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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 12-17

Delay in initiation of treatment of tuberculosis: A cross-sectional study from rural Wardha

Department of Community Medicine, MGIMS, Sewagram, Maharashtra, India

Date of Submission29-Dec-2017
Date of Decision29-Apr-2018
Date of Acceptance24-Jun-2018
Date of Web Publication14-Feb-2019

Correspondence Address:
Abhishek V Raut
Department of Community Medicine, MGIMS, Sewagram, Wardha - 442 102, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_127_17

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Background: India with 2.2 million incident cases annually contributed to around 25% of global incidence. Along with conventional indicators, magnitude of treatment delay would prove as a performance indicator for tuberculosis (TB) control in high TB burden countries like India. Objectives: The objectives of the study were to find out the magnitude of treatment delay among the TB patients, to describe the factors responsible for delay in treatment, if any, and to assess the knowledge of patients in a rural area about TB and directly observed treatment short course (DOTS). Study Design: Descriptive cross-sectional study was conducted among patients registered in the DOTS center at Mahatma Gandhi Institute of Medical Sciences Sewagram. Materials and Methods: Information of all 40 new sputum smear-positive TB patients registered at DOTS center between February and April 2015 was collected. Of these, thirty patients could be contacted successfully and were included in the study after obtaining consent. Data were entered in Microsoft Excel and analyzed using Epi Info software. Mean and median delay in terms of days were estimated. Mann–Whitney U-test was used to determine factors associated with treatment delay. Descriptive analysis using frequency and percentage was carried out to assess the knowledge regarding TB and DOTS. Results: Median delay was 35.5 days with diagnostic delay comprising 84% of it. Male patients and patients belonging to Below Poverty Line (BPL) families had significantly (P < 0.05) lesser median delay. Conclusions: Definite delay was seen in treatment initiation for TB with diagnostic delay contributing the most to the total delay.

Keywords: Health-care quality indicator, Mycobacterium, program evaluation, time-to-treatment

How to cite this article:
Patki GA, Raut AV, Datar S. Delay in initiation of treatment of tuberculosis: A cross-sectional study from rural Wardha. CHRISMED J Health Res 2019;6:12-7

How to cite this URL:
Patki GA, Raut AV, Datar S. Delay in initiation of treatment of tuberculosis: A cross-sectional study from rural Wardha. CHRISMED J Health Res [serial online] 2019 [cited 2022 May 25];6:12-7. Available from: https://www.cjhr.org/text.asp?2019/6/1/12/252285

  Introduction Top

Slow progress has led to frustration, we have the tools to end TB as a pandemic and public health threat, but we are not doing it.”

- Mark Dybul, Executive Director GFATM.

Tuberculosis (TB) has haunted the human race since time immemorial and continued to do so. Globally, TB was the second-most common cause of death from infectious disease after HIV/AIDS. Developing countries of Asia and Africa bear most of the TB burden as compared to the developed nations like the United States or the United Kingdom. Hopes of controlling TB as a public health problem would remain a distant dream because of many factors such as the expensive and time-consuming diagnostic process, prolonged treatment, the increase in HIV-associated TB, and the emergence of multidrug-resistant cases and lack of an effective vaccine.[1]

TB persisted to be one of the most important public health problems in India. It accounted for about 2.2 million incident cases, which was around 25% of global incidence.[1] The World Health Organization included India in high TB burden countries despite effective implementation of directly observed treatment short course (DOTS) under the Revised National Tuberculosis Control Programme (RNTCP).[1] In countries like India, the challenge lies not only in providing effective treatment but also in reducing the interval between suspecting TB and actually initiating the treatment. RNTCP emphasized on initiation of treatment within 7 days of diagnosis for patients with sputum smear-positive pulmonary TB (SS-PTB) as an indicator for monitoring DOTS implementation.[2]

The systematic review conducted by Sreeramareddy et al. had underscored the need to develop novel strategies for reducing patient and diagnostic delays and engaging first-contact health-care providers.[3] Similarly, a recent study by Virenfeldt et al. from Guinea-Bissau had stated that long delay in initiation of treatment of TB was associated with increased clinical severity of disease in about 33.9% patients.[4] According to another study from China, delay in treatment seemed to be a significant risk factor for increased TB infections.[5] Furthermore, delay in diagnosis and initiation of treatment increased transmission rates and mortality due to TB.[6]

Along with conventional indicators, magnitude of treatment delay would prove as a performance indicator for TB control in high TB burden countries like India.

