Introduction
Patients and methods
Study area
Population
Data collection
Definitions
Data analysis
Traditional healers
Ethical considerations
Results
Characteristics of the study population
Sex | Distance to hospital | ||
Male | 18 | <5 km | 5 |
Female | 10 | 5–10 km | 13 |
>10 km | 10 | ||
Age (mean 46.1, median 43.5, range 18–80 years) | Children | ||
<45 | 14 | 0 | 3 |
≥45 | 14 | 1–5 | 16 |
>5 | 9 | ||
Occupation | Religion | ||
Farmer | 26 | Christian | 19 |
Student | 1 | Muslim | 1 |
Priest | 1 | Noneb
| 8 |
Education | Smokingc
| ||
No education | 11 | Yes | 0 |
Primary school, not completed | 6 | Stopped because of symptoms | 4 |
Completed primary school | 10 | No | 24 |
Secondary school, not completed | 1 | ||
Completed secondary school | 0 | ||
Marital status | Alcohold
| ||
Unmarried | 4 | Yes | 5 |
Married | 15 | Stopped because of complaints | 2 |
Widowed | 6 | No | 21 |
Divorced | 3 | ||
HIV | Type of TB | ||
Negative | 20 | Smear-positive pulmonary TB | 14 |
Positivea
| 8 | Smear-negative pulmonary TB | 12 |
CD4 0–100 | 1 | Osteal TB | 1 |
CD4 100–200 | 2 | Spinal TB | |
CD4 200–300 | 2 | 1 | |
CD4 300–500 | 2 | ||
CD4 >500 | 1 |
Patient number | Sex | Age (years) | First symptom | TB signs and symptoms | Osteoarticular abnormalities | X-ray | TB diagnosis | HIV status | |||
---|---|---|---|---|---|---|---|---|---|---|---|
Sputum ZN | Cough >21 days | Fever/night sweats | Weight loss | ||||||||
1 (Laura) | Female | 61 | Pain knee and hip | Negative | Yes | Yes | Yes | Localised pain right hip | Erosion of femoral head and joint space narrowing | Hip osteal TB | Negative |
2 (Steve) | Male | 42 | Fatigue | Positive | Yes | Yes | Yes | Ghon focus with bronchopneumonic consolidation | Smear-positive pulmonary TB | Negative | |
3 (Maria) | Female | 42 | Chest pain | Positive | Yes | Yes | Yes | Not performed | Smear-positive pulmonary TB | Negative | |
4 (Jacob) | Male | 54 | Fatigue | Positive | Yes | Yes | Yes | Not performed | Smear-positive pulmonary TB | Positive | |
5 | Male | 64 | Fatigue | Positive | Yes | Yes | Yes | Not performed | Smear-positive pulmonary TB | Negative | |
6 | Male | 27 | Chest tightness | Positive | Yes | Yes | Yes | Not performed | Smear-positive pulmonary TB | Positive | |
7 | Female | 66 | Chest tightness | Positive | Yes | Yes | Yes | Not performed | Smear-positive pulmonary TB | Negative | |
8 | Male | 31 | Chest pain | Positive | Yes | Yes | Yes | Cavernous TB | Smear-positive pulmonary TB | Negative | |
9 | Male | 47 | Cough | Positive | Yes | Yes | Yes | Not performed | Smear-positive pulmonary TB | Positive | |
10 (Lena) | Female | 52 | Cough | Positive | Yes | Yes | Yes | Not performed | Smear-positive pulmonary TB | Negative | |
11 | Male | 71 | Cough | Positive | Yes | Yes | No | Not performed | Smear-positive pulmonary TB | Negative | |
12 | Male | 26 | Fatigue | Negative | No | Yes | Yes | Truncal rigidity, spinal gibbus | Erosion of vertebral centra and disc space narrowing | Spinal TB | Negative |
13 | Male | 18 | Weight loss | Negative | Yes | Yes | Yes | Bronchopneumonic consolidation | Smear-negative pulmonary TB | Negative | |
14 (Sam) | Male | 46 | Fatigue | Positive | Yes | No | Yes | Not performed | Smear-positive pulmonary TB | Positive | |
15 | Male | 21 | Chest pain and chest tightness | Negative | Yes | Yes | Yes | Bronchopneumonic consolidation | Smear-negative pulmonary TB | Negative | |
16 | Male | 78 | Chest pain | Negative | Yes | Yes | Yes | Cavernous TB | Smear-negative pulmonary TB | Negative | |
17 | Male | 22 | Cough | Positive | Yes | Yes | Yes | Cavernous TB and pleural effusion | Smear-positive pulmonary TB and pleural TB | Negative | |
18 | Male | 45 | Chest tightness | Positive | Yes | Yes | Yes | Not performed | Smear-positive pulmonary TB | Positive | |
