Health-seeking pathway and factors leading to delays in tuberculosis diagnosis in West Pokot County, Kenya: A grounded theory study

Analysis of care-seeking and diagnosis delay among pulmonary tuberculosis patients in Beijing, China

Background

Tuberculosis (TB) remains a significant public health challenge in China. Early detection and diagnosis of TB cases are crucial to interrupt disease transmission and prevent its progression. This study aims to describe the delay in seeking care and diagnosis among patients with pulmonary tuberculosis (PTB) and identify the influencing factors in two counties in Beijing.

Methods

A retrospective analysis was carried out to investigate care-seeking and diagnosis delay in two counties in Beijing. Basic information of PTB patients from January 1 to December 31, 2021, was extracted from the Tuberculosis Information Management System of China (TBIMS), and all enrolled patients were interviewed via telephone using a standard questionnaire. Statistical description was performed using the median and interquartile range (IQR). Chi-square test and multivariate logistic regression model were used to analyze the influencing factors.

Results

537 patients were enrolled. The median duration of care-seeking and diagnosis delay was 11 (IQR: 5-26) days and 8 (IQR: 0-18) days, with 41.71 and 35.20% of patients experiencing delays (>14 days). The study found that being asymptomatic (OR = 2.791, 95%CI: 1.710-4.555) before seeking medical care and not attending work during treatment (OR = 2.990, 95%CI: 1.419-6.298) were identified as risk factors for care-seeking delay. Patients who were tracked (OR = 2.632, 95%CI: 1.062-6.521) and diagnosed at tuberculosis control and prevention institutions (OR = 1.843, 95%CI: 1.061-3.202) had higher odds of diagnostic delays. 44.69% of patients presented a total delay (>28 days), with a median duration of 25 (IQR: 13-39) days. A multivariate logistic regression analysis showed that healthy examination (OR = 0.136, 95%CI: 0.043-0.425) was a protective factor for total delay.

Conclusion

Public interventions are necessary to improve the efficiency of PTB patients detection and treatment in Beijing. Medical services should focus on the target population and improve access to medical care to further reduce delays for PTB patients.

Gendered gaps to tuberculosis prevention and care in Kenya: a political economy analysis study

BACKGROUND

Tuberculosis (TB) remains a public health concern in Kenya despite the massive global efforts towards ending TB. The impediments to TB prevention and care efforts include poor health systems, resource limitations and other sociopolitical contexts that inform policy and implementation. Notably, TB cases are much higher in men than women. Therefore, the political economy analysis (PEA) study provides in-depth contexts and understanding of the gender gaps to access and successful treatment for TB infection.

DESIGN

PEA adopts a qualitative, in-depth approach through key informant interviews (KII) and documentary analysis.

SETTING AND PARTICIPANTS

The KIIs were distributed among government entities, academia, non-state actors and community TB groups from Kenya.

RESULTS

The themes identified were mapped onto the applied PEA analysis framework domains. The contextual and institutional issues included gender concerns related to the disconnect between TB policies and gender inclusion aspects, such as low prioritisation for TB programmes, limited use of evidence to inform decisions and poor health system structures. The broad barriers influencing the social contexts for TB programmes were social stigma and cultural norms such as traditional interventions that negatively impact health-seeking behaviours. The themes around the economic situation were poverty and unemployment, food insecurity and malnutrition. The political context centred around the systemic and governance gaps in the health system from the national and devolved health functions.

CONCLUSION

Broad contextual factors identified from the PEA widen the disparity in targeted gender efforts toward men. Following the development of effective TB policies and strategies, it is essential to have well-planned gendered responsive interventions with a clear implementation plan and monitoring system to enhance access to TB prevention and care.

Community views on active case finding for tuberculosis in low- and middle-income countries: a qualitative evidence synthesis

BACKGROUND

Active case finding (ACF) refers to the systematic identification of people with tuberculosis in communities and amongst populations who do not present to health facilities, through approaches such as door-to-door screening or contact tracing. ACF may improve access to tuberculosis diagnosis and treatment for the poor and for people remote from diagnostic and treatment facilities. As a result, ACF may also reduce onward transmission. However, there is a need to understand how these programmes are experienced by communities in order to design appropriate services.