This study, therefore, was conducted with an objective to find out the possible reasons from patient, provider, and health systems' perspective that are responsible for causing delay in initiation of the treatment of TB in a rural setting.

  Materials and Methods Top

Study design

This descriptive cross-sectional study was carried out among new SS-PTB patients who were registered with the DOTS center at Mahatma Gandhi Institute of Medical Sciences Sewagram.

Study duration

The study was conducted between the months of February and April 2015.

Study population

Patients of all age groups and both sexes were considered eligible to participate in the study. Detailed information of patients including address and phone number was obtained from the TB register maintained at the DOTS center. Of the 40 new SS-PTB patients registered at DOTS center during the study period, 34 patients had contact number recorded in the records. Of these, 30 patients could be contacted successfully and were included in the study. It was not possible to establish contact with four patients despite making multiple efforts, either the phone number was reported as being incorrect or was switched off. Contact numbers for six patients were not available in the records.

Data collection

Data were collected using a predesigned, pretested, semi-structured questionnaire. The questionnaire had questions regarding sociodemographic information, knowledge regarding TB and DOTS, health-seeking behavior, and estimation of delay. Data were collected through telephonic interviews. Before beginning the interview, the purpose of the research was explained to the participants and verbal consent was obtained. On an average, each telephonic interview required around 30–40 min. The identity of the patients who gave consent to participate in the study was kept confidential by assigning them a unique identification number. The filled questionnaires were checked before beginning the data entry for assessing the validity of information. Concerned patients were contacted again to fill the missing variables or to clarify the recorded data. Furthermore, if patients had any concerns/queries regarding their treatment or any misconceptions or if noncompliance were found, then they were counseled during the interview. Data entry checks were applied while entering the data so as to prevent wrong entry. Entered data were cleaned before performing statistical analysis. Data were entered in Microsoft Excel and analyzed using Epi Info™ 7 version developed by Centers for Disease Control and Prevention (CDC), Atlanta.

Data analysis

Descriptive analysis using frequency and percentage was carried out to assess the knowledge regarding TB and DOTS. Delay was estimated using mean and median separately for patient delay, diagnostic delay, and treatment delay as well as for total delay. Mann–Whitney U-test was used to find the factors associated with delay.

Ethical considerations

The study was initiated after getting approval from the Institutional Ethics Committee. Only the patients who gave consent to participate in the study were included in the study.

Operational definitions

The delay in treatment initiation of TB was defined and estimated as:[3]

  1. Total delay defined as time interval from the onset of symptoms until treatment initiation
  2. Patient delay defined as the time interval between onset of symptoms and the patient's first contact with a health-care provider
  3. Diagnostic delay defined as the time interval between the first consultation with a health-care provider and diagnosis
  4. Treatment delay defined as the time interval between diagnosis and initiation of anti-TB treatment.

