Afar Region is one of the 9 regions with estimated area of 100,000 square km [8
]. The Region with its 5 zones is home to about 1.4 million people 87
% of which living in rural areas [9
]. The Region is arid and semiarid mainly inhabited by pastoralists [10
]. The health service coverage in the Region is low with only 40
% of the population accessing health facilities in 10 kilometers walk [10
]. The population in Afar Region is affected with a variety of infectious diseases. TB is a major health problem with a notification rate of 103 per 100,000 populations [11
Study design and study population
Institution-based cross-sectional study was conducted between September 2009 and March 2010 among TB patients coming to TB clinics of two health facilities in Afar Region. Because of poor infrastructure and security threats in the Region, we selected Dubti hospital and Asayta health centre, both located in Zone one where nearly a third of the Region’s population lives [9
]. Both health facilities provide diagnostic and treatment services for various illness including TB. Dubti Hospital is a general hospital with better qualified staff including medical doctors whereas Asayta health centre is mainly staffed with nurses and health officers.
years or older) diagnosed with TB of all forms according to the national TB guideline [12
] and came to TB clinics of the two health facilities were included consecutively and interviewed with a semi-structured questionnaire just before commencing treatment. Patients younger than 18
years, those started on treatment prior to interview and those who decline to respond were excluded.
A sample size of 216 was estimated by taking a proportion of 90
% diagnostic delay for more than one month from a study in a similar setting [6
], a 95
% confidence interval and a margin error of 4
Operational definitions of variables
Smear positive pulmonary TB (PTB) patients: patients with two or more sputum smears positive for AFB (acid fast bacilli) or one sputum positive for AFB and radiological abnormalities consistent with active TB.
Smear negative PTB patients: Patients with three smears negative for AFB and radiological abnormality consistent with active TB or failure to respond to antibiotic trials.
EPTB patients: TB in organs other than the lungs proven by histo-pathology or TB based on strong clinical evidence consistent with active EPTB and the decision by a physician to treat with a full course of anti-TB therapy.
Patients’ delay: The time interval between date of onset of TB symptoms and first presentation to a professional health provider.
Health system’s delay: The time interval between date of first presentation of patients to a professional health provider and initiation of treatment.
Diagnostic delay: The time interval between the onset of TB symptoms and diagnosis of TB.
Treatment delay: The time interval between date of diagnosis and initiation of treatment.
Total delay: The time interval between date of onset of TB symptoms and initiation of treatment.
Distance: The distance between place of residence and the nearest health facility at the time of illness.
Non-formal health providers: These include traditional health providers, local injectors and drug retail outlets.
Formal health providers: Professional health providers working in modern health facilities i.e. hospitals, health centres, clinics owned by the government or the private sector.
Pastoralist: People whose source of livelihood is livestock with which they move seasonally in search of pasture and water.
Self-treatment: Any kind of self-prescribed treatment taken by patients for their illness.
Pre-tested, semi-structured questionnaire was used to collect data on socio-demographic characteristics; distance of residence at the time of illness from the nearest health facility; knowledge on TB, its cause, its seriousness and its treatment (able to mention bacteria/germ as a cause of TB, able to classify TB as a transmissible disease, able to tell that untreated TB could lead to death, able to mention that TB is a treatable disease, able to mention the approximate duration of treatment, knows that the drugs are available at health facilities for free); time interval between onset of symptoms and first visit to a health facility; time interval between first visit of a health facility and diagnosis; and time interval between diagnosis and treatment were collected. One nurse at each TB clinic conducted the interview after training.
The date of onset for the main symptoms was taken as the date of onset for the illness. For PTB patients, cough was taken as the main symptom whereas for EPTB patients, either localizing symptoms like swelling for TB lymphadenitis, chest pain for TB pleurisy or constitutional symptoms (fever, night sweats, weight loss, loss of appetite) were taken as the onset of the illness whichever came first.
Data was analyzed using SPSS for Windows version 16. Since data were skewed, non- parametric tests (Mann–Whitney/Kruskal Wallis) were used in evaluating group differences. In some studies, experts agreed 30
days as acceptable cut-off for delay [13
] whereas others used median value of the observed data as a cut-off [6
] and we adopted the later to dichotomize data into delayed and not delayed. Responses to questions to assess TB knowledge were analyzed by calculating their mean and interquartile scores. Using the mean score as a cut- off, the responses were categorized into good (equal or above the mean) and poor knowledge (below the mean) and were cross-tabulated with the main outcome variables for possible associations.
Independent variables that are either significantly associated with the dependent variables on bivariate analysis or are known to be associated with the dependent variables from previous studies were selected and multivariate logistic regression was done to identify independent predictors of dependent variables. The association of predictor variables with the dependent variables was assessed by using 95
% confidence interval (CI) and adjusted odds ratio (aOR). A p-value of
0.05 was considered statistically significant.
The study has been ethically approved by the Norwegian Ethics Committee (Regionale komiteer for medisinsk og helsefaglig forskningsetikk (2009/284a)) and Ethics Committee of Aklilu Lemma Institute of Pathobiology, Addis Ababa University (01/2000 Ethiopian Calendar). Patients fulfilling the inclusion criteria were invited to participate in the study and written consent was obtained.