OBJECTIVES

To synthesize community views on tuberculosis active case finding (ACF) programmes in low- and middle-income countries.

SEARCH METHODS

We searched MEDLINE, Embase, and eight other databases up to 22 June 2023, together with reference checking, citation searching, and contact with study authors to identify additional studies. We did not include grey literature.

SELECTION CRITERIA

This review synthesized qualitative research and mixed-methods studies with separate qualitative data. Eligible studies explored community experiences, perceptions, or attitudes towards ACF programmes for tuberculosis in any endemic low- or middle-income country, with no time restrictions.

DATA COLLECTION AND ANALYSIS

Due to the large volume of studies identified, we chose to sample studies that had 'thick' description and that investigated key subgroups of children and refugees. We followed standard Cochrane methods for study description and appraisal of methodological limitations. We conducted thematic synthesis and developed codes inductively using ATLAS.ti software. We examined codes for underlying ideas, connections, and interpretations and, from this, generated analytical themes. We assessed the confidence in the findings using the GRADE-CERQual approach, and produced a conceptual model to display how the different findings interact.

MAIN RESULTS

We included 45 studies in this synthesis, and sampled 20. The studies covered a broad range of World Health Organization (WHO) regions (Africa, South-East Asia, Eastern Mediterranean, and the Americas) and explored the views and experiences of community members, community health workers, and clinical staff in low- and middle-income countries endemic for tuberculosis. The following five themes emerged. • ACF improves access to diagnosis for many, but does little to help communities on the edge. Tuberculosis ACF and contact tracing improve access to health services for people with worse health and fewer resources (High confidence). ACF helps to find this population, exposed to deprived living conditions, but is not sensitive to additional dimensions of their plight (High confidence) and out-of-pocket costs necessary to continue care (High confidence). Finally, migration and difficult geography further reduce communities' access to ACF (High confidence). • People are afraid of diagnosis and its impact. Some community members find screening frightening. It exposes them to discrimination along distinct pathways (isolation from their families and wider community, lost employment and housing). HIV stigma compounds tuberculosis stigma and heightens vulnerability to discrimination along these same pathways (High confidence). Consequently, community members may refuse to participate in screening, contact tracing, and treatment (High confidence). In addition, people with tuberculosis reported their emotional turmoil upon diagnosis, as they anticipated intense treatment regimens and the prospect of living with a serious illness (High confidence). • Screening is undermined by weak health infrastructure. In many settings, a lack of resources results in weak services in competition with other disease control programmes (Moderate confidence). In this context of low investment, people face repeated tests and clinic visits, wasted time, and fraught social interaction with health providers (Moderate confidence). ACF can create expectations for follow-up health care that it cannot deliver (High confidence). Finally, community education improves awareness of tuberculosis in some settings, but lack of full information impacts community members, parents, and health workers, and sometimes leads to harm for children (High confidence). • Health workers are an undervalued but important part of ACF. ACF can feel difficult for health workers in the context of a poorly resourced health system and with people who may not wish to be identified. In addition, the evidence suggests health workers are poorly protected against tuberculosis and fear they or their families might become infected (Moderate confidence). However, they appear to be central to programme success, as the humanity they offer often acts as a driving force for retaining people with tuberculosis in care (Moderate confidence). • Local leadership is necessary but not sufficient for ensuring appropriate programmes. Local leadership creates an intrinsic motivation for communities to value health services (High confidence). However, local leadership cannot guarantee the success of ACF and contact tracing programmes. It is important to balance professional authority with local knowledge and rapport (High confidence).

AUTHORS' CONCLUSIONS

Tuberculosis active case finding (ACF) and contact tracing bring a diagnostic service to people who may otherwise not receive it, such as those who are well or without symptoms and those who are sick but who have fewer resources and live further from health facilities. However, capturing these 'missing cases' may in itself be insufficient without appropriate health system strengthening to retain people in care. People who receive a tuberculosis diagnosis must contend with a complex and unsustainable cascade of care, and this affects their perception of ACF and their decision to engage with it.

