Delay in a seeking care among tuberculosis patients attending tuberculosis clinics in yaqshid district Mogadishu-Somalia

Delay in a seeking care among tuberculosis patients attending tuberculosis clinics in
yaqshid district Mogadishu-Somalia
College Of Health Science School Of Public Health
1
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COLLEGE OF HEALTH SCIENCE
SCHOOL OF PUBLIC HEALTH
DELAY IN A SEEKING CARE AMONG TUBERCULOSIS
PATEINTS ATTENDING TUBERCULOSIS CLINCS IN
YAQSHID DICTRECT MOGADISHU-SOMALIA
Submitted by
Hassan Omar Mohamed
This thesis is submitted in partial fulfillment for the degree of Bachelor
science in Public Health of University of Somalia
July 2017
Republic of Somalia ‫الصومـا‬ ‫جمــــــهورية‬‫ل‬

2

I
I hereby humbly declare that this research work entitled “DELAY IN A SEEKING CARE
AMONG TUBERCULOSIS PATEINTS ATTENDING TUBERCULOSIS CLINCS IN
YAQSHID DISTRECT” Was carried out by me and is submitted as thesis in partial fulfillment
of the requirements for the bachelor degree of Public Health, University of Somalia in
Mogadishu-Somalia.
Student’s Name:
Hassan Omar Mohamed
Signature…………………………… Date: _____/____/2017
DECLARATION

II
I confirm that the thesis was performed by Hassan Omar mohamed, under any supervision and
now ready for the submission of school of public health.
Hassan Omar mohamed ID: U050007539 and has been approved.
Name of Supervisor:
MR Said Warsame Nur M.P.H-Epidemiology
Lecture: UNISO
Signature…………………………… Date: _____/____/2017
Head School Of Public Health
MR. Abdirisaq Mohamed Abdi
Signature…………………………… Date: _____/____/2017
APPROVAL

III
I dedicate this thesis to my beloved father
Omar mohamed jima’ale
And
To My dear uncle
Abdirahman omar mohamed
And
To the loving memory of my mother
Halwo Omar Mohamed
You have successfully made me the person I am becoming
You will always be remembered
DEDICATION

IV
I am starting in the name of ALLAH, the benevolent, the compassionate who made me Muslim
and enabled me to perform this remarkable thesis and become graduate and gave me a chance
to write this thesis.
I w o u l d l i k e t o e x p r e s s m y supervisor MR Said Warsame Nur for
excellent guidance and critical review of my thesis. He is given me his time, guidance, variable
in sighted and suggestions relating of my original research plan. I also thank him for the
unforgettable helpful role in stage of this study. I say a lot of thank my supervisor and I hope
good life and prosperity and also thanks to all my lecturers of university of Somalia particularly
my faculty.
The same gratitude also goes to dean of my faculty Mr. Abdirisaq Mohamed abdi. I would like
also to thank university of Somalia especially faculty of public health and health science in
provision of education to Somali community and also thank all my lectures who taught me
different courses of this program and trained me to be a public health graduate for this university.
I give special thanks to my dear friends: Zaynab Muse Elmi , Samiir Ibrahim Ali, Abdi Risaq
Ali Nur , Said Abdi Jimcale ,Mohamed Tahlil Aadam, Hassan Osman Mohamud,
Mohamud Abdulahi Mohamed, Mohamed Cise Mohamed, Libaan Mohamed Ahmed
,Fu’aad Husein Abdule, Najiib Mustaf Farah, Duniya Abdi Majiid Jama, Shamso
Abdukadir Ali , Sacdiyo Ahmed Mohamed , Yasmin Mohamed Ibrahim, Sowdo Elmi
Abdule, Sagal Abdulahi Abdi ,Hamdi Abdi Barre, Hamdi Hassan Osman , Hawo
Abdukadir Jama , Huda Said Abdukadir and all my classmates .
I also give special thanks to my dear brothers and sisters: Abdi Risaq Omar Mohamed, Nim’a
Omar Mohamed, Nur Omar Mohamed, Zahra Abdi Abdule, Bashiir Ahmed Omar, Farah
Ahmed Omar, Hodan Abdirahman Omar, Anisa Abdirahman Omar, Fadumo Sheikh
Abdi, and all may family
I am also grateful to all people who were helped me in collecting data scattered locations and
respondents of my questionnaire those to name all of them is impossible Allah blesses you all. I
give special thanks to my all teachers, particularly MR Said Warsame Nur.
ACKNOWLEDGEMENT

V
Tuberculosis is an infectious disease caused by the bacillus mycobacterium tuberculosis which
typically affects the lungs but can affect other parts of the body. The disease spreads through air
when a patient expels bacteria, for example, by coughing.
Tuberculosis (TB) continues to be one of the major public health problems in the world; the
burden is increasing as a result of poverty, population growth and HIV/AIDS. In 1993 the World
Health Organization declared TB to a global public health emergency at a time when estimated 7
to 8 million cases and 1.3 to 1.6 deaths occurred each year.
In Somalia, TB remains one of the greatest health threats and is a leading cause of death in the
economically active age groups, especially due to the risk of dual HIV/AIDS and TB infection
(WHO, 2004).
The study was a cross sectional analytical in nature conducted in Yaqshid district involved 80
TB patients .Exit interview were used to collect data and data were analyzed computer software,
Statistical Package for Social Science (SPSS) version 16. Convenience sampling was used to
select study participants. Results were presented in frequencies, percentages. Ethical issues were
observed.
The majority of the respondent age is (15-30) years the frequency was 48 (60.0%) while the
others such as (30-50) are 23 (28.8%), (50-70) are 7 (8.8%), (70-90) are 2 (2.5%)
The majority respondents are never go to school education, 45 (56.2%) while of the respondent,
reported to have attained secondary education 15(18.8%). 13 (16.2%) had primary education ,7
(8.8%) respondents reported to have had attained College/University education
The study found that the majority (70.0%) had a significant delay in seeking care beyond a
reasonable cutoff, as seen in similar societies to Somalia, to Vinsom TB clinic and continue to
serve as reservoirs of infection. Most of Patients (51.2%) took time more than 30 days from
ABSTRACT

VI
onset of symptoms to treatment, with young people exhibiting more delay than their older
counterparts.
The study found that people’s perception about cause and severity of the disease is a strong
determinant of their decision to seek health care.
There is need for TB care and treatment providers to educate the community (including TB
cases) on causes, transmission, prevention and recovery in order to improve their knowledge on
tuberculosis.Strengthening integration of TB care into Public Health Care services.Private health
practitioners (e.g. Traditional healers, Pharmacists, etc.) should be trained in handling TB cases especially
in early diagnoses

VII
TABLE OF CONTENTS
Declaration....................................................................................................................................... I
Approval ........................................................................................................................................ II
Dedication...................................................................................................................................... III
Acknowledgement ......................................................................................................................... IV
Abstract........................................................................................................................................... V
Table of Content .......................................................................................................................... VII
List of Tables ............................................................................................................................... XII
List of Figures ............................................................................................................................. XIII

VIII
CHAPTER ONE
INTODUCTION
1.1 Background of study ...............................................................................................................1
1.2 Problem statement ...................................................................................................................2
1.3 Justification of the study ..........................................................................................................3
1.4 Research questions ..................................................................................................................3
1.5 Objectives ................................................................................................................................3
1.5.1 General objective ...............................................................................................................3
1.5.2 Specific objectives .............................................................................................................3
1.6 Scope of the study ...................................................................................................................4
1.6.1 Time scope .........................................................................................................................4
1.6.2 Theoretical scope ................................................................................................................4
1.6.3 Geographical scope ............................................................................................................4
1.6.4 Content scope ......................................................................................................................4
1.7 Limitation of the study ............................................................................................................4
1.8 Conceptual framework .............................................................................................................5

IX
CHAPTER TWO
REVIEW OF LITERATURE
2.0 Introduction ...............................................................................................................................6
2.1 Epidemiology of tuberculosis ..................................................................................................7
2.2 Socio demographic ................................................................................................................. 9
2.3 Socio economic ...................................................................................................................... 10
2.3.1 Poverty .............................................................................................................................10
2.3.2 Accessibility to the health service ....................................................................................11
2.3.3 Affordability to health service .........................................................................................11
2.3.4 Missed diagnosis to health facilities ...............................................................................12
2.3.5 Health promotion ............................................................................................................13
2.4 Socio cultural factors ..............................................................................................................13
2.4.1 Place of first resorts ..........................................................................................................14
2.4.2 Psychosocial ..................................................................................................................... 14
2.4.2.1 Stigma ......................................................................................................................14
2.4.2.2 Knowledge and participation ...................................................................................16
2.4.2.3 Patients delay of tuberculosis treatment ................................................................17

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CHAPTER THREE
MATERIAL AND METHODOLOGY
3.0 Introduction..............................................................................................................................19
3.1 study type and design...............................................................................................................19
3.2 study area ........................................................................................................................................... 19
3.3 study variables .........................................................................................................................20
3.3.1 Independent variables .....................................................................................................20
3.3.2 Dependent variables.........................................................................................................20
3.4 Study Population......................................................................................................................21
3.5 Sample Size..............................................................................................................................22
3.6 Sampling Technique ................................................................................................................22
3.7 Data collection procedures.......................................................................................................22
3.7.1 Validity and reliability .......................................................................................................22
3.8 Data management and analysis................................................................................................23
3.9 Ethical Implication...................................................................................................................23
CHAPTER FOUR
DATA ANALAYSIS
4.0RESULT--------------------------------------------------------------------------------------24-48

