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DELAY IN DIAGNOSIS AMONG SPUTUM SMEAR POSITIVE

TUBERCULOSIS PATIENTS IN KUCHING, SARAWAK

Deburra Peak Ngadan

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

materials regarding the history of ATAS and ATAS Clinic, my gratitude goes to the
with

My heartfelt thanks to Dr Marilyn Umar for the guidance and advices spared
organization.

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 needsto be strengthenedto 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 l

Abstract W

Abstrak V.
Table of Contents vii
List of Tables xi
List of Figures xii

List of Abbreviations xiv

CHAPTER 1: INTRODUCTION
1.0 Introduction I
1.1 Background of the study 1

1.2 Problem statement 3

1.3 Objectives of the study 4
1.3.1 Specific objectives 4
1.4 Conceptual framework S
1.5 Significance of the study S
1.5.1 Contribution to literature 6
1.5.2 Contribution to practice 7
1.5.3 Contribution to future research 7
1.6 Operational definitions of terms 7
CHAPTER 2: LITERATURE REVIEW

2.0 Introduction 11
2.1 Tuberculosis and its diagnostic procedure 11
2.1.1 Tuberculosis and its burden 15
2.2 Global prevalence of TB 19
2.2.1 Global prevalence of TB 19
2.2.2 Prevalence of tuberculosis in Malaysia and Sarawak 20
2.3 TB control strategies 23
2.4 Challenges in TB control 28
2.5 Definitions and factors contributing to delayed in diagnosis 33
2.5.1 Patient delay 34
2.5.2 Factors contributing to delay 35

vii.
 2.5.3 Health system delay 44
2.5.3 Treatment delay 49
2.5.4 Total delay 50
2.6 Conclusion 52
CHAPTER 3: METHODOLOGY
3.0 Introduction 53

3.1 Researchdesign and setting 53

3.2 Population and sampling method 55

3.2.1 Inclusion criteria 56

3.2.2 Exclusion criteria 57

3.3 Research instruments 57

3.4 Pilot study 59
3.5 Ethical consideration 62
3.6 Data collection 63

3.7 Analysis of data 64

3.8 Conclusion 64
CHAPTER 4: RESULTS
4.0 Introduction 65

4.1 Respondent's sociodemographic characteristics 65

4.1.1 Healthcare facility and services 68

4.2 Respondent'sknowledge regarding TB 69

4.3 Clinical symptoms during onset and presentation 73

4.4 Patient and health system delay 74

4.5 Contributing factors to patient delay 79

4.5.1 Contributing factors of health system delay 79

4.6 Predicting factors of health system delay 82

4.7 Treatment delay 83

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 99
5.3 Implications of the study 100
5.4 Limitations of the study 101
5.5 Conclusion 101
5.6 Recommendation 102
REFERENCES 104

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

xi
 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 responseregarding TB knowledge sources (*Others: 70

friends, family members,other informal form of information).

Figure 4.2 Respondent's knowledge

response regarding of TB treatment 71

duration

Figure 4.3 Respondents' duration of working with colleagues with 72

similar

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.

I
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

2
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 issueof 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 appearedto have longer delay. Also, respondentsliving 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

4
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:

h
- Age, Gender, Occupation, Income, Education
Level

Residence location:

FI
10 bn healthcare centre PATIENT
-distance within of
DELAY
- exvensesincurred
Health care seeking behaviour:

F
- duration of symptoms
- number of visits

Severity of TB:
- Sputum AFB results
- C-Xray results DELAYED
DIAGNOSIS FOR
SPUTUM SMEAR
POSITIVE PTB
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: HEALTH CARE
- community clinic! hospital/ polyclinic FACILITY DELAY

Category of health personnel for first contact

for TB:
- medical assistant/ medical doctor/ specialist

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.

6
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.

TREATMENT
TOTAL DELAY DELAY
ýý

PATIENT 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
 as coughing, loss
Pulmonary TB symptoms: The presence of any of the symptoms of such

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

30 per cent of the housing units having

activities as well as

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

9
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