Tuberculosis (TB) has been a continuous major public health problem. It is one of the top 10 causes of death worldwide. According to World Health Organization (WHO) TB report 2019, globally, an estimated 10 million people fell ill with TB in 2018. It is one of the main cause of deaths related to antimicrobial resistance and the leading killer of people with HIV. Sustainable development goal target 3.3 includes ending TB epidemic by 2030 [1].

Government of India has set the target to eliminate TB by 2025 [2] whereas Himachal Pradesh kept this target to achieve in 2021 [3]. In Himachal Pradesh, according to TB India report 2019, there were 16,485 cases notified in 2018. Early diagnosis of tuberculosis can reduce the mortality associated with this disease. Whereas delayed diagnosis is not only associated with increased mortality but also with the increased risk of transmission of disease to the non-infected individuals [4].

The treatment delay affects an individual, the community, a country’s health and economy. In general, it is very difficult to quantify the crisis in country’s health and economy, especially in the era of MDR-TB, from suffering and death of economically productive individuals from such preventable and treatable disease because of delayed initiation of treatment [5].

WHO conducted a multi country study in 2006 and results showed that the mean duration of delay with onset of symptoms until initiation of treatment ranged from one month to four and a half months in the different countries. According to Revised National Tuberculosis Programme (RNTCP) guidelines, patient should get his sputum examination for cough of two weeks duration and initiation of treatment within seven days [6].

Understanding the causes behind delay in diagnosis and treatment is essential for all partners involved in tuberculosis control. Delays in case-finding are common and have been studied in many countries. In low prevalence countries, delay is mainly attributed to the fact that tuberculosis is not suspected, or to disintegration of the previous infrastructure for tuberculosis control [4].

In high prevalence countries, delays are often prolonged and relate to both delays on the side of patients in seeking treatment and on the side of physicians in diagnosis. Determinants of delay include specific patient groups (i.e. women, rural versus urban residents, nationality etc.), or the availability and accessibility to health services. These studies also highlight the association between delay and an increased economic burden and mortality attributed to tuberculosis. Country-specific determinants of delay must be studied, clearly identified and addressed in order to improve the quality and effectiveness of the national tuberculosis control [7].

There is very less literature regarding the causes of delay in diagnosis and the treatment of T.B patients in Himachal Pradesh, so this cross-sectional study was planned. The objective of the study was to determine delays at patient level in seeking care, diagnostic delay at health care provider level and treatment delay of patients of tuberculosis visiting DOTS centre I.G.M.C. Shimla.

The cross-sectional study was conducted among the patients of tuberculosis diagnosed at I.G.M.C. Shimla and notified from DOTS center from 1^st August 2018 through 31^st July 2019. A consecutive sample of 105 patients was collected after satisfying the eligible criteria and obtaining consent of the patients of tuberculosis diagnosed in the I.G.M.C. Shimla:

• Inclusion Criteria: All new cases of pulmonary and extra-pulmonary TB patients aged 18 years and above were included in the study

• Exclusion Criteria: Relapse, failure, defaulters and transfer in patients were excluded from the study since it is difficult to ascertain the date of the onset of symptoms and measure delay as well as knowledge, patients who did not give consent and patients who were seriously ill

• Study Tool: A structured, validated and pre-tested questionnaire was adapted from the WHO multi country tuberculosis treatment delay survey. Questionnaire consists of basic demographic profile of patients, type of tuberculosis and associated co-morbidities, TB knowledge, attitude toward TB and regarding potential delays. Data was collected from patients at the time of their registration for treatment at DOTS centre for of anti-TB treatment

Data Collection

The interview was carried out face to face at the time of registration of the patient for treatment after obtaining written informed consent. Detailed information was collected comprising of personal and socio demo graphic data, onset of symptoms, cause of delay and health seeking behavior of patients. 

