Delay in seeking initial care for Tuberculosis Diagnosis* OA - SciELO

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Delay in seeking initial care for Tuberculosis Diagnosis* Atraso na procura pelo primeiro atendimento para o diagnóstico da tuberculose Demora en la búsqueda de la primera consulta para el diagnóstico de la tuberculosis Anneliese Domingues Wysocki1, Maria Amélia Zanon Ponce2, Beatriz Estuque Scatolin3, Rubia Laine de Paula Andrade4, Silvia Helena Figueiredo Vendramini5, Antonio Ruffino Netto6, Tereza Cristina Scatena Villa7 Abstract

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Descriptive study, which aimed to analyze the time between the perception of TB symptoms onset and the first search for health services, according to TB patient characteristics in São José do Rio Preto - SP. 97 TB patients in treatment were interviewed with a structured instrument. The delay was identified by the median time between the perception of TB symptom’s onset and the patients demand for care (> 15 days). To identify the variables related to delay the prevalence ratio were calculated. There was a delay seeking care among: male patients, aged 18 to 29 and 50 to 59 years, lower education and higher family income, pulmonary cases without HIV co-infection, presenting milder symptoms, users of alcoholic beverages and tobacco, those who did not perform preventive health control, and who sought health services closer to home. The recognition of users’ profiles in the search for care is paramount for defining strategies that favor the use of services in a timely manner.

Tuberculosis Delayed diagnosis Health Services Accessibility Patient acceptance of health care

Estudo descritivo que objetivou analisar o tempo decorrido entre a percepção dos sintomas da tuberculose (TB) e a primeira busca por serviço de saúde segundo características dos doentes com TB em São José do Rio Preto – SP. Entrevistaram-se 97 doentes com TB utilizando instrumento estruturado. Identificou-se atraso do doente pela mediana do tempo entre a percepção dos sintomas e busca por atendimento (> 15 dias). Calculou-se a razão de prevalência para identificar variáveis relacionadas ao atraso. Houve atraso entre: doentes do sexo masculino, com 18 a 29 e 50 a 59 anos, baixa escolaridade, maior renda familiar, casos pulmonares, não coinfectados com HIV, sintomas fracos, consumidores de bebidas alcoólicas e tabaco, que não realizavam controle preventivo de saúde e procuravam o serviço de saúde mais próximo do domicílio. O reconhecimento do perfil dos usuários na busca por atendimento é primordial para definir estratégias que favoreçam a utilização dos serviços em momento oportuno. Tuberculose Diagnóstico tardio Acesso aos Serviços de Saúde Aceitação pelo paciente de cuidados de saúde

Estudio descriptivo objetivando analizar el tiempo transcurrido entre la percepción de los primeros síntomas de tuberculosis (TB) y la búsqueda de una primera consulta en servicios de salud, según características de los enfermos de TB en São José de Rio Preto-SP. Fueron entrevistados 97 enfermos de TB, utilizándose instrumento estructurado. Se identificó atraso del enfermo por la mediana de tiempo entre percepción de síntomas y búsqueda de atención (>15 días). Se calculó la razón prevalente para identificar variables relacionadas al atraso. Existió atraso entre: enfermos masculinos, con 18 a 29 y 50 a 59 años, baja escolarización, mayor renta familiar, casos pulmonares, no coinfectados con HIV, síntomas débiles, consumidores de alcohol y tabaco, sin control sanitario preventivo, buscando servicio de salud próximo al domicilio. El reconocimiento del perfil de pacientes buscando atención es primordial para definir estrategias que favorezcan la utilización de los servicios en el momento oportuno.