Missed opportunity for tuberculosis screening among patients presenting at two health facilities in Manafwa district, Uganda

Missed opportunities for Tuberculosis (TB) screening are key drivers of continued tuberculosis transmission. To determine the proportion of and factors associated with missing TB screening amongst patients who attended Bubulo and Butiru health facilities in the Manafwa district to inform future TB prevention and control efforts in Uganda. This was a facility-based, cross-sectional study with quantitative methods of data collection. 125 patients (≥18 years) with at least one symptom suggestive of TB were systematically selected and interviewed at the exit. Data analysis was done by Stata version 15, using a cluster-based logistic regression model. Of the 125 patients enrolled at both sites, 39% (n=49) were aged between 30 and 49 years; 75.2% (n=94) were females; 44% (n=55) were married while 66.4% (n=83) had a primary level of education. Of the patients enrolled in the study, 68% (n=85) had a missed opportunity for TB screening. Having a; post-primary education level (Adjusted Odds Ratio [AOR]=5.9; 95% Confidence Interval [95% CI]=1.3, 27.1) and attending Bubulo HCIV (AOR=0.01; 95% CI: 0.01, 0.2) were significantly associated with having a missed opportunity for TB screening. Our findings show that slightly more than two-thirds of the patients who presented to the study health facilities with symptoms suggestive of TB missed the opportunity to be screened for TB. Study findings suggest a need for interventions to increase TB screening, particularly among better-educated TB patients.

Quality of death among older adults in China: The role of medical expenditure and timely medical treatment

Medical expenses in the last year of life consume a large portion of healthcare expenditures, yet little is known about the relationship between medical expenditures in the last year of life and quality of death. Few empirical studies have investigated the association between timely medical treatment before dying and quality of death. This study aimed to examine the associations between medical expenditures in the last year of life, timely medical treatment before dying, and quality of death. Data derived from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), the largest national representative study of the oldest-old in China. Results from multinomial logistic regression suggested that higher medical expenses in the last year of life and lack of timely medical treatment before dying are associated with lower quality of death. These findings highlight an urgent need for strengthening education on death and dying, developing hospice and palliative care services, and improving pain management at the end of life in China.

Clinic presentation delay and tuberculosis treatment outcomes in the Lake Victoria region of East Africa: A multi-site prospective cohort study

In the Lake Victoria region of East Africa, little is known about delays between tuberculosis (TB) symptom onset and presentation at a clinic. Associations between clinic presentation delay and TB treatment outcomes are also poorly understood. In 2019, we abstracted data from routine TB treatment records for all adults (n = 776) initiating TB treatment in a 6-month period across 12 health facilities near Lake Victoria. We interviewed 301 cohort members and assessed whether they experienced a clinic presentation delay longer than 6 weeks. We investigated potential clinical and demographic correlates of clinic presentation delay and examined the association between clinic presentation delay and an unfavorable TB treatment outcome (death, loss to follow-up, or treatment failure). Clinic presentation delay was common, occurring among an estimated 54.7% (95% CI: 48.9%, 61.2%) of cohort members, though no specific correlates were identified. Clinic presentation delay was slightly associated with unfavorable TB treatment outcomes. The 180-day risk of an unfavorable outcome was 14.2% (95% CI: 8.0%, 20.4%) among those with clinic presentation delay, compared to 12.7% (95% CI: 5.1%, 20.3%) among those presenting earlier. Multi-level community-based interventions may be necessary to reduce clinic presentation delays in communities near Lake Victoria.

Providers' Understanding of Cancer Aetiology and Supportive Features for Indigenous Palliative Cancer Care Service Provision in Kenya

Background

Palliative care is a fundamental component of providing people-centred health services to cancer patients. However, the primary pillars of indigenous palliative care such as provider understanding of cancer, its aetiology, and features are undocumented.

