Mark Johnuel M. Duavis1,2,3*
1MSN, College of Nursing – Graduate Studies
Cebu Normal University, Cebu City 6000 Philippines
2Development Management Officer, Department of Health
Regional Office VII, Cebu City 6000 Philippines
3Medical Student, University of Cebu School of Medicine
Mandaue City 6014 Cebu, Philippines
Tuberculosis (TB) remains a major public health dilemma in the Philippines. While free and effective TB diagnosis and treatment are available since 1996, a number of patients still delay accessing them. This study was aimed at measuring the TB patient’s average health care seeking delay (HCSD) from symptom onset to presentation at the directly observed treatment short-course (DOTS) facility and identifying its significant determinants. A descriptive, analytical, correlational, cross-sectional survey was done to 127 newly-diagnosed TB patients from 10 government-owned TB DOTS facilities in Cebu City from May–July 2017. Respondents were categorically grouped into “prompt health seekers” and “delayed health seekers” using a 49-d norm-referenced median dichotomy. A mean HCSD of 59 d was recorded. Seventy-five percent (75%) of the respondents experienced cough. At the onset of symptoms, more than a third of them reported not having any knowledge about TB-related symptoms nor were aware of the available public TB services. Most respondents have made 2–3 prior health recourses, mostly through self-medication (51%), before finally contacting a DOTS facility. Thirty-one percent (31%) of them first contacted a private medical clinic before any other health care provider or institution. On univariate analysis, seven independent variables – namely, marital status (p = 0.044), number of symptoms experienced (p = 0.000), type of symptom first experienced (p = 0.016), perceived dangerousness of all the symptoms experienced (p = 0.009), perceived dangerousness of the first symptom experienced (p = 0.001), perceived social stigma (p = 0.035), and perceived social support (p = 0.002) – were found to significantly determine health-seeking delays. On multivariate analysis, the presence of marital partners (p-value 0.014) and a low level of perceived social support (p-value 0.038) are significant determinants of longer delays. With these extended delays, expanding TB interventions to include family engagement, social mobilization, and the creation of social support groups is recommended to increase the country’s TB notification rate.
ALMEIDA CP, SKUPIEN EC, SILVA DR. 2015. Health Care Seeking Behavior and Patient Delay in Tuberculosis Diagnosis. Cadernos de Saúde Pública, Rio de Janeiro.
AUER C, SAROL JJ, TANNER M, WEISS M. 2000. Health seeking and perceived causes of tuberculosis among patients in Manila, Philippines. Tropical Medicine and International Health 5(9): 648–656
BARBER D, CASQUEJO E, YBANEZ P, PINOTE M, CASQUEJO L, PINOTE L, …, YOUNG A. 2017. Prevalence and correlates of antibiotic sharing in the Philippines: antibiotic misconceptions and community-level access to non-medical sources of antibiotics. Tropical Medicine and International Health 22(5): 567–575
BRUNICARDI FC, ANDERSEN DK, BILLIAR TR, DUNN DL, HUNTER JG, KAO LS, …, POLLOCK RE. 2019. Chest Wall, Lung, Mediastinum, and Pleura. In: Schwartz’s Principles of Surgery, 11th Edition, Volume 1. McGraw-Hill Education. 680p.
BURGESS CC, HUNTER MS, RAMIREZ AJ. 2001. A qualitative study of delay among women reporting symptoms of breast cancer. British Journal of General Practice 51: 967–971
CAMBANIS A, YASSIN M, RAMSAY A, SQUIRE SB, ARBID EI, CUEVAS L. 2005. Rural poverty and delayed presentation to tuberculosis Services in Ethiopia. Tropical Medicine and International Health 10(4): 330–335.
[CDC] United States Centers for Disease Control and Prevention. 2013. Antibiotic Resistance Threats in the United States. Atlanta, GA.
COHEN S, HOBERMAN H. 1983. Positive events and social supports as buffers of life change stress. Journal of Applied Social Psychology 13: 99–125.
COHEN S, MERMELSTEIN R, KAMARCK T, HOBERMAN HM. 1985. Measuring the functional components of social support. In: Social support: theory, research, and applications. Sarason IG, Sarason BR eds.