  Results Top

Majority of the study participants (73.4%) were between 20 and 60 years with almost equal number of males and females. Very few of the study participants (6.6%) were illiterate. Around 40% of the study participants were unemployed including homemakers and students. Color of ration card was used as a proxy indicator for assessing the socioeconomic status of the participants. Most of them (70%) were above poverty line (APL). Around two-third (63.4%) of the study participants stayed in nuclear families [Table 1].
Table 1: Sociodemographic characteristics of study participants

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Diagnostic delay accounts for maximum amount (84%) of total delay. Patient delay comprises 10%, while treatment delay is 6% [Figure 1].
Figure 1: Magnitude of treatment delay with different subtypes

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Around half of the study participants (53.3%) did not know regarding the cause of TB. Only around one-fourth of the participants (26.7%) responded that TB spreads through air. Common responses given by the participants when asked about the symptoms of TB were cough (27 [90%]) and fever (16 [53.3%]). Majority of the participants (86.6%) considered the disease to be severe, while four (13.4%) did not. Majority of the participants (83.4%) said that it is important to disclose the TB status to family and friends.

Responses about diagnostic test for TB included sputum examination (17 [56.6%]), chest X-ray (14 [46.6%]), and blood sample (12 [40%]). Regarding treatment, 27 (90%) participants responded that it can be availed from government hospital, while 12 (40%) participants said that it is also available from private practitioners. Majority of the participants (86.6%) knew about availability of free of cost treatment, i.e., DOTS for TB. Reasons for preferring the particular health facility included that the health facility was closer (25 [83.3%]), better care received (14 [46.6%]), and had more trust on doctor (8 [26.6%]). Most of the patients (22 [73.3%]) were not informed about possibility of having TB, during their first contact with the health-care provider. Almost all of the participants (93.3%) had to visit more than one health-care providers or health facilities before final diagnosis of TB [Table 2].
Table 2: Knowledge about availability of directly observed treatment short course and health care seeking characteristics

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Mean total delay was 41.2 ± 27.9 days, in which patient delay comprises 6.4 ± 4.9 days, diagnostic delay accounts for 32.7 ± 19.8 days, and treatment delay for 2.1 ± 1.6 days. Median total delay was 35.5 (interquartile range [IQR]: 13–44) days. The median patient delay was found out to be 3.5 (IQR: 2–4) days. Median diagnostic delay was 30 (IQR: 14–39) days, while median treatment delay of 2 (IQR: 1–2) days was found [Table 3].
Table 3: Magnitude of delay (n=30)

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Male patients (P < 0.01) and patients belonging to Below Poverty Line (BPL) families (P < 0.05) had significantly lesser median delay as compared to females and Above Poverty Line (APL) patients. Literate patients, patients staying in nuclear families, and those who were not daily wage laborers by occupation had a lesser median delay; however, these were not found to be statistically significant [Table 4].
Table 4: Determinants of delay (n=30)

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  Discussion Top

Under RNTCP, estimation of total delay in treatment initiation for sputum-positive TB cases is an important performance indicator if the targets specified for TB in the Millennium Development Goals are to be achieved.[7] There are fewer studies conducted in rural setting for the assessment of total delay in treatment initiation of TB and its determinants.

The present study revealed that there was a median total delay of 35.5 days in the initiation of treatment of TB. It could be because TB was not suspected earlier and at least 40% of the participants had to visit four or more health-care providers before TB was diagnosed.

The median delay in the present study is lower as compared to results of a systematic review by Sreeramreddy et al. (median total delay = 55.3 days). This mostly could be because of overall better literacy status of the study population.[3] Furthermore, Kiwuwa et al. found that median total delay in patients attending National Referral Hospital, Mulago, was 12 weeks (84 days), which is more than double the findings of the present study.[6] This may be due to the difference in geographical areas.

The median patient delay of 3.5 days was <16 days found by Behera et al.[8] Median diagnostic delay was 30 days and comprised of a significant amount of total delay, which is similar to the findings of Kiwuwa et al. where health service delay was noticed to be more than 4 weeks and constituted a major portion of total delay.[6] Mean diagnostic delay obtained by the study (32.7 days) is far lesser than the findings of Behera et al., which is 60.4 days.[8] Median treatment delay obtained from the data is 2.1 days which is far lesser than that obtained by Virenfeldt et al. and Ilangovan et al.(12.1 weeks and 14 days, respectively) and this may because of the awareness created by RNTCP.[4],[9]

According to Biya et al., unsatisfactory knowledge (P = 0.04) was significantly associated with patient delay.[10] Virenfeldt et al. also concluded that low educational level is a risk factor for causing delay.[4] Zhao et al. found that the knowledge about national TB subsidy policy was associated with patient delay (Odds Ratio [OR] = 1.7).[11] In the present study, only being females and belonging to upper socioeconomic class were found to be significantly associated with delay. The association with educational status could be nonsignificant because very few of the participants were illiterate.