The case definitions explained below:

• New Case: A patient who is diagnosed as case of TB and had never taken anti TB drugs or had taken them for less than for a month

• Pulmonary TB: Any microbiologically confirmed or clinically diagnosed case of TB involving lung parenchyma or trachea-bronchial tree

• Extra Pulmonary TB: It refers to any microbiologically confirmed or clinically diagnosed case of TB involving organs other than lungs [8]

• Current Smokers: A person who was smoking daily or less than daily basis at the time of interview

• Never Smoker: A person who had never smoked 

• Ever Smoker: All current and past smokers considered as ever smokers [9]

• The Total Delay: It is the time interval from the onset of illness until the initiation of anti-tuberculosis drugs. It is the sum of two time intervals: diagnostic delay and treatment delay 

• Diagnostic Delay: It is the time interval between the onset of symptoms and labeling of the patient as a tuberculosis patient (>7days)

• Treatment Delay: It is the time interval between tuberculosis diagnosis and initiation of anti-tuberculosis drugs (>7 days)

• Patient Delay: The time interval between onset of symptom and presentation to a health care provider (> 15 days) [6]

Out of the 105 participants documented for study, (52.38%) were males. Only 19% were educated up to university level. Among all the participants, 47.6% were unemployed (Table 1). 

Table 1: Demographic Profile of the Study Participant

The most common levels of delays identified in study participants were patient delay and health care provider delay (Table 2).

Table 2: Levels of Delays Indentified in Study Participants

*Delay at Level of Patient Delay >15 Days, ** Delay at Level of Heath Care Provider >7 Days, *** Treatment Delay >7 Days

The mean delay at patient level was 66 days and delay at health care provider was 83 days. Total delay among participants was 130 days (Table 3).

Table 3: Time Period of Delay in the Study Participants

Among all study participants, 31.03% thought that their symptoms would go at their own. The economic constraint was found in 22.41% (Table 4).

Table 4: Reasons Cited for Diagnostic Delay at Health Care Provider Level

Reason of delay among 41.42% participants was late diagnosis at level of health care provider. Out of total, 18.5% who visited private practitioner, were not diagnosed (Table 5).

Table 5: Reasons of treatment delay

Among all the participants treatment delay was found in 7 patients only. Reason of delay was late collection of report by patients in 28.5% (Table 6).

Table 6: Risk Factors for Delay in Heath Care Seeking

In our study, it was revealed that the mean delay was 66 days. In this study, it was found that females, literate, patients of pulmonary tuberculosis had longer delay for seeking care in the health facility. Other risk factors like rural residence and smokers were associated with longer delay in seeking care but none of the above-mentioned risk factors had a significant association with the delay in seeking healthcare (Table 7). 

Table 7: Risk Factor for Delay in Diagnosis at the Level of Health Care Provider

In our study, it was found that the mean delay for diagnosis of TB at level of health care provider was 83.51±175 days and median 30 days with inter quartile range (12.5-54.75). It was revealed in this study that among all the participants males, illiterate, smokers, extra pulmonary tuberculosis and those with low income were less likely to had delayed diagnosis at the level of health care provider. Participants who had to travel less than 5 km to reach health facility showed longer delay and were found statistically significant (p<0.05) (Table 7).

Our study had observed that total mean delay from the onset of symptoms to initiation of treatment was 130 days with median of 67 days (IQR 43-103 days). WHO had also reported the mean duration of delay between onset of symptoms until treatment with anti-tuberculosis drugs ranged from one month and a half to four months in the different countries [9]. In study by Nasehi et al. [10] this delay in duration was 54 days, while Cheng et al. reported 58 days, Hussen et al. 97 days and Saifodine et al. [11] 150 days. The reasons for these differences depend on people's access to health services.

In our study patients level delay was observed in 53.5% participants for seeking care. The mean delay observed was 65 days with median of 45 and (IQR 30-60 days). A longer delay was observed in females in our study for seeking care at health facility. A study from Nepal [12] reported a longer median patient delay of 50 days and females have a longer delay in health seeking, which is almost similar to our study findings. Contrary to our findings Yamada et al. [13] also observed that women were found to have a significantly longer total delay before diagnosis of tuberculosis (median 2.3 months for men, 3.3 months for women) [13]. It was observed in the present study that the reason of delay at patients level was that 31.4% patients thought that their symptoms will go away at their own. The most of TB suspects, considering their symptoms normal, often seek help from health facility where facility for diagnosis of TB was not available, delaying timely consultation with appropriate ones. Among all the patients enrolled in our study, 37.4% felt ashamed of having diagnosed with TB. Similarly other studies conducted showed that patient’s perception and knowledge towards the TB disease do have impact on the care seeking practices [14,15]. Other reasons of delay found in our study were lack of knowledge, fear of social stigma and economic constraint. In our study patients had multiple consultations at .public hospital, private practitioner, public hospitals and ayurvedic health centre’s for seeking care. It was also reported in study conducted from south India [16]. Multiple care seeking were also reported to be associated with longer health seeking delay.

