descriptive statistics while bivariate analysis
were used to test the strenght of association
between health facility factors and duration
of tuberculosis before diagnosis. Qualitative
data was analysed thematically. The study
catergorised TB diagnosis time into either
delay (>21 days) or no delay (<21 day),
through assumption of a 21 day cutoff
adopted from WHO. Frequencies and
percentages were used to present study
results. Institutional ethical approval was
sought from Chuka University Ethics and
Research Committee (NACOSTI/NBC/AC-
08120) and NACOSTI research permit
(NACOSTI/p /23/24959). Permission for
data collection was sought from hospital
administrators. The researcher observed all
ethical considation during data collection.
RESULT
The researcher approached 154 patient
respondents, of which 3 were excluded due
to inadeqaute filling of the research tool,
resulting to 151 study respondents (98.0%
response rate). Data analysed revealed a
mean age of 38.71(SD, 13.65) years, median
and mode of 36.0 and 42.0 years
respectively among patients’ respondents. In
addition, nearly 30%(n=48) of the
respondents were aged 31-40 years. It was
further observed that more than a half of the
respondents were male[n=85(56.29%)] and
married[n=84(55.62%)]. Regarding
respondents’ education status only
18.54%(n=28) had attained post secondary
education. Almost a half of the respondents
were self employed[n=74(49.01%)] and had
household income
<10,000/=[n=88(58.28%), Table 1].

Linda B.K et.al. Tuberculosis diagnosis delays and associated institutional barriers among Tertiary Hospitals in
Tharaka Nithi County, Kenya
International Journal of Health Sciences and Research (www.ijhsr.org) 172
Volume 14; Issue: 3; March 2024
Table 1: Respondents socio-demographic characteristics
Variables
Frequency
Percent
Respondents’ gender
Male
85
56.29
Female
66
43.71
Totals
151
100.0
Respondents’ Age
20-30
33
21.85
31-40
48
31.79
41-50
44
29.13
Over 50
26
17.22
Totals
151
100.0
Respondents’
Marital status
Single
21
13.91
Married
84
55.62
Divorced
27
17.88
Widowed
19
12.58
Totals
151
100
Respondents’
education status
Never attended school
17
11.26
Primary
49
32.45
Secondary
57
37.75
Post secondary education
28
18.54
Totals
151
100.0
Respondents’
Occupation
Unemployed
47
31.13
Self employed
74
49.01
Government employed
30
19.86
Total
151
100
Respondents’ household income
<10,000/=
88
58.28
10,000-20,000/=
23
15.23
>20,000/=
40
26.49
Totals
151
100.0
TB diagnostic Duration
The study sought to identify percentage of
respondent experiencing delayed diagnosis.
The results are presented in figure 1 below.
It was observed that
majority[n=107(70.86%) of the respondents
delayed in T diagnosis while only
29.14%(n=44) were diagnosed on time
(Figure 1).
Figure 1: A bar graph of Uptake of diagnostic Services.
Hospital based barriers to timely
diagnosis
From table 2 below, respondents who
visited hospital more than three times prior
to diangosis were 3.24 times(95%;CI=1.55-
6.76;p=0.002) more likey to delay in
dignosis compared than those who visited
less than three times. Turn arround time of
more than three hours was reported to
increase diagnostic delay by 2.3
times(95%;CI=1.06-5.30;p=0.035)
compared to turnarround time of less than 3
hours. Similary, it was observed that
respondents worse laboratory investigation
results took more than 2 day were 2.4
times(95%;CI=1.18-5.26;p=0.016) more
likely to experience diagnostic delay
compared to respondents whose results took

Linda B.K et.al. Tuberculosis diagnosis delays and associated institutional barriers among Tertiary Hospitals in
Tharaka Nithi County, Kenya
International Journal of Health Sciences and Research (www.ijhsr.org) 173
Volume 14; Issue: 3; March 2024
less than 2 days. Respondents who didn’t
reveice health eduation on TB were 2.7
times (95%;CI=1.29-5.64;p=0.008) more
likely to delay in TB diagnosis than
respondend educated on TB before
diagnosis. With reference to insurance
payment, cash paying respondents were
4.5(95%;CI=1.82-11.23;p=0.001).
Respondents living more than five
kilometers from TB diagnostic centers were
3.8 times(95%;CI=1.71-8.78;p=0.001) more
likely to diagnostic delay than respondents
living less than five kilometers form
diagnostic centers.
Table 2: Association between hospital factors and TB diagnostic duration
Diagnostic Duration
Variable
No Delay
(%)
Delay (%)
OR (95%CI)
P-
value
Prior visits with TB suggestive symptoms before
diagnsis of TB
<3 times
23(15.2)
27(17.9)
*
*
>3 times
21(13.9)
80(53.0)
3.24(1.55-6.76)
0.002
Consultation Turn around time
<3 hours
34(22.5)
63(41.7)
*
*
>3 hours
10(6.6)
44(29.2)
2.38(1.06-5.30)
0.035
Health Education on TB before diagnosis
Yes
21(13.9)
27(17.9)
*
*
No
23(15.2)
80(53.0)
2.71(1.29-5.64)
0.008
Laboratory tests turn around time
>2 days
25(16.6)
82(54.2)
2.49(1.18-5.26)
0.016
<2 days
19(12.6)
25(16.6)
*
*
Service Payment Methods
Cash
30(19.9)
97(64.2)
4.53(1.82-11.23)
0.001
Insurances
14(9.3)
10(6.6)
*
*
Distance to Diagnostic centers
<5 KM
17(11.3)
15(9.9)
*
*
>5 KM
27(17.9)
97(78.8)
3.86(1.71-8.73)
0.001
Health factors associated with delay in
diagnosis of TB: Qualitative findings
Theme 1: Misdiagnosis
Nurses and Clinical Officers interview
revealed that misdiagnosis among TB
sysmptomatic patients precipitated
diagnostic delay. Most tuberculosis patients
ended up been diagnosed with lower
respiratory tract infections particulary
pneumonia. Therefore, medication
presecribed resulted to subsiding of TB
sysmptoms and recurrence of sysmptoms
after the dosage was over.
“Majority of the patients when they come to
TB clinic usually report of been on
antibiotic treatment for pneumonia or other
diseases affecting the lower part of the
respiratory system before diagnosis of TB is
made. The antibiotics normally subsides the
symptoms then after the duration of taking
the drugs is over the symptoms emerge. This
results to prolonging the duration of TB
diagnosis. ” (Respondents No.1, 2 and 5).
The interview was further designed to
gather information of the caused of
misdiagnosis within the county, among the
respondents it was reported that, inadequate
onjob training, unclear chest imaging
results, low suspicion index and high
workload as contributors to misdiagnosis.
One of the respondents had this to say:
“When patients report in a hospital they
first go through the outpatient department.
In most cases we are few in the consultation
rooms and patients waiting to be seen are
very many. So it becomes very difficult to
ask patients questions pertaining to night
sweats, loss of weight, coughing among
other. But instead focus more on the
patients main complain.” (Respondents No.
10).
Another Clinical officer indicated that:
“Sometimes, we may send a patient for an
X-ray to help in the diagnosis. When we
review the films of the X-ray they are not
clear to help in making a
diagnosis”(Respondent No.10)
A nurse during the interview has this to
say:-
“There is few on-job training on the update
of TB among members not on the TB clinic
or outreach services. This results to failure
to be aware of recent diagnostic and
treatment plan of the diseases.”(Respondent
No.3)

Linda B.K et.al. Tuberculosis diagnosis delays and associated institutional barriers among Tertiary Hospitals in
Tharaka Nithi County, Kenya
International Journal of Health Sciences and Research (www.ijhsr.org) 174
Volume 14; Issue: 3; March 2024
Clinical officers at different hospital further
added that:-
Some of the health workers may have low
suspicion of the disease depending on the
information given by the patients resulting
into wrong treatment when one already has
TB.” (Respondent No. 1 & 10)
Theme 2: Inadequate Counselling
Health proffessional interviewd reported
that inadequate counselling or health
education resulted to unwanted delays in Tb
diagnosis. Inadditions, challenges such as
lack of privance, poor doctor patient
relationship, high workload and
communication barriers were identified as
hinderance to proper individual health
education. The nurses and clinial officers
had this to say:
“Majority of the patients are not educated
on reasons for examination, causes of
symptoms they are experiencing.
Furthermore, only a few patients are able to
recognize TB symptoms. Thus, they end up
leaving the hospital not understanding what
they are suffering from.”(Respondents No.
1,5 &10).
Similar observation were further
collaborated by clinical officers:
“As health care providers we are faced with
some challenges which prevent us from
providing proper counselling. For example,
communication becomes a challenges if you
met patients who do not understand
kiswahili or English, lack of privacy in the
consultation rooms, unsupportive health
professionals and high workload.”
(Respondents No. 2&6).
Theme 3: GeneXpert machine
breakdown
Laboratory technologists reported that
machine breakdown among the few
GeneXpert machines in the county was a
big problem:
“Sometimes the hospital GeneXpert
machine does not work, for example we
have been sending samples to chogoria for
the last two months.” (Respondent No. 9)
“Currently, the GeneXpert machine we have
operated under three modules, despite it
being a four module machine. The fourth
module has some problems.” (Respondents
No.3)
Another respondents had this to say:
“In the county we have three genexpert
machine, when one of them fails we receive
large number of samples(approximately 60).
So we tell the patients to go home they will
be called or texted when the results are
ready......high number of samples also
results in stockout of reagents for the
samples exceeds the normal approximated
montly analysis resulting to waiting for the
reagents to be bought a process which may
take approximately a week.”(Respondent
No. 11)
Theme 4: Distance to facility.
Delay in sputum results was reported as a
crucial barrier within health system whose
interaction with other barriers at individual
level such as lack of fare and distance to
hospital further minimized the chances of
commencing anti-TB treatment.
“Patients are very much disappointed when
they are told to come back tomorrow for
resultes and they fail to get them. Some of
the patients come from far areas and use
fare to come to hospital. If the come the
third time and fail to get results they
normally dont come again.” (Respondent
No. 5)
DISCUSSION
In this study majority (70.86%) of the
respondents experienced diagnostic delay.
This was slightly lower compared to
diagnostic delay (87.4%) reported in
India[19]. However, this finding didn’t
concur with findings of a study done in
Ethiopia which reported diagnostic delay of
50.9% [10] . This differences in the findings
may be associated with cutoff of delayed
diagnosis and study sample size. A
relationship between multiple visits to
health providers before diagnosis and
diagnostic duration was established. This

