Four Degrees of Separation: Social Contacts and Health Providers Influence the Steps to Final Diagnosis of Active Tuberculosis Patients in Urban Uganda

Below:  Conceptual Model of Social and Provider Contacts in TB Patients’ Diagnostic Pathway. Legend: The TB patient (lighter grey) initiates movement through the network. Solid lines are directional and indicate the types of movement between contacts in the network; heavier lines have double arrows representing bidirectional movement allowing for iterative paths and loops in the networks. The TB provider making the final diagnosis (darker grey) represents the absorbing step for all movements

Below:   Illustration of a Realized Pathway to Final TB Diagnosis. Legend: Solid line represents the linear representation of the path through the diagnostic network. Non-solid circles represent the contact points, or nodes, of the network leading to diagnosis. The interval between each node is characterized by a step number (s) and a time interval (t). The total steps to diagnosis is s1 + s2 + s3 + s4 + s5. Total time to diagnosis is t1 + t2 + t3 + t4 + t5

Below: Percent of TB Patients’ First Contact by TB Treatment Category

Below:  Percent Distribution of First Contact Place or Person. Legend: Gov’t hospital, health center and private hospital = All TB Provider. Herbal healer, private clinics, drugs stores, village health worker = Non-TB providers. Parent, spouse, siblings, adult child, other relative, friend, co-worker, neighbor = Social contacts

Of 294 TB patients, 58 % were male and median age was 30 (IQR: 24–38) years. The median number of steps was 4 (IQR: 3, 7) corresponding to 70 (IQR: 28,140) days to diagnosis. New patients had more steps and time to diagnosis compared retreatment patients (5 vs. 3, P < 0.0001; 84 vs. 46 days P < 0.0001). Fifty-eight percent of patients first contacted persons in their social network. The first step to initiate seeking care accounted for 41 % of the patients’ time to diagnosis while visits to non-TB providers and TB providers (without a TB diagnosis) accounted for 34 % and 11 % respectively. New TB patients vs. retreatment (HR: 0.66, 95 % CI; 1.11, 1.99), those who first contacted a non-TB health provider vs. contacting social network (HR: 0.72 95 % CI; 0.55, 0.95) and HIV seronegative vs. seropositive patients (HR: 0.70, 95 % CI; 0.53, 0.92) had a significantly lower likelihood of a timely final diagnosis.

There were four degrees of separation between the onset of symptoms in a TB patient and a final diagnosis. Both social and provider networks of patients influenced the diagnostic pathways. Most delays occurred in the first step which represents decisions to seek help, and through interactions with non-TB health providers. TB control programs should strengthen education and active screening in the community and in health care settings to ensure timely diagnosis of TB.

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