The risk factors explored for association with patient level delay were age, education, residence locality and history of smoking, type of tuberculosis, income and distance to reach health facility for treatment. Risk factor for delay in seeking treatment found in our study was low income. It was positively associated with longer delay (prevalence ratio 1.20) for seeking care at health facility but found statistically insignificant. A study conducted by Jayasri et al. [17] also reported longer delay in patients from low socio economic status.

It was also revealed in our study that patients of pulmonary TB had longer delay for seeking care. It may be due to smoker’s participants in our study because they neglect the cough which is a common symptom in pulmonary TB. It was also observed in a study conducted by Seyed Mohammad Alavi [18].

In our study it was also found that rural residence of patients showed longer delay. It may be due lack of knowledge regarding TB. In a meta-analysis study also showed that studies either included urban health facilities with patients from rural areas or included both rural and urban health facilities found rural residence to be associated with patient delay [19].

Our study had observed that mean delay of 83 days with median of 30 and (IQR 12-54 days at the level of health care provider for diagnosis of TB. The mean delay of 38-108 days was also reported in study conducted in Uganda [20]. Health care provider delay (interval between reporting to health care facility and diagnosis) reported by various studies ranged from 4.0 to 54.5 days [21]. Reasons of delay identified in our study were referral of patients from peripheral health institutions due the lack infrastructure for diagnosis, late diagnosis at public hospitals and patients visited private practitioners. It was also reported in various studies that multiple health seeking encounters contributed to the prolonged duration of health service delay in the diagnosis of Tuberculosis. It was more common among the patients from village area compared to the patients form urban area [13].

Delays at health care provider level in TB management are mediated by individual, socioeconomics and diagnostic factors. Low TB knowledge caused a delay in referring patients to health facilities, as well as a delay in tuberculosis diagnosis [17]. In rural areas peripheral health institution lacked diagnostic facilities which contributes to delay at health care provider. The longer delay was observed for pulmonary TB in our study. It may be due referral of complicated cases of pulmonary TB to tertiary care centre. Similar finding was also reported in a previous study that diagnostic delay was significantly higher among pulmonary patients [22].

A longer delay was found in present study in patients from higher socioeconomic status. It may be due to reason that they repeatedly consult different hospitals for confirming the diagnosis. This finding is contrary to findings of other studies those reported that delayed diagnosis found in patients of low socioeconomic status. Patients especially from village area, often go far away for seeking health care due to poor diagnostic facility which results delay in diagnosis [23].

The present study showed longer delay in patients who traveled less than five kilometers to reach the first health facility for seeking treatment. This delay may be due to lack diagnostic facility. This finding was also contrary to finding of other studies done in Ethiopia and North east India [23].

The mean treatment delay observed in present study was 20 days with median of 10 days (IQR 8-15). Our findings were contrary to findings of a study conducted by Arun N bhatt that showed the median delay of 4 days (IQR 3-8 days) [23]. The main reason of delay identified was late collection of reports by patients and shortage of drugs at DOTS centre.

So, to increase the awareness in the community, a mass scale awareness campaign should be started through appropriate channel. Community should be made aware regarding the importance of seeking early care and availability of free diagnostics.

There was a delay of 66 days for seeking treatment and 84 days for diagnosis of tuberculosis at health care provider level. A longer delay was revealed in smoker, residents of rural area and patients from low income group for seeking treatment. The delay at the level of health care provider was significantly associated in participants who travelled less than five kilometers to reach first health facility for seeking treatment. The delay in pulmonary patients was longer for seeking treatment and for diagnosis but it was statistically insignificant.

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