Four Degrees of Separation: Social Contacts and Health Providers Influence the Steps to Final Diagnosis of Active Tuberculosis Patients in Urban Uganda
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Date
2015
Journal Title
Journal ISSN
Volume Title
Publisher
BMC infectious diseases
Abstract
Delay in tuberculosis (TB) diagnosis adversely affects patients’ outcomes and prolongs transmission in
the community. The influence of social contacts on steps taken by active pulmonary TB patients to seek a diagnosis
has not been well examined.
Methods: A retrospective study design was use to enroll TB patients on treatment for 3 months or less and
aged ≥18 years from 3 public clinics in Kampala, Uganda, from March to July 2014. Social network analysis was
used to collect information about social contacts and health providers visited by patients to measure the
number of steps and time between onset of symptoms and final diagnosis of TB.
Results: Of 294 TB patients, 58 % were male and median age was 30 (IQR: 24–38) years. The median number of steps
was 4 (IQR: 3, 7) corresponding to 70 (IQR: 28,140) days to diagnosis. New patients had more steps and time to
diagnosis compared retreatment patients (5 vs. 3, P < 0.0001; 84 vs. 46 days P < 0.0001). Fifty-eight percent of patients
first contacted persons in their social network. The first step to initiate seeking care accounted for 41 % of the patients’
time to diagnosis while visits to non-TB providers and TB providers (without a TB diagnosis) accounted for 34 % and
11 % respectively. New TB patients vs. retreatment (HR: 0.66, 95 % CI; 1.11, 1.99), those who first contacted a non-TB
health provider vs. contacting social network (HR: 0.72 95 % CI; 0.55, 0.95) and HIV seronegative vs. seropositive patients
(HR: 0.70, 95 % CI; 0.53, 0.92) had a significantly lower likelihood of a timely final diagnosis.
Conclusions: There were four degrees of separation between the onset of symptoms in a TB patient and a final
diagnosis. Both social and provider networks of patients influenced the diagnostic pathways. Most delays occurred in
the first step which represents decisions to seek help, and through interactions with non-TB health providers. TB
control programs should strengthen education and active screening in the community and in health care settings to
ensure timely diagnosis of TB.
Description
Keywords
Separation, Social Contacts, Health Providers, Tuberculosis Patients, Uganda
Citation
Sekandi, J. N., Zalwango, S., Martinez, L., Handel, A., Kakaire, R., Nkwata, A. K., ... & Whalen, C. C. (2015). Four degrees of separation: social contacts and health providers influence the steps to final diagnosis of active tuberculosis patients in urban Uganda. BMC infectious diseases, 15(1), 1-10. DOI 10.1186/s12879-015-1084-8