Objective

We sought to understand Traditional Health Providers (THPs) understanding of cancer aetiology, and the functional features that support indigenous palliative cancer care service provision in Kenya.

Method

The study used a mixed methods cross-sectional design. A semi-structured questionnaire was administered to 193 THPs, who self-reported to manage cancer patients. The findings were enriched and validated through member checking in 6 focus group discussions and five journey mapping in-depth interviews.

Results

Despite diversity in culture and experience among the indigenous providers in Kenya, their description of cancer etiology and their management practices and primary goal were similar. Cancer was consistently described as a deadly life-deforming disease by 61.1% of THPs (n = 118/193) and attributed to chemicals and toxins in the body 41.5% (n = 80). The indigenous palliative-care system was reported to be characterized by five tiered levels of care, diversity in expertise and experience, shared and consultative process (60%) and family involvement in medical decision (59.5%). Herbal regimen (60.1%) was found to be the cornerstone of informal palliative care blended with nutrition management 78.2% (n = 151), lifestyle changes 63.7% (n = 123) and counseling services 55.9% (n = 108). Payments for service were arbitrarily made in cash or in kind.

Conclusion

The features of indigenous palliative care services are informed by the providers' distinctive cultural terms and descriptions of cancer and cancer aetiology. Shared and consultative protocols, regimen exchange, referral to cascaded care, and caregiver involvement were all important palliative-care clues to saving and enhancing lives. The features provide context for development of indigenous palliative care framework, engagement of policy makers, and promotion of culturally-inclusive indigenous palliative care model for adoption.

Re-Evaluating the Merits of Decentralisation as a Core Strategy for Effective Delivery of Drug-Resistant Tuberculosis Care in Pakistan

Decentralized, person-centred models of care delivery for drug-resistant tuberculosis (DR-TB) continue to be under-resourced in high-burden TB countries. The implementation of such models—made increasingly urgent by the COVID-19 pandemic—are key to addressing gaps in DR-TB care. We abstracted data of rifampicin-resistant (RR)/multidrug-resistant tuberculosis (MDR-TB) patients initiated on treatment at 11 facilities between 2010 and 2017 in Sindh and Balochistan provinces of Pakistan. We analysed trends in treatment outcomes relating to programme expansion to peri-urban and rural areas and estimated driving distance from patient residence to treatment facility. Among the 5586 RR/MDR-TB patients in the analysis, overall treatment success decreased from 82% to 66% between 2010 and 2017, as the programme expanded. The adjusted risk ratio for unfavourable outcomes was 1.013 (95% confidence interval 1.005–1.021) for every 20 km of driving distance. Our analysis suggests that expanding DR-TB care to centralized hubs added to increased unfavourable outcomes for people accessing care in peri-urban and rural districts. We propose that as enrolments increase, expanding DR-TB services close to or within affected communities is essential.

Time to care-seeking for TB symptoms

BACKGROUND: Early presentation to healthcare facilities is critical for early diagnosis and treatment of TB. We studied self-reported time to care-seeking from the onset of TB symptoms among primary healthcare clinic (PHC) attendees in Limpopo Province, South Africa.METHODS: We used data from participants enrolled in a cluster-randomized trial of TB case finding in 56 PHC clinics across two health districts. We fitted log-normal accelerated failure time regression models and we present time ratios (TRs) for potential risk factors.RESULTS: We included 2,160 participants. Among the 1,757 (81%) diagnosed with active TB, the median time to care-seeking was 30 days (IQR 14-60); adults sought care later than children/adolescents (adjusted TR aTR 1.47, 95% CI 1.10-1.96). Among those not diagnosed with TB, the median was 14 days (IQR 7-60); being HIV-positive (aTR 1.57, 95% CI 1.03-2.40); having less than grade 8 education and currently smoking were associated with longer time to care-seeking. In the combined analysis, living with HIV and having underlying active TB was associated with faster care-seeking (TB status x HIV interaction: TR 0.68, 95% CI 0.48-0.96).CONCLUSION: Delay in care-seeking was associated with age, lower education and being a current smoker. TB awareness campaigns targeting these population groups may improve care-seeking behavior and reduce community TB transmission.

