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Determinants of patient and health system delay among Italian and foreign-born patients with pulmonary tuberculosis: a multicentre cross-sectional study
  1. Annalisa Quattrocchi1,
  2. Martina Barchitta1,2,
  3. Carmelo G A Nobile3,
  4. Rosa Prato4,
  5. Giovanni Sotgiu5,
  6. Alessandra Casuccio6,
  7. Francesco Vitale6,
  8. Antonella Agodi1,2
  9. on behalf of the CCM 2013 TB network
    1. 1 Department of Medical and Surgical Sciences and Advanced Technologies ’GF Ingrassia', University of Catania, Catania, Italy
    2. 2 LaPoSS, Laboratory of Policies and Social Services, University of Catania, Catania, Italy
    3. 3 Department of Health Sciences, University of Catanzaro ’Magna Græcia', Catanzaro, Italy
    4. 4 Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
    5. 5 Department of Biomedical Sciences, Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
    6. 6 Department of Sciences for Health Promotion and Mother-Child Care ’G. D’Alessandro', University of Palermo, Palermo, Italy
    1. Correspondence to Prof. Antonella Agodi; agodia{at}


    Objectives The aim of this cross-sectional study was to identify key factors associated with patient delay (PD), health system delay (HSD) and total delay (TOTD) in patients with tuberculosis (TB) to inform control programmes.

    Setting The study was conducted in four Italian regions in 2014–2016. Data were obtained using a questionnaire including: sociodemographic and lifestyle data, TB comorbidities, patient knowledge and attitudes towards TB, stigma, access to TB care and health-seeking behaviours.

    Participants Patients’ inclusion criteria were being diagnosed as a new smear positive pulmonary TB case and living in one of the participating Italian regions. Overall, 344 patients from 30 healthcare centres were invited to participate and 253 patients were included in the analysis (26.5% non-response rate); 63.6% were males and 55.7% were non-Italian born.

    Outcome measures Risk factors for PD, HSD and TOTD in patients with TB were assessed by multivariable analysis. Adjusted ORs (aOR) and 95% CIs were calculated.

    Results Median PD, HSD and TOTD were 30, 11 and 45 days, respectively. Factors associated with longer PD were: stigma (aOR 2.30; 95% CI 1.06 to 4.98), chest pain (aOR 2.67; 95% CI 1.24 to 6.49), weight loss (aOR 4.66; 95% CI 2.16 to 10.05), paying for transportation (aOR 2.66; 95% CI 1.24 to 5.74) and distance to the health centre (aOR 2.46; 95% CI 1.05 to 5.74) (the latter three were also associated with TOTD). Shorter HSD was associated with foreign-born and female status (aOR 0.50; 95% CI 0.27 to 0.91; aOR 0.28; 95% CI 0.15 to 0.53, respectively), dizziness (aOR 0.18, 95% CI 0.04 to 0.78) and seeking care at hospital (aOR 0.35; 95% CI 0.18 to 0.66). Prior unspecific treatment was associated with longer HSD (aOR 2.25; 95% CI 1.19 to 4.25) and TOTD (aOR 2.55; 95% CI 1.18 to 5.82). Haemoptysis (aOR 0.12; 95% CI 0.03 to 0.43) and repeated visits with the same provider (aOR 0.29; 95% CI 0.11 to 0.76) showed shorter TOTD.

    Conclusions This study identifies several determinants of delays associated with patient’s behaviours and healthcare qualities. Tackling TB effectively requires addressing key risk factors that make individuals more vulnerable by the means of public health policy, cooperation and advocacy to ensure that all patients have easy access to care and receive high-quality healthcare.

    • surveillance
    • public health policy
    • social epidemiology
    • quality in health care
    • tuberculosis patients

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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    • Contributors AA, CGAN, RP and GS conceived, designed and supervised the study and coordinated regional data collection. AC and FV coordinated the project. MB and AQ designed the questionnaire and managed data collection at the central level. AQ performed the statistical analysis and wrote the first draft of the manuscript. AA, MB and AQ interpreted the results and wrote the advanced version of the manuscript. All Authors critically reviewed the manuscript and approved the final version.

    • Funding The project entitled ’Valutazione dei determinanti di ritardo nell’accesso ai servizi sanitari, nella diagnosi e nel trattamento della tubercolosi polmonare (PTB) in popolazioni vulnerabili. Valutazione dell’impatto sull’epidemiologia locale e sulla prevalenza di resistenza/multiresistenza ai farmaci antitubercolari'—’Assessment of determinants of delay in healthcare access for the diagnosis and treatment of PTB in vulnerable populations. Assessment of the impact on the local epidemiology and on the prevalence of antituberculosis drug resistance/multiresistance' was approved and financially supported by the Italian Ministry of Health (Centro nazionale per la prevenzione e il Controllo delle Malattie, CCM 2013).

    • Competing interests None declared.

    • Patient consent Obtained.

    • Ethics approval All procedures followed were in accordance with the Declaration of Helsinki 1975, as revised in 2008.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data available.

    • Collaborators CCM 2013 TB network: Alessandro Bisbano; Celestino Bonura; Bruno Cacopardo; Maria Giovanna Cappelli; Antonio Cascio; Francesco Cesario; Paola Di Carlo; Anna Di Taranto; Francesca Fortunato; Antonina Franco; Anna Grimaldi; Carmelo Iacobello; Maria Clara La Rosa; Valentina Mascaro; Andrea Maugeri; Arturo Montineri; Salvatore Nisticò; Cecilia Occhino; Grazia Pantò; Maria Polimeni; Vincenzo Portelli; Graziano Provenzano; Pasquale Quartararo; Francesco Quintieri; Salvatore Requirez; Francesca Savalli; Consiglia Venitucci; Maria Teresa Zorzetto; Rossella Zucco.

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