Dataset Information

Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis.

ABSTRACT:

Background

Thirty countries with the highest tuberculosis (TB) burden bear 87% of the world's TB cases. Delayed diagnosis and treatment are detrimental to TB prognosis and sustain TB transmission in the community, making TB elimination a great challenge, especially in these countries. Our objective was to elucidate the duration and determinants of delayed diagnosis and treatment of pulmonary TB in high TB-burden countries.

Methods

We conducted a systematic review and meta-analysis of quantitative and qualitative studies by searching four databases for literature published between 2008 and 2018 following PRISMA guidelines. We performed a narrative synthesis of the covariates significantly associated with patient, health system, treatment, and total delays. The pooled median duration of delay and effect sizes of covariates were estimated using random-effects meta-analyses. We identified key qualitative themes using thematic analysis.

Results

This review included 124 articles from 14 low- and lower-middle-income countries (LIC and LMIC) and five upper-middle-income countries (UMIC). The pooled median duration of delays (in days) were-patient delay (LIC/LMIC: 28 (95% CI 20-30); UMIC: 10 (95% CI 10-20), health system delay (LIC/LMIC: 14 (95% CI 2-28); UMIC: 4 (95% CI 2-4), and treatment delay (LIC/LMIC: 14 (95% CI 3-84); UMIC: 0 (95% CI 0-1). There was consistent evidence that being female and rural residence was associated with longer patient delay. Patient delay was also associated with other individual, interpersonal, and community risk factors such as poor TB knowledge, long chains of care-seeking through private/multiple providers, perceived stigma, financial insecurities, and poor access to healthcare. Organizational and policy factors mediated health system and treatment delays. These factors included the lack of resources and complex administrative procedures and systems at the health facilities. We identified data gaps in 11 high-burden countries.

Conclusions

This review presented the duration of delays and detailed the determinants of delayed TB diagnosis and treatment in high-burden countries. The gaps identified could be addressed through tailored approaches, education, and at a higher level, through health system strengthening and provision of universal health coverage to reduce delays and improve access to TB diagnosis and care. PROSPERO registration: CRD42018107237.

SUBMITTER: Teo AKJ

PROVIDER: S-EPMC8459488 | biostudies-literature | 2021 Sep

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis.

Teo Alvin Kuo Jing AKJ Singh Shweta R SR Prem Kiesha K Hsu Li Yang LY Yi Siyan S

Respiratory research 20210923 1

<h4>Background</h4>Thirty countries with the highest tuberculosis (TB) burden bear 87% of the world's TB cases. Delayed diagnosis and treatment are detrimental to TB prognosis and sustain TB transmission in the community, making TB elimination a great challenge, especially in these countries. Our objective was to elucidate the duration and determinants of delayed diagnosis and treatment of pulmonary TB in high TB-burden countries.<h4>Methods</h4>We conducted a systematic review and meta-analysis ...[more]

PMID: 34556113

Similar Datasets

Project description:BACKGROUND:Cambodia is among the 30 countries in the world with the highest burden of tuberculosis (TB), and it is estimated that 40% of people with TB remain undiagnosed. In this study, we aimed to investigate the determinants of delayed diagnosis and treatment of TB in Cambodia. METHODS:This mixed-method explanatory sequential study was conducted between February and September 2019 in 12 operational districts in Cambodia. It comprised of a retrospective cohort study of 721 people with TB, followed by a series of in-depth interviews. We assessed factors associated with time to TB diagnosis and treatment initiation using Cox proportional hazards model. Subsequently, we conducted in-depth interviews with 31 people with TB purposively selected based on the time taken to reach TB diagnosis, sex, and residence. Transcripts were coded, and thematic analyses were performed. RESULTS:The median time from the onset of symptoms to TB diagnosis was 49 days (Interquartile range [IQR]: 21-112). We found that longer time to diagnosis was significantly associated with living in rural area (Adjusted hazards ratio [aHR] = 1.25; 95% confidence interval [CI]: 1.06-1.48); TB symptoms-cough (aHR: 1.52; 95% CI: 1.18-1.94), hemoptysis (aHR 1.32; 95% CI: 1.07-1.63), and night sweats (aHR: 1.24; 95% CI: 1.05-1.46); seeking private health care/self-medication (aHR: 1.23; 95% CI: 1.04-1.45); and higher self-stigma (aHR: 1.02; 95% CI: 1.01-1.03). Participants who received education level above the primary level were inversely associated with longer time to diagnosis (aHR: 0.78; 95% CI: 0.62-0.97). The median time from TB diagnosis to the initiation of treatment was two days (IQR: 1-3). The use of smear microscopy for TB diagnosis (aHR: 1.50; 95% CI: 1.16-1.95) was associated with longer time to treatment initiation. Seeking private health care and self-medication before TB diagnosis, lack of perceived risk, threat, susceptibility, and stigma derived qualitatively further explained the quantitative findings. CONCLUSIONS:TB diagnostic delay was substantial. Increasing public awareness about TB and consciousness regarding stigma, engaging the private healthcare providers, and tailoring approaches targeting the rural areas could further improve early detection of TB and narrowing the gap of missing cases in Cambodia.