[DOH] Department of Health. 2012. National objectives for health Philippines, 2011–2016. Health Policy Development and Planning Bureau.
[DOH] Department of Health. 2014. National Tuberculosis Control Program Manual of Procedures Fifth Edition. Retrieved on 05 Dec 2017 from www.doh.gov.ph/sites/default/fi les/ ntp_2001.html
GLANZ K, RIMER B, VISWANATH K. 2008. Health Behavior and Health Education, theory, research and practice, 4th edition. Jossey-Bass [a Wiley Imprint].
GEBEYEHU E, AZAGE M, ABEJE G. 2014. Factors Associated with Patient’s Delay in Tuberculosis Treatment in Bahir Dar City Administration, Northwest Ethiopia. BioMed Research International.
GOVERNMENT OF THE PHILIPPINES. 2015. Republic Act 10918: an act regulating and modernizing the practice of pharmacy in the Philippines, repealing for the purpose Republic Act numbered five thousand nine hundred twenty-one (RA No. 5921), otherwise known as the Pharmacy Law. Metro Manila, Philippines.
HARGREAVES J, BOCCIA D, EVANS C, ADATO M, PETTRICREW M, PORTER J. 2011. The Social Determinants of Tuberculosis: From Evidence to Action. American Journal of Public Health.
HU A, LOO E, WINCH P, SURKAN P. 2012. Filipino Women’s Tuberculosis Care Seeking Experience in an Urban Poor Setting: A Socioecological Perspective. Health Care for Women International 33: 29–44
[ILEP] International Federation of Anti-Leprosy Associations and the Netherlands Leprosy Relief. 2011. Guidelines to Reduce Stigma: how to assess health-related stigma. Amsterdam, Netherlands.
LANSANG MA, LUCAS-AQUINO R, TUPASI TE, MINA VS, SALAZAR LS, JUBAN N, …, KUNIN C. 1990. Purchase of antibiotics without prescription in Manila, the Philippines. Inappropriate choices and doses. Journal of Clinical Epidemiology 43(1): 61–67.
LAMBERT ML, VAN DER STUYFT P. 2005. Delays to tuberculosis treatment: shall we continue to blame the victim? Tropical Medicine International Health 10: 945–946.
LEUNG ECC, LEUNG CC, TAM CM. 2007. Delayed presentation and treatment of newly diagnosed pulmonary tuberculosis patients in Hong Kong. Hong Kong Medical Journal 13(3).
LI Y, EHIRI J, TANG S, LI D, BIAN Y, LIN H, …, CAO J. 2013. Factors associated with patient and diagnostic delays in Chinese TB patients: a systematic review and meta-analysis. BMC Public Health.
LIN X, CHONGSUVIVATWONG V, GEATER A, LIJUAN R. 2008. The effect of geographical distance on TB patient delays in a mountainous province of China. The International Journal of Tuberculosis and Lung Disease.
MEYSSONNIER V, LI X, SHEN X, WANG H, LI DY, LIU ZM, …, GAO Q. 2013. Factors associated with delayed tuberculosis diagnosis in China. European Journal of Public Health 23(2): 253, 257.
ODUSANYA O, BABAFEMI J. 2004. Patterns of delay amongst pulmonary tuberculosis patients in Lagos, Nigeria. BMC Public Health.
OSEI E, AKWEONGO P, BINKA F. 2015. Factors associated with DELAY in diagnosis among tuberculosis patients in Hohoe Municipality, Ghana. BMC Public Health.
PATHANIA V, ALMEIDA J, KOCHI A. 1997. TB Research. TB Patients and Private for-Profit Health Care Providers in India. Global TB Programme of the World Health Organisation, Geneva [WHO/TB/97.223].
