Community determinants of health care seeking for tuberculosis : the role of socio-cultural determinants and gender in Tanzania

The WHO End TB strategy targets to end the global tuberculosis epidemic by 2035 with a reduction of 90% new cases, a 95% reduction in deaths, and to ensure that no family is burdened by catastrophic costs as a result of tuberculosis. In order to reach this ambitious goal, not only strengthening of tuberculosis control programs, discovery, development and evaluation of novel and sensitive tuberculosis diagnostics tools will be required, but also actions with regard to social determinants of tuberculosis and health care seeking, particularly in low-income settings with high tuberculosis burden. Furthermore, novel and more sensitive TB diagnostics tools will only have an impact at the population-level if the millions of undiagnosed TB cases reach health care centres timely for diagnosis and treatment. The low tuberculosis case detection observed in Tanzania and elsewhere is not only due to limitations in tuberculosis diagnostics, but also in the socio-cultural and economic factors which are relevant for tuberculosis healthcare seeking, timely diagnosis and treatment. This doctoral thesis therefore aimed to assess the pathways and costs of care from the onset of tuberculosis symptoms, to explain patient and diagnostic delays and loss to diagnostic follow-up during health care seeking, and finally to explore the role of traditional healers in tuberculosis management and control in Tanzania, using quantitative and qualitative methods. It firstly makes use of data obtained from the on-going tuberculosis cohort study in Dar es Salaam Tanzania, interviewing 100 confirmed and 100 presumptive tuberculosis patients on pathways to care and on direct and indirect costs, with data recording on tablets using the OpenDataKit (ODK) application. Secondly, data were collected during an intervention study on intensified case findings at pharmacies in Tanzania, administering a semi-structured explanatory model interview based on the EMIC framework for cultural epidemiology to 136 presumptive and confirmed TB patients. It further used data from in-depth interviews and structured interviews with 90 traditional healers in urban, peri-urban and rural districts of Tanzania. Pathways to care in confirmed tuberculosis patients were complex compared to the presumptive patients. In confirmed patients, pathways involved several visits to health care facilities before diagnosis, while that of the presumptive patients were more direct with only one or few visits to healthcare facilities before diagnosis. Confirmed and presumptive TB patients spent a median of 31% of their monthly household income on health expenditure for all five visits to healthcare facilities. Indirect costs were considerably higher than direct costs both in confirmed and presumptive TB patients. A patient delay of ≥3 weeks was observed in almost two thirds of our participants from the intervention study. In addition, loss to diagnostic follow-up was observed in 44.1%. Prior consultations with traditional healers were associated with patient delay but not with loss to diagnostic follow-up. Gender differences were observed in patient delay and LDFU, whereby the odds of patient delay were higher in females than in males, and also loss to diagnostic follow-up was higher in females than in males. Knowledge on cough and tuberculosis related symptoms was limited among traditional healers and varied in urban, peri-urban and the rural settings. Costs spent for traditional healers for treatment of cough and tuberculosis symptoms were lower than costs incurred by patients from the formal healthcare providers. Traditional healers in all three study sites referred patients for further treatment. Collaboration among the traditional healers, the government (NTLP) and other stakeholders was limited. There was a significant association between collaboration with the government and referring patients to hospitals for further treatment. The results from this PhD project contribute to our understanding on the pathways and costs of care in confirmed and presumptive tuberculosis patients. This study is among a few to report costs associated with tuberculosis taking into account gender differences and poverty status. Furthermore, it contributes to open questions regarding patient delay and loss to diagnostic follow-up during healthcare seeking. Our study is also among the few to address the gap on the role of traditional healers in tuberculosis management particularly from sub-Sahara Africa. Given the importance of tuberculosis in terms of global disease burden, and the WHO’s ambitious goal to end tuberculosis by 2035, planning and specific interventions which integrate social and biomedical solutions are needed