Project description:Tuberculosis (TB) remains a leading cause of morbidity and mortality worldwide. Considering the World Health Organization recommendation to implement child contact management (CCM) for TB, we conducted a mixed-methods systematic review to summarize CCM implementation, challenges, predictors, and recommendations. We searched the electronic databases of PubMed/MEDLINE, Scopus, and Web of Science for studies published between 1996-2017 that reported CCM data from high TB-burden countries. Protocol details for this systematic review were registered on PROSPERO: International prospective register of systematic reviews (#CRD42016038105). We formulated a search strategy to identify all available studies, published in English that specifically targeted a) population: child contacts (<15 years) exposed to TB in the household from programmatic settings in high burden countries (HBCs), b) interventions: CCM strategies implemented within the CCM cascade, c) comparisons: CCM strategies studied and compared in HBCs, and d) outcomes: monitoring and evaluation of CCM outcomes reported in the literature for each CCM cascade step. We included any quantitative, qualitative, mixed-methods study design except for randomized-controlled trials, editorials or commentaries. Thirty-seven studies were reviewed. Child contact losses varied greatly for screening, isoniazid preventive therapy initiation, and completion. CCM challenges included: infrastructure, knowledge, attitudes, stigma, access, competing priorities, and treatment. CCM recommendations included: health system strengthening, health education, and improved preventive therapy. Identified predictors included: index case and clinic characteristics, perceptions of barriers and risk, costs, and treatment characteristics. CCM lacks standardization resulting in common challenges and losses throughout the CCM cascade. Prioritization of a CCM-friendly healthcare environment with improved CCM processes and tools; health education; and active, evidence-based strategies can decrease barriers. A focused approach toward every aspect of the CCM cascade will likely diminish losses throughout the CCM cascade and ultimately decrease TB related morbidity and mortality in children.

Project description:Summary Background About 45.1% of all induced abortions are unsafe and 97% of these occur in low- and middle-income countries (LMICs). Women's abortion decisions may be complex and are influenced by various factors. We aimed to delineate women's abortion decision-making trajectories and their determinants in LMICs. Methods We searched Medline, EMBASE, PsychInfo, Global Health, Web of Science, Scopus, IBSS, CINAHL, WHO Global Index Medicus, the Cochrane Library, WHO website, ProQuest, and Google Scholar for primary studies and reports published between January 1, 2000, and February 16, 2021 (updated on June 06, 2022), on induced abortion decision-making trajectories and/or their determinants in LMICs. We excluded studies on spontaneous abortion. Two independent reviewers extracted and assessed quality of each paper. We used “best fit” framework synthesis to synthesise abortion decision-making trajectories and thematic synthesis to synthesise their determinants. We analysed quantitative findings using random effects model. The study protocol is registered with PROSPERO number CRD42021224719. Findings Of the 6960 articles identified, we included 79 in the systematic review and 14 in the meta-analysis. We identified nine abortion decision-making trajectories: pregnancy awareness, self-reflection, initial abortion decision, disclosure and seeking support, negotiations, final decision, access and information, abortion procedure, and post-abortion experience and care. Determinants of trajectories included three major themes of autonomy in decision-making, access and choice. A meta-analysis of data from 7737 women showed that the proportion of the overall women's involvement in abortion decision-making was 0.86 (95% CI:0.73–0.95, I2 = 99.5%) and overall partner involvement was 0.48 (95% CI:0.29–0.68, I2 = 99.6%). Interpretation Policies and strategies should address women's perceptions of safe abortion socially, legally, and economically, and where appropriate, involvement of male partners in abortion decision-making processes to facilitate safe abortion. Clinical heterogeneity, in which various studies defined “the final decision-maker” differentially, was a limitation of our study. Funding Nuffield Department of Population Health DPhil Scholarship for PL, University of Oxford, and the Medical Research Council Career Development Award for MN (Grant Ref: MR/P022030/1).

