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ABSTRACT |
 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Delay in case detection and reporting could be attributed to the health system5–7 and/or patient factors.8–10 Studies on delay in case detection were performed on diagnosed cases,9–11 although none have been done on yet undiagnosed cases. These studies are particularly needed to guide the process of TB elimination.
Jordan has achieved the 2005 and 2015 set targets and is currently targeting TB elimination by 2050.12 Therefore, this study was conducted within the context of strengthening the ongoing process of TB elimination. This study was aimed at determining the prevalence of TB suspects and investigating their healthcare-seeking behavior in urban and rural Jordan.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Study subjects. Consented household members older than 15 years of age were enrolled in the study. Confirmed TB cases, which were already identified as TB cases and were on anti-TB treatment at the moment of the survey, and nomads were excluded.
Study design. A cross-sectional survey was carried out during a four-month period (June–September, 2005), whereby all household members older than 15 years of age and residing in the study area were inquired about the presence of persistent cough (productive or not) for more than three weeks to identify TB suspects. These household members were then interviewed using a structured and pre-tested questionnaire about their socio-demographic characteristics, risk factors for tuberculosis, knowledge, stigma, healthcare-seeking behavior with the onset of symptoms (first action with onset of symptoms, type of healthcare providers visited with the onset of illness, etc.), types of facilities in the area, and predictors of delay in seeking care for more than three weeks from the onset of symptoms.
For each suspect, one on-the-spot sputum specimen was collected, and the suspect was referred then to the nearest health center for clinical examination and sputum smear examination.
Before surveying a certain district, the population of that district was informed about the survey through community leaders, media, and so on, and the survey was carried out after working hours, which ensured maximum level of attendance.
Sample size. Assuming a prevalence of TB suspects of 5%, with an acceptable error of 2.5% at 95% confidence interval (CI), the least reliable sample size that would detect a prevalence of TB suspects between 2.5–7.5% was equal to 29,196 household members. Adjusting for adult population (60%), the sample size was 48,660. Allowing for 20% drop-out, the final sample size was 60,825 eligible household members.
Sampling technique. A multi-stage stratified random sampling was carried out, whereby three regions from Middle and South Jordan were randomly selected using the random number list of Epi Info program. Two sampling frames were constructed for urban and rural districts in each region, and a random sample of districts was selected from each. The sample size allocated to each district was proportionate to the population size of that district. Within each district, a central building was selected and households were consecutively enrolled until fulfilling the sample size allocated to each district.
Study definitions.
Stigma. Variables measuring stigma were recorded on a 5-point Likert scale (0 the highest and 4 the lowest degree of stigma). These included feeling ashamed of having tuberculosis; having to hide tuberculosis diagnosis; cost incurred by the long disease duration; isolation as a result of tuberculosis; whether a girl is able to decide about getting tuberculosis treatment and the extent to which tuberculosis affects social, family, marital, and work relations.
Data management and statistical analysis. Data analysis was performed using the statistical packages SPSS for Windows version 11 and Epi Info 2000 (Atlanta, GA). Descriptive statistics were used and the mean percentage score for stigma and knowledge was calculated as follows:
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The studied variables were expressed as falling between 0% and 100% with the highest percentage reflecting the increase in that characteristic/variable.
Comparisons between groups were made using the 
2 test or Fischer’s exact test for qualitative/categorical variables. The later was used whenever the expected values were below 5 in a 2 x 2 contingency table. The Student t-test was used to compare between 2 means normally distributed, and Mann-Whitney test for quantitative variables with non-parametric distribution.
A univariate analysis was performed to study the determinants of delayed healthcare-seeking behavior of more than three weeks. Multivariate regression analysis was then performed to adjust for confounders. The level of significance was determined at 95% (P value < 0.05), and all tests were two-sided.
The proposal was approved by the national ethical review committee. All participants gave their verbal consent voluntarily.
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RESULTS |
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). The TB suspects living in rural areas were significantly older in age and with lower socioeconomic statuses. (Table 2).
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Cough was reported from all suspects (as per the definition), followed by chest pain (57.7% and 59.9% of urban and rural TB suspects, respectively), fever (15.2% and 6.8%, respectively), haemoptysis (18.6% and 9.8%, respectively), and loss of weight (8.1% and 9.0%, respectively). There was no significant difference between the two groups regarding TB symptoms. On the other hand, the duration of symptoms was significantly longer for cough, loss of weight, chest pain, and haemoptysis, but not fever among rural TB suspects. The mean duration of cough was 6.8 (40) months and 7.4 (3.9) months in urban and rural TB suspects, respectively.
Table 3 shows there was no significant association between knowledge and residence of TB suspects. The main source of information was mass media, followed by medical personnel.
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Health centers were the main services available for 95.3% and 92% of urban and rural TB suspects, respectively, followed by private practitioners and TB centers (Table 4).
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The first action with the onset of symptoms was to visit the health center in 68.7% and 70.9% of urban and rural TB suspects, respectively. A significantly higher proportion of urban TB suspects visited private medical practitioners (PMP) or TB centers, although a significantly higher proportion of rural TB suspects visited traditional healers (41% versus 15.5%).
More than half of the TB suspects residing in urban districts sought care for the current illness compared with 45% of those who lived in rural districts. The main reasons for seeking care at the mentioned facilities were accessibility and confidence in obtaining a cure, and obstacles were mistaken beliefs that symptoms are not serious, being busy for urban residents, or economic constraints for rural residents (Table 5).