XI
CHAPTER FIVE
CONCLUSION, FINDINGS & RECOMMENDATION
5.1 Discussion ...............................................................................................................................49
5.1.1 Delay in seeking care among tuberculosis patients ......................................49
5.1.2 Socio-cultural Characteristics ............................................................................51
5.1.3 Perceived stigma ...................................................................................................52
5.2 Conclusion ..............................................................................................................................52
5.3 Recommendations ...................................................................................................................53
Government .......................................................................................................................53
District Health Management Team (DHMT) ...................................................................53
District Assembly...............................................................................................................53
References .....................................................................................................................................54
Appendix .......................................................................................................................................58
Appendix XI questioner ...............................................................................................................58
Appendix XI Somalia map ...........................................................................................................63
Appendix XI Mogadishu map ......................................................................................................64
Appendix XI yaqshid map ...........................................................................................................65

XII
LIST OF TABLES
Table 4.1 Age Distribution of respondent .....................................................................................24
Table 4.2 sex distribution ..............................................................................................................25
Table 4.3 marital status of Respondents ........................................................................................26
Table 4.4 Education level of Respondents ....................................................................................27
Table 4.5 Distribution of Occupation ............................................................................................28
Table 4.6income distribution in $ .................................................................................................29
Table 4.7house hold size ...............................................................................................................30
Table 4.8 reported major symptoms before seeking for treatment ................................................31
Table 4.9Can Effect more than once in their lifetime ..................................................................32
Table 4.10stander of length of treatment for newly diagnose case of TB ....................................33
Table 4.11primary diagnostic test that is usually requested in order to active pulmonary TB......34
Table 4.12What do you think are the best ways a person can prevent getting pulmonary TB......35
Table 4.13How long did it take from the time you first feel sick and you went to the health
facility ...........................................................................................................................................36
Table 4.14 D you consider this time is a delay or not....................................................................37
Table 4.15 what do you think is cause of your delay to seek care ................................................38
Table 4.16where was your first place to seek care? ......................................................................39
Table 4.17why did you go to that place? ......................................................................................40
Table 4. 18 do you feel ashamed for having this disease? ............................................................41
Table 4.19 does this disease affect relation with the others? ........................................................42
Table 4.20does this disease affect relation with the others? .........................................................43
Table 4.21is the disease very costly to you ...................................................................................44
Table 4.22 Do you prefer to live isolated since you diagnosed that you have this disease ...........45
Table 4.23Does this disease affect your work performance? ......................................................46
Table 4.24 does this disease effect your marital relation? ............................................................47
Table 4.25does this disease effect family responsibility? ............................................................48

XIII
LIST OF FIGURES
Figure 4.1 Age Distribution of respondent ...................................................................................24
Figure 4.2 sex distributions............................................................................................................25
Figure 4.3 marital status of Respondents. .....................................................................................26
Figure 4.4 Education level of Respondents ..................................................................................27
Figure 4.5 Distribution of Occupation ..........................................................................................28
Figure 4.6income distribution in $.................................................................................................29
Figure 4.7house hold size .............................................................................................................30
Figure 4.8 reported major symptoms before seeking for treatment ..............................................31
Figure 4.9Can Effect more than once in their lifetime .................................................................32
Figure 4.10stander of length of treatment for newly diagnose case of TB....................................33
Figure 4.11primary diagnostic test that is usually requested in order to active pulmonary TB ....34
Figure 4.12What do you think are the best ways a person can prevent getting pulmonary TB ....35
Figure 4.13How long did it take from the time you first feel sick and you went to the health
facility ...........................................................................................................................................36
Figure 4.14 D you consider this time is a delay or not? ...............................................................37
Figure 4.15 what do you think is cause of your delay to seek care ..............................................38
Figure 4.16where was your first place to seek care? ....................................................................39
Figure 4.17why did you go to that place? .....................................................................................40
Figure 4. 18 do you feel ashamed for having this disease? ..........................................................41
Figure 4.19 does this disease affect relation with the others? .......................................................42
Figure 4.20does this disease affect relation with the others? .......................................................43
Figure 4.21is the disease very costly to you .................................................................................44
Figure4.22 Do you prefer to live isolated since you diagnosed that you have this disease...........45
Figure 4.23Does this disease affect your work performance? .....................................................46
Figure 4.24 does this disease effect your marital relation? ...........................................................47
Figure 4.25does this disease effect family responsibility? ..........................................................48

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1
CHAPTER ONE
INTRODUCTION
1.1 Background
Tuberculosis is an infectious disease caused by the bacillus mycobacterium tuberculosis which
typically affects the lungs but can affect other parts of the body. The disease spreads through air
when a patient expels bacteria, for example, by coughing. In general relatively small proportion
of people infected with mycobacterium tuberculosis will develop TB disease, people who have
much higher chance of developing the disease are those infected with human immunodefiency
virus. Tuberculosis is also more common among men than women, and affects mostly adults in
the productive age groups; around two-thirds of cases are estimated to occur among people aged
15-59 years.
Tuberculosis (TB) continues to be one of the major public health problems in the world; the
burden is increasing as a result of poverty, population growth and HIV/AIDS. In 1993 the World
Health Organization declared TB to a global public health emergency at a time when estimated 7
to 8 million cases and 1.3 to 1.6 deaths occurred each year. In 2010, it was estimated that there
were between 8.5-9.2 million new TB cases in the world and 1.2-1.5 million deaths due to the
disease [Global Tuberculosis Control.2011]. China and India accounted for 40% of notified
tuberculosis case in 2010, Africa accounted for 24%. [Global Tuberculosis Control.2011]. upon
early diagnosis of the disease, treatment success rate is high in the year 2009, 87% of smear
positive pulmonary tuberculosis cases were successfully treated. [Global Tuberculosis
Control.2011]. Direct observed treatment (DOTs) strategy was established in 1995 in order to
control tuberculosis.
Poor and vulnerable populations are those most likely to contract infection, develop disease,
have poor treatment outcomes, and experience severe social and economic hardship from the
disease. If TB is not effectively diagnosed and treated among these groups, it can perpetuate the
epidemic and put the whole Population at continuous risk of TB.

2
In Africa, there were 2.3 million new cases and 254,000 deaths in the year 2010. Nine countries
out of 22 high burden countries were in Africa. In Nigeria prevalence of tuberculosis was
estimated to be 64,000 cases with incidence of 283 cases per 100,000 populations.
economically active age groups, especially due to the risk of dual HIV/AIDS and TB infection
(WHO, 2004). By 2001, Somalia had a high tuberculosis burden with an estimated incidence rate
of all forms of tuberculosis of 352/100 000, a smear positive case detection rate of 32% and a
close to the target treatment success rate of 83%. With 100% DOTS coverage reached at the end
of 2001, the smear positive case detection slightly increased to 37% by 2003 (WHO, 2003,
WHO, 2006b).
1.2 Problem Statement
Somalia is among the countries with the highest TB incidences and prevalence in the world
(about 372 per 100,000 populations), with approximately 25,000 expected TB cases per year.
The number of estimated smear positive cases is 11,000 per year (162 per 100,000 people) with
80% of the cases occurring in the productive age group of 15-44 years. Tuberculosis is thus a
major public health problem in Somalia.
As in many other resource-constrained settings, treatment outcomes for TB have not been
satisfactory in southern and central Somalia, mainly due to poor treatment compliance, low case
detection and low coverage of DOT centers. Barriers such as poverty, lack of knowledge
/information, Stigmatization, lack of family support and complexity of the health care system in
Somalia could delay seeking care or contacting a health care provider (SACAB, 2003). The TB
Centre utilizes the most effective TB treatment strategy, the Directly Observed Treatment Short-
course (DOTS) method.
Delay in seeking care for TB may be detrimental not only to the individual, whose illness may be
more severe, but also to the community, as ongoing transmission will continue until effective
chemotherapy is instituted.

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1.3 Justification of the study
Early diagnosis and treatment of Tuberculosis is crucial for reduction of infection rate and
improving outcome of the treatment. Despite efforts made through media to sensitize community
warning symptoms of TB still there is a significant delay in healthcare seeking among TB
patients. There are a few studies in Somalia which have tied to explore socio cultural factors
associated with a delay. In my study will provide useful information on magnitude and factors
influence delay in healthcare seeking among TB patients. This information will be useful to
others who will do studies in this area, and for planning of TB activities.
1.4 Research question
1. What are social and cultural factors that are contributing to patients delay in seeking
health care
2. What proportion of TB patients delayed in starting treatment
1.5 Objectives
1.5.1 General objectives
i. To identify factors influencing delay in seeking care among tuberculosis patients
attending tuberculosis clinics in Yaqshid distract
1.5.2 Specific objectives
i. To determine proportion of TB patients who delayed to seek health care in yaqshid
district.
ii. To determine association between socio-cultural factors and delay in health seeking care
among TB patients attending DOTS clinics in yaqshid district.
iii. To determine association between perceived stigma and delay in healthcare seeking
among TB patients attending DOTS clinics in yaqshid District.