Tuberculosis Diagnóstico tardío Accesibilidad a los Servicios de Salud Aceptación de la Atención de Salud

*Extracted from the dissertation “Tuberculose: tempo decorrido entre o início dos sintomas e a procura pelo Serviço de Saúde em São José do Rio Preto”, Program of Maternal Child and Public Health, School of Nursing of Ribeirão Preto, University of São Paulo, 2011. 1Nurse. Master of Health Sciences. Doctoral student, Graduate Interdisciplinary Program in Nursing, School of Nursing of Ribeirão Preto, University of São Paulo. Ribeirão Preto, SP, Brazil. [email protected] 2 Nurse. Doctoral student, Graduate Program in Maternal Child and Public Health Nursing, School of Nursing of Ribeirão Preto, University of São Paulo. Ribeirão Preto, SP, Brazil. [email protected] 3Nurse. Master of Health Sciences. Doctoral student, Graduate Interdisciplinary Program in Nursing, School of Nursing of Ribeirão Preto, University of São Paulo. Ribeirão Preto, SP, Brazil. [email protected] 4Nurse. Doctoral student, Graduate Interdisciplinary Program in Nursing. Laboratory Specialist of the School of Nursing of Ribeirão Preto, University of São Paulo. Ribeirão Preto, SP, Brazil. [email protected] 5Nurse. Doctorate. Professor of the Faculty of Medicine of São José do Rio Preto. São José do Rio Preto, SP, Brazil. silviahve@gmail. com 6Full Professor, Faculty of Medicine of Ribeirão Preto, University of São Paulo. Ribeirão Preto, SP, Brazil. [email protected] 7Full Professor of the School of Nursing of Ribeirão Preto, University of São Paulo. Ribeirão Preto, SP, Brazil. [email protected]

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Rev Esc Enferm USP 2013; 47(2):434-40 www.ee.usp.br/reeusp/

Received: 10/20/2011 Approved: 07/06/2012

Delay in seeking initial care for Tuberculosis Português / Inglês Diagnosis www.scielo.br/reeusp Wysocki AD, Ponce MAZ, Scatolin BE, Andrade RLP, Vendramini SHF, Ruffino-Netto A, Villa TCS

INTRODUCTION The control of tuberculosis (TB) provides, among its principal activities, the elimination of the infections source in the community as a fundamental aspect for decreasing morbidity and mortality and interrupting the chain of transmission of this disease(1). In the year 2009, the global TB incidence was 140 cases per 100,000 inhabitants, while in Brazil 71,700 new cases were reported, with an estimated incidence of 45 cases per 100,000 inhabitants, leading the country to occupy 19th place in the ranking of 22 countries with the highest incidence of TB, and the 13th highest number of bacillipherous cases(1).

for health services according to sociodemographic, clinical, economic and behavioral TB patients characteristics. METHOD Epidemiological cross sectional study conducted in the city of São José do Rio Preto – SP – Brazil in 2009. In the mentioned year, the municipal TB care network was regionalized in five health districts. At the primary care level, the municipality had 13 Basic Health Units (BHU), 11 Family Health Units (FHU) and five Emergency Care Units (ECU). At the secondary level, there was a Regional Specialty Clinic (NGA-60) with the Tuberculosis Control Program (TCP) and the Outpatient Aids Clinic. There were six hospitals in the tertiary level.