Impact of early chest radiography on delay in pulmonary tuberculosis case notification in Ethiopia

Background:

One-third of tuberculosis (TB) cases are missed each year and delays in the diagnosis of TB are hampering the whole cascade of care. Early chest X-ray (CXR) in patients with cough irrespective of duration may reduce TB diagnostic and treatment delays and increase the number of TB patients put into TB care. We aimed to evaluate the impact of CXR on delay in the diagnosis of pulmonary tuberculosis (PTB) among people with cough of any duration.

Methods:

A facility-based cross-sectional study was conducted in four selected health facilities from two regions and two city administrations of Ethiopia. Patients who sought health care were screened for cough of any duration, and those with cough underwent CXR for PTB and their sputum specimens were tested for microbiological confirmation. Delays were followed up and calculated using median and inter-quartile range (IQR) to summarize (first onset of cough to first facility visit, ≥15 days), diagnosis delay (first facility visit to date of PTB diagnosis, >7 days), and total delay (first onset of cough to date of PTB diagnosis, >21 days). Kruskal–Wallis and Mann–Witney tests were used to compare the delays among independent variables.

Results:

A total of 309 PTB cases were consecutively diagnosed of 1853 presumptive TB cases recruited in the study that were identified from 2647 people who reported cough of any duration. The median (IQR) of patient delay, diagnosis delay, and the total delay was 30 (16–44), 1 (0–3), and 31 (19–48) days, respectively. Patients’ delay contributed a great role in the total delay, 201/209 (96.2%). Median diagnosis delay was higher among those that visited health center, diagnosed at a facility that had no Xpert mycobacterium tuberculosis (MTB)/RIF assay, radiologist, or CXR (P < 0.05). Factors associated with patients delay were history of previous TB treatment (adjusted prevalence ratio [aPR] = 0.79, 95% confidence interval [CI]: 0.63–0.99) and history of weight loss (aPR = 1.12; 95% CI: 1.0–1.25). Early CXR screening for cough of <2 weeks duration significantly reduced the patients’ delay and thus the total delay, but not diagnostic delay alone.

Conclusion:

Early screening using CXR minimized delays in the diagnosis of PTB among people with cough of any duration. Patients’ delay was largest and contributed great role in the delay of TB cases. Screening by cough of any duration and/or CXR among people seeking healthcare along with ensuring the availability of Xpert MTB/RIF assay and skilled human power at primary healthcare facilities are important to reduce patient and diagnostic delays of PTB in Ethiopia.

Knowledge and transmission risk awareness of tuberculosis among the pilgrims attending a religious mass gathering in India: a cross-sectional study

Background

Tuberculosis infection accounts for more annual deaths than any other single infectious disease, except the Corona Virus infection. It is a significant global issue and India is one of the most affected countries. Religious mass gatherings congregate millions of pilgrims at one place. Over-crowding is a high-risk factor for the transmission of tuberculosis. Knowledge and awareness of the disease are proven prerequisites for the spread-prevention and early diagnosis of tuberculosis. The present study was designed to explore the knowledge of tuberculosis and awareness of disease transmission risk among pilgrims attending a religious mass gathering, the Kumbh Mela (2016) in Ujjain, India.

Methods

Self-reported data on the pilgrims’ tuberculosis-knowledge were collected using a cross-sectional study design. A contextual, pre-tested questionnaire was used, using the convenience sampling method. In addition to the anonymous descriptive analyses, a composite knowledge-score was developed to enable comparisons between demographic groups.

Results

In total, 1665 pilgrims participated in the study with 38.8 years of mean age and 59% literacy rate. The most recognized symptoms of tuberculosis were “Cough for more than 15 days with sputum” (94%) and “Blood in sputum” (81%). Most participants knew that tuberculosis is an infectious disease (93%) and not hereditary (91%). Additionally, 84% considered it is a potentially lethal disease that requires extensive treatment. However, vaccine awareness was poor (4%). “Direct contact with tuberculosis patient” (78%) and “To be in a crowded area” (4%) were considered as the most important risk factors for tuberculosis transmission. For the composite knowledge-score, a significantly higher mean score was seen among those with at least ten years of schooling compared with illiterates (p <  0.001). Occupation and residency also affected the mean score.