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1.6 Scope of the Study
The scope of this has four dimensions: Time Scope, Theoretical scope, Geography scope, and
Content scope.
1.6.1 Time scope
The time scope of this study will be between 17 march 2017 up to end of July 2017.
1.6.2 Theoretical scope:
Delay in seeking care among tuberculosis patients attending tuberculosis clinics in yaqshid
district Mogadishu-Somalia.
1.6.3 Geography scope
Study will be conducted tuberculosis clinics in yaqshid district Mogadishu- Somalia.
1.6.4 Content scope
The study will focus delay in seeking care among tuberculosis patients attending tuberculosis
clinics in yaqshid district Mogadishu-Somalia.
1.7: Limitations of the study
In this study, the researchers faced some problems, including:
Shortage of time.
the most significant limitation of our study was security challenges.
financial accessibility.

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1.8 Conceptual framework
I V
D V
Delay in seeking care
Socio cultural factors
 Stigma
 Religion
 Traditional healing
Socio economic factors
 Occupation
 Accessibility of health service
 Distance of health facility
 Missed diagnoses at health
facilities
Socio demographic factors
 Gender
 Age
 Level of education
 Increase spread of
infection. (Increased
number of new
cases)
 Worsen prognosis
(may cause death,
MDRT)

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CHAPTER TWO
LITRATURE REVIEW
2.0 Introduction
This chapter looks at various studies conducted looking at knowledge of tuberculosis in general
population and among TB patients.
The review of literature will also look at various studies conducted that looked at health seeking
behavior and its associated factors in general population and in patients with TB symptoms.
Studies have identified several factors that are responsible for delay in diagnosis and treatment of
tuberculosis. Delay in treatment has been categorized as patient’s delay which is a time taken by
the patient before consulting health facility from the onset of symptoms and health system delay,
a time between receiving a patient and final diagnosis of TB.
A number of studies have found association between health seeking behavior and knowledge,
awareness, stigma, gender differences, family support, social and cultural influences, and
distance to the health facilities, poverty, preference of buying drugs from medical stores and
going to traditional healers. These factor influence behavior of people with TB symptoms and
are responsible for delay in healthcare seeking.
Tuberculosis (TB) is an infectious disease that spreads through the air from person to person. It
is caused by Mycobacterium TB. When a person with TB of the lung coughs, sneezes, talks or
even sings, the bacteria are sprayed out into the air as infectious droplets. These droplets dry up
rapidly but the smallest of the droplets remain suspended in the air for several hours. Not all
infected individuals develop TB - approximately 10% develop the disease.
TB is a major public health concern globally; and is rated second only to HIV/AIDS as a cause
of morbidity and adult mortality, accounting for nearly nine million cases of active disease and
two million deaths in 200. In 1993, the World Health Organization (WHO) declared a state of
global emergency for TB due to the steady increase of the disease worldwide. In 1995 Directly
Observed Treatment Short-course (DOTS) strategy was established as the key intervention to

7
achieve TB control worldwide. The global targets of this strategy were to achieve 70% case
detection and 85% cure rates by 2005.
In 2003, DOTS programs successfully treated 84% of all registered new smear positive patients,
but detected only 28% of the estimated tuberculosis cases in the world. Early diagnosis and
prompt effective therapy form the key Elements of the tuberculosis control program. Delay in
diagnosis results in increased infectivity in the community and it is estimated that an untreated
smear-positive patient can infect, on average, 10 contacts annually and over 20 during the natural
history of the disease until death (WHO, 2006).
Delay in tuberculosis diagnosis may also lead to a more advanced disease state at presentation,
which contributes to late squealed and overall mortality. Smear-positive cases are more likely to
infect other individuals. Case detection was estimated at 53% globally in 2004. The number of
TB cases has, however, been growing in Africa where the TB epidemic is still driven by the
spread of HIV. More than 80% of all TB patients live in sub-Saharan Africa and Asia.
2.1 Epidemiology of TB
TB is one of the major causes of death from a curable infectious disease (WHO, 2004). Findings
from results of surveys, surveillance systems and death registrations estimated that 8·9 million
new cases of TB were reported in 2004, less than half of which were reported to public-health
authorities and WHO. About 3·9 million cases were sputum-smear positive, the most infectious
form of the disease.
The report further maintains that countries in Africa have the highest estimated incidence rate
(356 per 100000 persons per year), but the majority of patients with TB live in the most populous
countries of Asia. Bangladesh, China, India, Indonesia, and Pakistan together account for nearly
half (48%) of the new cases that arise every year (WHO, 2004). According to Dye (2006), TB is
first and foremost a disease of men.
Where the transmission of Mycobacterium TB has been rising for many years, the disease is
common in young adults with most TB cases are new infections in this case of rising incidence.

8
Reservoirs for high levels of TB transmission rest predominantly in those with undiagnosed
pulmonary disease. The contagion parameter suggests that where TB is endemic, each infectious
case will result in between 20 and 28 secondary infections (Jochem, 1999).
The review by Harries et al, (2001) stated that in many African countries, the time between onset
of symptoms and diagnosis of smear-positive pulmonary TB is about 3–4 months, thereby
increasing the spread of disease. If detection occurred far closer to the onset of symptoms,
secondary cases would automatically fall.
TB situation in Somalia The actual scope of the tuberculosis problem in Somalia was first
examined in the early fifties, when a tuberculin survey led to an estimation of the annual risk of
infection (ARI) at a level of 8% in 1956. Another study conducted in 1986 estimated the ARI to
be 3.7% (WHO, 2006 a). In March 2006, WHO carried out a new tuberculin surveys throughout
Somalia funded by Global fund for HIV/AIDS, TB and Malaria (GFATM).The surveys revealed
that the ARI was at 2.26%. Assuming the Stýblo ratio of 50 new smear positives for each 1%
ARI, the incidence of new sputum smear positive was 111/100,000, which assuming a total
population of 8.495 million, yields 9430 new cases of smear positive TB and about 11316 smear
negative and extra pulmonary (WHO, 2006 a).
In Somalia, TB mostly affects people of reproductive age, with about 56% of notified cases from
the age group 15-34 years. It is also noted that men are more affected than women. Somalia, TB
is strongly correlated with poor economic conditions where many patients are refugees or
returnees from neighboring countries and many others have lived for more than a decade in war
zones. Malnutrition is also common among TB patients and HIV co-infection is rapidly
increasing. (SACB, 2003).
The TB Program achieved the regional target of DOTS in all parts of Somalia in 2000, by
establishing at least one TB centre in each of the 18 regions. However, the vast regions with the
nomadic lifestyle of Somalis contribute to the inaccessibility of these centers.
The WHO increased the case detection rate through the expansion of the TB centers In 2006,
11,945 cases were reported in health facilities in Somalia working under DOTS, of which 6,895
were new smear positive cases with DOTS case detection rate of 71 % (WHO, 2006a) Case

9
detection rates are lower in the North East Zone (34%) than in Central and South Somalia (29%
and 63% respectively) where instability and limited number of TB hospitals have affected the
provision of services to the population. The treatment success rate was 80% in 2000, with no
significant regional differences (SACB, 2003).
economically active age groups, especially due to the risk of dual HIV/AIDS and TB infection.
By 2001, Somalia had a high tuberculosis burden with an estimated incidence rate of all forms of
tuberculosis of 352/100 000, a smear positive case detection rate of 32% and a close to the target
treatment success rate of 83%. With 100% DOTS coverage reached at the end of 2001, the smear
positive case detection slightly increased to 37% by 2003.
2.2 Socio demographic factors
Social demographic characteristics of the patients have a role in diagnosis and treatment of
tuberculosis. Gender and age differences have been reported to have influence in seeking care. In
Pakistan it found that women had less access to health care than men, [WHO 2006].
This may be attributed to low social economic status of women and lack of power of deciding to
go to the health facility. Patient Delay in tuberculosis diagnosis of TB has a negative impact in a
community, it increases infectivity in a community and it is estimated that one untreated case of
tuberculosis can infect 10 contacts annually and over 20 during the natural history of the disease
until death [WHO 2006]. Delay in tuberculosis diagnosis may also lead to patient developing
more advanced stage of the disease which is difficult to treat and contribute to increase in cost of
care and overall mortality.
A study conducted in Ilala, Dar es Salaam showed that only 25.5% of the patients reported to
have been diagnosed within 4 weeks since initiation of symptoms that means 74.5% of the
patients delayed to start treatment. It was found that the median time for delaywas 7 weeks.
Financial constrains, seeking care from sources other than health facilities and low awareness of
the symptoms was associated with this delay.