In a study conducted by Kar and Logaraj, only 20% of the patients were having satisfactory knowledge about TB and only 34% patients were aware about availability of free DOTS treatment for TB.[12] This is far less than the result obtained in the present study, wherein 49.9% of patients were aware of the causes and spread. High literacy rate among study participants may be the reason for better knowledge about the cause of disease. One of the possible reasons for delay in health-care seeking was lack of awareness about the severity of their symptoms, as reported by 73.3% of the study participants. Furthermore, in the present study, 86.6% of the study participants were aware of availability DOTS treatment. Television and other mass media advertisements regarding RNTCP and DOTS may have played a major role in creating awareness regarding this issue.

The study, being conducted in rural setting, goes in consistence with the findings in systematic review given by Satyanarayana et al. that patients assessing treatment from outside the RNTCP, i.e., from private practitioners were more likely from rural areas (OR = 2.5).[13] Around one-fourth (26.7%) of the patients preferred government hospital and 73.3% patients preferred private practitioners as their first point for seeking treatment, which is more than 50% and 20% population attending private sector in studies conducted by Hazarika and Kar and Logaraj, respectively.[12],[14]

Information about possibility of having TB was not given to 73.3% of patients and 53.3% of them visited 1–3 health-care providers before final diagnosis of TB, which is in accordance with Sreeramreddy et al., who stated in their systematic review that the average of 2.7 health-care providers was consulted before diagnosis.[3]

When enquired about diagnostic test for TB, the responses were Chest X-ray (46.6%), blood test (40%), and sputum examination (56.6%). First preference to private practitioners may be the reason for these responses as underlined by Bharaswadkar et al. in their study, who assessed the diagnostic practices among private practitioners in Pune, Maharashtra and 37% of provider responses were not consistent with standard diagnostic practices of using SS for the diagnosis of PTB.[15] Satyanarayana et al. also reported that less than a quarter of private practitioners ordered SS for chest symptomatic.[13]

Most of the patients (83.4%) were in favor of disclosing their TB status to others, similar to the finding by Kar and Logaraj, who found out that < 10% of the patients were not willing to disclose their TB status to others.[12] None of the patient responses mentioned about discrimination or social stigma and negligence. This is a very good result compared to the findings of Tasnim et al., where 46.6% mentioned discrimination and 21.4% felt socially neglected.[16] This may be because of variation in perception of patients about TB, educational status, and cultural factors. The findings of this study need to interpret considering its limitations of smaller sample size and possible confounders.

  Conclusions Top

In our study, we found that diagnostic delay forms a major part of total delay. Patient delay and treatment delay, though much lesser than diagnostic delay, also contribute to the total delay. For reducing diagnostic delay, sensitization of private practitioners may prove helpful as maximum population prefers the private practitioners as the first level of seeking treatment.


  • We thank Professor and Head, Department of Community Medicine, MGIMS, Sevagram, for allowing us to conduct the research in the department
  • Our sincere thanks to the staff in the DOTS center in Kasturba Hospital, Sevagram, without support of whom it would not have been possible for us to complete this research project
  • Our heartfelt thanks to all the study participants for their active participation.

Financial support and sponsorship

This short research project was done as part of the Indian Council of Medical Research's Short-Term Studentship program (ICMR STS Reference ID: 2015-00246).

Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Global Tuberculosis Report 2014. World Health Organization; 2014. Available from: http://www.apps.who.int/iris/bitstream/10665/137094/1/9789241564809_eng.pdf. [Last accessed on 2015 Oct 12].  Back to cited text no. 1
Central Tuberculosis Division. Strategy Document for Supervision and Monitoring of the Revised National Tuberculosis Control Programme. Directorate General of Health Services. Ministry of Health and Family Welfare, Government of India; 2005.  Back to cited text no. 2
Sreeramareddy CT, Qin ZZ, Satyanarayana S, Subbaraman R, Pai M. Delays in diagnosis and treatment of pulmonary tuberculosis in India: A systematic review. Int J Tuberc Lung Dis 2014;18:255-66.  Back to cited text no. 3
Virenfeldt J, Rudolf F, Camara C, Furtado A, Gomes V, Aaby P, et al. Treatment delay affects clinical severity of tuberculosis: A longitudinal cohort study. BMJ Open 2014;4:e004818.  Back to cited text no. 4
Lin X, Chongsuvivatwong V, Lin L, Geater A, Lijuan R. Dose-response relationship between treatment delay of smear-positive tuberculosis patients and intra-household transmission: A cross-sectional study. Trans R Soc Trop Med Hyg 2008;102:797-804.  Back to cited text no. 5
Kiwuwa MS, Charles K, Harriet MK. Patient and health service delay in pulmonary tuberculosis patients attending a referral hospital: A cross-sectional study. BMC Public Health 2005;5:122.  Back to cited text no. 6
United Nations, The Millennium Development Goals Report; 2015. Available from: http://www.refworld.org/docid/51f8fff34.html. [Last accessed on 2015 Oct 15].  Back to cited text no. 7
Behera BK, Jain RB, Gupta KB, Goel MK. Extent of delay in diagnosis in new smear positive patients of pulmonary tuberculosis attending tertiary care hospital. Int J Prev Med 2013;4:1480-5.  Back to cited text no. 8
Ilangovan K, Nagaraja SB, Ananthakrishnan R, Jacob AG, Tripathy JP, Tamang D, et al. TB treatment delays in Odisha, India: Is it expected even after these many years of RNTCP implementation? PLoS One 2015;10:e0125465.  Back to cited text no. 9
Biya O, Gidado S, Abraham A, Waziri N, Nguku P, Nsubuga P, et al. Knowledge, care-seeking behavior, and factors associated with patient delay among newly-diagnosed pulmonary tuberculosis patients, federal capital territory, Nigeria, 2010. Pan Afr Med J 2014;18 Suppl 1:6.  Back to cited text no. 10
Zhao X, Yang P, Gai R, Mei L, Wang X, Xu L, et al. Determinants of health care-seeking delay among tuberculosis patients in Shandong Province, China. Eur J Public Health 2014;24:757-61.  Back to cited text no. 11
Kar M, Logaraj M. Awareness, attitude and treatment seeking behaviour regarding tuberculosis in a rural area of Tamil Nadu. Indian J Tuberc 2010;57:226-9.  Back to cited text no. 12
Satyanarayana S, Subbaraman R, Shete P, Gore G, Das J, Cattamanchi A, et al. Quality of tuberculosis care in India: A systematic review. Int J Tuberc Lung Dis 2015;19:751-63.  Back to cited text no. 13
Hazarika I. Role of private sector in providing tuberculosis care: Evidence from a population-based survey in India. J Glob Infect Dis 2011;3:19-24.  Back to cited text no. 14
Bharaswadkar S, Kanchar A, Thakur N, Shah S, Patnaik B, Click ES, et al. Tuberculosis management practices of private practitioners in Pune municipal corporation, India. PLoS One 2014;9:e97993.  Back to cited text no. 15
Tasnim S, Rahman A, Hoque FM. Patient's knowledge and attitude towards tuberculosis in an urban setting. Pulm Med 2012;2012:352850.  Back to cited text no. 16


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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