Pulmonary Tuberculosis in Mumbai, India: Factors Responsible for Patient and Treatment Delays

Purpose: To determine the factors responsible for patient delay and treatment delay in newly diagnosed sputum smear-positive pulmonary tuberculosis (TB) patients. Methods: Study subjects (N = 150) were randomly selected from municipal health centers in Mumbai, India. Duration of symptoms, treatment, and reason for delay were assessed using interviews and medical records. We defined patient delay as presentation to a health care provider (HCP) >20 days of the onset of TB-related symptoms and treatment delay as therapy initiated more than 14 days after the first consultation (for TB-related symptoms) with an HCP. Results: Of the 150 subjects, 29% had patient delays and 81% had treatment delays. In multivariable analysis, patient delay was significantly associated with the self-perception that initial symptoms were due to TB [odds ratio (OR) = 3.8, 95% confidence interval (CI) = 1.1-12.6] and perceived inability to pay for care (OR = 2.9, 95% CI = 1.2-7.1). Treatment delay was significantly associated with consulting a non-allopathic provider (OR = 12.3, 95% CI = 1.4-105) and consulting >3 providers (OR = 5.0, 95% CI = 1.4-17.4). Patient interval was half the treatment interval (median days: 15 vs. 31). Women were slightly more likely to experience patient and treatment delays than men. For two-thirds of the patients, another TB patient was a source of TB-related knowledge, while health education material (16%) and television (10%) played a smaller role. Conclusion: Treatment delay, primarily due to diagnosis delay, was a greater problem than patient delay. Expanding public-public and public- private partnerships and regular training sessions for HCPs might decrease treatment delay. Media coverage and cured TB patients as peer advocates may help to reinforce TB-related health education messages.