Studies have shown that high rates of TB incidence and prevalence are the result not only of the conditions that enable vulnerability to the illness, but also the delay in making The TB suspects entrance for diagnosis in the municipal the disease diagnosis(2-5). Therefore, early diagnosis appears health care could be at any point of care and, once diagas a challenge considering the difficulties related both to nosed, patients and communicants were referred to primary the organization of health services, as the precariousness care services for their case management. At this care level, of integration of priority actions and the utilization of fragmented practices that limit the access to services offered in the TB patient is followed by a minimum team of generalhealth(6), as well as sociocultural, economic and geographic ist professionals (physician, nurse and auxiliary / technical nurse) who worked with technical support aspects intrinsic to the TB patients that deoffered by the specialized team of TCP. The termine the search, the utilization and the acceptance of care provided. These issues Studies have shown monitoring of the TB cases that required more attention, such as patients with medicines are seen as possible obstacles to the effecthat high rates of intoxication, atypical mycobacteria and multitiveness of programs and health services TB incidence and drug resistence (MDR) was conducted directly since the results of the health indicators are prevalence are the by the specialist teams of the TCP and the outobtained from the moment that the services patient AIDS clinic (coinfected). result not only of the are accessible and the users accept, utilize (3) conditions that enable and give continuity to this assistance . It is worth highlighting the important role vulnerability to the of nurses in the management of TB cases in Once the importance of the contribution illness, but also the the municipality, as the professional that of the patients to TB diagnosis delay, international studies(3,5) have been attempting to delay in making the assumes the care coordination with other health services and maintains the bond with uncover the aspects that contribute to the disease diagnosis. the users, promoting their participation in delayed utilization of health services and their treatment. that, therefore, are characterized as a barrier to obtaining timely diagnosis. Aspects related The study population consisted of TB patients under to the patient’s knowledge about the disease, the distance treatment in the municipality during the period of Novembetween home and the health facility, costs related to transber 2008 to November 2009. During this period, 135 patients portation, inability to miss work and commitments, as well as satisfaction with the health care services provided, and registered in São Paulo State TB information system (TB-WEB) the search for alternatives care are identified as determi- were in treatment; however, only 110 met the inclusion crinants for access to diagnosis of the disease(3,5). In Brazil, how- teria of the study. Those excluded were: 12 patients younger ever, little is known about the behavioral aspects intrinsic to than 18 years, three inmates, two psychiatric patients and the TB patient and the aspects that influence the search for eight with diagnostic change. Nine patients refused to parcare and obtaining diagnostics, as well as the time spent in ticipate in the research, and one was unable to respond. A this process. Using the descriptors delayed diagnosis and tu- total of 100 patients were interviewed, however the final berculosis, 79 studies were identified in a systematic search study population consisted in 97 subjects: two of them could in the Virtual Health Library (VHL) without specifying the not inform the time involved between the perception of the year of publication. Of these, however, only three were con- TB symptoms onset and the search for the first consultation, ducted in Brazil and only one of these analyzed the aspects and one did not inform the first health service sought. related to the TB diagnosis delay in seeking health care after Data were collected throught primary sources (interperception of the symptoms of disease(2,7-8). views) and secondary sources (medical records consults Due to the burden of TB as a public health problem and and the TB-Web information system) in the period of July the importance of early diagnosis as one of the conditions to December of 2009. A structured data collection instrufor its control, this study aimed to analyze the time between ment was used for the interviews to retrieve the course of the perception of TB symptom’s onset and the first search the patient from the moment he perceived the TB sympDelay in seeking initial care for Tuberculosis Diagnosis Wysocki AD, Ponce MAZ, Scatolin BE, Andrade RLP, Vendramini SHF, Ruffino-Netto A, Villa TCS

Rev Esc Enferm USP 2013; 47(2):434-40 www.ee.usp.br/reeusp/

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study, we defined patient delay in seeking care throught one cutoff point for the variable time of the patient. This cutoff point was the median time and delay was defined as more than 15 days, forming two groups: with and without delay (dependent variables). We decided to use the median because the distribution of the values related to patients’ responses to the variable time was asymmetrical, enabling the interference of outliers.

toms onset until the search for the first health services consultation. Interviews occurred in patients’ homes or in the health services where they were followed. For data analysis, the time (days) between TB patients realized their symptoms and the search for a first health care was labeled as the variable time of the patient. It is emphasized that this information related to the patient’s seeking care, based on their health status self-assessment, which does not mean that the symptoms started exactly when the patient took the initiative to search for health services.

The prevalence ratio (PR) (Figure 1) was calculated to identify which categories of the selected independent variables were associated with patient delay in seeking care. The first category of each variable was standardized as the numerator. We constructed confidence intervals (95% CI), adopting a significance level of 5%.

Then, due to the fact that there was no consensual definition of the appropriate time for TB patients seeking care after realizing the symptoms of the disease(3), in this

Delay in seeking the first health service

Variable of patients profile

YES (>15 days)

NO(