Conclusion

Most pilgrims attending the Kumbh Mela had basic knowledge of the characteristics of tuberculosis, but some important knowledge gaps concerning the transmission risks associated with crowded situations existed. These gaps need to be addressed in future policies to enable safer mass gatherings and to end the TB epidemic, globally.

Contributing Factors in the Tuberculosis Care Cascade in India: A Systematic Literature Review

Tuberculosis (TB) care cascade is a recently evolved care model for patient retention across the sequential stages of care for a successful treatment outcome. The care cascade is multi-folded and complex in setting where the health system is reforming for its resilience. India, one of the countries with the highest burden of tuberculosis mortality and morbidity, is not an exception to this complexity. With the diverse challenges in the Indian health system and societal diversity, it is essential to understand the factors contributing to this TB care cascade. Thus, this study aims to map all the contributing factors to the TB care cascade in India. Further, it also captures the different patterns of factors explored so far in different countries’ regions. This systematic literature review was conducted between October 2020 and February 2021 in India using PubMed databases, Web of Science, and Google Scholar. Two reviewers extracted the data from eligible studies to summarize and tabulate important findings. Data were extracted and tabulated for study design, location of the study, type of TB patients, methodological approach, system side challenges, and demand-side challenges in the study’s findings. Out of 692 initial hits from the literature search, 28 studies were finally included to synthesize evidence in this review as per the inclusion and exclusion criteria. This review provides an insight into different factors such as the system-side (health workforce, institutional) and the demand-side (individual, societal) contributing towards the care cascade. The prime factors reflected in most of the studies were socio-economic condition, disease awareness, myths/beliefs, addictions among the demand-side factors and accessibility, the attitude of the healthcare staff, delay in referral for diagnosis among the system-side factors. The accountability for addressing these diverse factors is recommended to close the gaps in the TB care cascade.

Improving pathways to care through interventions cocreated with communities: a qualitative investigation of men's barriers to tuberculosis care-seeking in an informal settlement in Blantyre, Malawi

INTRODUCTION

Men have a higher prevalence of undiagnosed tuberculosis (TB) than women and can spend up to a year longer contributing to ongoing transmission in the community before receiving treatment. Health outcomes are often worse for patients with TB living in informal settlements especially men. This study aimed to understand the barriers preventing men from seeking care for TB and cocreate interventions to address these barriers.

METHODS

We used qualitative research methods including in-depth interviews and participatory workshops. Researchers worked with women and men living in Bangwe, an informal settlement in Blantyre, Malawi to develop interventions that reflected their lived realities. The study took place over two phases, in the first phase we undertook interviews with men and women to explore barrier to care seeking, in the second phase we used participatory workshops to cocreate interventions to address barriers and followed up on issues emerging from the workshops with further interviews. In total, 30 interviews were conducted, and 23 participants joined participatory workshops. The team used a thematic analysis to analyse the data.

RESULTS

Three interconnected thematic areas shaped men's health TB seeking behaviour: precarious socioeconomic conditions; gendered social norms; and constraints in the health system. Insecurity of day labour with no provision for sick leave; pressure to provide for the household and a gendered desire not to appear weak and a severely under-resourced health system all contributed to men delaying care in this context. Identified interventions included improved patient-provider relations within the health-system, improved workers' health rights and broader social support for households.

CONCLUSION

Improving mens' pathways to care requires interventions that consider contextual issues by addressing individual level socioeconomic factors but also broader structural factors of gendered social dynamics and health systems environment.

