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Abstract：
BACKGROUND: Tuberculosis (TB) infectiousness decreases significantly with only a few days of treatment, but delayed diagnosis often leads to late treatment initiation. We conducted a sequential explanatory mixed methods study to understand the barriers and facilitators to prompt diagnosis among people with TB.
METHODS: We enrolled 100 adults who started TB treatment in the Carabayllo district of Lima, Peru, between November 2020 and February 2022 and administered a survey about their symptoms and healthcare encounters. We calculated total diagnostic delay as time from symptom onset to diagnosis. We conducted semi-structured interviews of 26 participants who had a range of delays investigating their experience navigating the health system. Interview transcripts were inductively coded for concepts related to diagnostic barriers and facilitators.
RESULTS: Overall, 38% of participants sought care first from public facilities and 42% from the private sector. Only 14% reported being diagnosed with TB on their first visit, and participants visited a median of 3 (interquartile range [IQR] health facilities before diagnosis. The median total diagnostic delay was 9 weeks (interquartile range [IQR] 4-22), with a median of 4 weeks (IQR 0-9) before contact with the health system and of 3 weeks (IQR 0-9) after. Barriers to prompt diagnosis included participants attributing their symptoms to an alternative cause or having misconceptions about TB, and leading them to postpone seeking care. Once connected to care, variations in clinical management, health facility resource limitations, and lack of formal referral processes contributed to the need for multiple healthcare visits before obtaining a diagnosis. Facilitators to prompt diagnosis included knowing someone with TB, supportive friends and family, referral documents, and seeing a pulmonologist.
CONCLUSIONS: Misinformation about TB among people with TB and providers, poor accessibility of health services, and the need for multiple encounters to obtain diagnostic tests were major factors leading to delays. Extending the hours of operation of public health facilities, improving community awareness and provider training, and creating a formal referral process between the public and private sectors should be priorities in the efforts to combat TB.
METHODS: We enrolled 100 adults who started TB treatment in the Carabayllo district of Lima, Peru, between November 2020 and February 2022 and administered a survey about their symptoms and healthcare encounters. We calculated total diagnostic delay as time from symptom onset to diagnosis. We conducted semi-structured interviews of 26 participants who had a range of delays investigating their experience navigating the health system. Interview transcripts were inductively coded for concepts related to diagnostic barriers and facilitators.
RESULTS: Overall, 38% of participants sought care first from public facilities and 42% from the private sector. Only 14% reported being diagnosed with TB on their first visit, and participants visited a median of 3 (interquartile range [IQR] health facilities before diagnosis. The median total diagnostic delay was 9 weeks (interquartile range [IQR] 4-22), with a median of 4 weeks (IQR 0-9) before contact with the health system and of 3 weeks (IQR 0-9) after. Barriers to prompt diagnosis included participants attributing their symptoms to an alternative cause or having misconceptions about TB, and leading them to postpone seeking care. Once connected to care, variations in clinical management, health facility resource limitations, and lack of formal referral processes contributed to the need for multiple healthcare visits before obtaining a diagnosis. Facilitators to prompt diagnosis included knowing someone with TB, supportive friends and family, referral documents, and seeing a pulmonologist.
CONCLUSIONS: Misinformation about TB among people with TB and providers, poor accessibility of health services, and the need for multiple encounters to obtain diagnostic tests were major factors leading to delays. Extending the hours of operation of public health facilities, improving community awareness and provider training, and creating a formal referral process between the public and private sectors should be priorities in the efforts to combat TB.
摘要：
背景：只有几天的治疗，结核病（TB）传染性显着降低，但是延迟诊断通常会导致延迟开始治疗。我们进行了一项连续的解释性混合方法研究，以了解结核病患者中提示诊断的障碍和促进因素。
方法：我们在利马的Carabayllo区招募了100名开始结核病治疗的成年人，秘鲁,在2020年11月至2022年2月之间，并进行了一项关于他们的症状和医疗保健遭遇的调查。我们将总诊断延迟计算为从症状发作到诊断的时间。我们对26名参与者进行了半结构化访谈，这些参与者有一系列延误，调查了他们在卫生系统中的经验。面试笔录对与诊断障碍和促进者有关的概念进行了归纳编码。
结果：总体而言，38%的参与者首先从公共设施寻求护理，42%从私营部门寻求护理。只有14%的人在第一次就诊时被诊断为结核病，参与者在诊断前访问了中位数为3（四分位距[IQR]的医疗机构。中位总诊断延迟为9周（四分位距[IQR]4-22），与卫生系统接触前的中位数为4周（IQR0-9），与卫生系统接触后的中位数为3周（IQR0-9）。提示诊断的障碍包括参与者将他们的症状归因于其他原因或对结核病有误解。导致他们推迟寻求治疗。一旦连接到护理，临床管理的变化，卫生设施资源限制，缺乏正式的转诊流程导致在获得诊断之前需要多次医疗就诊.提示诊断的促进者包括认识结核病患者，支持朋友和家人,推荐文件，去看肺科医生.
结论：结核病患者和提供者中有关结核病的错误信息，医疗服务的可及性差，需要多次接触以获得诊断测试是导致延误的主要因素。延长公共卫生设施的运行时间，提高社区意识和提供者培训，在公共和私营部门之间建立正式的转诊程序应该是防治结核病工作的优先事项。
方法：我们在利马的Carabayllo区招募了100名开始结核病治疗的成年人，秘鲁,在2020年11月至2022年2月之间，并进行了一项关于他们的症状和医疗保健遭遇的调查。我们将总诊断延迟计算为从症状发作到诊断的时间。我们对26名参与者进行了半结构化访谈，这些参与者有一系列延误，调查了他们在卫生系统中的经验。面试笔录对与诊断障碍和促进者有关的概念进行了归纳编码。
结果：总体而言，38%的参与者首先从公共设施寻求护理，42%从私营部门寻求护理。只有14%的人在第一次就诊时被诊断为结核病，参与者在诊断前访问了中位数为3（四分位距[IQR]的医疗机构。中位总诊断延迟为9周（四分位距[IQR]4-22），与卫生系统接触前的中位数为4周（IQR0-9），与卫生系统接触后的中位数为3周（IQR0-9）。提示诊断的障碍包括参与者将他们的症状归因于其他原因或对结核病有误解。导致他们推迟寻求治疗。一旦连接到护理，临床管理的变化，卫生设施资源限制，缺乏正式的转诊流程导致在获得诊断之前需要多次医疗就诊.提示诊断的促进者包括认识结核病患者，支持朋友和家人,推荐文件，去看肺科医生.
结论：结核病患者和提供者中有关结核病的错误信息，医疗服务的可及性差，需要多次接触以获得诊断测试是导致延误的主要因素。延长公共卫生设施的运行时间，提高社区意识和提供者培训，在公共和私营部门之间建立正式的转诊程序应该是防治结核病工作的优先事项。
