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Pulmonary tuberculosis among migrants in Shandong, China: Factors associated with treatment delay
ForJournal: peerBMJ Open review only Manuscript ID: bmjopen-2014-005805
Article Type: Research
Date Submitted by the Author: 29-May-2014
Complete List of Authors: Zhou, Chengchao; School of Public Health, Shandong Univeristy Chu, Jie; Shandong Centre for Disease Control and Prevention, Geng, Hong; Shandong Center for Tuberculosis Prevention and Control, Wang, Xingzhou; School of Public health, Shandong University, Xu, Lingzhong; Shandong University, School of Public health
Primary Subject Health services research Heading:
Secondary Subject Heading: Health services research, Health policy, Infectious diseases
HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Health policy < Keywords: HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Tuberculosis < INFECTIOUS DISEASES
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1 2 3 4 Pulmonary tuberculosis among migrants in Shandong, China: 5 6 Factors associated with treatment delay 7 8 9 10 Chengchao Zhou1, Jie Chu2, Hong Geng3, Xingzhou Wang1, Lingzhong Xu1 11 12 13 14 1. Department of Health Management and Maternal and Child Healthcare, 15 For peer review only 16 School of Public Health, Shandong University, Ji’nan, China; 17 18 2. Shandong Centre for Disease Control and Prevention, Ji’nan, China; 19 20 3. Shandong Center for Tuberculosis Prevention and Control ,Ji’nan, China 21 22 23 24 25 *Corresponding Author: Chengchao Zhou (Associate Prof.), Department of 26 27 Health Management and Maternal and Child Healthcare, School of Public 28 29 Health, Shandong University, Wen hua xi Road No.44, Jinan City, 250012, 30 31 China 32 33 E mail address: [email protected]
34 http://bmjopen.bmj.com/ 35 Tel: (+86) 531 8838 1567 36 37 Fax: (+86) 531 8838 2553 38 39 40 41 Key words: Migrants, Pulmonary tuberculosis, treatment delay, 42 on September 30, 2021 by guest. Protected copyright. 43 Cross sectional study, China 44 45 46 47 Word count: 1764 48 49 50 51 52 53 54 55 56 57 58 59 60 1
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1 2 3 4 Abstract 5 6 Objectives A timely initiation of treatment is crucial to better control 7 8 tuberculosis(TB).The aim of this study is to describe treatment delay among 9 10 migrant TB patients and to identify factors associated with treatment delay, 11 12 so as to provide an evidence for the development and improvement of TB 13 14 control strategy among migrants in China. 15 For peer review only 16 Design A cross sectional study was conducted in Shandong province of 17 18 China and a total of 314 confirmed smear positive migrant pulmonary TB 19 20 patients were enrolled. Descriptive and inferential analyses were performed 21 22 23 as appropriate. Univariate logistic regression was used to analyze the 24 25 association of variables with treatment delay among migrant PTB patients. 26 27 Multi logistic regression model was developed to further assess the impact 28 29 of variables on treatment delay. 30 31 Results Of 314 migrant PTB patients, 65.6% experienced treatment delay. 32 33 The migrant patients whose household income level, whose diagnosis
34 http://bmjopen.bmj.com/ 35 symptom severity, cognition on whether TB was curable or not and 36 37 knowledge about TB free treatment policy were factors significantly 38 39 associated with treatment delay. 40 41 Conclusions Economic status and cognition on TB cure of migrant PTB 42 on September 30, 2021 by guest. Protected copyright. 43 patients were key barrier to access TB treatment. Implementing TB related 44 45 health education and TB free treatment policy promotion was essential to 46 47 better control tuberculosis among migrants. 48 49 50 51 52 Key Words 53 54 Tuberculosis, migrant, treatment delay, cross sectional study ,China 55 56 57 58 59 60 2
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1 2 3 4 Strengths and limitations of this study 5 6 This study is one of the first to try to analyze treatment delay among 7 8 migrant pulmonary TB patients in China. 9 10 11 12 A cross sectional study to examine the treatment delay and its risk 13 14 factors was conducted in Shandong province of China with a recruitment 15 For peer review only 16 of 314 confirmed smear positive migrant TB patients. 17 18 19 20 Migrant pulmonary TB patients’ economic status and cognition on TB 21 22 cure were key barriers to access timely TB treatment. 23 24 25 26 The measurement of treatment delay was self reported, and reporting 27 28 bias was unavoidable. 29 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3
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1 2 3 4 Introduction 5 6 China has highest burden of tuberculosis (TB) and it ranks second 7 8 among the 22 high burden countries in the world (1). Since 1991, China has 9 10 implemented Directly Observed Treatment Short Course (DOTS) strategy 11 12 and it has universally covered TB patients (2). As a result, the cure rate of 13 14 active TB cases has reached over 90% (3). However, DOTS for migrant 15 For peer review only 16 population remains as one of the main challenges in China TB control (4 5). 17 18 In 2011, the number of migrants in China has increased to 230 million, 19 20 and it would increase continuously in the up coming decades (6). As 21 22 23 reported in other studies, TB management among migrants is more difficult 24 25 than that of local residents due to migrants “migratory” nature, poor 26 27 financial conditions, low education level and weak awareness of TB, which 28 29 presents an important barrier for National TB Control Program in China (4 5, 30 31 7). 32 33 Management of TB patients among migrants which involves early
34 http://bmjopen.bmj.com/ 35 diagnosis and timely initiation of treatment is crucial to reduce transmission, 36 37 morbidity, mortality and development of drug resistance (8 11). Many 38 39 studies have reported the length of time from onset of symptoms related to 40 41 TB to diagnosis of PTB and risk factors for the delay (12 15). However, to 42 on September 30, 2021 by guest. Protected copyright. 43 the author’s knowledgement, few studies have documented the length of 44 45 time from the time of PTB diagnosis to the start of anti tuberculosis 46 47 treatment among migrant PTB patients, and few have reported on risk 48 49 factors for this delay. Hence treatment delay among migrants is of a high 50 51 52 priority among topics for study in China TB control. 53 54 The objective of this study is to describe treatment delay among migrant 55 56 PTB patients in Shandong, China, and to identify factors associated with 57 58 treatment delay, so as to provide an evidence for the development and 59 60 4
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1 2 3 4 improvement of TB control strategy among migrants in China. 5 6 Materials and Methods 7 8 Study design 9 10 This study was conducted in Shandong Province, which consists of 140 11 12 counties (districts) with a total population of nearly 100 million. DOTS 13 14 strategy for TB was introduced in the 1990s and is now 100% available in 15 For peer review only 16 all counties (districts) in Shandong province. By the end of 2008, Shandong 17 18 had about 6.91 million migrants.A total of 12 counties/districts (including 19 20 Huaiyin District, Lixia District, Dongying District, Guangrao County, 21 22 23 Penglai County, Laizhou County, Zouping County, Chengyang District, Jimo 24 25 County, Luozhuang District, Lanshan District, Gaomi County) were selected 26 27 as study sites after considering the larger number of migrants in these 28 29 counties (districts) and the feasibility of the study implementation. 30 31 The participants should meet the following selection criteria: 1) They 32 33 were smear positive migrant PTB patients registered in county TB
34 http://bmjopen.bmj.com/ st 35 dispensary(CTD) of the 12 sampling sites during the period from August 1 36 st 37 2007 to July 31 2008; 2) If the patients were being treated, the treatment 38 39 time must be over 1 month; 3) If the patients had finished normal treatment, 40 41 the closure must happen within 6 months. There were 314 patients finally 42 on September 30, 2021 by guest. Protected copyright. 43 recruited in this study. 44 45 Data collection 46 47 A cross sectional study was conducted between August 2nd 2008 and 48 49 October 17th 2008. All the participants were interviewed face to face at local 50 51 52 CTD using self making questionnaire. The interviews were undertaken by 53 54 trained postgraduates from School of public health of Shandong University 55 56 and physicians from Shandong Centre for TB Prevention and Control. 57 58 Definitions 59 60 5
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1 2 3 4 In this study, “migrants” were non local residents who had lived or 5 6 planned to live in a certain area for more than 3 months (16). The “diagnosis 7 8 symptoms severity” was divided into three categories: mild, moderate and 9 10 severe. The “mild symptoms” included the initial symptoms of cough, 11 12 sputum, night sweats, the “moderate symptoms” refered to the initial 13 14 symptoms of the chest pain, weight loss, fever and the “severe symptoms” 15 For peer review only 16 included high fever and haemoptysis (12). Treatment time was the period 17 18 from the diagnosis of PTB to the initiation of treatment. Using the median as 19 20 the cut off point, a period of longer than 1 day was defined as a treatment 21 22 delay. 23 24 Data analysis 25 26 The data was double entered using EPI Data 6.04, and the two copies 27 28 were verified. We used SPSS 13.0 for Windows to analyze the data. 29 30 31 Descriptive and inferential analyses were performed as appropriate. 32 33 Univariate logistic regression was used to analyze the association of each