Lived experiences of tuberculosis patients and their implications for early tuberculosis case identification and management in pastoralist community setting: a qualitative study in Borena zone, Oromia region of Ethiopia

BACKGROUND

Ethiopia has highly diversified population with notable socioeconomic and cultural differences. Regardless of the differences, short course directly observed treatment,where patients should take drugs under direct observasion of health care providers, is uniformly applied all over the country. Evidences are scarce on how well does this uniform approach fits with the pastoral community setting. The purpose of this study was to explore lived experiences of TB patients in the pastoral community under the uniform approach, and their implications to early case identification and management.

METHOD

Qualitative method with phenomenological study design was undertaken to explore lived experiences of TB patients. Patients from all levels of health care (hospital, health center and health post) were included. Experience of both drug susceptible and drug resistant TB patients were documented. Twenty one patients, who consented to in the study, were selected by a convenience sampling method. In-depth interview was conducted using a semi-structured interview guide and the interview ended subsequent to information saturation. The interview was audio recorded; and field notes were also taken. Data analysis was done concurrently with the data collection using a word processor designed for qualitative text analysis. InductiveThematic analysis was undertaken to identify key themes.

RESULTS

Twenty one patients (eight from hospitals, nine from health centers and four from health posts) were interviewed. Three of the eight hospital patients were on drug resistant tuberculosis (TB) treatment. Sixty two codes, five code categories and three themes emerged from the interviews. The three themes were health system, stigma and discrimination, and socioeconomic problem related experiences. Inaccessibility to health facilities due to scattered settlement and mobility, delay in care seeking TB symptoms, low index of suspecting TB by care providers, fear of stigma and indirect treatment related costs were some of the codes identified.

CONCLUSION

TB patients in the pastoral setting were experiencing multifaceted challenges with the current application of 'one-size-fits-all' approach which implied hampered timely case identification and compromised patient management. Therefore, designing context appropriate intervention approach is required to ensure unprejudiced services.

Effect of public-private interface agency in Patna and Mumbai, India: Does it alter durations and delays in care seeking for drug-sensitive pulmonary tuberculosis?

Background: Public–private interface agency (PPIA) intervention models in Patna (E. India) and Mumbai (W. India) for pulmonary drug-sensitive (DS) tuberculosis (TB) patients were evaluated over 2 years after maturity to examine effect on reduction of patient pathways and retention.  The models engaged private providers, diagnostic facilities and pharmacies into an effective network providing free diagnostic tests and treatment.

Methods: A population-based retrospective study was undertaken to assess effectiveness of the PPIA model in care pathways of 64 (Patna) and 86 (Mumbai) patients through in-depth interviews conducted within 6 months of initiation treatments to identify types and facilities accessed, duration to diagnosis and treatment. Median durations based on facilities accessed were statistically analysed.  Comparisons were made with baseline values and endline pathways of patients accessing PPIA engaged/non-engaged facilities in private and public sectors.

Results: Compared to non-engaged facilities, persons accessing engaged facilities at first point-of-care had shorter pathways (Mumbai: 32 vs 43 days), (Patna: 15 vs 40 days).  Duration for first care-seeking was considerably shorter for patients accessing PPIA in Patna and for both engaged and non-engaged private facilities in Mumbai (4 days).  Whilst PPIA engaged facilities diagnosed more cases than others, the RNTCP in Mumbai provided diagnosis early.  There was good retention of patients by PPIA-engaged (1 ^st) facilities (90% post-diagnosis in Patna) but this was affected by the hub-spoke referral system in Mumbai (13%). Second diagnosis is a common feature in Mumbai.  The spoke-hub model in Mumbai contributed considerably to treatment delay; PPIA-engaged providers were better at retaining patients post treatment initiation 11/25 (44%).

Conclusion: PPIA-engaged facilities, accessed at onset, result in marked reduction in pathway durations.  Such initiatives should engage a critical mass of competent providers, proximal investigation facilities with enhanced disease awareness and literacy efforts amongst communities.  Patient movement should be minimized for early treatment and retention.