10
2.3 socio economic factors
Socio-economic factors clearly influenced the likelihood of accessing diagnosis and health care .
The most important factor was income, which was similarly found to be a barrier to health care
in other areas. A nationwide study on the income of TB patients [Wang L, Yue S, Qian Y.
Socio-economic investigation towards TB patients. J Chin Anti-Tuberc Assoc 2002;24: 130–2. ]
demonstrated that among 628 newly discovered TB cases in rural areas, 502 (80%) cases have a
per capita annual income lower than the national average.
In the present study, we discovered that poverty limited TB patients’ access to and affordability
of health care, because of high treatment costs and opportunity costs. When patients decided to
seek care, they had to resort to low quality providers who charged lower prices.
2.3.1 Poverty
There is a relationship between poverty and tuberculosis. Poor people are more vulnerable to
tuberculosis due to their living conditions, studies have shown that people living in overcrowded
rooms (L. Kabalimu, T.K. & Kasesela 2007). More over infected individuals becomes less
economically productive due to their ill health which result into poverty, therefore poverty and
TB infection fuel each other (Killewo J. Poverty,2002) .
The prevalence of TB has been higher in poor countries, majority of the 22 countries with high
burden of TB are least developed countries. Delay in seeking treatment is more pronounced
among poor patients, especially females and elders. It was found that a significant number of
patients did not seek care due to lack of money for transportation to health facility (Abebe G,
Deribew A, Apers L, Woldemichael K, Shiffa J, Tesfaye, M, et al. 2010).
Another study showed that delay over four weeks were associated with rural residence, transport
time of over 2 hours, overnight travel, and high cost of transportation in such a way that people
had to sell their assets to get money for transport.( Cambanis A., Yassin MA., Ramsay A., Bertel
Squire S., Arbide I., Cuevas L.E.2005 )

11
2.3.2 Accessibility to health service
Accessibility to health facilities contribute to health seeking decisions. Difficult in access in to
health services may account for delay. Distance from the health facilities, traveling costs and
other indirect costs such as loosing work days may hinder patients from being tested. Studies in
Ethiopia have shown that patients who had to travel longer distances to health facilities (with the
median transport time of 2 hours) had more chances to discontinue treatment (Abebe G, Deribew
A, Apers L, Woldemichael K, Shiffa J, Tesfaye, M, et al. 2010) .
This is also true for the ones who have to seek health care for the first time. Structural and
financial factors may make healthcare services inaccessible for poor communities. Another study
in China found that patients were not able to seek treatment due to poverty and distance to the
health facilities (Zhang T., Liu X., Bromley H., & Tang S 2007).
On the other hand perceived quality of care may influence patients’ decision to care seeking
regardless of the distance to the health facility. A study done in Ethiopia found that 49% of the
patients made their first visit in hospitals, out of them 34% reported that they visited hospital in
order to get quality services regardless of the distance(Mesfin M.M., Tasew T.W., Tareke I.G.,
Kifle Y.T., Karen W.H & Richard M.J. 2005).
2.3.3 Affordability of health care
TB represents a financial disaster for farmers’ families, resulting in reduced income from lost
productivity and increased expenditure for medical care. The questionnaire survey showed that
98% of the 614 respondents were not covered by health insurance of any kind. The resulting debt
may continue for many years.
Survey respondents estimated that to cure a TB patient, the median of total cost (including
medical expenditure and opportunity cost) was about 5000 Yuan (US$ 610). This cost is roughly
equal to70%of annual household disposable income (7136 Yuan or US$ 870) in a middle-
income family (Statistics Bureau of Inner Mongolia. Statistical year book

12
2002. Beijing, China: Chinese Statistical Publishing House; 2002.) However, because most TB
patients were from poor families, the problem of affordability was more serious. Seventy percent
of survey respondents said their family could not afford TB treatment.
The survey also showed that 80% of families who could not afford treatment would have to
borrow money in order to pay for treatment. Nine percent of respondents said that they would
have to stop having treatment: ‘They [those cannot afford the treatment] have to stop having
treatment and wait for death, because they have run out of all borrowed money and are unable to
return it: nobody would lend them any more’ (Older Mongolian Women Group, no. 1). Many
older FGDs participants could identify someone they had known who had died of TB because of
their inability to pay for treatment.
2.3.4 Missed diagnoses at health facilities
Lack of money for diagnostic tests and low suspicion of TB at health facilities caused further
delay in obtaining correct treatment, once a person decided to seek care at a health facility. Only
half of patients who visited public health facilities and only one among those who visited a
private facility for the first time were diagnosed with TB.
Though we did not investigate this, an extensive review of previous studies show that most
private hospitals serving the urban and rural poor in the developing world are ill-equipped and
their staff unqualified, hence the low suspicion for TB among patients who visited these facilities
[. Malmborg R, Mann G, Thomson R, Squire SB: Can public-private collaboration promote
tuberculosis case detection among the poor and vulnerable? Bull World Health Organ 2006,
84:752-758.].
This confirms findings from a previous study in Kenya that showed that health units failed to
investigate chronic coughs in a certain proportion of TB suspects [Fox W: Tuberculosis case-
finding and treatment programs in the developing countries. British Medical Bulletin 1988,
44:717-737]. Even though a good proportion of patients visited providers in the private sector,
there was a marked decrease in the number of patients seeking care at these facilities. For
instance, at attempt 1, 12 out of the 31 sought diagnosis at a private facility; attempt 2, only 3 out
loss of confidence in these facilities by patients, more investigation is needed to explain this shift

13
in health care seeking. There are many consequences of missing the diagnosis of tuberculosis,
and this raises several programmed and policy issues [Thomson EM, Myrdal S: Tuberculosis –
the patients’ perspective.
South African Medical Journal 1986, 70:263-264. ]. For the patient, misdiagnosis and faulty
treatment leads to loss of scarce time and money in the search for treatment, and may increase
the duration of illness and the possibility of death.
For public health officials, misdiagnosis causes an underestimate in the rate of incident TB, and
increases the duration of infectivity. Interventions that could improve the likelihood of TB
diagnosis at health facilities may include implementation of standard screening procedures,
additional training of health care workers, education of patients (so that they expect and request
diagnostic testing for TB when appropriate), and better access to and reduced costs for
diagnostic tests.
2.3.5 Health promotion
Health Promotion Strategy (IEC strategy/Information, Education and Communication strategy, a
part of WB/DFID UK TB Control Program), which is currently being drafted, should focus on
local perceptions and interpretations of TB, such as understandings of the mechanisms of
transmission and treatment.
Health education needs to inform the public without raising additional fears, and should
emphasize that TB is perfectly curable, in order to eliminate social stigma against TB patients.
Local key persons should be identified, such as TB patients and local health care providers.
Ways of employing them to dispel myths about TB diagnosis and treatment could be explored.
Health education training courses for patients, as well as local health care providers, should be
considered.
2.4 socio cultural factors
In any cultural context, a precondition of health-seeking behavior is the recognition and
interpretation of symptoms by the individuals affected and by those around them [Calnan M:
Towards a conceptual framework of lay evaluation of health care. Soc Sci Med 1988, 27:927-
933.]. Who is consulted once symptoms are recognized will depend on pre-existing beliefs about

14
the likely meaning of the symptoms and the availability and accessibility of the various potential
sources of help (traditional, spiritual, western medicine) [Ward H, Mertens TE, Thomas C:
Health seeking behaviour and the control of sexually transmitted disease.
Health Policy Plan 1997, 12:19-28. ]. Many beliefs about disease are culturally sensitive;
therefore health education must also be culturally sensitive and adapted to the local context.
Tuberculosis education should build on existing knowledge and focus on changing
misconceptions about its cause and transmission, which could in turn reduce stigmatization.
This availability of multiple sources of care, combined with uncertainty about TB symptoms,
stigma, and problems of access and affordability may further lead to considerable delays in
diagnosis and treatment of TB.
2.4.1 Place of first resort
Place where patient first visited have a contribution to delay in reporting to health facility. A
study conducted by FIDELIS initiative found that patient visited traditional healers before they
attend modern medical services, visited traditional healers had more delay to report to health
facilities (Hinderaker S.G., Madland S., Ullenes M., Ullenes M., Enarson D.A., Rusen I.D &
Kamara D2001). Some patients have religious beliefs that every illness can be cured by miracle.
Studies in Ethiopia showed that 50.4% of the respondents believed that TB is caused by evil eye.
Another Study in Nigeria showed that 10 % of the respondents believed that TB is caused by
spiritual attack (Okeibunor J.C., Onyeneho N.G., Chukwu J.N., 2007). Self medication in time of
illness has a role in patient delay; this is associated with low knowledge and low perceived
susceptibility of TB infection. In China it has been reported that farmers did seek healthcare only
after they failed to treat themselves and most of them sought care from less qualified village care
providers, this contribute to delay TB diagnosis(. Zhang T., Liu X., Bromley H., & Tang 2007).
2.4.2 Psychosocial
2.4.2.1 Stigma
Studies demonstrated that stigma prevent people from seeking care and diagnosis. Stigma of TB
has persisted for a long time as a disease of the poor, recently HIV/AIDS stigma affect TB

15
directly especially in areas with high prevalence of HIV. Therefore TB patients who are co
infected with HIV suffers double stigma because the disease is regarded as symptomatic of HIV.
Stigma found among TB patients in Ilala where 36% of them noted relatives, friends and
neighbors and 46% prefer not to disclose their TB status due to fear of stigma(L. Kabalimu, T.K.
& Kasesela2007).
Association of TB and HIV pause a challenge on early detection the disease, Ngamvisayaponget
all found people who suspect themselves to have HIV infection do hesitate to test for TB due to
fear of HIV detection(Ngamvithayapong. J, Winkvist.A. & Diwan 2000). On the other hand
community members do suspect TB patient having HIV even though they are not
(Ngamvithayapong. J, Winkvist.A. & Diwan 2000). Furthermore stigma has been shown to
hinder people from early seeking healthcare because they fear of been diagnosed to have TB.
A study conducted in Pakistan found that stigma exists in a society, 27% of respondents reported
it, and both men and women were equally affected. People delayed to seek health care for the
fear of been stigmatized (Quareshi S.A., Morkve O & Mustafa T 2008). In contrary another
study conducted in Somalia indicated that patients, who perceived high degree of stigma,
reported earlier to the health facilities(Diagnosis and treatment delay in tuberculosis WHO 2006)
Evidenced both in research and in practice, stigma associated with TB appears to be universal.
The consequences of stigma can be seen affecting care-seeking behaviors, as persons have been
known to hesitate or choose not to disclose their TB status to family, friends, and co-workers out
of fear of being socially ostracized (Auer et al. 2000). TB and HIV are closely linked in people’s
minds in Lusaka and probably throughout the Southern African region, where as many as two
thirds of TB patients may also be infected with HIV. Even patients who have been declared
cured from TB are still socially disadvantaged (Meursing, 1997).
Other studies have highlighted the silence and discrimination that surround people suffering from
HIV and TB, that may deter people from seeking care (Meursing, 1997) and (Liefooghe, 1997).
It is possible that those with more severe symptoms may have underlying HIV disease and be
less inclined to visit the clinic, fearing stigmatization (Liefooghe, 1997).