34 http://bmjopen.bmj.com/ 35 variable with treatment delay among migrant PTB patients. Multi logistic 36 37 regression model was developed to further assess the impact of variables on 38 39 treatment delay. The magnitude of the association was measured by the odds 40 41 ratio (OR) with 95% confidence interval (95%CI). A P value of <0.05 was 42 on September 30, 2021 by guest. Protected copyright. 43 considered statistically significant. 44 45 Ethical consideration 46 47 The Ethical Committee of School of Public Health of Shandong 48 49 University approved this study. All participants provided written informed 50 51 consents to participate in the study. The investigation was conducted after 52 53 obtaining the informed consents of all participants . 54 55 56 Results 57 58 Of the 314 respondents, 63.4% were male. The age of the participants 59 60 6
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1 2 3 4 ranged from 15 to 70 years, with a mean age of 31.8 years, and 53.8% are 5 6 from 15 to 29, 31.5% from 30 to 44, 14.7% are 45 years old and above. 7 8 About 18.8% were with primary education or illiterate, 40.1% with junior 9 10 education and 41.1% with senior education and above. With regards to 11 12 marital status, 44.6% of the respondents were single (never married), while 13 14 51.9% were married, 3.5% divorced or widowed. 88.2% of the respondents 15 For peer review only 16 are from rural areas, and 11.8% from urban areas. 64.6% of the patients did 17 18 not have any kind of health insurance (Table 1). 19 20 Table 1 Socio demographic characteristics of the participants 21 22 23 Characteristic Patients No. % 24 Gender 25 26 Male 199 63.4 27 Female 115 36.6 28 29 Age(in years) 30 31 15~29 169 53.8 32 30~44 99 31.5 33 ≥45 46 14.7 34 http://bmjopen.bmj.com/ 35 Educational level 36 37 Primary school and below 59 18.8 38 Junior school 126 40.1 39 40 Senior school and above 129 41.1 41 Marital Status 42 on September 30, 2021 by guest. Protected copyright. 43 Single 140 44.6 44 Married 163 51.9 45 46 Divorced/ bereft of spouse 11 3.5 47 48 Household origin 49 Rural 277 88.2 50 51 Urban 37 11.8 52 Health insurance status 53 54 yes 111 35.4 55 no 203 64.6 56 57 58 59 60 7
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1 2 3 4 During the study period, 65.6% of the subjects experienced treatment 5 6 delay. The treatment delay was compared among different subgroups using 7 8 univariate logistic regression analysis. We found that migrant patients who 9 10 were younger (PPP＜0.05), who were single (PPP＜0.05), whose household 11 12 income level were lower(PPP＜0.01),who had a debt (PPP＜0.01), who were 13 14 from guarantee household (PPP＜0.05),who were not companied by families (PPP 15 For peer review only 16 17 ＜0.01),whose diagnosis symptoms were mild (PPP＜0.01), who thought TB 18 19 was incurable(PPP＜0.01) and who didn’t know TB free treatment policy (PPP＜ 20 21 22 0.01 ) were more likely to experience treatment delay (Table 2). 23 24 25 Table 2 Univariate analysis of the risk factors for treatment delay(T-delay) among 26 27 migrant PTB patients 28 29 T-delay No T-delay 30 Variables OR 95%CI P 31 n % n % 32 33 Sex 0.38
34 Male 127 63.8 72 36.2 1.0 http://bmjopen.bmj.com/ 35 36 Female 79 68.7 36 31.3 1.24 0.76 2.03 37 Age(in years) 0.01 38 39 15~29 124 73.4 45 26.6 1.0 40 30~44 56 56.6 43 43.4 0.47 0.28 0.80 41 42 ≥45 26 56.5 20 43.5 0.47 0.24 0.93 on September 30, 2021 by guest. Protected copyright. 43 Educational level 0.26 44 45 Primary school and below 35 59.3 24 40.7 1.0 46 47 Junior school 89 70.6 37 29.4 1.65 0.87 3.15 48 Senior school and above 82 63.6 47 36.4 1.20 0.64 2.25 49 50 Marital Status 0.04 51 Single 102 72.9 38 27.1 1.0 52 53 Married 96 58.9 67 41.1 0.53 0.33 0.87 54 Divorced/ bereft of spouse 8 72.7 3 27.3 0.99 0.25 3.94 55 56 Household origin 0.64 57 Rural 183 66.1 94 33.9 1.0 58 59 60 8
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1 2 3 4 Urban 23 62.2 14 37.8 0.84 0.42 1.72 5 Household income level 0.00 6 7 Lowest group 60 75.0 20 25.0 1.0 8 Lower group 54 76.1 17 23.9 1.06 0.50 2.23 9 10 Higher group 58 63.0 34 37.0 0.57 0.29 1.10 11 12 Highest group 34 47.9 37 52.1 0.31 0.15 0.61 13 Debt status 0.00 14 15 No For peer135 review 60.3 89 39.7 only 1.0 16 ≤10000 Yuan(RMB) 44 77.2 13 22.8 2.23 1.14 4.38 17 18 ＞10000Yuan(RMB) 27 81.8 6 18.2 2.97 1.18 7.48 19 Guaranteeing household** 0.03 20 21 Yes 16 94.1 1 5.9 1.0 22 No 190 64.0 107 36.0 0.11 0.02 0.85 23 24 Working hours per day 0.65 25 ≤8 134 64.7 73 35.3 1.0 26 27 ＞8 72 67.3 35 32.7 1.12 0.68 1.84 28 29 Working days per week 0.22 30 ≤5 93 69.4 41 30.6 1.0 31 32 ＞5 113 62.8 67 37.2 0.74 0.46 1.20 33 Companied by families or not 0.00
34 http://bmjopen.bmj.com/ 35 No 126 78.3 35 21.7 1.0 36 Yes 80 52.3 73 47.7 0.30 0.19 0.50 37 38 Health insurance status 0.97 39 Yes 73 65.8 38 34.2 1.0 40 41 No 133 65.5 70 34.5 0.99 0.61 1.61 42 Distance to local CTD (Kms) 0.56 on September 30, 2021 by guest. Protected copyright. 43 44 0 51 68.0 24 32.0 1.0 45 48 67.6 23 32.4 0.98 0.49 1.97 46 5 47 10 73 67.0 36 33.0 0.95 0.51 1.79 48 49 20 34 57.6 25 42.4 0.64 0.32 1.30 50 Diagnosis symptom severity 0.001 51 52 mild 21 42.9 28 57.1 1.0 53 moderate 122 67.0 60 33.0 2.71 1.42 5.17 54 55 severe 63 75.9 20 24.1 4.20 1.97 8.96 56 Cognition on whether TB is curable or not 0.009 57 58 59 60 9
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1 2 3 4 Yes 182 63.2 106 36.8 1.0 5 No 24 92.3 2 7.7 6.99 1.62 30.16 6 7 Knowledge about TB free treatment policy 0.001 8 Yes 139 59.9 93 40.1 1.0 9 10 No 67 81.7 15 18.3 2.99 1.61 5.55 11 *:Household income level: 1) Lowest group (≤10000 RMB Yuan per year); 2) Lower 12 13 group(10001 20000 RMB Yuan per year); 3) Higher group (20001 30000 RMB Yuan per 14 year ); 4) Highest group (＞30000 RMB Yuan per year)；**：Guaranteeing household：：： 15 the low incomeFor household peer subsidized byreview bureau of civil affairs. only 16 17 18 19 The output of multivariate logistic regression model showed that 20 21 patients’ household income level, diagnosis symptom severity, cognition on 22 23 whether TB was curable or not and knowledge about TB free treatment 24 25 policy were factors significantly associated with treatment delay. None of 26 27 the others entered the model (Table 3). 28 29 30 Table 3 Final model of the risk factors for treatment delay(T-delay) among migrant PTB 31 patients 32 33 Variables OR adj 95%CI P
34 http://bmjopen.bmj.com/ 35 Age(in years) 36 ≥45 1.0 37 38 15~29 1.56 0.55 4.42 0.40 39 30~44 1.03 0.43 2.48 0. 95 40 41 Marital Status 42 Single 1.0 on September 30, 2021 by guest. Protected copyright. 43 44 Married 1.37 0.56 3.34 0.49 45 Divorced/ bereft of spouse 0.97 0.14 6.70 0.97 46 47 Household income level 48 Highest group 1.0 49 50 Lowest group 3.79 1.55 9.29 0.00 51 52 Lower group 2.37 0.96 5.81 0.06 53 Higher group 1.42 0.66 3.07 0.37 54 55 Debt status 56 No 1.0 57 58 59 60 10
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1 2 3 4 ≤10000 Yuan(RMB) 1.91 0.84 4.32 0.12 5 ＞10000Yuan(RMB) 2.23 0.76 6.52 0.14 6 7 Guaranteeing household 8 Yes 1.0 9 10 No 0.14 0.02 1.24 0.08 11 12 Companied by families or not 13 No 1.0 14 15 Yes For peer review0.21 only 0.11 0.43 0.00 16 Diagnosis symptom severity 17 18 mild 1.0 19 moderate 7.00 2.91 16.84 0.00 20 21 severe 13.35 4.87 36.63 0.00 22 Cognition on whether TB is curable or not 23 24 No 1.0 25 Yes 0.04 0.01 0.23 0.00 26 27 Knowledge about TB free treatment policy 28 29 No 1.0 30 Yes 0.22 0.10 0.50 0.00 31 *:Household income level: 1) Lowest group (≤10000 RMB Yuan per year); 2) Lower 32 33 group(10001 20000 RMB Yuan per year); 3) Higher group (20001 30000 RMB Yuan per
34 year ); 4) Highest group (＞30000 RMB Yuan per year)；**：Guaranteeing household：：： http://bmjopen.bmj.com/ 35 the low income household subsidized by bureau of civil affairs. 36 37 38 39 Discussion 40 41 Providing timely treatment after diagnosis is a key intervention to 42 on September 30, 2021 by guest. Protected copyright. 43 prevent the spread of TB among migrants. Therefore, to identify risk factors 44 45 for treatment delay among migrant PTB patients is of high significance. The 46 47 median treatment delay in our study was 1 day, which was similar to the 48 49 reported median (1 day) among permanent residents conducted in Ghana (17) 50 51 and Ethiopia (18), and the median(1 day) of the study conducted in the same 52 53 province among permanent residents(19), but it was a little longer than 0 day 54 55 reported among migrants in Changning District,Shanghai City(13). 56 57 58 Similar to the findings of other studies, this study also indicated that 59 60 11