19 (George) | Male | 80 | Breathing difficulties | Negative | Yes | No | Yes | Ghon’s complex | Smear-negative pulmonary TB | Negative | |
20 | Female | 68 | Fever | Negative | Yes | Yes | Yes | Cavernous TB | Smear-negative pulmonary TB | Negative | |
21 (David) | Male | 35 | Fever | Negative | Yes | Yes | Yes | Ghon focus with bronchopneumonic consolidation | Smear-negative pulmonary TB | Negative | |
22 | Female | 20 | Chest tightness | Positive | Yes | Yes | No | Not performed | Smear-positive pulmonary TB | Negative | |
23 | Male | 61 | Fever | Negative | Yes | Yes | Yes | Bronchopneumonic consolidation | Smear-negative pulmonary TB | Negative | |
24 | Female | 30 | Cough | Negative | Yes | Yes | Yes | Cavernous TB | Smear-negative pulmonary TB | Positive | |
25 (Marc) | Male | 40 | Fever | Negative | Yes | Yes | Yes | Ghon’s complex and bronchiectasis | Smear-negative pulmonary TB | Positive | |
26 | Female | 70 | Headache | Negative | Yes | Yes | Yes | Ghon focus with bronchopneumonic consolidation | Smear-negative pulmonary TB | Negative | |
27 | Female | 37 | Cough | Negative | Yes | Yes | Yes | Bronchopneumonic consolidation | Smear-negative pulmonary TB | Positive | |
28 | Female | 19 | Chest pain | Negative | Yes | Yes | Yes | Cavernous TB | Smear-negative pulmonary TB | Negative |
Factors associated with delay
Patient number | First contact person | Advised/forced to visit non-hospital health provider (what provider, lead to visit?) | Contact person (s) that advised/forced to visit Sumve DDH (lead to hospital visit?) | First health provider visited (TB diagnosed in this visit?) | Visits made before TB diagnosis in Sumve DDHb
| Median total delayc (days) | Median patient delay (days) | Median provider delay (days) | Median diagnostic delay (days) | Median treatment delay (days) | Median health system delayd (days) |
---|---|---|---|---|---|---|---|---|---|---|---|
1 (Laura) | Neighbours | Advised by neighbours, former TB patient (no) | Other hospitala (no) | 237 | 14 | 0 | 220 | 3 | 223 | ||
2 (Steve) | Family member | Advised by son-in-law (dispensary, yes) | Sumve DDH (no) | Traditional healer, dispensary | 1,146 | 31 | 0 | 1,115 | 0 | 1,115 | |
3 (Maria) | Neighbour | Advised by neighbour (traditional healer, yes) | Advised by former TB patient (no) | Dispensary (no) | Traditional healer, pharmacy | 159 | 120 | 36 | 3 | 0 | 3 |
4 (Jacob) | Traditional healer | Advised by former TB patient (yes) | Traditional healer (no) | Pharmacy | 235 | 14 | 205 | 16 | 0 | 16 | |
5 | Partner | Advised by wife (traditional healer, yes) | Advised by former TB patient (no) | Pharmacy (no) | Traditional healer, dispensary | 83 | 21 | 57 | 2 | 3 | 5 |
6 | Family member | Advised by former TB patient (yes) | Traditional healer (no) | Pharmacy, dispensary | 600 | 546 | 51 | 3 | 0 | 3 | |
7 | Family member | Sumve DDH (no) | 595 | 190 | 0 | 403 | 2 | 405 | |||
8 | Dispensary personnel | Advised by neighbours (yes) | Dispensary (no) | Other hospitala
| 160 | 45 | 96 | 18 | 1 | 19 | |
9 | Hospital personnel | Advised by former TB patient (no) | Pharmacy (no) | 94 | 14 | 74 | 4 | 2 | 6 | ||
10 (Lena) | Partner | Forced by older brother and husband (traditional healer, yes) | Forced by older brother and husband (yes) | Other hospitala (no) | Traditional healer, Sumve DDH | 443 | 396 | 0 | 46 | 1 | 47 |
11 | Family members | Advised by family members (yes) | Sumve DDH (no) | 520 | 367 | 0 | 152 | 1 | 153 | ||
12 | Traditional healer | Advised by father (traditional healer, yes) | Advised by traditional healer (yes) | Traditional healer (no) | Pharmacy, Sumve DDH, traditional healer | 917 | 7 | 603 | 307 | 0 | 307 |
13 | Family member | Forced by mother (pharmacy, yes) | Forced by mother (yes) | Pharmacy (no) | 32 | 3 | 11 | 9 | 9 | 18 | |
14 (Sam) | Neighbours | Advised by neighbours (traditional healer, no) | Advised by neighbours (yes) | Pharmacy (no) | Sumve DDH, Sumve DDH | 335 | 95 | 34 | 206 | 0 | 206 |
15 | Family member | Forced by grandmother (dispensary, yes) | Forced by grandmother (yes) | Dispensary (no) | Sumve DDH | 226 | 45 | 157 | 22 | 2 | 24 |
16 | Pharmacy personnel | Advised by family members (yes) | Pharmacy (no) | 300 | 62 | 234 | 4 | 0 | 4 | ||
17 | Family members | Forced by older family members (traditional healer, yes) | Advised by traditional healer (yes) | Other hospitala (no) | Pharmacy, traditional healer | 177 | 14 | 0 | 163 | 0 | 163 |
18 | Family members | Forced by older family members (traditional healer, yes) | Forced by older family members (yes) | Traditional healer (no) | Other hospitala
| 199 | 122 | 14 | 62 | 1 | 63 |
19 (George) | Traditional healer | Advised by neighbours, former TB patients (no) | Traditional healer (no) | 759 | 21 | 732 | 5 | 1 | 6 | ||
20 | Pharmacy personnel | Advised by former TB patients (no) | Pharmacy (no) | 59 | 4 | 28 | 13 | 14 | 27 | ||
21 (David) | Family member | Forced by older brother (traditional healer, yes) | Advised by traditional healer (yes) | Pharmacy (no) | Other hospitala, traditional healer | 41 | 0 | 4 | 36 | 1 | 37 |
22 | Pharmacy personnel | Advised by dispensary personnel (yes) | Pharmacy (no) | Traditional healer, dispensary, Sumve DDH | 81 | 7 | 66 | 7 | 1 | 8 | |
23 | Family members | Advised by neighbours (traditional healer, no) | Advised by family members (yes) | Sumve DDH (yes) | 71 | 61 | 0 | 9 | 1 | 10 | |
24 | Family members | Advised by family members (traditional healer, yes) | Advised by family member (yes) | Traditional healer (no) | Dispensary | 240 | 151 | 27 | 61 | 1 | 62 |
25 (Marc) | Hospital personnel | Advised by neighbour (yes) | Other hospitala (no) | Pharmacy, traditional healer, Sumve DDH | 160 | 7 | 0 | 152 | 1 | 153 | |
26 | Traditional healer | Traditional healer (no) | Pharmacy | 40 | 14 | 16 | 8 | 2 | 10 | ||
27 | Traditional healer | Advised by neighbours, family members (no) | Traditional healer (no) | Pharmacy, dispensary, other hospitala
| 83 | 8 | 37 | 36 | 2 | 38 | |
28 | Family member | Forced by grandmother (traditional healer, yes) | Forced by grandmother (yes) | Traditional healer (no) | 92 | 0 | 80 | 8 | 4 | 12 |
Smear-negative | Smear-positive | p value | |
---|---|---|---|
Sex | 0.43 | ||
Female | 6 | 4 | |
Male | 8 | 10 | |
Patient delay in days | 0.07 | ||
1st quartile (<8) | 6 | 1 | |
2nd quartile (8–20) | 3 | 3 | |
3rd quartile (21–113) | 4 | 4 | |
4th quartile (>113) | 1 | 6 | |
Provider delay in days | 0.05 | ||
1st quartile (<1) | 3 | 5 | |
2nd quartile (1–30) | 5 | 1 | |
3rd quartile (31–78) | 1 | 6 | |
4th quartile (>78) | 5 | 2 | |
Health system delay in days | 0.29 | ||
1st quartile (<9) | 2 | 5 | |
2nd quartile (9–25) | 5 | 2 | |
3rd quartile (26–152) | 4 | 2 | |
4th quartile (>152) | 3 | 5 | |
Total delay in days | 0.20 | ||
1st quartile (<9) | 5 | 1 | |
2nd quartile (9–25) | 3 | 5 | |
3rd quartile (26–152) | 4 | 3 | |
4th quartile (>152) | 2 | 5 |
Patient and provider delay and care-seeking
Reasons to delay a hospital visit
Before I got TB, I knew nothing about this illness. People from my village just mention TB as a disease that should be treated by hospital medication. They say that when you have TB, you should not go to the traditional healer. Anything else about TB, its causes and symptoms, they do not say. (David, 35-year-old male, sputum-smear-negative pulmonary TB)