16
2.4.2.2 Knowledge and participations
An individual’s knowledge, attitudes, and perceptions with respect to health in general and With
a specific illness, such as TB influence his/her behavior. Good general knowledge of TB is
important for both health care seeking and adherence to treatment. Studies from Malaysia (Lim
et al., 1999).and Vietnam (Xu B et al. 2004) have shown that treatment is often delayed due to
poor knowledge, particularly in lower socioeconomic groups. Many in these groups are not
aware of the risks associated with longstanding cough, they are not reached by national
programs, and they do not recognize the need for prompt case detection, follow-up and
treatment.
Weintraub (1975) reported that the significant reason for the increasing prevalence of TB is poor
patient compliance with treatment regimens. Although some patients may have sufficient
knowledge of their disease or treatment objectives, there is a poor correlation between having
such knowledge and adherence to treatment and follow-up. Weintraub concluded that TB control
programs that use incentives to improve adherence to a medication regimen or the direct
observed therapy method, in which the taking of medication is directly observed have the
potential to increase TB cure rates.
A study done in Mankweng in Limpopo province, South Africa among community members,
revealed that majority of the respondents perceived the cause of TB as smoking. The perceived
cause of cigarette smoking may be associated with TB because many other lung diseases such as
emphysema and lung cancer are caused by smoking. Symptoms are the same – cough, phlegm
etc. Moreover, smoking reduces appetite among some, but not all and that can cause them to
become thin. Similarly, people infected with TB may become thin.
This study also mentioned other misconceptions, such as TB being transmitted through dust,dirty
air, and chemicals, eating unclean food, using dirty dishes, drinking unclean water and drinking
alcohol (Supa & Peltzer, 2005, pp.74-81). With reference to health care, in the Lusaka urban
health centres study, delay was associated with older age, severe underlying illness, poor
perception of health services, distance from the clinic and prior attendance at a private clinic.

17
There was no relationship between patient delay and knowledge about tuberculosis or with
education, socio-economic level or gender (NRITLD, 2002).
Patient delay was also found not significantly associated with patients' socio-demographic
characteristics such as age, gender and educational level in a study carried out in Nigeria
(Olumuyiwa et al., 2004). In another study conducted in Kenya, TB was perceived to be
contagious, sensitive, and difficult to diagnose and treat. According to the study, community
members believe that TB should be diagnosed and treated in a hospital or by a medical doctor
and not at the peripheral level.
Many participants also believed TB to be hereditary. Prolonged incidences of self-treatment and
consultation with the traditional health sector as well as the social stigma attached to the disease
increase patients’ delay (Liefooghe, et al, 1997). According to a review (Brown, 1999),
individual perception of the disease threat is composed of a personal perception of susceptibility
to and severity of a certain disease. Personal perception of severity of a disease refers to feeling
concerned about the seriousness of contracting an illness as an evaluation of the medical
consequences e.g. death, disability and possible social consequences.
When individuals feel that they are at risk of contracting a certain disease, they may or may not
act to protect themselves from that situation. This means that the two factors combined,
perceived susceptibility and perceived severity of certain diseases bring about the individual
psychological readiness to take proposed action (Brown, 1999). In a study conducted in Ethiopia
aimed to determine the length of delay between the onset of symptoms and patient first visit to
health care (patient delay) and length of delay between health care visit and diagnosis of
tuberculosis, the time before diagnosis in TB patients was long and appeared to be associated
with patient inadequate knowledge of TB treatment and distance to the health centre (Madebo T,
Lindtjørn B. 1999.
2.4.2.3 Patient’s Delay of TB Treatment
The starting point from which the delays in seeking treatment are measured is uncertain an there
is no agreed definition as to what constitutes an acceptable delay. The cutoff point in studies of
risk factors for an acceptable delay has been defined in two ways: either a panel of experts agrees

18
on a reasonable period of time or, alternatively, the median delay in observed data is used. Panels
of expert have agreed on an acceptable total delay of 30 days [Wandwalo ER, Morkve, 2000, pp-
133-138) or 60 days (Pirkis, et al, 1996, pp. 389-390 and Martinho et. al. 2005) Knowledge and
understanding of the delay behaviour is very important for every TB programme as an individual
may live with one or more potentially serious symptoms for amonth or more and not seek help.
This is called delay behavior.
Patient delay is defined as the time between when a person first suspects his own symptoms may
be of TB and when he actually seeks treatment (Kawathana, 1998). A delayer is likely to be
poorly educated and low class in the society (Yusuf, 2004). Older people delay longer than
younger people and this situation is common to people with no regular contact with a health
provider (Yusuf, 2004).
Study results from rural Ethiopia; indicate that patients' delay was found to average 30 days
(Solomon et al, 2005). This is in accordance with other studies conducted in Ghana, by Lawn, S.,
Afful, B.& Acheampong J (1998), which showed a median patients' delay of 3 – 4 weeks. A
multi-country study from seven countries of the WHO Eastern Mediterranean Region was
conducted during 2003–2004 in order to study the extent of delay in the diagnosis and treatment
of tuberculosis patients, and its determinants.
The results showed that the mean duration of delay between onset of symptoms until treatment
with anti-tuberculosis drugs, ranged from one month and a half to 4 months in the different
countries. The mean delay was 46 days in Iraq, 57 in Egypt, 59.2 in Yemen, 79.5 in Somalia,
80.4 in Syrian Arab Republic, 100 in Pakistan, and 127 in Islamic Republic of Iran. The main
determinants of delay were: socio-demographic (illiteracy, suburban residence); economic;
stigma; time to reach the health facility; seeking care from non-specialized individuals; and
visiting more than one health care provider before diagnosis(WHO, 2006b).

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CHAPTER THREE
METHEDOLOGY
3.0 Introduction
This chapter presents the methodology adopted to investigate the delays in seeking TB treatment.
The chapter describes operational definitions; study area, study population, sampling methods
techniques and tools administered for documenting information, reliability and validity, data
management and analysis and conclude with ethical aspects of this study.
3.1 Study design
This research employed a cross sectional analytical study. A cross-sectional study, a type of
descriptive, observational study, involves measuring different variables in the population of
interest at a single point in time. This simultaneous data gathering is often thought of as a
snapshot of conditions present at that instant. . This design has advantage several advantages,
such as the ease of assessing the prevalence of diseases and relatively low cost.
Its disadvantages are the inability to establish causal relationship. We decided to use this design
due to the limited time and resource..
3.2 Study area
The study has covered in yaqshid district. There are three DOTS centers managed by local
NGOs, with support from WHO. The study covered two of the DOTs centers. The clinic was
purposively selected due to ease in access.

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3. 3 Variables.
3.3.1 Dependent variable
Delay in seeking care for tuberculosis patients. This was obtained by asking patients the time
interval between onset of symptom and presentation to a health care facility. Thirty days was
used as cut-off point for delay.
3.3.2 Independent variables
Stigma: Likert scale was used to measure perceived stigma of the patients, which ranges from 1
being highest degree of stigma to 5 lowest degree of stigma. Questions asked included: feeling
ashamed of having tuberculosis, having to hide tuberculosis diagnosis from others; cost incurred
by the long disease duration; isolation due to tuberculosis, and the extent to which tuberculosis
affects the following: relation with others; work performance; marital relations; family
responsibilities; chances of marriage; family relations. Reported perceived stigma was cross
tabulated against delay to establish their relation.
Traditional beliefs
Patients were asked how their traditional beliefs influence their decision of seeking health care.
Education level
Patients were asked their level of education, and then they were categorized in three groups. First
group was those who never went to school, second group was those who had primary education
and the third group was those who had above primary education.
Occupation
Patients were asked about their current occupation or what they were doing before falling seek.