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1 2 3 4 economic status of migrant PTB patients was a key barrier to access TB 5 6 treatment (20 22). The policy implemented by Chinese government to 7 8 provide free treatment for TB patients had covered migrants. The free policy, 9 10 to a certain extent, had reduced financial burden of patients. However, there 11 12 were also some items being not included in the free package, such as 13 14 transport costs occurring in the care seeking process and additional 15 For peer review only 16 treatment for side effects. Those high out of pocket medical expenditures 17 18 would probably affect migrant PTB patients’ to seek timely TB treatment 19 20 after diagnosis. Therefore, TB control programme for migrants should 21 22 address economic factors to maximize its efficiency by expanding the free 23 24 package or making pro poverty policies to extend the range of 25 26 reimbursement for TB related health services for the poor among migrant 27 28 PTB patients. 29 30 31 As compared with migrant patients companied by families, patients 32 33 living along were more vulnerable to have treatment delay. Some previous
34 http://bmjopen.bmj.com/ 35 studies found that lack of social support was a positively associated risk 36 37 factor of TB related health seeking behavior (23 24). As the most important 38 39 source of social support for migrant TB patients, family members played an 40 41 important role in encouraging them to seek timely treatment after diagnosis. 42 on September 30, 2021 by guest. Protected copyright. 43 We found that migrant PTB patients with mild and moderate diagnosis 44 45 symptoms were more easily to experience treatment delay than severe 46 47 diagnosis symptoms ones. An explanation for such phenomenon might be 48 49 patients’ deficient knowledge on TB symptoms and thus many patients 50 51 would delay to seek treatment after diagnosis based on their subjective 52 53 cognition on mild diagnosis symptoms, then treatment delay would easily 54 55 appear. 56 57 A clear association was observed between treatment delay and patients 58 59 60 12
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1 2 3 4 cognition on TB cure. The patients thought TB was incurable would be more 5 6 likely to experience treatment delay than those who thought TB was curable. 7 8 We also found that the patients had not known TB free treatment policy 9 10 were more easily to experience treatment delay. As National TB Control 11 12 Program Implementation Guide in China (2008) proposed that to improve 13 14 TB related cognitive level among PTB patients was a crucial measure to 15 For peer review only 16 control TB in China(25). The findings should therefore give an impetus to 17 18 carry out TB related health education and also free treatment policy 19 20 promotion among migrant PTB patients. 21 22 This study had potential limitations. One limitation was that the 23 24 selection of migrant PTB patients might be biased. The target population of 25 26 this study were those who registered in local CTD, but the cases who were 27 28 undetected or had no registration in local CTD or had left the sample 29 30 31 counties(districts) during the period of the survey were not included, thus 32 33 affected to some extent the representativeness of our result. Another
34 http://bmjopen.bmj.com/ 35 limitation was that the measure of treatment delay was self reported, and 36 37 recall bias was unavoidable. 38 39 Conclusions 40 41 In this study, 65.6% of the participants experienced treatment delay. 42 on September 30, 2021 by guest. Protected copyright. 43 The study indicates that treatment delay was associated with economic status 44 45 of migrant patients, which implicated for policymakers that pro poverty 46 47 policies should be made to extend the range of reimbursement for TB related 48 49 health services for the poor among migrant PTB. We also found that TB 50 51 patient poor cognition on TB cure might have negative impact on treatment 52 53 delay. It suggests for policy makers to carry out extensive TB related health 54 55 education among migrant TB patients. Furthermore, we also found that 56 57 factors including diagnosis symptom severity and whether companied by 58 59 60 13
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1 2 3 4 families or not were associated with treatment delay, which would be helpful 5 6 for policymakers to make target policies. 7 8 Competing interests 9 10 The authors declare there are no competing interests. 11 12 Contributorship statement 13 14 CZ, LX and HG conceived the idea, CZ and HG implemented the field 15 For peer review only 16 17 study. JC and XW participated in the statistical analysis and interpretation of 18 19 the results. CZ wrote the manuscript. All authors read and approved the final 20 21 manuscript. 22 23 Funding 24 25 This study was supported by Department of Science and Technology of 26 27 Shandong Province (BS2012SF010) and Independent Innovation Foundation 28 29 of Shandong University (2012DX006). 30 31 32 Data sharing 33
34 Extra data is available by emailing CZ. http://bmjopen.bmj.com/ 35 36 Acknowledgements 37 38 We would like to thank all participants and staffs at the study sites for 39 40 their cooperation. 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 14
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1 2 3 References 4 5 1.WHO.Global Tuberculosis Control：Surveillance，Planning，Financing．In：Communicable 6 7 Diseases．World Health Organization,Geneva,2002. 8 9 2.Ministry of Health of PRC. National Tuberculosis Control Program (1991–2000).Chinese Journal of 10 Public Health. 1992,8(4):1 5 (in Chinese) 11 12 3.Xianyi C, Fengzeng Z, Hongjin D, Liya W, Lixia W, Xin D, Chin DP. The DOTS strategy in 13 China: Results and lessons after 10 years. Bull World Health Organ. 2002;80: 430 436. 14 15 4.Zhou C, ChuFor J, Liu J, Gaipeer Tobe R, Gen H,review Wang X, Zheng W, onlyXu L. Adherence to tuberculosis 16 treatment among migrant pulmonary tuberculosis patients in Shandong, China: a quantitative survey 17 18 study.PLoS One. 2012;7(12):e52334. doi: 10.1371/journal.pone.0052334. 19 5.Tobe RG, Xu L, Zhou C, Yuan Q, Geng H, Wang X. Factors affecting patient delay of diagnosis and 20 21 completion of Direct Observation Therapy, Short course (DOTS) among the migrant population in 22 23 Shandong, China. Biosci Trends. 2013 Jun;7(3):122 8 24 6.National Population and Family Planning Commission,China. Report on National Developments of 25 26 Migrants in China in 2012.Beijing,China,2012(in Chinese) 27 7.Li X, Zhang H, Jiang S, Wang J, Liu X, Li W, Yao H, Wang L. Active Pulmonary Tuberculosis 28 29 Case Detection and Treatment Among Floating Population in China: An Effective Pilot. J Immigrant 30 31 Minority Health (2010) 12:811–815 32 8.WHO: Global Tuberculosis Control: report.: 2011.WHO,2012. 33 9.Whitehorn J, Ayles H, Godfrey Fausset P. Extra pulmonary and smear negative forms of 34 http://bmjopen.bmj.com/ 35 tuberculosis are associated with treatment delay and hospitalization. Int J Tuberc Lung Dis 2010, 36 37 4:741–744. 38 10. Liam CK, Tang BG: Delay in the diagnosis and treatment of pulmonary tuberculosis in patients 39 40 attending a university teaching hospital. Int J Tuberc Lung Dis 1997, 1:326–332. 41 11. Madebo T, Lindtjorn B: Delay in treatment of pulmonary tuberculosis: ananalysis of symptom 42 on September 30, 2021 by guest. Protected copyright. 43 duration among Ethiopian patients. Med Gen Med1999, 18:E6. 44 12. Zhou C, Tobe RG, Chu J, Gen H, Wang X, Xu L. Detection delay of pulmonary tuberculosis 45 46 patients among migrants in China: a cross sectional study. Int J Tuberc Lung Dis. 2012 47 48 Dec;16(12):1630 6. doi: 10.5588/ijtld.12.0227. 49 13. Huang LQ,Wang WB,Li HD,Xu B,Yang H.A descriptive study on diagnostic delay and factors 50 51 impacting accessibility to diagnosis among TB patients in floating population in Changning 52 District,Shanghai City.Chinese Journal of Antituberculosis. 2007;29(2):127 129(in Chinese) 53 54 14. Long Q, Wang Y, Tang S, Rachel T, Zhan S, Yue Y, Li Y. Study on patient delay and the 55 influencing factors of TB suspect patients among rural to urban migrants in Chongqing. Modern Prev 56 57 Med 2007; 34:810 812. (in Chinese) 58 59 60 15
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1 2 3 15.Xu B, Jiang Q W, Xiu Y, Diwan V K. Diagnostic delays in access to tuberculosis care in counties 4 5 with or without the National Tuberculosis Control Programme in rural China. Int J Tuberc Lung Dis 6 2005; 9: 784–790. 7 8 16. China Global Fund Project Office. The Implementation of Floating Population TB Control Pilot 9 Project (China Global Fund TB Program Round 5), Beijing,China, 2006. (in Chinese) 10 11 17.Lawn SD, Afful B, Acheampong JW: Pulmonary tuberculosis: diagnostic delay in Ghanaian adults. 12 13 Int J Tuberc Lung Dis 1998, 2(8):635–640 14 18. Belay M, Bjune G, Ameni G, Abebe F. Diagnostic and treatment delay among Tuberculosis 15 For peer review only 16 patients in Afar Region, Ethiopia: a cross sectional study. BMC Public Health. 2012 May 23;12:369. 17 doi: 10.1186/1471 2458 12 369. 18 19 19.Zhao X, Xu L, Guo Z, Zheng W, Zhou C, Wang X, Yu X, Qi H, Yang P. Analysis on treatment 20 delay of tuberculosis patients and its influencing factors. Chinese Journal of Health 21 22 Statistics,2013,30(2):187 189(in Chinese) 23 20.Liu Q,Wang Y. Study on the floating population tuberculosis prevalence and Control 24 25 Countermeasures. Journal of Preventive Medicine Information.2005;21(6):680 682(in Chinese) 26 27 21.Cambanis A, Yassin MA, Ramsay A, Bertel Squire S, Arbide I, Cuevas LE.Rural poverty and 28 delayed presentation to tuberculosis services in Ethiopia.Trop Med Int Health. 2005,10(4):330 5 29 30 22.Enarson DA.Conquering tuberculosis:dream or reality?Int J Tuberc Lung Dis.2002;6:369 370. 31 23.Lin HP, Deng CY, Chou P. Diagnosis and treatment delay among pulmonary tuberculosis patients 32 33 identified using the Taiwan reporting enquiry system, 2002 2006. BMC Public Health. 2009 Feb
34 12;9:55. doi: 10.1186/1471 2458 9 55. http://bmjopen.bmj.com/ 35 36 24.Kirwan DE, Nicholson BD, Baral SC, Newell JN.The social reality of migrant men with 37 tuberculosis in Kathmandu: implications for DOT in practice. Trop Med Int Health. 2009 38 39 Dec;14(12):1442 7. 40 41 25.Ministry of Health of PRC. National TB Control Program Implementation Guide in China (2008 42 Edition).Beijing,2009.(in Chinese) on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 16
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1 2 STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies 3 Item Reported on 4 No Recommendation page # 5 Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the 2，5 6 7 title or the abstract 8 (b) Provide in the abstract an informative and balanced summary 2 9 of what was done and what was found 10 11 Introduction 12 Background/rationale 2 Explain the scientific background and rationale for the 4，5 13 investigation being reported 14 Objectives 3 State specific objectives, including any prespecified hypotheses 4，5 15 For peer review only 16 Methods 17 Study design 4 Present key elements of study design early in the paper 5 18 Setting 5 Describe the setting, locations, and relevant dates, including 5 19 periods of recruitment, exposure, follow-up, and data collection 20 21 Participants 6 (a) Give the eligibility criteria, and the sources and methods of 5 22 selection of participants 23 Variables 7 Clearly define all outcomes, exposures, predictors, potential 6 24 confounders, and effect modifiers. Give diagnostic criteria, if 25 26 applicable 27 Data sources/ 8* For each variable of interest, give sources of data and details of 28 measurement methods of assessment (measurement). Describe comparability of 29 assessment methods if there is more than one group 30 31 Bias 9 Describe any efforts to address potential sources of bias 5 32 Study size 10 Explain how the study size was arrived at 5 33 Quantitative variables 11 Explain how quantitative variables were handled in the analyses. 6
34 If applicable, describe which groupings were chosen and why http://bmjopen.bmj.com/ 35 Statistical methods 12 (a) Describe all statistical methods, including those used to control 6 36 37 for confounding 38 (b) Describe any methods used to examine subgroups and 39 interactions 40 (c) Explain how missing data were addressed 41 d 42 ( ) If applicable, describe analytical methods taking account of on September 30, 2021 by guest. Protected copyright. 43 sampling strategy 44 (e) Describe any sensitivity analyses 45 46 Results 47 Participants 13* (a) Report numbers of individuals at each stage of study—eg 7 48 numbers potentially eligible, examined for eligibility, confirmed 49 eligible, included in the study, completing follow-up, and analysed 50 (b) Give reasons for non-participation at each stage 51 52 (c) Consider use of a flow diagram 53 Descriptive data 14* (a) Give characteristics of study participants (eg demographic, 7 54 clinical, social) and information on exposures and potential 55 confounders 56 57 (b) Indicate number of participants with missing data for each 58 variable of interest 59 Outcome data 15* Report numbers of outcome events or summary measures 8 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml1 BMJ Open Page 18 of 18 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 Main results 16 (a) Give unadjusted estimates and, if applicable, confounder- 8-11 3 adjusted estimates and their precision (eg, 95% confidence 4 interval). Make clear which confounders were adjusted for and 5 why they were included 6 7 (b) Report category boundaries when continuous variables were 8 categorized 9 (c) If relevant, consider translating estimates of relative risk into 10 absolute risk for a meaningful time period 11 12 Other analyses 17 Report other analyses done—eg analyses of subgroups and 13 interactions, and sensitivity analyses 14 Discussion 15 For peer review only 16 Key results 18 Summarise key results with reference to study objectives 11-13 17 Limitations 19 Discuss limitations of the study, taking into account sources of 13 18 potential bias or imprecision. Discuss both direction and 19 magnitude of any potential bias 20 Interpretation 20 Give a cautious overall interpretation of results considering 11-13 21 22 objectives, limitations, multiplicity of analyses, results from 23 similar studies, and other relevant evidence 24 Generalisability 21 Discuss the generalisability (external validity) of the study results 25 26 Other information 27 Funding 22 Give the source of funding and the role of the funders for the 14 28 present study and, if applicable, for the original study on which 29 the present article is based 30 31 32 *Give information separately for exposed and unexposed groups. 33
34 Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and http://bmjopen.bmj.com/ 35 published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely 36 37 available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at 38 http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is 39 available at www.strobe-statement.org. 40 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml2 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
Pulmonary tuberculosis among migrants in Shandong, China: Factors associated with treatment delay
ForJournal: peerBMJ Open review only Manuscript ID: bmjopen-2014-005805.R1
Article Type: Research
Date Submitted by the Author: 19-Nov-2014
Complete List of Authors: Zhou, Chengchao; School of Public Health, Shandong Univeristy Chu, Jie; Shandong Centre for Disease Control and Prevention, Geng, Hong; Shandong Center for Tuberculosis Prevention and Control, Wang, Xingzhou; School of Public health, Shandong University, Xu, Lingzhong; Shandong University, School of Public health
Primary Subject Health services research Heading:
Secondary Subject Heading: Health services research, Health policy, Infectious diseases
HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Health policy < Keywords: HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Tuberculosis < INFECTIOUS DISEASES
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1 2 3 4 Pulmonary tuberculosis among migrants in Shandong, China: 5 6 Factors associated with treatment delay 7 8 9 10 Chengchao Zhou1, Jie Chu2, Hong Geng3, Xingzhou Wang1, Lingzhong Xu1 11 12 13 14 1. Department of Health Management and Maternal and Child Healthcare, 15 For peer review only 16 School of Public Health, Shandong University, Ji’nan, China; 17 18 2. Shandong Centre for Disease Control and Prevention, Ji’nan, China; 19 20 3. Shandong Center for Tuberculosis Prevention and Control, Ji’nan, China 21 22 23 24 25 *Corresponding Author: Chengchao Zhou (Associate Prof.), Department of 26 27 Health Management and Maternal and Child Healthcare, School of Public 28 29 Health, Shandong University, Wen-hua-xi Road No.44, Jinan City, 250012, 30 31 China 32 33 E-mail address: [email protected]
34 http://bmjopen.bmj.com/ 35 Tel: (+86) 531 8838 1567 36 37 Fax: (+86) 531 8838 2553 38 39 40 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1
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1 2 3 4 Abstract 5 6 Objective A timely initiation of treatment is crucial to better control 7 8 tuberculosis (TB).The aim of this study is to describe treatment delay among 9 10 migrant TB patients and to identify factors associated with treatment delay, 11 12 so as to provide evidence for strategy development and improvement of TB 13 14 control among migrants in China. 15 For peer review only 16 Design A cross-sectional study was conducted in Shandong province of 17 18 China. A total of 314 confirmed smear positive migrant pulmonary TB 19 20 patients were included. Univariate logistic regression was used to analyze 21 22 23 the association of variables with treatment delay among migrant TB patients. 24 25 Multi-logistic regression model was developed to further assess the effect of 26 27 variables on treatment delay. 28 29 Results Of 314 migrant TB patients, 65.6% experienced treatment delay (＞ 30 31 1day). Household income level, diagnosis symptom severity, understanding 32 33 of whether TB is curable or not and knowledge about the free TB treatment
34 http://bmjopen.bmj.com/ 35 policy are factors significantly associated with treatment delay. 36 37 Conclusions Economic status and knowledge about TB are key barriers to 38 39 accessing TB treatment. An integrated policy of carrying out TB-related 40 41 health education and publicizing the free TB treatment policy among 42 on September 30, 2021 by guest. Protected copyright. 43 44 migrants is needed. Health insurance schemes for migrants should be 45 46 modified to make them transferrable and pro-poor. 47 48 49 50 Key Words 51 52 Tuberculosis, migrant, treatment delay, cross-sectional study, China 53 54 55 56 57 58 59 60 2
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1 2 3 4 5 6 Strengths and limitations of this study 7 8 9 10 11 This study is one of the first to try to analyze treatment delay among 12 13 migrant pulmonary TB patients in China. 14 15 For peer review only 16 17 A cross-sectional study to examine the treatment delay and its risk 18 19 factors was conducted in Shandong province of China with a recruitment 20 21 of 314 confirmed smear positive migrant TB patients. 22 23 24 25 Economic status and knowledge about TB are key barriers to accessing 26 27 timely TB treatment among migrants. 28 29 30 31 The measurement of treatment delay was self-reported, and reporting 32 33 bias was unavoidable.
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3
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1 2 3 4 Introduction 5 6 China has one of the highest burdens of tuberculosis (TB) worldwide 7 8 and it ranks second among the 22 high-burden countries in the world (1). 9 10 Since 1991, China has implemented the Directly Observed Treatment-Short 11 12 Course (DOTS) strategy and has provided universal coverage for TB 13 14 patients (2). As a result, the cure rate of active TB cases has reached over 15 For peer review only 16 90% (3). However, the implementation of DOTS for the migrant population 17 18 remains one of the main challenges in China for controlling TB (4-5). 19 20 As of 2012, the migrant population in China has reached 236 million, 21 22 23 and is expected to increase continuously in the up-coming decades (6). As 24 25 reported in other studies, TB case management among migrants is more 26 27 difficult than among local residents due to their “migratory” nature, poor 28 29 financial conditions, low education level and minimal awareness of TB (4-5, 30 31 7). The challenge of administering to the migrant population presents an 32 33 important barrier for National TB Control Program in China. Early detection
34 http://bmjopen.bmj.com/ 35 of cases and timely treatment of TB are essential for effective TB control 36 37 (8-11). Delays occurring in any part of the health-seeking process would 38 39 increase the probability of TB transmission and eventually result in a higher 40 41 disease burden (12). Studies of delays have been conducted in many 42 on September 30, 2021 by guest. Protected copyright. 43 countries, most of which explain the delays in terms of patient delay, 44 45 diagnosis delay and treatment delay (13-14). 46 47 In China, a number of studies have reported the length of the patient 48 49 delay among migrant TB patients to last from 10 days (median) in Shandong 50 51 52 province (12) to 20 days (median) in Changning District of Shanghai (15) to 53 54 43 days (median) in Shijiazhuang city (16). Previous studies have also 55 56 reported diagnosis delays among migrant TB patients of 5 days (median) in 57 58 Putuo District of Shanghai (17) to 8 days (median) in Shandong province 59 60 4
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1 2 3 4 (12) to 13 days (median) in Changning District of Shanghai (15). Factors 5 6 including age, economic status, TB symptoms, health insurance, educational 7 8 level, working time, the specific health facilities first visited by the TB 9 10 patients were found to be associated with the patient and diagnosis delays 11 12 (12, 15-19). However, to the author’s knowledge, few studies have 13 14 documented the length of treatment delay, and few have identified risk 15 For peer review only 16 factors for treatment delay. Therefore, treatment delay among migrants is of 17 18 a high priority among topics for study in China TB control. 19 20 The objective of this study is to describe treatment delay among migrant 21 22 TB patients in Shandong, China, and to identify factors associated with 23 24 treatment delay, so as to provide evidence for strategy development and 25 26 improvement of TB control among migrants in China. 27 28 29 Materials and Methods 30 31 Study design 32 33 This study was conducted in Shandong Province, which consists of 140
34 http://bmjopen.bmj.com/ 35 counties (districts) with a total population of nearly 100 million. By the end 36 37 of 2008, Shandong had about 6.91 million migrants. The DOTS strategy for 38 39 TB was introduced in the 1990s and is now available in 100% of counties 40 41 (districts) in Shandong province. In China, TB cases are usually diagnosed 42 on September 30, 2021 by guest. Protected copyright. 43 and treated in local TB dispensaries (LTD). However, service providers at 44 45 other levels, especially the lowest level providers (such as township health 46 47 centers and clinics) cannot diagnose and treat the TB cases, only to identify 48 49 suspected TB cases and refer them to the LTD. All diagnosed TB cases 50 51 52 (including new and relapsed patients) are required to be registered in the 53 54 LTD and reported to upper level health authorities. 55 56 A total of 12 counties/districts (including Huaiyin District, Lixia District, 57 58 Dongying District, Guangrao County, Penglai County, Laizhou County, 59 60 5
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1 2 3 4 Zouping County, Chengyang District, Jimo County, Luozhuang District, 5 6 Lanshan District, Gaomi County) were selected as study sites after 7 8 considering the larger number of migrants in these counties (districts) and 9 10 the feasibility of the study implementation. The participants should meet the 11 12 following selection criteria: 1) They were smear-positive migrant pulmonary 13 14 TB patients registered in LTD of the 12 sampling sites during the period 15 For peer review only 16 from August 1 2007 to July 31 2008; 2) If the patients were being treated, 17 18 the treatment time must be over 1 month; 3) If the patients had finished 19 20 normal treatment, the end of treatment must happen within 6 months. 21 22 Table.1. Economic status and distribution of cases of study sites 23 24 Sites GDP per capita 25 No. of Participants 26 (RMB)* 27 28 Huaiyin 34511 25 29 30 Lixia 75148 25 31 32 Dongying 48163 25 33 Guangrao 41125 26
34 http://bmjopen.bmj.com/ 35 Penglai 54584 34 36 37 Laizhou 26936 26 38 39 Zouping 47566 25 40 41 Chengyang 97426 22 42 Jimo 39011 27 on September 30, 2021 by guest. Protected copyright. 43 44 Luozhuang 34706 26 45 46 Lanshan 31111 26 47 48 Gaomi 22093 27 49 50 *The data of the GDP per capita sourced from Shandong Statistical Yearbook 2007. 51 52 53 There were a total of 418 migrant TB patients registered in the 12 54 55 sampling sites during the period, 372 of which met the above criteria. Of the 56 57 372 eligible cases, 20 individuals were unreachable because they had left the 58 59 60 6
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1 2 3 4 area, 16 individuals were unresponsive to contact, 11 individuals refused to 5 6 participate in the study, and 11 individuals did not participate for other 7 8 reasons. There were 314 patients successfully recruited into the study. Table 9 10 1 presents the economic status and distribution of the patients in different 11 12 sites. 13 14 Data collection 15 For peer review only 16 A cross-sectional study was conducted between August 2 2008 and 17 18 October 17 2008. The participants were contacted and recruited by staff of 19 20 the LTD and were interviewed face-to-face at the LTD of the study site using 21 22 questionnaires which included socio-demographic characteristics, household 23 24 income, health insurance status, health service geographic accessibility, 25 26 knowledge about TB and its related policies, and patient health-seeking 27 28 experiences from diagnosis to the initiation of treatment.The interviews were 29 30 31 undertaken by trained postgraduates from the School of Public Health of 32 33 Shandong University and physicians from the Shandong Center for TB
34 http://bmjopen.bmj.com/ 35 Prevention and Control. 36 37 Definitions 38 39 In this study, “migrants” were non-local residents who had already lived 40 41 or intended to stay in our study areas for at least 3 months (20). The 42 on September 30, 2021 by guest. Protected copyright. 43 “diagnosis symptoms severity” was divided into three categories: mild, 44 45 moderate and severe. The “mild symptoms” included the initial symptoms of 46 47 cough, sputum, and night sweats; the “moderate symptoms” referred to the 48 49 initial symptoms of chest pain, weight loss, and fever; and the “severe 50 51 symptoms” included high fever and haemoptysis (12). Treatment time was 52 53 the period from the diagnosis of TB to the initiation of treatment. Using the 54 55 median (1 day) as the cut-off point, a period of longer than 1 day was 56 57 defined as a treatment delay. 58 59 60 7
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1 2 3 4 Data analysis 5 6 The data was double entered using EPI Data 6.04 and the two copies 7 8 were verified. We used SPSS 13.0 for Windows to analyze the data. Gender, 9 10 age, educational level, marital status, residence and health insurance status 11 12 were presented as percentages. Univariate logistic regression was used to 13 14 analyze the association of each variable with treatment delay across different 15 For peer review only 16 subgroups of migrant TB patients. The identified risk factors (P<0.05) were 17 18 included into a multivariate logistic regression model to further assess the 19 20 impact of variables on treatment delay. The magnitude of the association was 21 22 measured by the odds ratio (OR) with 95% confidence interval (95% CI). A 23 24 P-value of <0.05 was considered statistically significant. 25 26 Ethical consideration 27 28 The Ethical Committee of School of Public Health of Shandong 29 30 31 University approved this study. All participants signed written informed 32 33 consents for participation prior to the start of study activities.
34 http://bmjopen.bmj.com/ 35 Results 36 37 Of the 314 respondents, 63.4% were male. The age of the participants 38 39 ranged from 15 to 70 years, with a mean of 31.8 years, and 53.8% were from 40 41 15 to 29 years, 31.5% were from 30 to 44 years, 14.7% were 45 years and 42 on September 30, 2021 by guest. Protected copyright. 43 above. As for educational level, 18.8% had primary education or below, 44 45 40.1% had junior high education and 41.1% had high school education and 46 47 above. With regards to marital status, 44.6% of the respondents were single 48 49 (never-married), while 51.9% were married, and 3.5% were divorced or 50 51 52 widowed. 88.2% of the respondents were from rural areas and 11.8% were 53 54 from urban areas. 64.6% of the patients did not have any kind of health 55 56 insurance plans (Table 2). 57 58 59 60 8
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1 2 3 4 5 6 Table.2. Socio-demographic characteristics of the participants 7 8 9 Characteristic No. of Patients % 10 Gender 11 12 Male 199 63.4 13 Female 115 36.6 14 15 Age(inFor years) peer review only 16 15~29 169 53.8 17 18 30~44 99 31.5 19 ≥45 46 14.7 20 21 Educational level 22 23 Primary or below 59 18.8 24 Junior high 126 40.1 25 26 High school and above 129 41.1 27 Marital Status 28 29 Single 140 44.6 30 Married 163 51.9 31 32 Divorced/ bereft of spouse 11 3.5 33 Residence
34 http://bmjopen.bmj.com/ 35 Rural 277 88.2 36 Urban 37 11.8 37 38 Health insurance status 39 40 yes 111 35.4 41 no 203 64.6 42 on September 30, 2021 by guest. Protected copyright. 43 44 The median of treatment delay was 1 day, with a mean of 2.5 days, 45 46 ranging from 0 to 90 days. When we examined the treatment delay at the 47 48 49 individual level, we found that 65.6% of the subjects experienced treatment 50 51 delay during the study period. The treatment delay was compared across 52 53 different subgroups using univariate logistic regression analysis. We found 54 55 that migrant TB patients who were younger (PPP＜0.05), who were single (PPP＜ 56 57 0.05), whose household income level were lower (PPP＜0.01),who had a debt 58 59 60 9
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1 2 3 4 (PPP＜0.01), who were from Dibao household (Low-income households 5 6 identified and subsidized by local bureau of civil affairs—PPP＜0.05), who 7 8 migrated without families (PPP＜0.01), whose diagnosis symptoms were mild 9 10 11 (PPP＜0.01), who thought TB was incurable (PPP＜0.01) and who didn’t know 12 13 about the free TB treatment policy (PPP＜0.01 ) were more likely to experience 14 15 treatment delayFor (Table peer 3). review only 16 17 Table.3. Univariate analysis of the risk factors for treatment delay (T-delay) among 18 19 migrant TB patients in Shandong, China 20 21 T-delay No T-delay 22 Variables OR 95%CI P 23 n % n % 24 Gender 0.38 25 26 Male 127 63.8 72 36.2 1.0 -- 27 Female 79 68.7 36 31.3 1.24 0.76-2.03 28 29 Age(in years) 0.01 30 31 15~29 124 73.4 45 26.6 1.0 -- 32 30~44 56 56.6 43 43.4 0.47 0.28-0.80 33 ≥45 26 56.5 20 43.5 0.47 0.24-0.93 34 http://bmjopen.bmj.com/ 35 Educational level 0.26 36 37 Primary and below 35 59.3 24 40.7 1.0 -- 38 Junior high 89 70.6 37 29.4 1.65 0.87-3.15 39 40 High school and above 82 63.6 47 36.4 1.20 0.64-2.25 41 Marital Status 0.04 42 on September 30, 2021 by guest. Protected copyright. 43 Single 102 72.9 38 27.1 1.0 -- 44 Married 96 58.9 67 41.1 0.53 0.33-0.87 45 46 Divorced/ bereft of spouse 8 72.7 3 27.3 0.99 0.25-3.94 47 Residence 48 0.64 49 Rural 183 66.1 94 33.9 1.0 -- 50 51 Urban 23 62.2 14 37.8 0.84 0.42-1.72 52 Household income level 0.00 53 54 Lowest group 60 75.0 20 25.0 1.0 55 Lower group 54 76.1 17 23.9 1.06 0.50-2.23 56 57 Higher group 58 63.0 34 37.0 0.57 0.29-1.10 58 59 60 10
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1 2 3 4 Highest group 34 47.9 37 52.1 0.31 0.15-0.61 5 Debt status 0.00 6 7 No 135 60.3 89 39.7 1.0 8 ≤10000 Yuan(RMB) 44 77.2 13 22.8 2.23 1.14-4.38 9 10 ＞10000Yuan(RMB) 27 81.8 6 18.2 2.97 1.18-7.48 11 12 Dibao household** 0.03 13 Yes 16 94.1 1 5.9 1.0 14 15 No For peer 190 64.0review 107 36.0 only 0.11 0.02-0.85 16 Working hours per day 0.65 17 18 ≤8 134 64.7 73 35.3 1.0 19 ＞8 72 67.3 35 32.7 1.12 0.68-1.84 20 21 Working days per week 0.22 22 ≤5 93 69.4 41 30.6 1.0 23 24 ＞5 113 62.8 67 37.2 0.74 0.46-1.20 25 Migrating with families or not 0.00 26 27 No 126 78.3 35 21.7 1.0 28 29 Yes 80 52.3 73 47.7 0.30 0.19-0.50 30 Health insurance status 0.97 31 32 Yes 73 65.8 38 34.2 1.0 33 No 133 65.5 70 34.5 0.99 0.61-1.61
34 http://bmjopen.bmj.com/ 35 Distance to local CTD (Kms) 0.56 36 0- 51 68.0 24 32.0 1.0 37 38 5- 48 67.6 23 32.4 0.98 0.49-1.97 39 10- 73 67.0 36 33.0 0.95 0.51-1.79 40 41 20- 34 57.6 25 42.4 0.64 0.32-1.30 42 Diagnosis symptom severity 0.00 on September 30, 2021 by guest. Protected copyright. 43 44 mild 21 42.9 28 57.1 1.0 45 46 moderate 122 67.0 60 33.0 2.71 1.42-5.17 47 severe 63 75.9 20 24.1 4.20 1.97-8.96 48 49 Understanding of whether TB is curable or not 0.01 50 Yes 182 63.2 106 36.8 1.0 51 52 No 24 92.3 2 7.7 6.99 1.62-30.16 53 Knowledge about the free TB treatment policy 0.00 54 55 Yes 139 59.9 93 40.1 1.0 56 No 67 81.7 15 18.3 2.99 1.61-5.55 57 ≤ 58 *:Household income level: 1) Lowest group ( 10000 RMB Yuan per year); 2) Lower 59 60 11
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1 2 3 group(10001-20000 RMB Yuan per year); 3) Higher group (20001-30000 RMB Yuan per year ); 4) 4 Highest group (＞30000 RMB Yuan per year)；**：Dibao household：：：Low-income households 5 identified and subsidized by local bureau of civil affairs. 6 7 8 9 The multivariate logistic regression model indicated that household 10 11 income level, diagnosis symptom severity, understanding of whether TB was 12 13 curable or not and knowledge about the free TB treatment policy were 14 15 factors significantlyFor associatedpeer with review treatment delay only (Table 4). 16 17 Table.4. Multivariate logistic regression model of the risk factors for treatment delay 18 among migrant TB patients in Shandong ,China 19 20 Variables OR adj 95%CI P 21 22 Age(in years) 23 ≥45 1.0 24 25 15~29 1.56 0.55-4.42 0.40 26 30~44 1.03 0.43-2.48 0. 95 27 28 Marital Status 29 Single 1.0 30 31 Married 1.37 0.56-3.34 0.49 32 Divorced/ bereft of spouse 0.97 0.14-6.70 0.97 33
34 Household income level* http://bmjopen.bmj.com/ 35 Highest group 36 1.0 37 Lowest group 3.79 1.55-9.29 0.00 38 39 Lower group 2.37 0.96-5.81 0.06 40 Higher group 1.42 0.66-3.07 0.37 41 42 Debt status on September 30, 2021 by guest. Protected copyright. 43 No 1.0 44 45 ≤10000 Yuan(RMB) 1.91 0.84-4.32 0.12 46 ＞10000Yuan(RMB) 2.23 0.76-6.52 0.14 47 48 Dibao household** 49 Yes 1.0 50 51 No 0.14 0.02-1.24 0.08 52 Migrating with families or not 53 54 No 1.0 55 56 Yes 0.21 0.11-0.43 0.00 57 Diagnosis symptom severity 58 59 60 12
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1 2 3 4 mild 1.0 5 moderate 7.00 2.91-16.84 0.00 6 7 severe 13.35 4.87-36.63 0.00 8 Understanding of whether TB is curable or not 9 10 No 1.0 11 12 Yes 0.04 0.01-0.23 0.00 13 Knowledge about the free TB treatment policy 14 15 No For peer review1.0 only 16 Yes 0.22 0.10-0.50 0.00 17 *:Household income level: 1) Lowest group (≤10000 RMB Yuan per year); 2) Lower 18 group(10001-20000 RMB Yuan per year); 3) Higher group (20001-30000 RMB Yuan per year ); 4) 19 20 Highest group (＞30000 RMB Yuan per year)；**：Dibao household: Low-income households 21 identified and subsidized by local bureau of civil affairs. 22 23 24 25 Discussion 26 27 Providing timely treatment after diagnosis is a key intervention to 28 29 prevent TB transmission in community. Therefore, understanding the risk 30 31 factors for treatment delay is of high significance. The median treatment 32 33 delay in our study was 1 day, which was similar to the reported median (1
34 http://bmjopen.bmj.com/ 35 day) among permanent residents in research conducted in Ghana (21) and 36 37 Ethiopia (13), and the median (1 day) of delay found in another study among 38 39 permanent residents in the same study area (Shandong Province—22), but it 40 41 was a slightly longer delay than the 0 day median reported among migrant 42 on September 30, 2021 by guest. Protected copyright. 43 TB patients in Changning District of Shanghai (15). 44 45 Similar to the findings of other studies, this study also indicated that 46 47 economic status of migrant TB patients was a key barrier to accessing TB 48 49 50 treatment (23-25). The policy implemented by the Chinese government to 51 52 provide free treatment for TB patients has reached migrants and has, to a 53 54 certain extent, reduced the financial burden of migrant TB patients. However, 55 56 there are also some items that are critical to treating TB among migrants that 57 58 59 60 13
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1 2 3 4 have not yet been included in the free policy, such as transport costs 5 6 occurring in the care-seeking process and ancillary drugs for treatment. 7 8 Those high out-of-pocket health expenditures may hinder migrant TB 9 10 patients from seeking timely TB treatment after diagnosis. Therefore, in 11 12 order to efficiently reach migrants and make these policies more pro-poor, 13 14 the free TB control program should address the economic factors. 15 For peer review only 16 When compared with migrant patients who had migrated with their 17 18 families, we found that patients living along in the study sites were more 19 20 vulnerable to treatment delay. Some previous studies found that lack of 21 22 social support was a positively-associated risk factor of TB-related health 23 24 seeking behavior (26-27). As the most important source of social support for 25 26 migrant TB patients, family members played an important role, which could 27 28 not be replaced by any other sources, in encouraging them to seek timely 29 30 31 treatment after TB diagnosis. 32 33 We found that migrant TB patients with mild and moderate diagnosis
34 http://bmjopen.bmj.com/ 35 symptoms were more likely to experience treatment delay than those with 36 37 severe diagnosis symptoms. In China, 80% of migrants are rural-to-urban 38 39 workers (28). Among this population the average educational level is rather 40 41 low (28), which may result in poor understanding of TB symptoms, the 42 on September 30, 2021 by guest. Protected copyright. 43 importance of timely treatment and the free TB treatment policy. Thus, the 44 45 migrant TB patients may delay in seeking timely treatment after diagnosis 46 47 due to their poor understanding of these factors. 48 49 A clear association was observed between treatment delay and patient 50 51 understanding of the possibility of curing TB. Patients who thought TB was 52 53 incurable were more likely to experience treatment delay than those who 54 55 thought TB was curable. We also found that the patients who did not know 56 57 about the free TB treatment policy were more likely to experience treatment 58 59 60 14
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1 2 3 4 delay. The National TB Control Program Implementation Guide in China 5 6 (2008) proposed that improving TB-related understanding level among TB 7 8 patients was crucial to controlling TB in China (29). These findings should 9 10 therefore give an impetus to carry out TB-related health education and also 11 12 publicize the free TB treatment policy among migrants. 13 14 We were somewhat surprised to observe that health insurance status had 15 For peer review only 16 no significant effect on the treatment delay among migrant TB patients. One 17 18 possible explanation for this finding is the weakness of health insurance 19 20 policies towards the migrants. In China, the health insurance system is 21 22 tightly tied to the hukou (household registration) system. Due to localized 23 24 management, health insurance is generally not transferrable to a new 25 26 location. This means that insured migrants are generally unable to utilize 27 28 local health services. Instead, insured migrants are usually required to return 29 30 31 to their hometowns (hukou registered locations) if they want to make use of 32 33 these benefits. Given general poor financial conditions among the migrant
34 http://bmjopen.bmj.com/ 35 population, it is unlikely that insured migrants would travel all the way back 36 37 to their hometowns to utilize these health services (30). Therefore, the true 38 39 financial protection level among migrants through health insurance is 40 41 relatively low, even if they had been covered by some kind of health 42 on September 30, 2021 by guest. Protected copyright. 43 insurance plans in their hometowns. This finding underlies the need for 44 45 policymakers to make health insurance plans transferable for migrants. 46 47 This study had potential limitations. First, the selection of migrant TB 48 49 patients might be biased. The target population of this study was the patients 50 51 who had registered in a LTD. This means that undetected TB patients, 52 53 patients who had not registered in a LTD and patients who had left the 54 55 sample counties (districts) during the period of the survey were not included. 56 57 This thus affects to some extent the representativeness of our result. Second, 58 59 60 15
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1 2 3 4 the measure of treatment delay was self-reported and recall bias was 5 6 unavoidable. 7 8 Conclusions 9 10 In this study, 65.6% of the participants experienced treatment delay (＞ 11 12 1 day). The study indicates that treatment delay was associated with the 13 14 economic status of migrant patients, which suggests that future policies 15 For peer review only 16 should extend the range of reimbursement for TB-related health services for 17 18 the poor among migrant TB patients to make them more pro-poor. We find 19 20 that TB patients’ poor understanding of TB was significantly associated with 21 22 23 higher treatment delay. This suggests that policymakers should carry out 24 25 extensive TB-related health education among migrant TB patients. We also 26 27 find that factors including diagnosis symptom severity and whether migrants 28 29 lived with their families were associated with treatment delay. 30 31 Understanding these risk factors may be helpful for policymakers to make 32 33 more effective policies targeting the most at-risk patients.
34 http://bmjopen.bmj.com/ 35 Competing interests 36 37 The authors declare there are no competing interests. 38 39 40 Contributorship statement 41 42 CZ, LX and HG conceived the idea, CZ and HG implemented the field on September 30, 2021 by guest. Protected copyright. 43 44 study. JC and XW participated in the statistical analysis and interpretation of 45 46 the results. CZ wrote the manuscript. All authors read and approved the final 47 48 manuscript. 49 50 Funding 51 52 This study was supported by the National Science Foundation of China 53 54 (71473152), Department of Science and Technology of Shandong Province 55 56 57 (BS2012SF010) and Independent Innovation Foundation of Shandong 58 59 60 16
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1 2 3 4 University (2012DX006). 5 6 Data sharing 7 8 No additional data available. 9 10 Acknowledgements 11 12 We would like to thank all participants and staffs at the study sites for 13 14 their cooperation and also thank Miss Natalie Johnson from REAP of 15 For peer review only 16 17 Stanford University for her contribution to polish this paper. 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 17
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1 2 3 References 4 5 1.WHO.Global Tuberculosis Control：Surveillance，Planning，Financing．In：Communicable 6 7 Diseases．World Health Organization, Geneva, 2002. 8 9 2.Ministry of Health of People’s Republic of China. National Tuberculosis Control Program 10 (1991–2000).Chinese Journal of Public Health, 1992,8(4):1-5 (in Chinese) 11 12 3.Xianyi C, Fengzeng Z, Hongjin D, et al. The DOTS strategy in China: Results and lessons after 10 13 years. Bull World Health Organ, 2002;80: 430-436. 14 15 4.Zhou C, ChuFor J, Liu J, peer et al. Adherence review to tuberculosis treatment only among migrant pulmonary 16 tuberculosis patients in Shandong, China: a quantitative survey study.PLoS One, 2012;7(12):e52334. 17 18 doi: 10.1371/journal.pone.0052334. 19 5.Tobe RG, Xu L, Zhou C, et al. Factors affecting patient delay of diagnosis and completion of Direct 20 21 Observation Therapy, Short-course (DOTS) among the migrant population in Shandong, China. 22 23 Biosci Trends, 2013 Jun;7(3):122-8 24 6.National Health and Family Planning Commission of People’s Republic of China. Report on 25 26 National Developments of Migrants in China in 2013.Beijing,China,2013(in Chinese) 27 7.Li X, Zhang H, Jiang S,et al. Active Pulmonary Tuberculosis Case Detection and Treatment Among 28 29 Floating Population in China: An Effective Pilot. J Immigrant Minority Health (2010) 12:811–815 30 31 8.WHO: Global Tuberculosis Control: report.: 2011.World Health Organization,2012. 32 9.Whitehorn J, Ayles H, Godfrey-Fausset P. Extra-pulmonary and smear negative forms of 33 tuberculosis are associated with treatment delay and hospitalization. Int J Tuberc Lung Dis, 2010, 34 http://bmjopen.bmj.com/ 35 4:741–744. 36 37 10. Liam CK, Tang BG. Delay in the diagnosis and treatment of pulmonary tuberculosis in patients 38 attending a university teaching hospital. Int J Tuberc Lung Dis ,1997, 1:326–332. 39 40 11. Madebo T, Lindtjorn B.Delay in treatment of pulmonary tuberculosis: ananalysis of symptom 41 duration among Ethiopian patients. Med Gen Med,1999, 18:E6. 42 on September 30, 2021 by guest. Protected copyright. 43 12. Zhou C, Tobe RG, Chu J, et al. Detection delay of pulmonary tuberculosis patients among 44 migrants in China: a cross-sectional study. Int J Tuberc Lung Dis, 2012 Dec;16(12):1630-6. doi: 45 46 10.5588/ijtld.12.0227. 47 48 13. Belay M, Bjune G, Ameni G, et al. Diagnostic and treatment delay among Tuberculosis patients in 49 Afar Region, Ethiopia: a cross-sectional study. BMC Public Health, 2012 May 23;12:369. 50 51 14.Solomon Yimer, Gunnar Bjune,Getu Alene. Diagnostic and treatment delay among pulmonary 52 tuberculosis patients in Ethiopia: a cross sectional study.BMC Infectious Diseases,2005,5:112 53 54 15. Huang LQ,Wang WB,Li HD,et al.A descriptive study on diagnostic delay and factors impacting 55 accessibility to diagnosis among TB patients in floating population in Changning District,Shanghai 56 57 City.Chinese Journal of Antituberculosis, 2007;29(2):127-129(in Chinese) 58 59 60 18
