A multi-method assessment of factors associated with delay in care-seeking and diagnosis of tuberculosis and non -adherence to treatment in Limpopo Province, South Africa

Background. Tuberculosis is responsible for an unnecessary burden of deaths throughout Sub-Saharan Africa. Health services in the study site, Limpopo Province, South Africa, have experienced a steady decrease in case-finding (87% in 2004 to 72% in 2007) and the current cure rate for the province as a whole, (60%), is far below the WHO 2015 target of 85%. Knowledge about factors associated with delay in care-seeking and diagnosis and with nonadherence and about methods used to assess factors is mixed. Moreover, previous reviews have not explored the association between HIV prevalence and care-seeking and nonadherence to treatment for TB. Objectives and Methods. This dissertation used multiple methods to examine factors associated with delay in care-seeking and diagnosis and non-adherence including: (1) a systematic review of studies assessing factors associated with delayed care-seeking and diagnosis or non-adherence to TB treatment in countries with a high TB/HIV burden; (2) eleven interviews with key informants and local researchers assessing perceptions of TB, care-seeking, and treatment for TB; and (3) pretesting of Limpopo-specific rapid assessment interview guides. Results. The systematic review identified 20 eligible articles for delay and 17 articles for non-adherence that demonstrated variability in study design, methods, and measurement of delay or non-adherence. The majority of tested associations were predisposing factors (primarily socio-demographic characteristics). The majority of statistically significant associations were with enabling factors. Only six studies tested an association between HIV-status or HIV-related variables and delay or non-adherence. Interviews with key informants and local researchers demonstrated that knowledge, social environment (specifically HIV-related stigma and social support), and accessibility of health care services may influence care-seeking and adherence to treatment. The pretest participants expressed problems with unclear items and items that were considered too similar to each other. Piloting of the pretest instrument showed participants\u27 lack of knowledge in regards to how TB and HIV can worsen the outcome for each disease. Discussion. While there is a large volume of literature exploring the reasons for patient delay in care-seeking or non-adherence in high-TB/HIV burden areas of Sub-Saharan Africa, these studies are not easily comparable. Interviews and the pretest suggest that social support and HIV-related stigma and knowledge about how TB and HIV are related are important factors to consider when discussing care-seeking and adherence. Future research should explore the role of HIV known status in care-seeking and adherence behavior with the aim of better targeting interventions in Limpopo Province and similar regions