Factors associated with delays in diagnosis and treatment initiation among tuberculosis patients in Mombasa County, Kenya

Abstract

Background: Delay in diagnosis remains a major gap in TB control and leads to increased transmission of TB, resulting in increased TB mortality. Objectives: This study was conducted the study to determine the median time to diagnose and initiate TB treatment and identify the risk factors for delays in pulmonary TB (PTB) diagnosis and treatment initiation in Mombasa County. Methods: A facility based cross-sectional study among PTB patients on intensive phase of treatment was carried out. Interviews were conducted using structured pre- tested questionnaires. Data on demographic, clinical and laboratory factors, health seeking behaviors and health services offered to PTB patients were collected. Median time (days) of diagnosis was calculated based on time of onset of TB symptoms to when TB diagnosis was confirmed. Delay in diagnosis was defined as time period exceeding the calculated median time. Delay in treatment initiation was defined as time period >2 days from diagnosis to treatment initiation based on the national TB program target of initiating treatment within 2 days of diagnosis. Using STATA version 13, I calculated proportions and frequencies, crude and adjusted-odds-ratios (AOR) at 95% confidence-intervals (CI) and factors with p-value of ≤0.05 in the final logistic regression model were considered as risk factors. Results: Interviewees were conducted for 354 patients; median age was 33 years (range 3–81 years), 72% (255/354) were male, 51.7% (183/354) were married, 24.9% (88/354) were HIV positive, 85.9% (304/354) presented with a cough, and 42.4% (150/354) first sought care from a private health facility. The median for diagnosis was 67 days (range 3 – 411 days) and 61.6% (218/354) of the patients had experienced delay in diagnosis and 38.4% (136/354) had no delays in diagnosis. From diagnosis to treatment initiation, the duration ranged from 0 – 63 days with 36.7% (130/3534) having delays and 63.3% (224/354) had no delays in treatment initiation. The difference between those who experienced delay in diagnosis and those who did not experience delay in diagnosis as well as between those who experienced delay in treatment initiation and those who did not experience delay in treatment initiation were statistically significant (p<0.001). Factors independently associated with delay in diagnosis included; delays in getting laboratory results due to Xpert MTB/RIF referrals (aOR 4.59, CI= 2.17, 9.71) compared to other reasons; those on treatment for other conditions (aOR 3.74, CI=1.42, 9.86) unlike those who had no other comorbidity and distance to the nearest health facility more than one kilometer (aOR 3.01, CI=1.64, 5.53) compared to less than one kilometer. Factors independently associated with delays in treatment initiation were; using a motorcycle as compared to walking as transport means (aOR 1.99, CI=1.16, 3.42) and being male (aOR 2.07 CI=1.22, 3.52) compared to being female. Conclusion: Over half of the patients experienced diagnosis delays and a third experienced treatment delays. Patient and health care system related factors were associated with diagnosis and treatment initiation delays. I recommend strengthening of TB active case finding in the community, public private partnerships, laboratories sample networking and equipping more facilities with the Xpert MTB/RIF machines to reduce the turnaround time for the results.