21
3.4 Study Population:
The study population will be TB patients attending clinics in y a q s h i d d i s t r i c t
i n B a n a d i r r e g i o n M o g a d i s h u - S o m a l i a . 293 of TB
patients enrol in DTOS clinics in yaqshid district in every six months
Inclusion criteria
N e w s m e a r p o s i t i v e P u l m o n a r y T B p a t i e n t s
a b o v e 1 5 y e a r s o f a g e , d u r i n g t h e i r f i r s t t w o
m o n t h s o f i n t e n s i v e p h a s e o f t r e a t m e n t w e r e
i n c l u d e d i n t h e s t u d y . T h i s w a s d o n e t o
m i n i m i z e r e c a l l b i a s o f p a t i e n t s a n d a c c e s s
m o r e p a t i e n t s .
Exclusion criteria
T h e s t u d y e x c l u d e d t h e r e s e a r c h s u b j e c t s b a s e d
o n t h e f o l l o w i n g c o n d i t i o n s :
• P a t i e n t s b e l o w t h e a g e o f 1 5 y e a r s a t t h e d a t e
t r e a t m e n t s t a r t e d . T h i s w a s c o n f i r m e d b y
l o o k i n g a t t h e T B r e g i s t e r s a t t h e D O T S c e n t r e
a n d p a t i e n t s ' t r e a t m e n t c a r d s b e f o r e t h e
i n t e r v i e w .
• P a t i e n t s w h o d e f a u l t e d b e f o r e t h e d a t e o f d a t a
c o l l e c t i o n .
• S m e a r n e g a t i v e s a n d r e l a p s e d o r f a i l e d
t r e a t m e n t w e r e e x c l u d e d f r o m t h e s t u d y . T h i s
w a s b a s e d o n t h e f a c t t h a t i f a p a t i e n t i s s p u t u m
n e g a t i v e , h e / s h e m a y n o t h a v e T B a t a l l .

22
• P a t i e n t s w i t h o t h e r c o m p l i c a t i o n s t o g e t h e r
w i t h T B e . g . h e a r t d i s e a s e , r e n a l d i s e a s e s o r
p a t i e n t s u n w i l l i n g t o p a r t i c i p a t e i n t h e s t u d y
w e r e e x c l u d e d .
3.5 Sample size determination
Sample size was calculated using the following formula:
Slovene’s formula: n = N= sample n= sample size e=0.05 (constant)
n = 80.
3.6 Sampling technique
Study participants were selected from the district DTOS, two DTOS centers. Those were
purposely selected because they had a big number of Tuberculosis patients.
3.7 Data collection Methods
Before interviewing the patients, the numbers of eligible study subjects in the treatment centers
were recorded by reviewing the TB registered at the clinic. With the permission of health
workers at the DOTS clinic, patients coming to the centers for their treatment under DOTS were
requested for consent and then interviewed for the required information like date treatment
started was recorded from the TB registers and TB treatment cards. To assure confidentiality, no
permanent record of the study patients’ names and other information were made and patients
were asked to participate in the study voluntarily.
Data collected was used only for the purposes of the study and all information obtained during
interviews was treated confidentially. Careful attention was paid to maintain the patient's comfort
during the interview. It took approximately 35 to 45 minutes for a single interview. Pre-tested
anonymous interview guidelines in the form of semi-structured questionnaire in Somali language

23
were introduced to the study subjects by well-trained research assistants to collect the
information required. There were two research assistants and the researcher participated in this
study for information documentation. Study subjects were asked TB treatment seeking history
and their understanding about the disease, perception, stigma and some socio-economic issues
such as family income, level of education, gender, resident status e t c .
3.7.1 Validity and Reliability
A t w o d a y s t r a i n i n g o f e n u m e r a t o r s w a s
c o n d u c t e d c o v e r i n g i n t e r v i e w t e c h n i q u e s ,
s a m p l i n g p r o c e d u r e i n c l u s i o n a n d e x c l u s i o n
c r i t e r i a , i d e n t i f i c a t i o n o f d a t e o f o n s e t o f
s y m p t o m s o f T B a n d t h e g e n e r a l c o u r t e s y
d u r i n g t h e s t u d y . T h e t o o l s w e r e p r e - t e s t e d i n
o n e o f t h e f a c i l i t i e s o f f e r i n g D O T S s e r v i c e s n o t
s e l e c t e d f o r t h e m a i n s t u d y p r i o r t o t h e s t a r t o f
s t u d y , w i t h m o d i f i c a t i o n s i n c o r p o r a t e d i n t h e
f i n a l v e r s i o n . D u r i n g p i l o t i n g , t h e
q u e s t i o n n a i r e s w e r e i n d e p e n d e n t l y p r e - t e s t e d
u s i n g 5 v o l u n t e e r p a t i e n t s b y t w o d i f f e r e n t
e n u m e r a t o r s t o a s s e s s t h e i r v a l i d i t y . A f t e r t h e
p r e - t e s t i n g , v i e w s w e r e e x c h a n g e d t o a d d r e s s
t h e d i f f i c u l t i e s i d e n t i f i e d , a p p r o p r i a t e n e s s o f
t h e q u e s t i o n s r e v i e w e d a n d a p p r o p r i a t e
c h a n g e s m a d e . Q u a l i t y o f d a t a c o l l e c t i o n w a s
g i v e n f i r s t p r i o r i t y t h r o u g h o u t t h e s t u d y p e r i o d .
T h i s i n c l u d e d : c l o s e m o n i t o r i n g o f p a t i e n t s ,
i n t e r v i e w s b y s u p e r v i s o r s , c r o s s - c h e c k i n g o f
c o m p l e t e d q u e s t i o n n a i r e s o n d a i l y b a s i s , a n d
d a i l y r e v i e w s c o n d u c t e d w i t h t h e s u r v e y t e a m s
t o a d d r e s s a n y d i f f i c u l t i e s e n c o u n t e r e d . T o

24
e n s u r e t h e e x t e r n a l v a l i d i t y o f t h e s t u d y w a s
m a i n t a i n e d , r e l e v a n t l i t e r a t u r e w a s r e v i e w e d
a n d o p i n i o n s f r o m t h e e x p e r t s i n t h e c o n c e r n e d
f i e l d o f T B r e s e a r c h w e r e o b t a i n e d .
3.8 Data management and analysis
D a t a w a s e n t e r e d i n t o a d a t a b a s e c r e a t e d u s i n g
S P S S 1 6 . 0 f o r W i n d o w s . A p r e l i m i n a r y
a n a l y s i s w a s d o n e t o f a c i l i t a t e c o d i n g o f o p e n -
e n d e d q u e s t i o n s a n d r e c o d i n g o f v a r i a b l e s
w h e r e n e c e s s a r y . A n a l y s i s w a s d o n e u s i n g
S P S S 1 6 . 0 , M S e x c e l , M S w o r d f o r W i n d o w s .
D a t a w e r e a n a l y z e d t o c o m p a r e t h e d i f f e r e n t
r i s k f a c t o r s a m o n g t h e T B p a t i e n t s w h o h a d
d e l a y e d i n s e e k i n g t r e a t m e n t w i t h t h o s e w h o
h a d n o t d e l a y e d i n s e e k i n g T B t r e a t m e n t , a s
w e l l a s a s s e s s k n o w l e d g e a n d p e r c e p t i o n s
r e l a t e d t o T B . A 6 0 d a y s c u t - o f f o n p a t i e n t s ’
d e l a y w a s u s e d t o e s t i m a t e t h e t i m e b e t w e e n
o n s e t o f s y m p t o m s a n d i n i t i a t i o n o f t r e a t m e n t
a n d t o i d e n t i f y t h e r i s k f a c t o r s a s s o c i a t e d w i t h
t h e d e l a y i n p a t i e n t s w i t h T B . T h i s 6 0 d a y s c u t
o f f p e r i o d w a s u s e d t o d i c h o t o m i z e t h e s a m p l e
t o e i t h e r s h o r t e r o r l o n g e r d e l a y p e r i o d s .
T h e r e s u l t s a r e p r e s e n t e d i n f o r m o f t a b l e s a n d
c h a r t s / d i a g r a m s . D e s c r i p t i v e s t a t i s t i c s w e r e
d e t e r m i n e d d u r i n g d a t a a n a l y s e s . I n a d d i t i o n ,
l i n e a r r e g r e s s i o n a n a l y s i s w a s p e r f o r m e d t o
r e l a t e a g e , i n c o m e a n d d i s t a n c e w i t h T B
t r e a t m e n t d e l a y ( t a k e n a s a c o n t i n u o u s

25
v a r i a b l e ) . T h e 5 % s i g n i f i c a n c e l e v e l w a s u s e d
i n a l l t h e s t a t i s t i c a l t e s t s o f s i g n i f i c a n c e
c o n d u c t e d .
3.9 Ethical considerations and approval.
Approval to conduct the study will be sought from the concerned authorities which will include;
Research committee of Somalia University, Ministry of health MOH especially National TB
Program NTP and the Hospitals.
Selected participants will be informed about the relevance of the study and will be asked to
Consent before they participate in the study.
CHAPTER FOUR
RESULTS
4.0 Introduction
This chapter presents results of analysis based on data collected on Delay in Seeking Care among
Tuberculosis Patients Attending Tuberculosis Clinics in yaqshid District, Banadir-Somalia
Table 4.1 Age Distribution of Respondents
Age Frequency Percent
15-30 48 60.0%
30-50 23 28.8%
50-70 7 8.8%
70-90 2 2.5%
Total 80 100%
The above table shows the majority of the respondent age is (15-30) years the frequency was 48
(60.0%) while the others such as (30-50) are 23 (28.8%), (50-70) are 7 (8.8%), (70-90) are 2
(2.5%)