Caring for Tuberculosis Patients: Understanding the Plight of Nurses at a Regional Hospital in Limpopo Province, South Africa

Tuberculosis (TB) is a disease which is caused by a relatively large, non-motile, rod-shaped pathogen called Mycobacterium tuberculosis. TB is a major cause of illness and death worldwide, especially in Asia and Africa. Despite the fact that TB is a curable illness, the tragedy is that TB remains the biggest killer in the world as a single pathogen. The aim of this study was to determine the experiences of nurses caring for TB patients at a regional hospital in Limpopo Province, South Africa. Qualitative, exploratory, and descriptive designs were used. A non-probability purposive sampling method was used to select the participants. The personal experiences of six nurses with more than five years’ experience caring for TB patients at a regional hospital were explored, and it was guided by data saturation. Data were collected through in-depth individual interviews. Data were analyzed using Colaizzi’s method. Trustworthiness was ensured and ethical considerations were observed in this study. The research findings revealed six major themes from the raw data: challenges of the working environment, problems impacting on the quality of nursing care, fear, anxiety, stress and risk of contracting infection, nurses’ perceptions towards patients, support structure available in the hospital, and support needs for the nurses. Therefore, there is an urgent need to address the challenges experienced by nurses caring for communicable diseases through provision of a positive practice work environment.

A Study of Knowledge, Experience, and Beliefs About Hepatitis B Virus (HBV) Infection in South Western Uganda

Introduction: United Nations sustainable development goals aim for the elimination of viral hepatitis as a public health threat by 2030, leading to efforts to upscale the availability and accessibility of hepatitis B virus (HBV) vaccination, diagnosis, and treatment globally. However, a variety of societal factors, including beliefs, traditions, and stigma, can be a major obstacle to all of these interventions. We therefore set out to investigate how HBV is understood and described in communities in Uganda, and whether there is evidence of potential stigma. Method: We carried out a qualitative formative study in two sites in South Western Uganda: a village in Kalungu district (site A) and an area on the outskirts of Masaka town (site B). We undertook a rapid assessment to investigate how adults describe HBV infection and their perceptions about the infection. We collected data by conducting a transect walk, observations, community group discussions, and in-depth interviews, sampling a total of 131 individuals. We used inductive content analysis to extract key themes associated with HBV. Results: There is no specific word for HBV infection in local languages, and knowledge about this infection is varied. While some individuals were completely unfamiliar with HBV infection, some had heard of HBV. Radio was a common source of information. There was awareness of HBV as a cause of liver disease, but limited knowledge regarding the cause, mode of transmission, and treatment. Stigma in HBV may be rare in this community due to limited understanding and experience of HBV. Conclusion: There is an ongoing need to improve awareness and understanding of HBV in this community. Careful dissemination of accurate information is required to promote acceptance of interventions for prevention, diagnosis, and treatment.

Determinants of Patient Delay in Diagnosis of Pulmonary Tuberculosis in Somali Pastoralist Setting of Ethiopia: A Matched Case-Control Study

Background: Healthcare-seeking behavior is the basis to ensure early diagnosis and treatment of tuberculosis (TB) in settings where most cases are diagnosed upon self-presentation to health facilities. Yet, many patients seek delayed healthcare. Thus, we aimed to identify the determinants of patient delay in diagnosis of pulmonary TB in Somali pastoralist area, Ethiopia. Methods: A matched case-control study was conducted between December 2017 and October 2018. Cases were self-presented and newly diagnosed pulmonary TB patients aged ≥ 15 years who delayed > 30 days without healthcare provider consultation, and controls were patients with similar inclusion criteria but who consulted a healthcare provider within 30 days of illness; 216 cases sex-matched with 226 controls were interviewed using a pre-tested questionnaire. Hierarchical analysis was done using conditional logistic regression. Results: After multilevel analysis, pastoralism, rural residence, poor knowledge of TB symptoms and expectation of self-healing were individual-related determinants. Mild-disease and manifesting a single symptom were disease-related, and >1 h walking distance to nearest facility and care-seeking from traditional/religious healers were health system-related determinants of patient delay > 30 days [p < 0.05]. Conclusion: Expansion of TB services, mobile screening services, and arming community figures to identify and link presumptive cases can be effective strategies to improve case detection in pastoral settings.