Factors associated with delayed care seeking , diagnosis and non-adherence to treatment for TB in African high burden TB/HIV countries: A systematic review

Background: The tuberculosis (TB) epidemic in Sub-Saharan Africa is well documented and is a top priority for action; especially in high-TB/HIV burden countries. Objectives: We reviewed studies conducted in high-TB/HIV burden African countries to identify factors related to: 1) delayed care-seeking and diagnosis and 2) non-adherence to TB treatment; and to 3) describe data collection methods. Methods: We searched 5 databases and hand-searched reference lists of eligible studies. Studies published after 1991 in peer-reviewed journals and grey-literature in English, presented data from high burden African countries on individuals age 15 years and older, and assessed factors associated with delayed care-seeking or diagnosis or non-adherence. Two trained coders worked independently. Independent variables were categorized as predisposing, enabling, or reinforcing (PRECEDE Model). Results: Data collection most often was by structured interview with pretested instruments. Definitions of delay and non-adherence were inconsistent. Only 6 of 37 studies assessed any HIV-related factors. Patient socio-demographic characteristics, received the most attention; enabling factors received the least but were most often statistically significant. Of 20 delay studies (17 cross sectional, 2 qualitative, 1 cohort), consulting a traditional healer first was consistently associated with delay. Of 17 non-adherence studies (6 qualitative, 4 cross-sectional, 4 case-control, 3 cohort), negative social support and indirect costs of treatment were consistently associated with non-adherence; qualitative studies added 7 unique enabling factors. Conclusions: We recommend more emphasis on broader HIV-related and system factors, use of standard definitions of delay and non-adherence, and more qualitative studies to identify important enabling and reinforcing factors.