26
Figure 4.1 Age distribution of respondent
The below table shows sexy of respondent the most of them were males 53 (66.2%) while the
females 27 (33.8%)
Table 4.2 sexy of respondent
Sex Frequency Percent
Male 53 66.2%
Female 27 33.8%
Total 80 100%
Frequency
Percent
15-30
30-50
50-70
70-90
48
23
7
2
60%
28'8%
8'8%
2'5%
Frequency Percent

27
Figure 4.2 sex of respondent
The below table shows that about 30 (37.5 %) of the participant were married, 42(52%) were
single or unmarried, while only 8 (10.0%) of the respondents were divorced.
Table 4.3 marital status of respondent
Marital status Frequency Percent
Single 42 52.5%
Married 30 37.5%
Divorced 8 10%
Total 80 100%
53%
66'2%
27
33'8
Frequency Percent
Male Female

28
Figure 4.3 marital status of respondent
The majority respondents are never go to school education, 45 (56.2%) while of the respondent,
reported to have attained secondary education 15(18.8%). 13 (16.2%) had primary education ,7
(8.8%) respondents reported to have had attained College/University education.
Table 4.4 education level of respondent
Education Frequency Percent
No Formal Education 45 56.2%
Primary School 13 16.2%
Secondary School 15 18.8%
College/University 7 8.8%
Total 80 100%
42%
30%
8%
Frequency
single married divorced

29
Figure 4.4 education level of respondent
Majority of the respondents were not employed, 46 (57.5%), while 18 (22.5) were employed and
9 (11.2%) are business while others 7 (8.8%) were house wife.
Table 4.5 Distribution of Occupation
Occupation Frequency Percent
Business 9 11.2%
Employed 18 22.5%
Not employed 46 57.5%
Housewife 7 8.8%
Total 80 100%
45
13
15
7
56'2%
16'2% 18'8%
8'8%
Frequency Percent

30
Figure 4.5 Distribution of Occupation
Table 4.6 income distribution in $
Income Frequency Percent
0-100 $ 17 21.2%
100-300 $ 35 43.8%
300-500 $ 21 26.2%
500 and above $ 7 8.8%
Total 80 100%
9
18
46
7
11'2%
22'5%
57'5%
8'8%
Business
Employed
Not employed
Housewife
Percent Frequency

31
The above tabel indicates the distribution of the respondents by their income. The respondents in
this study were asked their monthly family income. It was observed that the income of the
participants was different according to their occupational status. Most of the respondents (43.8%)
their income was (100-300$). Some of the families their income was between (300-500$) with
proportion of 21 (26.2%). Some of the families their income above (500$) were also including
in the study with proportion 7(8.8%) according to poor people with less than 100 dollars
comprising17 (21.2%).
Figure 4.6 income distribution
Table 4.7 house hold size
house hold size Frequency Percent
Two 22 27.5%
Three 31 38.8%
Four 18 22.5%
greater than four 9 11.2%
Total 80 100%
0-100
100-300
300-500
500 and above
17
35
21
7
21'2%
43'8%
26'2%
8'8%
Frequency Percent

32
the above table shows that the most of respondent 31 (38.8%) are three persons in house , 22
(27.5%) were two persons in house , while 18 (22.5%) , 9 (11.2%) are four and more .
Figure 4.7 house hold size
The below table shows 31 (38.8%) respondents reported having cough and 3(3.8%) Coughing
blood as their main symptom that prompted them to seek for health care. Other Mentioned
symptoms were breathlessness 5 (6.2 %), fatigue or weakness 9(11.2 %), chest pain 12(15.0%) ,
fever 15(18.8%), loss of weight 4 (5.0%) of all Patients
Table 4.8 Reported major symptoms before seeking for treatment
symptoms before seeking
for treatment
Frequency Percent
Cough 31 38.8%
Coughing blood 3 3.8%
Two
27%
Three
39%
Four
23%
greater
than
four
11%
Frequency

33
Breathlessness 5 6.2%
Chest pain 12 15.0%
Fever 15 18.8%
Fatigue/weakness 9 11.2%
Loss of weight 4 5.0%
Loss of appetite 1 1.2%
Total 80 100%
Figure 4.8 Reported major symptoms before seeking for treatment
Table 4.9 Can someone become infected with TB more than once in their life
time
Can Effect more than once
in their lifetime
Frequency Percent
Yes 34 42.5%
No 22 27.5%
Don’t know 24 30%
Total 80 100%
31
3
5
12
15
9
4
1
38'8%
3'8%
6'2%
15%
18'8%
11'2%
5%
1'2%
Cough
Coughing blood
Breathlessness
Chest pain
Fever
Fatigue/weakness
Loss of weight
Loss of appetite
Percent Frequency

34
The above table indicates the most of respondents 34 (42.5%) tuberculosis can infect more than
ones in their lifetime wile 24 (30%) don’t knows, were 22 (27.5%) tuberculosis cannot infect
more than ones in their lifetime
Figure 4.9 Can Effect more than once in their lifetime
Table 4.10 stander of length of treatment for newly diagnose case of TB
stander Length Of
Treatment
Frequency Percent
1 month 2 2.5%
2-4 month 4 5.0%
5-6 month 64 80.0%
Don’t know 10 12.5%
Total 80 100%
Frequency
Percent
Yes
No
Don’t know
34
22
24
42'5%
27'5%
30%
Frequency Percent

35
The able above table shows the most of respondent 64 (80%) they know stander of length of
treatment for newly diagnose case of tuberculosis and 10(12.5%) don’t knows the stander length
TB treatment while 4(5.0%), 2(2.5%) believes stander length TB treatment are 1-4 month .
Figure 4.10 stander of length of treatment for newly diagnose case of TB
Table 4.11 primary diagnostic test that is usually requested in order to
confirm or rule out a case of active pulmonary TB
Primary Diagnostic Test Frequency Percent
Blood culture 12 15.0%
Chest X-ray 12 15.0%
Sputum smear microscopy 45 56.2%
Don’t known 11 13.8%
Total 80 100%
1 month
2-4 month
5-6 month
Don’t know
2
4
64
10
2'5%
5%
80%
12'5%
Frequency Percent

36
The above table indicates the most of participants 45(56.2%) they said the primary diagnostic
test of tuberculosis is Sputum smear microscopy while others such as blood culture 12(15%),
chest X-ray 12(15%), were 11(13.8%) don’t knows
Figure 4.11 Primary Diagnostic Test of tuberculosis
Table 4.12 What do you think are the best ways a person can prevent getting
pulmonary TB
Best way of TB prevention Frequency Percent
Avoid sexuality 12 15.0%
Avoid sharing dishes 23 28.8%
immunization with BCG 12 15.0%
Don’t known 33 41.2%
Blood culture
Chest X-ray
Sputum smear
microscopy Don’t known
12
12
45
11
15%
15%
56'2%
13'8%
Frequency Percent

37
Total 80 100%
According to above table the respondents think that the most way of prevention is Avoid sharing
dishes (28.8%,23 in N=80). And 33(41.2%) Don’t known best ways of tuberculosis prevention
,others such as Avoid sexuality 12(15.0%), and some of the respondent 12(15.0%) immunization
with BCG is the best way TB prevention
Figure 4.12 what do you think are the best ways a person can prevent getting
pulmonary TB
The below table shows difference between time taken at the onset of symptoms and when the
patient first visited the health facility was used to assess delay in reporting for treatment. A
patient was considered to have reported late for treatment if the duration between the onset of the
symptoms and seeking for treatment the majority of patients 41 (51.2%) had more than 30 days
and some of them 21 (26.2%) , 18 (22.5%) were less than or equal 15 days
Table 4.13 How long did it take from the time you first feel sick and the time
you went to health facility
12
23
12
33
15%
28'8%
15%
41'2%
Avoid sexuality Avoid sharing dishes immunization with BCG Don’t known
Frequency Percent

38
Delay time Frequency Percent
15 days 18 22.5%
16-30 days 21 26.2%
More than 30 days 41 51.2%
Total 80 100%
Figure 4.13 how long did it take from the time you first feel sick and the time
you went to health facility
Table 4.14 D you consider this time is a delay or not?
Perception of Delay Frequency Percent
Yes 56 70%
No 24 30%
Total 80 100%
18
21
41
22'5%
26'2%
51'2%15 days 16-30 days More than 30 days
Frequency Percent

39
The respondent was asked about their perceptions on delay to seek care from health facilities
since first experienced disease symptoms. 56(70.0 %) admitted that they were delayed to seek
health care and other hand 68 of the participants (30.0%) considered themselves to have not
delayed for treatment.
Figure 4.14 Perception of Delay
Table 4.15 what do you think is the cause of your delay to seek healthcare?
Reasons delay seeking
health care
Frequency Percent
Fear of what would be found
in diagnosis
10 12.5%
Hope that the symptoms will
be go away by themselves
46 57.5%
Fear of social isolation 18 22.5%
Financial constrains 2 2.5%
56
70%
24
30%
FREQUENCY PERCENT
Yes No

