The present study is one of the few studies of tuberculosis delay performed in countries with an intermediate burden of TB and the first one exploring health system delays in Croatia. We found that the median health system delay was 15 days. Numerous studies conducted elsewhere report longer delays [2, 12, 16–22], although a few studies show shorter delays [13, 23–25].
Among demographic factors, only the female gender was found to be significantly associated with both a long and extreme delay. This finding was also reported in other countries [18, 22, 26–28], usually without proper explanation. In some of these countries (Uganda, Bangladesh) [22, 26], cultural factors which might not have been relevant for Croatian females were likely to be involved. In our study, TB was clearly suspected and investigated more readily among men, although women did not seek care any later than men, as had previously been thought . Therefore, this interesting finding warrants further investigation. Although it cannot be explained why women experienced delay in being treated, it is clear that women with symptoms suggestive of TB should receive more attention after seeking care.
The symptoms most frequently reported by patients were a cough, fatigue and weight loss. Unexpectedly, median delays were the same or similar both in the case of having one of the symptoms or having none. In addition, the presence of other symptoms was significantly associated with a long delay. Symptoms, either usual or not, are obviously not thought to be alarming and/or TB-related.
One of the challenges of diagnosing TB in primary care is to distinguish the symptoms of TB from those of other common respiratory diseases especially common in settings where community-acquired pneumonia and other lung diseases are more frequent than TB . However, physicians have to be aware that a certain number of patients seeking medical assistance with symptoms of respiratory tract infections may have TB. It has been estimated that, on average, each general practitioner/family practice physician in Croatia has one TB patient every two years . Under these circumstances, it is easy to neglect many important issues in TB management and control, resulting from a lack of experience and expertise which had previously been found to be associated with health system delays . There was also a significant association between the sputum-smear status and health system delay among patients with negative smears who had double the median, as recently reported [27, 32, 33]. Smear-negative TB was obviously more difficult to diagnose and may have required an assessment of the response to antibiotic treatment, as well as chest radiography. These findings also indicate the urgent need for a more robust diagnostic test for diagnosing smear-negative cases in a timely manner.
The findings of this study need to be interpreted in the light of certain limitations. There may be a recall bias with reference to the symptoms and the timeliness of the health providers consulted. However, the participants were included prospectively and interviewed within one month after the TB diagnosis was made. Moreover, interviewers had received special training in two-day courses for proper data collection and control through as many sources as possible. This approach is believed to have minimised the bias. Another limitation of this study was the lack of data on the first point of contact with health professionals consulted for TB symptoms. However, the Croatian health care system is geared towards general practitioners/family practice physicians providing health care irrespective of socioeconomic class. If necessary, patients are referred to a specialist and TB drugs are available on prescription, and only on prescription. The few exceptions to this rule (emergency care, private doctor visit) are not likely to have significantly influenced our results.
The strength of this study lies in the fact that it was purpose designed. Secondly, this study covered almost 50% of all Croatian TB cases during the preceding year and more than 50% of the overall Croatian population in randomly selected counties. The dual TB notification system (physician and laboratory notification) had been successfully implemented since 1998 and so it can confidently be assumed that all confirmed cases were included in this study. Moreover, a larger sample size or more participating counties might have caused an under- or overestimation of delay.