I just stayed home because I was afraid I was suffering from HIV. I was not coughing too much, my family hardly noticed it. As I got thinner, the fear that I was suffering from HIV became bigger, really, I was so afraid to be HIV-infected! I feared to get that result when coming to the hospital; however, the HIV test was negative. Apparently, the symptoms of these diseases are similar. (Lena, 52-year-old female, sputum-smear-positive pulmonary TB)
I got ALU (Artemether Lumefantrine) and acetaminophen at the dispensary […] I went back again because 2 weeks after finishing the ALU and acetaminophen, I kept on coughing and feeling chest pain; there, I was prescribed ALU and acetaminophen again. The second course of ALU did not improve anything either, so I returned to the dispensary for the third time, just to get ALU and acetaminophen again. (Maria, 42-year-old female, sputum-smear-positive pulmonary TB)
When they investigate you in a hospital and the disease appears, it is a punishment of God. My disease appeared here in the hospital, so it is a disease given by God. However, if your disease does not appear when you are investigated in the hospital, the reason must be that you are cursed; that it is a witchcraft disease. (Jacob, 54-year-old male, sputum-smear-positive pulmonary TB)
The traditional healer confirmed my suspicions that somebody had put an evil spell on me. Me and my first wife, we had seven children. My second wife now wanted to punish me for the fact that I did not give her any children. (Steve, 42-year-old male, sputum-smear-positive pulmonary TB)
Now I realise it has nothing to do with witchcraft, like I thought in the past. It is a punishment of God. He pushes the wind that contains TB in the direction of the person that will subsequently develop TB. (Maria, 42-year-old female, sputum-smear-positive pulmonary TB)
I wanted to go to the hospital, but I did not have the money, so I went to a traditional healer first as I could pay him with goats. After being treated by him for a long time, my children sold my cows to get money for the treatment in Sumve hospital. (George, 80-year-old male, sputum-smear-negative pulmonary TB)
Role of relatives and neighbours in care-seeking
I felt a sharp chest pain, was coughing and suffered from fever. When the cough got worse, other people told me I might be suffering from a second tongue coming out of my throat and should visit a traditional healer. However, I did not really think this; I thought I just had a normal fever, just the fever you get sometimes and from which you recover with some medicine from the pharmacy. (Sam, 46-year-old male, sputum-smear-positive TB)
Health system delay
The first time I was prescribed chloramphenicol tablets for 2 weeks. Since the hip pain remained, I went back to the hospital 2 weeks later. I was given amoxicillin for 2 months and a pelvic X-ray was taken. They told me I might be having osteal TB but I did not get TB treatment […] I went to the hospital for the third time. They told me to continue amoxicillin for 2 more weeks. (Laura, 61-year-old female, hip osteal TB)
When I did not get better with the hospital medication, I thought that not God but witchcraft forces were making me ill. When witches spread cursed water on the road and you are the first one walking on that road, you are bewitched. For these diseases, we go to the traditional healer. (Marc, 40-year-old male, sputum-smear-negative pulmonary TB)
Traditional healers
Patients with fast breathing or dirty sputum I send to the hospital. But then, when I see an ill person coughing, and he coughs until there is really no breath left so that he can not stay inside the house anymore but has to go outside to get breath again, that one, I know he’s not suffering from TB. This is typically a cardiac disease. When this person coughs, it smells a lot. This I can treat, really, since this is not TB but a cardiac problem. (John, traditional healer since 1989)