[PSA] Philippine Statistics Authority. 2013. Statistical Tables on Family Income and Expenditure Survey (FIES) from the results of 2012 FIES. Retrieved on 08 Mar 2017 from https://psa.gov.ph/content/2012-fies-statistical-tables
[PSA] Philippine Statistics Authority. 2019. Registered Deaths in the Philippines, 2017. Retrieved on 05 Jun 2020 from https://psa.gov.ph/vital-statistics/id/138794
RASANATHAN K, SIVASANKARA KURUP A, JARAMILLO E, LONNROTH K. 2011. The social determinants of health: key to global tuberculosis control. International Journal of Lung Diseases 15(6): S30–S36.
REYES J. 2011. Loob and Kapwa: An Introduction to a Filipino Virtue Ethics. Asian Philosophy 25(2).
SABAWOON W, SATO H, KOBAYASHI Y. 2011. Delay in the treatment of pulmonary tuberculosis: a report from Afghanistan. The Japanese Society for Hygiene, Environmental Health and Preventive Medicine.
SREERAMAREDDY CT, PANDURU KV, MENTEN J, VAN DEN ENDE J. 2009. Time delays in diagnosis of pulmonary tuberculosis: a systematic review of literature. BMC Infectious Disease 9: 91.
STORLA DG, YIMER S, BJUNE GA. 2008. A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Public Health 8: 15.
TAKARINDA K, HARRIES AD, NYATHI B, NGWENYA M, MUTASA-APOLLO T, SANDY C. 2012. Tuberculosis treatment delays and associated factors within the Zimbabwe National Tuberculosis Programme. BMC Public Health.
TATTEVIN P, CHE D, FRAISSE P, GATEY C, GUICHARD C, ANTOINE D, …, BOUVET E. 2012. Factors associated with patient and health care system delay in the diagnosis of tuberculosis in France. The International Journal of Tuberculosis and Lung Disease 16(4): 510–515.
TRIPATHY JP, SRINATH S, NAIDOO P, ANANTHAKRISHNAN R, BHASKAR R. 2013. Is physical access an impediment to tuberculosis diagnosis and treatment? A study from a rural district in North India. The International Union against Tuberculosis and Lung Disease, Public Health Action 3(1).
TUPASI TE, RADHAKRISHNA S, CO VM, VILLA MLA, QUELAPIO MID, MANGUBAT NV, …, MANTALA MJ. 2000. Bacillary disease and health seeking behavior among Filipinos with symptoms of tuberculosis: implications for control. International Journal of Lung Diseases 4(12): 1126–1132
UKWAJA K, ALOBU I, NWEKE C, ONYENWE E. 2013. Healthcare-seeking behavior, treatment delays and its determinants among pulmonary tuberculosis patients in rural Nigeria: a cross-sectional study. BMC Health Services Research 13: 25.
WARD HA, MARCINIUK DD, PAHWA, P, HOEPPNER V. 2004. Extent of pulmonary tuberculosis in patients diagnosed by active compared to passive case finding. The International Journal of Tuberculosis and Lung Disease 8(5): 593-–597.
[WHO] World Health Organization. 2000. Guidelines for the Regulatory Assessment of Medicinal Products for Use in Self-medication. Geneva, Switzerland.
[WHO] World Health Organization. 2006. Diagnostic and treatment delay in tuberculosis. Cairo, Egypt.
[WHO] World Health Organization. 2019. Global tuberculosis report 2019. Geneva, Switzerland.
YIMER S, HOLM-HANSEN C, YIMALDU T, BJUNE G. 2009. Health care seeking among pulmonary tuberculosis suspects and patients in rural Ethiopia: a community-based study. BMC Public Health.
ZERBINI E, CHIRICO MC, SALVADORES B, AMIGOT B, ESTRADA S, ALGORRY G. 2008. Delay in tuberculosis diagnosis and treatment in four provinces of Argentina. The International Journal of Tuberculosis and Lung Disease
ZHAO X, YANG P, GAI R, MEI L, WANG X, XU L. 2014. Determinants of health care-seeking delay among tuberculosis patients in Shandong Province, China. European Journal of Public Health 24(5): 757.
ZHOU C, CHU J, GENG H, WANG X, XU L. 2014. Pulmonary tuberculosis among migrants in Shandong, China: factors associated with treatment delay. BMJ Open Access.