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DISCUSSION |
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Reports from the Region showed that TB suspects seek care initially at the private sector where they could be diagnosed or undiagnosed, and if diagnosed they could be treated or inadequately treated. In case of undiagnosis and inadequate treatment, they will continue to transmit infection in the community. Undetected cases will continue seeking care at other healthcare providers, such as other private or public providers, because of persistence of symptoms and increasing disease severity in some instances. Finally, they reach the national tuberculosis control program where they could be finally diagnosed and adequately treated.15 Obviously, this proportion varies according to program performance in different countries.
This study reported a relatively low prevalence of TB suspects in the community (2.51%), although higher than the prevalence of TB suspects in rural China (1.6%), having a significantly higher burden of tuberculosis.16 The prevalence of 3.24 of sputum smear positive pulmonary tuberculosis per 100,000 population suggests that a number comparable to that of detected cases is "yet undetected" in the community.
Compared with a similar study undertaken in China in 2007 where the positivity rate among suspects was 7.9%,16 the positivity rate in Jordan was only 0.13%. The low positivity rate is a reflection of the low disease burden in Jordan, but it could be also underestimated as a result of limited follow-up of referred cases.
The higher prevalence of TB suspects in Jordan compared with China could be attributed to the lower awareness about the disease in Jordan, which resulted in delayed healthcare-seeking behavior. By contrast, a high level of awareness exists in China with high disease burden. This was confirmed by the long duration of illness that reached six months and reported from a Jordan survey.
Diagnostic delay, knowledge, and stigma are important indicators to measure the extent of awareness of the community, the effectiveness of the advocacy, communication, and social mobilization activities, and to monitor progress over time. Adequate knowledge was reported from more than three-quarters of TB suspects, and the level of stigma was high (~70%).
The reported mean delay in seeking appropriate care was significantly longer than the mean delay reported from smear positive patients in seven Eastern Mediterranean Region (EMR) countries (Egypt, Iraq, Pakistan, Somalia, Syria, and Yemen).15 However, the mean percent knowledge score was comparable to that reported from patients in Egypt, Somalia, and Syria, but significantly higher than that reported from Iraq, Pakistan, and Yemen, using the same scoring system. By contrast, stigma was significantly higher than that reported from Egypt, Pakistan, Somalia, Syria, and Yemen, but not Iraq, using the same scoring system.15 In Jordan and in the previously mentioned countries, the media was the main source of information for the community, but it was not adequately exploited. The prevalence of smoking among these suspects was also alarming and significantly higher than the rates reported from other EMR countries.15
The accessibility of the community to health services was significantly better in urban compared with rural areas: TB centers and general hospitals exist almost exclusively in urban areas, although health centers seem to be equally distributed in both regions. Almost 97% and 69% of the TB suspects in urban and rural areas, respectively, access these health services within half an hour, as compared with 90% of TB patients in Iran and Syria, around half of the patients in Egypt, Somalia, and Yemen, and only one-quarter to one-third of the patients in Iraq and Pakistan.15
Unlike the seven surveyed countries in the EMR, the first healthcare-seeking behavior for the majority of the TB suspects in both areas was to seek care at the health centers, followed by private practitioners. Community behavior in seeking care at the health centers could be one of the factors that contributed to the achievement of the case detection rate target in Jordan. Different community behavior in seeking initial care at the private sector has hindered program efforts in achieving the case detection rate targets in other countries.
This study also indicated that delayed case findings in Jordan is mainly an accessibility problem because two of the reported significant risk factors for delayed healthcare-seeking behavior are rural residence and means of transportation. The lower socioeconomic statuses of the population living in rural areas aggravate the accessibility problem. The association between rural residence and delayed diagnosis is consistent with previous reports.15,17,18
The fact that expatriates were at a significantly higher risk for delayed healthcare-seeking behavior despite their proximity to the health services in urban areas highlight economic barriers to healthcare. This also indicates the need to ensure pre-employment and periodic medical examination to this group.
The study has certain limitations. First, the proportion of TB suspects that were investigated was not reported, because the referred TB suspects were not strictly followed-up in the health centers. This might underestimate the reported positivity rate. Second, the reported prevalence rate of active sputum smear positive tuberculosis should be taken with caution as a larger sample size would have been needed if the aim was active case finding in the community.
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CONCLUSION |
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Received April 3, 2008. Accepted for publication June 20, 2008.
Acknowledgments: We thank Dr. Imad Husni, Khawla Abu Kbeer, Ned’a’a Karqesh, Nayfeh Alaween, Maryam Joudeh, Aydah Abdul Wahed, Samiha Abu Ajameyeh, Ahmad Al-Sokhni, and Bdoor Rahamneh for their participation in the field teams.
Financial support: This study received technical and financial support from the Eastern Mediterranean Regional Office (EMRO)/Special Programme for Research and Training in Tropical Diseases (TDR) small grants scheme for operational research in tropical and other communicable diseases.
* Address correspondence to Amal Bassili, Eastern Mediterranean Regional Office of the World Health Organization, Abdulrazak Sanhouri St., P.O. box 7608 Nasr City, Cairo 11371, Egypt. E-mail: bassilia{at}emro.who.int 
Authors’ addresses: Khaled Abu Rhuman and Nadia Abu Sabra, National TB Control Programme, Amman, Jordan. Faris Bakri, Jordan University Hospital, Amman, Jordan. Akihiro Seita and Amal Bassili, Eastern Mediterranean Regional Office of the World Health Organization, Abdulrazak Sanhouri St., P.O. box 7608 Nasr City, Cairo 11371, Egypt, Tel: 00-202-276-5275, Fax: 00-202-276-5414, E-mail: bassilia{at}emro.who.int.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