Project description:BackgroundScreening of household contacts of tuberculosis (TB) patients is a recommended strategy to improve early case detection. While it has been widely implemented in low prevalence countries, the most optimal protocols for contact investigation in high prevalence, low resource settings is yet to be determined. This study evaluated contact investigation interventions in eleven lower and middle income countries and reviewed the association between context or program-related factors and the yield of cases among contacts.MethodsWe reviewed data from nineteen first wave TB REACH funded projects piloting innovations to improve case detection. These nineteen had fulfilled the eligibility criteria: contact investigation implementation and complete data reporting. We performed a cross-sectional analysis of the percentage yield and case notifications for each project. Implementation strategies were delineated and the association between independent variables and yield was analyzed by fitting a random effects logistic regression.FindingsOverall, the nineteen interventions screened 139,052 household contacts, showing great heterogeneity in the percentage yield of microscopy confirmed cases (SS+), ranging from 0.1% to 6.2%). Compared to the most restrictive testing criteria (at least two weeks of cough) the aOR's for lesser (any TB related symptom) and least (all contacts) restrictive testing criteria were 1.71 (95%CI 0.94-3.13) and 6.90 (95% CI 3.42-13.93) respectively. The aOR for inclusion of SS- and extra-pulmonary TB was 0.31 (95% CI 0.15-0.62) compared to restricting index cases to SS+ TB. Contact investigation contributed between <1% and 14% to all SS+ cases diagnosed in the intervention areas.ConclusionsThis study confirms that high numbers of active TB cases can be identified through contact investigation in a variety of contexts. However, design and program implementation factors appear to influence the yield of contact investigation and its concomitant contribution to TB case detection.

Project description:BackgroundThe World Health Organization (WHO) stresses the importance of active case-finding (ACF) for early detection of tuberculosis (TB), especially in the 30 high-burden countries that account for almost 90% of cases globally.ObjectiveTo describe the attitudes of National TB Programme (NTP) managers related to ACF policy development, implementation and scale-up in the 30 high-burden countries, and to review national TB strategic plans.MethodsThis was a mixed-methods study with an embedded design: A cross-sectional survey with NTP managers yielded quantitative and qualitative data. A review of national TB strategic plans complemented the results. All data were analyzed in parallel and merged in the interpretation of the findings.Results23 of the 30 NTP managers (77%) participated in the survey and 22 (73%) national TB strategic plans were reviewed. NTP managers considered managers in districts and regions key stakeholders for both ACF policy development and implementation. Different types of evidence were used to inform ACF policy, while there was a particular demand for local evidence. The NSPs reflected the NTP managers' unanimous agreement on the need for ACF scale-up, but not all included explicit aims and targets related to ACF. The NTP managers recognized that ACF may decrease health systems costs in the long-term, while acknowledging the risk for increased health system costs in the short-term. About 90% of the NTP managers declared that financial and human resources were currently lacking, while they also elaborated on strategies to overcome resource constraints.ConclusionNTP managers stated that ACF should be scaled up but reported resource constraints. Strategies to increase resources exist but may not yet have been fully implemented, e.g. generating local evidence including from operational research for advocacy. Managers in districts and regions were identified as key stakeholders whose involvement could help improve ACF policy development, implementation and scale-up.

