Factors Associated with Delay in Diagnosis and Treatment of Pulmonary Tuberculosis in Bangladesh: Comparison between Urban and Semi-urban Settings

Md. Adnanul Alam^{*, 1}, Abed Hussain Khan², Mohammad Ferdous Ur Rahaman³, Md. Noushad Ansari⁴, Shohael Mahmud Arafat⁵

¹Assitant Professor (Medicine)Saidpur 100 Bed Hospital, Saidpur, Nilphamari, Bangladesh

²Associate Professor, Department of Internal Medicine Bangladesh Medical University, Shahbag, Dhaka, Bangladesh

³Professor, Department of Internal Medicine Bangladesh Medical University, Shahbag, Dhaka, Bangladesh

⁴Consultant Physician Shree Hospital, Biratnagar, Nepal

⁵Professor, Département of Internal Medicine Bangladesh Medical University, Shahbagh, Dhaka, Bangladesh

*Corresponding Author: Md. Adnanul Alam, Assitant Professor (Medicine), Saidpur 100 Bed Hospital, Saidpur, Nilphamari, Bangladesh

Received: 24 May 2026; Accepted: 27 May 2026; Published: 03 June 2026

Introduction

Tuberculosis (TB) has haunted the human race since time immemorial and continues to do so. In 2019, 10 million people were infected with tuberculosis (TB), with 79 percent of those infected living in the 30 countries with the highest TB burden, and 1.2 million died because of the disease [1]. Bangladesh is one of the 30 countries with the highest TB burden, accounting for 3.6 percent of the global cases. The incidence of tuberculosis in Bangladesh is estimated to be 221 cases per 100,000, with a death rate of 24 cases per 100,000. In Bangladesh, pulmonary tuberculosis accounts for about 80% of all TB cases. Although in recent years, TB control has improved by the implementation of programs such as directly observed treatment short course (DOTS), TB remains a significant public health problem in countries like Bangladesh. DOTS strategy is mostly reliant on passive case finding which is heavily influenced by the treatment-seeking behavior of the patients, perceived social stigma, access to health care and delay in diagnosis at the health facilities [2]. Early diagnosis and prompt treatment of TB cases are the keystones of global TB control programs for containing the spread of the disease within the community. According to estimates, an infected person who remains undiagnosed and untreated can infect ten to fifteen people every year [3]. Delayed diagnosis and treatment of pulmonary tuberculosis raise the danger of infection spreading in the community, increases out-of-pocket expenses for patients and decreases the efficacy of TB treatment [4]. In addition, it may avert early mortality associated with more severe complications and severe disease due to delayed presentation. Majority of TB transmission occurs between the onset of cough and initiation of treatment, and patients become more contagious and result in ongoing transmission as the delay increases [5]. Different factors contributing to delay in treatment of TB patients have been assessed across the globe and broadly classified as factors associated to patients, healthcare system or a combination of the two. Unemployment, low income, male gender, limited knowledge about signs and symptoms of TB and the health-seeking behavior of the patients were reported as the factors contributing to the delay in diagnosis whereas long travel time to the first healthcare provider, poor diagnosis with long patient waiting time, and difficulty of disease management in health facilities were associated with prolonged delay in initiation of treatment [6,7]. Delay in TB diagnosis and treatment and its contributing factors vary among societies, type of visited health facilities, geographical locations and category of the disease. In Bangladesh, very few recent studies are available in this regard. Therefore, the main purpose of this study was to identify the factors associated with delay in the diagnosis and treatment of pulmonary tuberculosis patients reported to selected DOTS centers of an urban and a semi-urban area.

Materials and Methods

At the beginning of the study, one urban (DOTS Center, Bangladesh Medical University) and one semi-urban (DOTS Center, Upzilla Health Complex, Dohar) DOTS Center were selected. Adult patients (18 years or older) diagnosed with pulmonary TB according to the national TB guideline and first attending the respective DOTS center not more than one month ago were included in the study population by systematic randomized sampling. TB patients who were unable to communicate (critically ill, mute, patients with psychiatric disorders, dementia, hearing impairment), TB patients who had relapsed or treatment failed, or who were diagnosed with MDR-TB and/or XDR-TB, as well as patients with extra-pulmonary tuberculosis, were excluded. After getting informed consent, the participants were interviewed using a structured questionnaire containing all the variables of interest to collect information regarding socio-demographic status, clinical characteristics, healthcare seeking behavior and knowledge about TB. The questionnaire was adopted from the WHO multi-country tuberculosis treatment delay survey with some relevant modifications [8]. Dates of the first appearance of TB symptoms, the first visit to a healthcare provider and the initiation of TB treatment were extracted from the records. The time interval between the date of the onset of TB symptoms and the first presentation to a professional health provider was regarded as patients’ delay whereas the time interval between the date of the first visit to a professional health provider and the initiation of treatment was considered the health system’s delay. Cough, fever and hemoptysis were considered as the main symptoms as well as constitutional symptoms (night sweats, weight loss and loss of appetite) were also considered where applicable. Prior approval was obtained from the Institutional Review Board (IRB) of BMU. Data were processed and analyzed using computer software SPSS (Statistical Package for Social Sciences) 23 version. Qualitative data was described in frequency and percentage. Quantitative data was described using mean and standard deviation. One way ANOVA with post HOC analysis by the Bonferroni method was done. Significance was considered at P < 0.05.

Results

A total number of 174 patients were included from both DOTS centers in this study. The socio-demographic profile of the participants is summarized in Table-I. Majority of the respondents (28.2%) were aged more than 50 years. Mean age of the respondents was 42.30±14.12 years. Among the participants 54.6% were female and 45.4% were male while 52.3% were from semi-urban area and 47.7% were from urban area. Regarding level of education, 15.5% respondents were illiterate, 25.9% had Primary education. Sociodemographic profile of the respondents reveals majority (37.4%) of them were housewife and 16.1% were unemployed. Almost half (49.4%) of the respondents had monthly family income between 10001 to 15000 taka and 40.2% had family income above 15000 takas. Most of the participants (64.9%) belong to a family of more than four members. In terms of distance to the nearest health facility, 54.6% of respondents needed more than 30 minutes to reach the health care center. Majority of the patients (69%) had smear positive pulmonary TB. Fever (81%) was the main presenting complaints while 66.7% experienced night sweats, 62.1% had chest pain, 61.5% had cough and 36.2% complained of hemoptysis. Personal history revealed that 31% had habit of smoking and 10.9% had known exposure to TB patients. Regarding health care seeking behavior of the participants, 21.8% had practiced self-medication, 14.9% had used non-prescribed medicine. Moreover, 57.5% had more than 3 visits to health care centers. Among all the respondents, 36.2% felt stigmatized due to TB, 28.2% had a history of delayed referral to DOTS center and 29.3% was not instructed do chest X-ray or sputum test in 1^st visit. Overall, 56.9% had poor knowledge of TB. In terms of knowledge about TB, 89.7% respondents knew the kind of disease they have, 19.5% knew that tuberculosis is not hereditary, 93.1% knew that tuberculosis is contagious, 96.6% knew that tuberculosis is curable, but only 12.1% knew the transmission prevention method. Among all the participants, mean patients’ delay was 21.39±4.50 days, health system’s delay was 10.78 ± 3.042 days and total delay was 32.09±5.36 days. Patients’ delay was significantly associated with age, Residence, marital status, education, monthly income, family member, distance to hospital, TB category, practice of self-medication, TB stigma and number of health care contact. Health system’s delay was significantly associated with Distance to hospital, not doing chest x-ray or sputum test in first visit and number of health care contacts. Delay in diagnosis and treatment of TB was significantly found higher in Semi-Urban DOTS center.

Table 1

Table 2

Table 3

Table 4

Table 5

Figure 1: Delay of TB diagnosis and initiation of treatment among TB patients (n=174).

Table 6

*P value was determined by independent sample t test.

**P value was determined by post-Hoc analysis by Bonferroni method.

Table 7

*P value was determined by independent sample t test.

Table 8

Discussion

The mean age of the participants was 42.30±14.12 years and most of the respondents (28.2%) were aged > 50. Previous studies conducted in Ghana, Southern and Northern Ethiopia also found almost similar findings [4,5,7]. These observations are rational as elderly people are more likely to get sick and their immune systems weaken with increasing age. This population typically has concurrent systemic illnesses, which put them at risk for complications, disease transmission, and treatment difficulty owing to side effects. Furthermore, the inconveniences of visiting DOTS centers owing to illness and the need for an accompanying person may cause treatment to be delayed. Female predominance was observed with 56.4% female and 45.4% male among the study population. A previous study conducted in Bangladesh also observed female predominance where 60.9% participants were female [9]. Similar sex distribution was also observed in a study conducted in Ethiopia [10]. Males are more prone to develop tuberculosis in developing countries, which could be attributed to a variety of socioeconomic factors such as being the sole earner, having a larger probability of working in the informal sectors, and having less knowledge of the disease [11]. Female predominance in this study may be influenced by the demographic profile of the semi-urban area, where the female population is larger than the male population and a large portion of the male population is working overseas. Moreover, as men are busy with a variety of jobs both in urban and semi-urban areas, this may prolong the time it takes to report to the DOTS center and subsequently diagnose and initiate treatment. The current study also revealed that 89.7% of respondents knew the kind of disease they had, 19.5% knew that tuberculosis was not hereditary, 93.1% knew that tuberculosis was contagious and 96.6% knew that tuberculosis was curable, but only 12.1% knew how to prevent the transmission of TB. In a previous study conducted in Ethiopia, it was indicated that most (99%) of the respondents knew about the disease they had at the time of the interview. Only 36.5% knew that tuberculosis was not hereditary, while only 10.1% were aware that tuberculosis had a vaccine, but more than half (54.1%) knew how to prevent transmission of TB [10]. In this study, the mean patients’ delay was 21.39±4.50 days, health system’s delay was 10.78±3.042 days, and total delay was 32.09±5.36 days. In a study conducted in Ethiopia, it was revealed that the mean patient delay was 33.9±14 days and mean total days of delay for TB diagnosis and initiation of treatment was 41.6±16.6 days [10]. Another study found that mean patients’ delay was 26±26.9 days and mean health system’s delay was 19±22.9 days in their study conducted in Ethiopia [12]. According to a systematic review of literature from India, total delay ranged from 25 to 185 days, patient delay ranged from 4.9 to 162 days, and health system delay ranged from 2 to 87 days for the diagnosis of tuberculosis [13]. This study revealed that patients’ delays were significantly associated with older age, living in a semi-urban area, having a low monthly income, more than four family members and low level of education. Smear-negative TB category, practicing self-medication and perceived TB stigma also significantly increased the patient’s delay. In a study conducted in northern central Ethiopia, it was revealed that patients’ delay was significantly associated with rural residence, older age (≥55 years), having more than three family members in the household, practicing self-medication and smear-negative status [4]. In the same study, 14.7% of the patients reported using different forms of home-prepared self-medication, and 8.9% used different non-prescribed medications before visiting a formal health care provider. Low monthly income was found to be significantly associated with the patients’ delay in a study conducted in southern Ethiopia [5]. Negative sputum smear was found to be one of the main factors linked with diagnostic delay (> 6 days) in a study conducted in Brazil [3].

On the contrary, the health system’s delay was significantly associated with increased distance to the hospital, not doing a chest x-ray or sputum test on the first visit, and multiple health care contacts. In another study, health system’s delay was significantly associated with greater walking time (> 30 min) to reach a health facility, lack of diagnostic tests, and multiple healthcare contacts. The prolonged health system delay may also reflect insufficient knowledge of the signs and symptoms of TB among the different types of health service providers. This could be substantiated by the fact that most patients with symptoms of tuberculosis were not examined correctly for tuberculosis or referred to diagnostic facilities upon their first visits; rather, most of them were given treatment for diseases other than tuberculosis. Another reason might be the inadequacy of the clinical services diagnosed TB among symptomatic individuals in most of the semi-urban centers. This study also revealed that the delay of TB diagnosis and initiation of treatment was significantly higher in the semi-urban DOTS center than in the urban DOTS center. The longer treatment delay in the semi-urban DOTS center might be due to the lack of experienced staff in identifying suspected cases. Moreover, increased workload in semi-urban centers due to a heavy rush of patients may also contribute to this delay.

Conclusion

Effective strategies should be designed to eliminate the factors responsible for delay in diagnosis and treatment of pulmonary TB. Mass education and awareness programs regarding the importance of early detection and treatment of the disease should be implemented to reduce patients’ delays. Use of self-medication should be discouraged, and the sale of non-prescribed antibiotics should be minimized by strict implementation of the law. Healthcare workers should be trained to diagnose and advise treatment at the earliest opportunity. Access to health care centers should be increased to reduce the health system's delays.

Acknowledgement

The authors would like to express sincere gratitude to the authority of BMU and Upzilla Health Complex, Dohar for their kind co-operation during this study.

Conflict of interest

The authors declared that there is no conflict of interest.

Funding

The research project was not funded by any sponsor

Reference

1. World Health Organization. Global Tuberculosis Report. Geneva: World Health Organization; 2020 World Health Organization. Global tuberculosis report 2020. Geneva: World Health Organization. (2020).
2. Banu S, Rahman MT, Uddin MKM, et al. Epidemiology of tuberculosis in an urban slum of Dhaka City, Bangladesh. PloS one 8 (2013): 1-8.
3. Silva DR, Müller AM, Dalcin PD. Factors associated with delayed diagnosis of tuberculosis in hospitalized patients in a high TB and HIV burden setting: a cross-sectional study. BMC Infectious Diseases 12 (2012):1-6.
4. Seid A, Metaferia Y. Factors associated with treatment delay among newly diagnosed tuberculosis patients in Dessie city and surroundings, Northern Central Ethiopia: a cross-sectional study. BMC Public Health 18 (2018): 1-3.
5. Fuge TG, Bawore SG, Solomon DW, et al. Patient delay in seeking tuberculosis diagnosis and associated factors in Hadiya Zone, Southern Ethiopia. BMC research notes 11(2018): 1-6.
6. Cai J, Wang X, Ma A, et al. Factors associated with patient and provider delays for tuberculosis diagnosis and treatment in Asia: a systematic review and meta-analysis. PloS one 10 (2015): e0120088.
7. Osei E, Akweongo P, Binka F. Factors associated with DELAY in diagnosis among tuberculosis patients in Hohoe Municipality, Ghana. BMC public health 15 (2015): 1-1
8. World Health Organization (WHO). Diagnostic and treatment delay in tuberculosis: An in-depth analysis of the health-seeking behaviour of patients and health system response in seven countries of the Eastern Mediterranean Region. Egypt; World Health Organization Regional Office for the Eastern Mediterranean (2006).
9. Htike W, Islam MA, Hasan MT, et al. Factors associated with treatment delay among tuberculosis patients referred from a tertiary hospital in Dhaka City: a cross-sectional study. Public Health Action 3 (2013): 317-322
10. Bogale S, Diro E, Shiferaw AM, et al. Factors associated with the length of delay with tuberculosis diagnosis and treatment among adult tuberculosis patients attending at public health facilities in Gondar town, Northwest, Ethiopia. BMC infectious diseases 17 (2017): 1-10
11. Rao S. Tuberculosis and patient gender: An analysis and its implications in tuberculosis control. Lung India: Official Organ of Indian Chest Society 26 (2009): 46.
12. Adenager GS, Alemseged F, Asefa H, Gebremedhin AT. Factors associated with treatment delay among pulmonary tuberculosis patients in public and private health facilities in Addis Ababa, Ethiopia. Tuberculosis research and treatment (2017).
13. Sreeramareddy CT, Panduru KV, Menten J, et al. Time delays in diagnosis of pulmonary tuberculosis: a systematic review of literature. BMC infectious diseases 9 (2009): 1-10