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DELAY IN DIAGNOSIS AMONG SPUTUM SMEAR POSITIVE TUBERCULOSIS PATIENTS IN KUCHING, SARAWAK
Deburra Peak Ngadan
L 9 I 11
Master of Public Health 2012
ACKNOWLEDGEMENTS
My special thanks and gratitude is to God Almighty who has been a constant inspiration and
guide in my life and also my academic journey.
This study would not be possible to be completed without the support from my principal and
co-supervisors, colleagues and friends. My gratitude and special thanks goes to Associate
Professor Dr Chang Ching Thon for her constant guidance and constructive advice and
criticism, Dr Cheah Whye Lian, for her dedication and support throughout this study.
Through working with them, I was able to complete this study and achieve my potential as a
researcher and student.
This study also could not have been completed without the support from the survey
respondents and unconditional support from the staffs of ATAS Clinic at Mosque Road,
Kuching. The ATAS organization personnel Mr Micheal Au has been a huge help in aiding
with materials regarding the history of ATAS and ATAS Clinic, my gratitude goes to the
organization. My heartfelt thanks to Dr Marilyn Umar for the guidance and advices spared
during the study. I would also like to thank UNIMAS lecturers and staff for supporting me
during this study.
To my beloved father, Pastor Petrus Ngadan Kuju, my deepest thank to you for helping to
review and comment the draft of this thesis. My deepest thanks go to my best friend, Dr.
i.
ABSTRACT
Tuberculosis (TB) is a global problem, and the incidence of TB in Malaysia has been above the
target of less than 40 per 100,000 population since the past 15 years (1995 - 2010). TB control
strategies have been implemented and strengthened including directly observed treatment, short
course (DOTS), BCG vaccination, early detection, treatment and contact tracing. However, the
challenge remains in early diagnosis and prompt treatment, contributed by an increase in patient
delay duration and health system delay duration. This research study used a cross-sectional survey to
examine the rate of delay duration in diagnosing sputum smear positive pulmonary TB (PTB)
patients in Sarawak. In particular, this study aimed to determine the contributing factors associated
with patient delay and health system delay in diagnosing sputum smear positive PTB patients. A
total of 115 respondents participated in this survey. The median duration for patient delay was 16
days (range 0- 730) and health system delay was 14 days (range 0-294) and based on the cut-off
point of 30 days median patient delay, there were no factors significantly associated with patient
delay. Health system delay was found to be significantly associated with the number of doctors seen
(x2= 21.097, df = 1, p<0.001), whether chest X-ray (x2=16.312, df 1, p <0.001) and sputum
examination (x2=7.400, df-- 1, p <0.05) was done during the first healthcare visit and the
unavailability of any medical diagnostic facility (x2 = 9.080, df = 2, p<0.05). The number of doctors
seen was found to a predictor for health system delay in this study (OR 0.197; 95% Cl: 0.073,0.534)
P- 0.001). In conclusion, there is still a moderately long duration of health system delay which has
been associated with factors (number of doctors seen, chest X-ray and sputum examination done for
first visits); which should be taken for consideration in managing smear positive TB patients in
Kuching. Fervent domestic contact tracing, increasing public awareness regarding latest treatment
options and locations, increasing healthcare providers awareness regarding diagnostic tools, smart
Ill.
public and private partnership needs to be strengthened to enable a prompt and timely diagnosis for
smear positive TB patients in Kuching, Sarawak.
iv.
ABSTRAK
Tuberculosis (TB) merupakan masalah global dan kadar insiden penyakit TB di Malaysia sentiasa
di atas kadar insiden sasaran iaitu kurang daripada 40 per 100,000 populasi, semenjak 15 tahun
dahulu lagi (1995 - 2010). Strategi untuk kawalan penyakit TB telah diimplementasikan dan
diperkukuhkan, termasuk perlaksanaan program directly observed treatment, short course (DOTS),
program vaksinasi BCG, diagnosa dan rawatan awal penyakit TB dan termasuk aktiviti kontak
`tracing'. Walaubagaimanapun, eabaran untuk mengenalpasti dan mendiagnosa awal, rawatan
awal termasuk halangan dari segi kadar kelewatan pesakit datang (patient delay) dan juga kadar
kelewatan sistem kesihatan (health system delay). Kajian ini telah menggunakan kaedah survey
untuk mengkaji kadar kelewatan untuk mendiagnosa kahak sputum acid fast bacilli (SAFB) positif
pesakit PTB di Sarawak. Secara spesifik, kajian ini bertujuan untuk mengenalpasti faktor-faktor
yang berkaitan dengan kelewatan pesakit datang (patient delay) dan kelewatan sistem kesihatan
(health system delay) dalam mendiagnosa TB. Sejumlah 115 peserta telah menyertai kajian ini.
Kadar median untuk kelewatan pesakit (patient delay) adalah 16 harz (0-730) dan kadar median
kelewatan sistem kesihatan (health system delay) adalah 14 han (0-294). Kadar median 30 hari telah
digunakan untuk kategorikan kelewatan pesakit, dan telah menunjukkan tiada perhubungan statistik
yang signifrkan. Kadar kelewatan sistem kesihatan telah dianalisa dengan faktor-faktor yang
mempengaruhi kelewatan adalah bilangan doktor yang telah dijumpai (X2= 21.097, df = 1, p<
0.001), tiada X-ray (1=16.312, df-=1, p <0.001) dan ujian kahak (, v2=7.400, df= 1, p <0.05) telah
diambil pada jumpaan pertama di pusat kesihatan, serta ketiadaan fasiliti untuk mendiagnosakan
TB (x2 = 9.080, df = 2, p<0.05). Bilangan doktor yang dijumpai melebihi 3 orang ke atas
merupakan faktor untuk memprediktasikan kelewatan sistem kesihatan dalam kajian ini (OR 0.197;
95% CI: 0.073,0.534; P-0.001). Sebagai kesimpulan, masih terdapat kelewatan sistem kesihatan
yang dapat dipengaruhi oleh faktor-faktor (bilangan doktor dijumpai, X-ray dada, ujian kahak
V.
semasa lawatan pertama) yang perlu diambil kira dalam pengendalian kes-kes kahak positif pesakit
TB di Kuching. Kontak 'tracing' rumahtangga, menambahkan kesedaran orang awam mengenai
rawatan yang terbaru dan lokasi-lokasi rawatan untuk TB, meningkatkan pengetahuan para
kakitangan kesihatan mengenai kaedah menggunakan ujian untuk mendiagnosa TB serta
mengeratkan perhubungan diantara pihak kesihatan awam dan swasta adalah perlu untuk mencapai
diagnosa yang tepat dan cepat terutamanya untuk pesakit TB di Kuching, Sarawak
vi.
TABLE OF CONTENTS
Acknowledgement
Abstract
Abstrak
Table of Contents
List of Tables
List of Figures
List of Abbreviations
CHAPTER 1: INTRODUCTION
1.0 Introduction
1.1 Background of the study 1.2 Problem statement 1.3 Objectives of the study
1.3.1 Specific objectives 1.4 Conceptual framework
1.5 Significance of the study 1.5.1 Contribution to literature
1.5.2 Contribution to practice 1.5.3 Contribution to future research
1.6 Operational definitions of terms CHAPTER 2: LITERATURE REVIEW
2.0 Introduction
2.1 Tuberculosis and its diagnostic procedure 2.1.1 Tuberculosis and its burden
2.2 Global prevalence of TB
2.2.1 Global prevalence of TB
2.2.2 Prevalence of tuberculosis in Malaysia and Sarawak
2.3 TB control strategies
2.4 Challenges in TB control
2.5 Definitions and factors contributing to delayed in diagnosis
2.5.1 Patient delay
2.5.2 Factors contributing to delay
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2.5.3 Health system delay
2.5.3 Treatment delay
2.5.4 Total delay
2.6 Conclusion
CHAPTER 3: METHODOLOGY
3.0 Introduction
3.1 Research design and setting 3.2 Population and sampling method
3.2.1 Inclusion criteria
3.2.2 Exclusion criteria
3.3 Research instruments
3.4 Pilot study 3.5 Ethical consideration 3.6 Data collection 3.7 Analysis of data
3.8 Conclusion
CHAPTER 4: RESULTS
4.0 Introduction
4.1 Respondent's sociodemographic characteristics 4.1.1 Healthcare facility and services
4.2 Respondent's knowledge regarding TB 4.3 Clinical symptoms during onset and presentation 4.4 Patient and health system delay
4.5 Contributing factors to patient delay
4.5.1 Contributing factors of health system delay
4.6 Predicting factors of health system delay
4.7 Treatment delay
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4.8 Association of health system delay and severity of sputum smear positive 84
TB
4.9 Conclusion 84
viii.
CHAPTER 5: DISCUSSION AND CONCLUSION
5.0 Introduction 86
5.1 Discussion on the findings 86
5.1.1 Respondent's sociodemographic characteristics 86
5.1.2 Health facilities 88
5.1.3 Duration of patient delay and health system delay 88
5.1.4 Contributing factors to patient delay 92
5.1.5 Contributing factors to health system delay 95
5.1.6 Predictors of health system delay 98
5.1.7 Treatment delay 98
5.1.8 Association of delay of diagnosis and severity of sputum smear 99
positive TB
5.2 Summary of the major findings of this study 5.3 Implications of the study 5.4 Limitations of the study 5.5 Conclusion
5.6 Recommendation
REFERENCES
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ix.
LIST OF TABLES
Table 2.1 Estimates of the burden of disease caused by TB, 1990 - 2010.20
Adapted from WHO Global Tuberculosis Control 2011.
Table 3.1. Pilot study socio-demographic characteristics (n= 24) 59
Table 4.1 Respondent's sociodemographic characteristics (n=115) 67
Table 4.2 Healthcare facility and services nearest to the respondents' residence 68
Table 4.3 Duration of patient delay, health system delay and total diagnostic 75
delay
Table 4.4 Patient delay and health system delay after categorizing with median 75
cut off of 30 days (patient delay) and 22 days (health system delay)
(n=115)
Table 4.5 Patient delay respondents' sociodemographic characteristics 77
Table 4.6 Health system delay respondents' sociodemographic characteristics 78
Table 4.7 Factors associated with patient delay (n= 115) 80
Table 4.8 Factors associated with health system delay (Delay of diagnosis), 81
n=115
Table 4.9 Logistic regression predicting factors of health system delay 83
Table 4.10 Association between severity of TB disease (X-ray finding and 84
sputum) with health system delay, n=47
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LIST OF FIGURES
Figure 1.1 Study framework for delayed in diagnosis for sputum smear positive 6
pulmonary TB
Figure 1.2 Modified from definitions of delay in diagnosis of sputum smear 8
positive pulmonary TB from Yimer, Bjune and Alene, 2005.
Figure 2.1 Smear positive AFB (M. tuberculosis) under microscopy adapted 12
from Otolaryngology Houston (2012)
Figure 2.2 Adapted from The top 10 causes of death (2008), WHO (updated 16
2011)
Figure 2.3 Number of reported new tuberculosis cases (all forms) and 21
notification rates per 100,000,1990- 2009 (Economic and Planning
Unit, MDG report 2010 at www. epu. gov. my)
Figure 2.4 Incident (notification) rate from 1995 - 2010, adapted from the 23
Annual TB Report (2003 - 2010), Sarawak State Health Department.
Figure 2.5 Flowchart of diagnosis and treatment of TB. Adapted from WHO, 26
TB Treatment: Guidelines to National TB Programme, 2003
Figure 2.6 Targets and achievement for Malaysia National TB Control 27
Program, 2006. Taken from Malaysian Association For The
Prevention Of Tuberculosis (2007)
Figure 2.7 Model of treatment delay, adapted from Storla et al (2010) - 31
Treatment delay as variable for tuberculosis.
Figure 3.1 Pilot study respondent's race 60
xii.
Figure 4.1 Respondent's response regarding TB knowledge sources (*Others: 70
friends, family members, other informal form of information).
Figure 4.2 Respondent's response regarding knowledge of TB treatment 71
duration
Figure 4.3 Respondents' duration of working with colleagues with similar 72
symptoms
Figure 4.4 Clinical symptoms during onset and presentation 74
xiii.
LIST OF ABBREVIATIONS
AFB Acid-fast bacillus
AIDS Acquired immunodeficiency syndrome
CDC Centre for Disease Control and Prevention
DALY Disability adjusted life years
DOTS Directly Observed Treatment Short Course
GP General practitioner
HIV Human Immunodeficiency Virus
ISTC Internationally accepted level of care
MDG Millennium Development Goal
NTBCP National Tuberculosis Control Programme
PTB Pulmonary tuberculosis
SAT Self-administered treatment
TB Tuberculosis
WHO World Health Organization
ziv.
CHAPTER 1
INTRODUCTION
1.0 Introduction
This chapter gives an introduction to the background of the study in Section 1.1. In Section
1.2, the problem statement is being described and the objectives of the study are found in
Section 1.3. Section 1.4 describes the conceptual framework of the study whereas Section 1.5
provides the significance of the study. Section 1.6 provides the operational definition of
terms for this study.
1.1 Background of the study
The World Health Organization (WHO) has classified Malaysia as an intermediate
tuberculosis (TB) burden country with incidence rate of less than 25-100 per 100,000
population. In Malaysia, from 1995 up to 2002, the incidence has slowly increased. The
incidence rate was 59.8 per 100,000 population in 1994 rising to 65.6 in 1999 and to 65.9 in
2000 (Aziah, 2004). In 2002, the incidence rate declined to 58.7 per 100,000 population.
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The decline of incidence rate was attributed to the strengthening of the Directly Observed
Treatment, Short Course (DOTS) programme by the Ministry of Health Malaysia. DOTS was
developed from the collective best practices, clinical trials and programmatic operations of
TB control over the past two decades. In Malaysia, DOTS was absorbed in the national
control program in the late 90s (Aziah, 2004). If this pattern of slowly declining number was
to be maintained, it can be said that the target incidence less than 40 per 100,000 populations
for all forms and 20 per 100,000 population for infectious forms (WHO, 2010) can be
achieved for Malaysia by 2010. However, the trend for the past 6 years has been slowly
increasing reaching the incidence rate of up to 82 per 100,000 population in the year 2010
(WHO, 2011).
There may be a few possible reasons to this trend occurence, including the emergence of
HIV/AIDS patients, whereby their immunocompromised state of health will increase the risk
of being manifesting with active TB. The prevalence of TB including HIV/AIDS was 107 per
100,000 population in 2010 (WHO, 2011). Another possible reason is the stigmatization still
associated with TB disease which hinders patients with symptoms from seeking medical
care, thus delaying the prompt diagnosis of TB (Dodor et al, 2008; Christian et at, 2010).
Since the 1980s, Malaysia has been fully charged to take the challenge to control TB and
strengthening the National Tuberculosis Control Programme (NTBCP) since it was launched
in 1961 (Aziah, 2004). This is in accordance to achieve the United Nations Millennium
Development Goal 6, which is to have halted by 2015 and begun to reverse the incidence of
malaria and other major diseases including TB. Therefore, issues regarding diagnostic
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timeliness of TB have been a major concern when control of TB is being highlighted,
whether locally, nationally and internationally.
1.2 Problem statement
Since the incidence target has not been achieved in recent years, the issue of timely diagnosis
and treatment initiation has been of interest in the past ten to fifteen years, parallel with the
interest of tuberculosis control. Studies have been done globally and throughout the WHO
regions. These studies were done to understand the factors, patterns of delay and its
determinants in their regional setting. Several studies had been done in Malaysia in Penang,
Kuala. L- umpur, Kedah, Sarawak and Kelantan (Hooi, 1994; Liam and Tang, 1997; Ismail,
2002; 2004; Chang and Esterman, 2007; Noor et al, 2011). These studies were done in a
tertiary chest clinic setting (Hooi, 1994); a university teaching hospital in Kuala Lumpur
(Liam and Tang, 1997); in TB clinics in rural setting (Chang and Esterman, 2007) and also
few districts in the Kelantan (Noor et al, 2011). These studies found that there were still a
considerable number of patients with delayed diagnosis of sputum smear TB.
The study published by Chang and Esterman (2007) in the state of Sarawak, Malaysia
focused on the specific issue of delay in diagnosis among pulmonary TB patients, their health
behaviours and the predicting factors for TB diagnosis delay. They found that respondents'
incomes, health-care professional first consulted and actions taken by the health-care
providers during the first consultation were significantly associated with diagnosis delay.
Females appeared to have longer delay. Also, respondents living above the poverty line had
3
diagnosis delay as they made more visits to GPs or different government clinics. The study
setting was health clinics situated in the rural areas of Sarawak. Since this study, there was no
other follow-up research done to investigate the trend of patient delay and healthcare delay in
the rural setting of Sarawak. The study by Chang and Esterman (2007) focused on rural
community as well; hence, there is a need to study the problem of delay in urban setting in
Sarawak. There also is a need to study the factors associated with patient delay and health
system delay in an urban setting in Sarawak, whether it was similar or was there any
differences in these factors.
In this present study, the rate of the delay of diagnosis in sputum smear positive pulmonary
" TB patients from the onset of their symptoms until the starting treatment was examined. The
factors associated with the delay in diagnosis were also being studied. Specifically, the
objectives of this study are described in the following paragraph.
1.3 Objectives of the study
The general objective of this study was to identify delaying factors in diagnosing TB in an
urban setting.
1.3.1 Specific objectives
Specifically, this study aimed to:
a) Examine the duration of delay of diagnosis among sputum smear positive TB patients
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b) Identify the contributing factors of `patient delay' among sputum smear positive TB
patients
c) Identify the contributing factors of `health system delay' among sputum smear
positive TB patients
d) Examine the association between health system delay and the severity of sputum
smear positive TB
1.4 Conceptual framework
Figure 1.1 illustrates the conceptual framework of the study regarding patient delay and
healthcare facility delay, as well as the key factors which contributed to the delayed
diagnosis for sputum smear positive pulmonary TB (PTB) patients.
1.5 Significance of the study
Few local studies of delay of diagnosis in sputum smear positive TB patients had been done
in recent years either the rural or urban setting in Sarawak (Chang & Esterman, 2007).
Hence, this study could contribute to existing knowledge on delay in diagnosis of TB patients
and has a potential impact on the TB control program and management policy in Sarawak.
J
Socio-demographic factors:
- Age, Gender, Occupation, Income, Education Level
Residence location:
-distance within 10 bn of healthcare centre - exvensesincurred
Health care seeking behaviour:
- duration of symptoms - number of visits
Severity of TB:
- Sputum AFB results - C-Xray results
Health care provider: - type of healthcare facility
Medical facility for diagnosis
- presence of X-ray or laboratory facility
Category of health facility of first contact for TB symptoms: - community clinic! hospital/ polyclinic
Category of health personnel for first contact for TB:
- medical assistant/ medical doctor/ specialist
h FI F
PATIENT DELAY
DELAYED DIAGNOSIS FOR SPUTUM SMEAR
POSITIVE PTB
HEALTH CARE FACILITY DELAY
Figure 1.1 Study framework for delayed in diagnosis for sputum smear positive
pulmonary TB
The information and findings found in this study might assist in further guiding the TB
management team to strengthen the community (in terms of patient delay) and also the
medical services (health system delay) in obtaining prompt diagnosis for sputum smear
positive TB patients.
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15.2 Contribution to practice
The study findings of diagnostic delay in terms of patient and health system delay would
provide invaluable information to the current knowledge regarding patient management in
Malaysia, especially Sarawak. The information could be used to guiding decision-makers in
planning, programme developments and policy making pertaining to management of TB,
locally and nationally. It would also support the existing policy need for the country to further
manage and plan to achieve the target of United Nations Millennium Development Goal 6 to
combat TB and potentially contributing to a successful strategic planning for the National TB
Control Program (NTBCP).
1.5.3 Contribution to future research
Additionally, the findings of this study could be used as a basis for future research.
1.6 Operational definition of terms
Below are some definitions of terms specifically used in this study:
PTB patients: Patients who were diagnosed as having sputum smear positive TB
based on sputum examination, clinical and radiological findings, and
aged 15 years and above who attended the Anti-tuberculosis Clinic in
Kuching.
Patient delay: Total duration referred to the duration from the onset of patient's first
symptom until the first consultation made to any healthcare facility.
(Figure 1.2). Cut-off duration is the median of 30 days based on local
study in Sarawak (Chang and Esterman, 2007).
7
Health system delay: Total duration of first consultation visit to any healthcare facility up to
the time of diagnosis done at the healthcare facility. Cut-off duration is
the median of 14 days based on local study in Sarawak (Chang and
Esterman, 2007).
Total delay: Total duration of the onset of patient's first symptom until the time of
diagnosis of sputum smear positive pulmonary TB has been made.
Treatment delay: Total duration from the diagnosis of sputum smear positive pulmonary
TB to the initiation of treatment
Health facility: Any gazetted healthcare facility, under Malaysian Medical Council,
whether it was government or private facility.
TOTAL DELAY
ýý
PATIENT DELAY
TREATMENT DELAY
HEALTHCARE SYSTEM DELAY 1- 14
f--00
ONSET OF SYMPTOMS FIRST VISIT TO HEALTHCARE DIAGNOSIS TREATMENT
Figure 1.2 Modified from definitions of delay in diagnosis of sputum smear positive
pulmonary TB from Yimer, Bjune and Alene, 2005.
8
Pulmonary TB symptoms: The presence of any of the symptoms of such as coughing, loss
of weight, haemoptysis and/or fever.
Urban residence: Respondents' residential area of urban was defined according
to the Statistic Department of Malaysia's in their 2000
Population and Housing Census defined urban areas as
"Gazette areas and their adjoining built-up areas with a
combined population of 10,000 persons or more at the time of
census. Built-up areas were defined as areas contiguous to a
gazette area and had at least 60 per cent if their population
(aged 10 years and above) engaged in non-agricultural
activities as well as 30 per cent of the housing units having
modern toilet facilities. "
Poverty Line Index: PLI consists of two components, namely, Food PLI and Non-
food PLI. PLI is determined separately for each household in
the Household Income Survey according to household size,
demographic composition and location (state and strata).
Therefore, each household has its own PLI value based on the
demographic characteristics of each household. A household is
considered poor if its monthly household income is less than its
PLI, meaning that the households lack resources to meet the
basic needs of all its members. Whereas a household is
considered as hard core poor if its monthly household income is
less than the food PLI (Zin, 2007). Gross PLI in 2007 onwards
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was RM830 for Sarawak; with hard core gross PLI of RM520
(Economic and Planning Unit, Malaysia).
10
CHAPTER 2
LITERATURE REVIEW
2.0 Introduction
This chapter has seven sections. Section 2.1 introduces TB and its diagnostic procedure; section
2.1.1 describes TB and its burden; whereas section 2.2 describes the prevalence of TB globally
and in Malaysia. Section 2.3 describes strategies of TB control and section 2.4 discusses the
challenges of TB control. In Section 2.5, the issue of delay of diagnosis, types of delay in
diagnosis and treatment in TB, includes detailing the patient delay, health system delay,
treatment delay and the total delay. The determinants and associated factors contributing to these
types of delays are being elaborated as well in this section. And finally, the conclusion of this
chapter can be found in section 2.6.
2.1 Tuberculosis and its diagnostic procedure
Tuberculosis (TB) is an infectious disease caused by the organism Mycobacterium tuberculosis
(M. tuherculosis). It can infect directly person to person, through air-borne transmission (CDC,
2012). There are several strains of mycobacterium, but the commonly infecting and causing TB
is the M. tuberculosis strain. The organism is an acid-fast bacillus (AFB), identified using
sputum examination yielding a smear stained `positive' or `negative' results under direct
11