Project description:PurposeNon-adherence to tuberculosis therapy can lead to drug resistance, prolonged infectiousness, and death; therefore, understanding what causes treatment default is important. Pakistan has one of the highest burdens of tuberculosis in the world, yet there have been no qualitative studies in Pakistan that have specifically examined why default occurs. We conducted a mixed methods study at a tuberculosis clinic in Karachi to understand why patients with drug-susceptible tuberculosis default from treatment, and to identify factors associated with default. Patients attending this clinic pick up medications weekly and undergo family-supported directly observed therapy.MethodsIn-depth interviews were administered to 21 patients who had defaulted. We also compared patients who defaulted with those who were cured, had completed, or had failed treatment in 2013.ResultsQualitative analyses showed the most common reasons for default were the financial burden of treatment, and medication side effects and beliefs. The influence of finances on other causes of default was also prominent, as was concern about the effect of treatment on family members. In quantitative analysis, of 2120 patients, 301 (14.2%) defaulted. Univariate analysis found that male gender (OR: 1.34, 95% CI: 1.04-1.71), being 35-59 years of age (OR: 1.54, 95% CI: 1.14-2.08), or being 60 years of age or older (OR: 1.84, 95% CI: 1.17-2.88) were associated with default. After adjusting for gender, disease site, and patient category, being 35-59 years of age (aOR: 1.49, 95% CI: 1.10-2.03) or 60 years of age or older (aOR: 1.76, 95% CI: 1.12-2.77) were associated with default.ConclusionsIn multivariate analysis age was the only variable associated with default. This lack of identifiable risk factors and our qualitative findings imply that default is complex and often due to extrinsic and medication-related factors. More tolerable medications, improved side effect management, and innovative cost-reduction measures are needed to reduce default from tuberculosis treatment.

Project description:Migrants and refugees living in high income countries (HICs) have an increased risk of developing non-communicable diseases (NCDs) due to malnutrition at different stages over their life course. This systematic review aims to examine the double burden of malnutrition (DBM) among migrants and refugees in developed countries. This review was informed by the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. Eligible studies were peer-reviewed observational studies that focused on the DBM in refugee or migrant populations; and were written in English with full texts available and accessible. A combination of keywords was used to search 8 electronic bibliographic databases including Ovid MEDLINE, EMBASE, PsycINFO, CINAHL, ProQuest, Scopus, PubMed, and web of science. There is a paucity of research into the DBM among migrants and refugees residing in HICs. Of a total of 2344 articles retrieved from eight databases, 5 studies met the inclusion criteria. All included studies showed the co-existence of some form of undernutrition and overnutrition within the same population. Overnutrition (overweight and obesity) in the studied populations ranged from 11.1% to 42% while undernutrition (stunting, wasting and underweight) ranged from 0.3% to 17%. Standard measures for anthropometry as determined by World Health Organization (WHO) were used for data collection in all included studies. A piloted form informed by the Cochrane Public Health Group Data Extraction and Assessment Template was used in the extraction of data from retrieved studies. Quality assessment of included studies was performed using the study assessment tools of the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) and showed that all studies were of fair quality. Interventions that simultaneously target more than one form of malnutrition especially amongst migrant and refugee populations must be implemented for policy solutions to be effective. This review has been registered by the PROSPERO international prospective registry for systematic reviews, reference CRD42020192416.

Project description:IntroductionThe WHO endorsed the Xpert MTB/RIF (Xpert) technique since 2011 as initial test to diagnose rifampicin-resistant tuberculosis (RR-TB). No systematic review has quantified the proportion of pretreatment attrition in RR-TB patients diagnosed with Xpert in high TB burden countries.Pretreatment attrition for RR-TB represents the gap between patients diagnosed and those who effectively started anti-TB treatment regardless of the reasons (which include pretreatment mortality (death of a diagnosed RR-TB patient before starting adequate treatment) and/or pretreatment loss to follow-up (PTLFU) (drop-out of a diagnosed RR-TB patient before initiation of anti-TB treatment).MethodsIn this systematic review and meta-analysis, we queried EMBASE, PubMed and Web of science to retrieve studies published between 2011 and 22 July 2024, that described pretreatment attrition for RR-TB using Xpert in high TB burden countries. Data on RR-TB patients who did not start treatment after diagnosis and reasons for not starting were extracted in an Excel table. A modified version of the Newcastle-Ottawa scale was used to evaluate the risk of bias among all included studies. The pooled proportion of pretreatment attrition and reasons were assessed using random-effects meta-analysis. Forest plots were generated using R software.ResultsThirty eligible studies from 21 countries were identified after full-text screening and included in the meta-analysis. Most studies used routine programme data. The pooled proportion of pretreatment attrition in included studies was 18% (95% CI: 12 to 25). PTLFU and pretreatment mortality were, respectively, reported in 10 and nine studies and explained 78% (95% CI: 51% to 92%) and 30% (95% CI: 15% to 52%) of attrition.ConclusionPretreatment attrition was widespread, with significant heterogeneity between included studies. National TB programmes should ensure accurate data collection and reporting of pretreatment attrition to enable reliable overall control strategies.Prospero registration numberCRD42022321509.

Dataset Information

Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis.

Background

Methods

Results

Conclusions

Publications

Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets