Tuberculosis (TB) is the second leading cause of death in low- and middle-income countries and globally is the second leading cause of death from infectious disease. Delays in seeking healthcare and in diagnosis present barriers to the effective management of TB, increasing the risk of transmission as well as the development of multi-drug resistant TB. In China, an estimated 8.28 million cases of pulmonary TB occurred between 2001 and 2010. Jia Cao of the Third Military Medical University, China and colleagues carried out a systematic review and meta-analysis, published in BMC Medicine, to identify factors associated with delays in seeking care and in diagnosis of TB in China.
Scanning electron microphotograph of Mycobacterium tuberculosis. Image source: flickr, NIH NIAID
TB is a hugely important public health issue in China, with cases of multi-drug resistant TB on the increase. In 2010 resistance to first-line drugs among patients newly diagnosed with TB in China was 36.9 percent. Understanding why TB diagnosis is often delayed in China is needed to prevent the continued growth of multi-drug resistant TB. The researchers identified eligible studies that looked at factors associated with TB patient delay (a delay in patients presenting to a healthcare facility) and diagnostic delay (a delay in diagnosis of TB after a patients first visit to a healthcare facility) in three major international and Chinese databases up to November 2012. Studies were assessed for quality, and data was abstracted from eligible studies and meta-analyses conducted.
Cao and colleagues identified 29 studies that met their eligibility criteria for the systematic review, which involved 38,947 pulmonary TB patients from 17 provinces in China. This included 27 cross-sectional studies, one cohort study and one case-control study. Of these studies, 13 cross-sectional studies, involving 23,917 patients were included in the meta-analyses.
The majority of the studies included in the systematic review identified socio-demographic and economic factors as risk factors for healthcare seeking and diagnostic delays, including rural residence, lack of health insurance, low income, and poor knowledge of TB. Limited resources and a lack of qualified health workers also contributed to delays in diagnosis.
Results of the meta-analysis revealed living in a rural area as a risk factor for delays in seeking treatment, with women who lived in rural areas delaying seeking healthcare more than men. Other factors contributing to delays in presentation and diagnosis were low levels of education (only attending primary school or below) and first seeking care from a Chinese Traditional Medicine provider rather than at a formal TB health facility.
This study highlights the challenges of TB control in China and identifies the multifactorial causes of delays in seeking healthcare and in diagnosis. In light of these findings, potential strategies to reduce delays could include interventions to promote awareness of the benefits of early diagnosis and treatment, removal of financial barriers to accessing healthcare, and wider implementation of clinical guidelines for TB diagnosis across China, particularly in rural areas.