40
Poor health services 4 5.0%
Total 80 100%
The above table indicates Majority 46 (53.8%) of the patients who admitted that they delayed in
seeking care from health facilities because they thought that symptoms they were feeling will go
away without medication and 18(22.5%) fear of social isolation, 10 (12.5%) mentioned fear of
being diagnosed with a more serious problem in case they go to the health facility, while 2 of
participant delay for the financial constraints and 4 (5.0%) for poor health service.
Figure 4.15 Reasons delay seeking health care
The below table shows majority of patients, 43 (53.8%), reported to have directly visited the
hospital when they decided to seek for care. It was found that 22 (27.5 %) respondents visited to
the health facilities. Of these, 6 (7.5%) patients reported to have used un-prescribed drugs from
pharmacy shops for a long time before reported to health facilities as their first action following
onset of symptoms, 4 (5.0%) visited traditional healers , were 5 (6.2%) patients go to the
dispensary
0%
20%
40%
60%
80%
100%
Fear of what
would be found
in diagnosis
Hope that the
symptoms will be
go away by
themselves
Fear of social
isolation
Financial
constrains
Poor health
services
10 46 18 2 4
12'5% 57'5% 22'5% 2'5% 5%
Frequency Percent

41
Table 4.16 Where was your first place to seek care?
First Place To Seek Care Frequency Percent
Traditional healer 4 5.0%
Pharmacy shop 6 7.5%
Dispensary 5 6.2%
Health center 22 27.5%
Hospital 43 53.8%
Total 80 100%
Figure 4.16 First Place to Seek Care
The below table indicates some of respondents 28(35%) go to that place advised by some body,
28(35%) referred by previous provider, while others such as 13(16.2% ) free of service ,6(7.5%)
, were 5(6.2%) confidence in getting cure.
Table 4.17 why did you go to that place?
465
22
43
5%
7'5%
6'2%
27'5%
53'8%
Traditional healer
Pharmacy shop
Dispensary
Health centre
Hospital
Frequency Percent

42
why did you go to that
place
Frequency Percent
Confidence In Getting Cure 5 6.2%
Services Available Anytime 6 7.5%
Referred By Previous
Provider
28 35.0%
Free Services 13 16.2%
Advised By Somebody 28 35.0%
Total 80 100%
Figure 4.17 why did you go to that place
Table 4.18 Do you feel ashamed for having this disease?
feel ashamed for having
this disease
Frequency Percent
Agree 6 7.5%
Strongly agree 10 12.5%
Disagree 64 80%
5
6
28
13
28
6'2%
7'5%
35%
16'2%
35%
Confidence in getting
cure
Services available
anytime
Referred by previous
provider
Free services Advised by somebody
Frequency Percent

43
Total 80 100%
The above table shows majority of the respondents 64(80.0%) were disagree to feeling shamed
because of the disease, and 6(7.5%) patient were agree while 10(12.5%) of the participants
strongly agree to feel ashamed to have TB disease.
Figure 4.18 you feel ashamed for having this disease
The below table shows the most of the respondent 36(45.0%) are strongly agree to hide other
people that he diagnosed this disease and 12(15.0%) are agree, while 25(31.2%) are strongly
disagree, were 7(8.8%) are disagree
Table 4.19 Do you have to hide other people that you have diagnosed that you
have this disease?
Agree
Strongly agree
Disagree
6 10
64
7'5% 12'5%
80%
Frequency Percent

44
Do You Have To Hide
Other People
Frequency Percent
Agree 12 15.0%
Strongly Agree 36 45.0%
Disagree 25 31.2%
Strongly Disagree 7 8.8%
Total 80 100%
Figure 4.19 Do You Have To Hide Other People
The below table indicates 61(76.2%) are disagree the disease effect the relations with the others,
were 14(17.5%) are strongly agree and 5(6.2%) are agree to effect the relation with the others
Table 4.20 does this disease affect relation with the others?
Affect Relation With The
Others
Frequency Percent
12
36
25
7
15%
45%
31'2%
8'8%
Agree Strongly agree Disagree Strongly disagree
Frequency Percent

45
Agree 5 6.2%
Disagree 61 76.2%
Total 80 100%
Figure 4.20 Affect Relations with the Others
Table 4.21 is the disease very costly to you due to its long duration of
treatment?
Is The Disease Very Costly Frequency Percent
Agree 20 25.0%
AGREE
STRONGLY AGREE
DISAGREE
5
14
61
6'2%
17'5%
76'2%
Frequency Percent

46
Disagree 34 42.5%
Total 80 100%
The most of the respondent 34(42.5%) are disagree that disease treatment duration is very costly,
while 26(32.5%) are strongly agree and 20(25.0%) are agree is very costly
Figure 4.21 Is the Disease Very Costly
The below table shows 63(78.8%) 0f respondent are disagree to prefer live isolated, while
5(6.2%) are agree and 12(15.0%) are strongly agree
Table 4.22 Do you prefer to live isolated since you diagnosed that you have
this disease?
0
5
10
15
20
25
30
35
40
45
AGREE STRONGLY AGREE DISAGREE
20
26
34
25%
32'5%
42.5%
Frequency Percent

47
Prefer To Live Isolated Frequency Percent
Agree 5 6.2%
Disagree 63 78.8%
Total 80 100%
Figure 4.22 Prefer To Live Isolated
Table 4.23 Does this disease affect your work performance?
Affect your work
performance
Frequency Percent
Agree 15 18.8%
0
10
20
30
40
50
60
70
80
Agree Strongly agree Disagree
5
12
63
6'2%
15%
78'8%
Frequency Percent

48
Disagree 47 58.8%
Total 80 100%
The above table indicates most of patients 47(58.8) are disagree that disease does not affect the
working performance while 18(22.5%) are strongly agree and 15 (18.8%) agree to effect the
work performance
Figure 4.23 affect your work performance
The below table shows the most of the respondent 51(63.8%) disagree that this disease does not
affect marital relation, and 16(20.0%) are strongly disagree, while 6 (7.5%) strongly agree,
7(8.8%) are agree the disease effect marital relation
Table 4.24 does this disease affect marital relation?
15 18
4718'8%
22'5%
58'8%
Agree Strongly agree Disagree
Frequency Percent

49
Affect Marital Relation Frequency Percent
Agree 7 8.8%
Disagree 51 63.8%
Strongly Disagree 16 20.0%
Total 80 100%
Figure 4.24 does this disease affect marital relation?
Table 4.25 Does this disease affect family responsibilities?
Affect Family
Responsibilities
Frequency Percent
Agree 2 2.5%
7
6
51
16
8'8%
7'5%
63'8%
20%
Frequency Percent

50
Disagree 53 66.2%
Strongly disagree 21 26.2%
Total 80 100%
The above table shows the most of the respondent 53(66.2%) disagree that this disease does not
affect family responsibilities, and 21(26.2%) are strongly disagree, while 4(5.0%) strongly agree,
2( 2.5%) are agree the disease effect the family responsibilities
Figure 4.25 Affect Family Responsibilities
Chapter five
Discussion Conclusions Recommendations
5.1 Discussion
2
4
53
21
2'5%
5%
66'2%
26'2%
Frequency Percent

51
Delay to seek care has shown to be the major contributing factor for total treatment delay among
tuberculosis patients. This study has looked for the reasons contributing to the TB patient delay
in seeking care from the health facilities. Results from the study have shown unacceptably long
delay duration between onset of symptoms and reporting to the health facilities. Factors
contributed to the delay were, inappropriate health seeking behavior and stigma attached to
tuberculosis as it has been associated with HIV.
Several studies has revealed that delay in getting TB diagnosis and prompt treatment may lead to
adverse effects on the patients, their families and the whole community as a diseased person will
be transmitting infection as well as having poor prognosis. Early case detection and prompt
treatment of infectious TB cases are the basis for achieving the millennium development goals,
which aim to have halted and begun to reverse the incidence of TB by year 2015. The stop TB
strategy launched by W.H.O in 2006 aims at diagnosing at least 70% of people with infectious
TB and successfully treats 85% of these patients. Therefore understanding proportion of
tuberculosis patient’s delay in seeking care and reasons of delay is important in order to design
appropriate intervention.
5.1.1 Delay in seeking care among tuberculosis patients
Health seeking behavior of TB patients plays a major role in their delay to seek care from health
facilities. When they develop disease symptoms, some of the patients tend to seek care from
other places before going to health facilities therefore they spend much time without proper
treatment while the disease is progressing. In this study it was found that 56 (70.0 %) out of 80
patients had reported late for treatment. On the other hand out of 24 (30.0%) patients who had
chronic cough (dry or with blood).
The magnitude of delay of seeking care among patients (71.1%) found in this study correlates to
what was found in other studies conducted in Nigeria and Somalia. Another study conducted in
Dares Salaam in 2003 revealed the prevalence of delay to be slightly high 75%. Furthermore
chronic coughing was mentioned by most of the patients 35 (22.7%) as their main symptom that
prompted them to seek health care. This was also found in other studies. Others were
breathlessness, fatigue, chest pain, and fever, loss of weight and loss of appetite. Because chronic
cough is one of the cardinal symptoms of tuberculosis, it was expected that patients with this

Delay in a seeking care among tuberculosis patients attending tuberculosis clinics in yaqshid district Mogadishu-Somalia

Delay in a seeking care among tuberculosis patients attending tuberculosis clinics in yaqshid district Mogadishu-Somalia

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