Delay in the treatment of pulmonary tuberculosis: a report from Afghanistan

The aim of this study was to determine the length of delays and to investigate the factors associated with patient (care-seeking) and health-system (treatment initiation following care-seeking) delays, among smear-positive tuberculosis patients in Kunar province, Afghanistan, as delay in diagnosis and treatment results in more severe disease, higher mortality, and a longer period of infectivity in the community.

A cross-sectional study of 122 new smear-positive pulmonary tuberculosis patients, aged ≥15 years, registered at a hospital and a clinic in Kunar province, was conducted from September 2008 to February 2009 using a structured questionnaire interview.

Among the 122 participants, the average patient, health-system, and total delays were 205.2, 150.7, and 356.0 days, respectively. Patient delay was independently associated with an increase in the household size, social stigma linked with tuberculosis (social consequences of having tuberculosis), chest pain, longer time to reach a private health-care facility, initial seeking of alternative services (self-treatment with herbs or drugs; obtaining of drugs from pharmacy or drug store; visiting traditional health provider; and visiting community health worker), and initial consultation with a private health-care facility (p < 0.05). The risk of health-system delays increased with multiple visits and with time to reach private health facilities (p < 0.05). The risk of health-system delays decreased as social stigma increased (p < 0.05).

Delays in the initiation of tuberculosis treatment in Kunar province are daunting. Efforts to reduce delays must encourage early visits, reduce tuberculosis-associated stigma, encourage a public-private health-care mix, improve health-care providers' diagnostic capabilities, and encourage active case-finding with recording of symptoms and screening of contacts.