Linda B.K et.al. Tuberculosis diagnosis delays and associated institutional barriers among Tertiary Hospitals in
Tharaka Nithi County, Kenya
International Journal of Health Sciences and Research (www.ijhsr.org) 175
Volume 14; Issue: 3; March 2024
mirrored with finding of many studies that
reported multiple visits to health
proffessional as a risk factor to diagnostic
delay[1]; [7]; [14]; [19]; [20]; [21]. This may be due
to lack of patients’ satisfaction, poor quality
of care and health proffessional attitude
resulting to patients to seek consultation in
other facility. In this study, an assocaition
between long consultation turn around time
and diagnostic dealy was established. These
findings agreed with a systematic review
condicted among high burden nations which
reported that long turnarround time as a
barrier to timely TB diagnosis[1]. This may
be associated with busy schedules of
patients resulting to seeking care in either
chemist or private clinic, thus prolong
diagnostic time. Similary, delays in
laboratory results were identifed to
influence diagnostic delay in this study.
This was congruent with a study done in
Uganda[13]; [15].
There was a significant association between
health education before diagnosis and
duration of TB before diagnosis. This was in
line with findings of a study done in
Tanzania which revealed that more effort
was put on educating patients on
noncommunicable diseases, thus neglecting
communicable disease such TB health
education[12]. This may be associated with
raise of incidence rates of
noncommunicable disease, stigma assocated
with communicable disease, inadeqauate
knowledge among staffs about TB
managements updates. Moreover, in this
study, it was established that cash payment
method contributed to diagnostic delay. This
concurred with finding of studies done in
Nigeria[2];Indonesia[7] and Ethiopia[13]. This
may be due to the expenses the patients
incur before diagnosis is made. However, a
study conducted in Ghana revealed that
medical insurances were facilitors to TB
diagnosis[3]. An association was established
between distance to diagnostic centers and
duration of diagnosis in this study. This
findings concurred with other study finding
which established that long diastance to TB
diagnostic centers as a precipitator to
diagnostic delay[8]; [9]; [10]; [11]; [22]. However,
this finding did were not in line with finding
of a study done in Mombasa County,
Kenya[23].
In this study, it was revealed that inadequate
counselling of TB patients was a risk factor
to diagnostic delay from the interviews
conduted. This was agreed with as
conducted in Uganda, which reported that
inappropriate counselling of patients by
health care providers on TB resulted to
unacceptable delays[15]. This may be linked
with lack of privancy, high work load and
staff shortage. In addition, this study
reported misdiagnosis of tuberculosis
patients with other respiratory diseases as a
barrier to timely diagnosis. This was similar
to study finding from a study in West Pokot
County, Kenya, which reported that more
than eighty percent of the patients were
misdiagnosed and started on empirical
therapy despite having sysmptoms
suggestive of TB[6]. Moreover, other studies
reported of unclear chest imaging results[15],
staff shortage[24], inadequate onjob
trainging[6], non-adherence to guideline[2]
and clinical inertia[20] to precipitate
diagnostic delay. This was congruent with
findings of this study.
CONCLUSION
In this study a significant delay in diagnosis
was established. However, contributory
factors to the delay seems to be similar to
those of other African Nations. In addition,
misdiagnosis, multiple visits, distance to
diagnostic centers, long turnarround time
either in consultation or laboratory, lack of
TB health education, inadequate counselling
and machine breakdown were reported to
contribute to diagnostic delays within the
county. The study recommends
incorporation of people and developing their
skills to raise understanding of the policies
and infrastructures that the government
sector has at its disposal, through
establishment of specimen network
framework, and provision of necessary
resources need for TB control. There is also
need to do a research on patients level of

Linda B.K et.al. Tuberculosis diagnosis delays and associated institutional barriers among Tertiary Hospitals in
Tharaka Nithi County, Kenya
International Journal of Health Sciences and Research (www.ijhsr.org) 176
Volume 14; Issue: 3; March 2024
knowledge and its relationship with
diagnosis duration.
Declaration by Authors
Ethical Approval: Approved
Acknowledgement: None
Source of Funding: None
Conflict of Interest: The authors declare no
conflict of interest.
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How to cite this article: Linda B.K, Onchangwa
T.N, Gitonga L.K, Mukhwana E.S, M’Kiunga
K.S. Tuberculosis Diagnosis Delay and
Associated Institutional Barriers among Tertiary
Hospitals in Tharaka Nithi County, Kenya. Int J
Health Sci Res. 2024; 14(3):170-177. DOI:
https://doi.org/10.52403/ijhsr.20240325
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