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1 2 3 16.Xi HF, Li JJ. Analysis on patient delay among new pulmonary tuberculosis patients among urban 4 5 migrants.Modern Journal of Integrated Traditional Chinese and Western Medicine,2011,20(6):682-4 6 17.Deng HJ, Zheng YH, Zhang YY, Xu B.Study on diagnosis delay and its influencing factors among 7 8 migrant tuberculosis patients in Putuo District of Shanghai.Chin J Epidemiol,2006,27(4):311-315(in 9 10 Chinese) 11 18. Long Q, Wang Y, Tang S, et al. Study on patient delay and the influencing factors of TB suspect 12 13 patients among rural to urban migrants in Chongqing. Modern Prev Med,2007; 34:810-812. (in 14 Chinese) 15 For peer review only 16 19.Xu B, Jiang Q-W, Xiu Y, et al. Diagnostic delays in access to tuberculosis care in counties with or 17 without the National Tuberculosis Control Programme in rural China. Int J Tuberc Lung Dis,2005; 9: 18 19 784–790. 20 20. China Global Fund Project Office. The Implementation of Floating Population TB Control Pilot 21 22 Project (China Global Fund TB Program Round 5), Beijing,China, 2006. (in Chinese) 23 21.Lawn SD, Afful B, Acheampong JW. Pulmonary tuberculosis: diagnostic delay in Ghanaian adults. 24 25 Int J Tuberc Lung Dis,1998, 2(8):635–640 26 27 22.Zhao X, Xu L, Guo Z,et al. Analysis on treatment delay of tuberculosis patients and its influencing 28 factors. Chinese Journal of Health Statistics,2013,30(2):187-189(in Chinese) 29 30 23.Liu Q,Wang Y. Study on the floating population tuberculosis prevalence and Control 31 Countermeasures. Journal of Preventive Medicine Information,2005;21(6):680-682(in Chinese) 32 33 24.Cambanis A, Yassin MA, Ramsay A,et al.Rural poverty and delayed presentation to tuberculosis
34 services in Ethiopia.Trop Med Int Health,2005,10(4):330-5 http://bmjopen.bmj.com/ 35 36 25.Enarson DA.Conquering tuberculosis:dream or reality?Int J Tuberc Lung Dis,2002;6:369-370. 37 26.Lin HP, Deng CY, Chou P. Diagnosis and treatment delay among pulmonary tuberculosis patients 38 39 identified using the Taiwan reporting enquiry system, 2002-2006. BMC Public Health, 2009 Feb 40 41 12;9:55. doi: 10.1186/1471-2458-9-55. 42 27.Kirwan DE, Nicholson BD, Baral SC, et al.The social reality of migrant men with tuberculosis in on September 30, 2021 by guest. Protected copyright. 43 44 Kathmandu: implications for DOT in practice. Trop Med Int Health, 2009 Dec;14(12):1442-7. 45 28.National Population and Family Planning Commission,China. Report on National Developments of 46 47 Migrants in China in 2012.Beijing,China,2012(in Chinese) 48 49 29.Ministry of Health of PRC. National TB Control Program Implementation Guide in China (2008 50 Edition).Beijing,2009.(in Chinese) 51 52 30. Zhao Y, Kang B, Liu Y, et al. Health insurance coverage and its impact on medical cost: 53 observations from the floating population in china. PLoS One. 2014 Nov 11;9(11):e111555. doi: 54 55 10.1371/journal.pone.0111555. eCollection 2014. 56 57 58 59 60 19
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1 2 3 4 5 6 7 8 9 Pulmonary tuberculosis among migrants in Shandong, China: 10 Factors associated with treatment delay 11 12 13 1 2 3 1 1 14 Chengchao Zhou , Jie Chu , Hong Geng , Xingzhou Wang , Lingzhong Xu 15 For peer review only 16 17 1. Department of Health Management and Maternal and Child Healthcare, 18 19 School of Public Health, Shandong University, Ji’nan, China; 20 21 2. Shandong Centre for Disease Control and Prevention, Ji’nan, China; 22 3. Shandong Center for Tuberculosis Prevention and Control ,Ji’nan, China 23 24 25 26 *Corresponding Author: Chengchao Zhou (Associate Prof.), Department of 27 Health Management and Maternal and Child Healthcare, School of Public 28 29 Health, Shandong University, Wen hua xi Road No.44, Jinan City, 250012, 30 31 China 32 E mail address: [email protected] 33
34 Tel: (+86) 531 8838 1567 http://bmjopen.bmj.com/ 35 36 Fax: (+86) 531 8838 2553 37 38 39 Key words: Migrants, Pulmonary tuberculosis, treatment delay, 40 41 Cross sectional study, China 42 on September 30, 2021 by guest. Protected copyright. 43 44 Word count: 1764 45 46 47 48 49 50 51 52 53 54 1 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 42 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 9 Abstract 10 Objectives A timely initiation of treatment is crucial to better control 11 12 tuberculosis (TB).The aim of this study is to describe treatment delay among 13 14 migrant TB patients and to identify factors associated with treatment delay, 15 so as to provide Foran evidence peer for the strategy review development and improvement only 16 17 of TB control strategy among migrants in China. 18 19 Design A cross sectional study was conducted in Shandong province of 20 21 China. Aand a total of 314 confirmed smear positive migrant pulmonary TB 22 patients were enrolledincluded. Descriptive and inferential analyses were 23 24 performed as appropriate. Univariate logistic regression was used to analyze 25 26 the association of variables with treatment delay among migrant PTB 27 patients. Multi logistic regression model was developed to further assess the 28 29 effectimpact of variables on treatment delay. 30 31 Results Of 314 migrant PTB patients, 65.6% experienced treatment delay 32 (＞1 day). 33
34 The migrant patients whose hHousehold income level, whose diagnosis http://bmjopen.bmj.com/ 35 36 symptom severity, cognition understanding of on whether TB was is curable 37 38 or not and knowledge about the free TB free treatment policy were are 39 factors significantly associated with treatment delay. 40 41 Conclusions Economic status and cognition knowledge on about TB cure of 42 on September 30, 2021 by guest. Protected copyright. 43 migrant PTB patients weare key barriers to accessing TB treatment. An 44 integrated policy of carrying out Implementing TB related health education 45 46 and publicizing the free TB free treatment policy among migrants promotion 47 48 was essential to better control tuberculosis among migrantsis needed. Health 49 insurance schemes for migrants should be modified to make them 50 51 transferrable and pro poor. 52 53 54 2 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 42 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 9 10 Key Words 11 12 Tuberculosis, migrant, treatment delay, cross sectional study , China 13 14 15 For peer review only 16 17 18 19 Strengths and limitations of this study 20 21 This study is one of the first to try to analyze treatment delay among 22 23 migrant pulmonary TB patients in China. 24 25 26 A cross sectional study to examine the treatment delay and its risk 27 28 factors was conducted in Shandong province of China with a recruitment 29 of 314 confirmed smear positive migrant TB patients. 30 31 32 Migrant pulmonary TB patients’ eEconomic status and cognition 33
34 knowledge about on TB cure werare key barriers to accessing timely TB http://bmjopen.bmj.com/ 35 36 treatment. 37 38 39 The measurement of treatment delay was self reported, and reporting 40 41 bias was unavoidable. 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 3 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 42 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 9 Introduction 10 China has one of the highest burdens of tuberculosis (TB) worldwide 11 12 and it ranks second among the 22 high burden countries in the world (1). 13 14 Since 1991, China has implemented the Directly Observed Treatment Short 15 Course (DOTS) For strategy and peer it has provided review universally covered only coverage 16 17 for TB patients (2). As a result, the cure rate of active TB cases has reached 18 19 over 90% (3). However, the implementation of DOTS for the migrant 20 21 population remains as one of the main challenges in China for controllingTB 22 control (4 5). 23 24 As of 2012In 2011, the migrant population number of migrants in 25 26 China has reached increased to 230 6 million, and it is expected to would 27 increase continuously in the up coming decades (6). As reported in other 28 29 studies, TB case management among migrants is more difficult than that 30 31 ofamong local residents due to migrants their “migratory” nature, poor 32 financial conditions, low education level and weak minimal awareness of 33
34 TB(4 5, 7, ). The challenge of administering to the migrant population which http://bmjopen.bmj.com/ 35 36 presents an important barrier for National TB Control Program in China (4 5, 37 7). Early detection of cases and timely treatment of TB are essential for 38 39 effective TB control (8 11). Delays occurring in any part of the 40 41 health seeking process would increase the probability of TB transmission 42 on September 30, 2021 by guest. Protected copyright. 43 and eventually result in a higher disease burden (12). Studies of delays have 44 been conducted in many countries, most of which explain the delays in terms 45 46 of patient delay, diagnosis delay and treatment delay (13 14). 47 48 In China, a number of studies have reported the length of the patient 49 delay among migrant TB patients to last from 10 days (median) in Shandong 50 51 province (12) to 20 days (median) in Changning District of Shanghai (15) to 52 53 43 days (median) in Shijiazhuang city (16). Previous studies have also 54 4 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 42 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 reported diagnosis delays among migrant TB patients of 5 days (median) in 9 10 Putuo District of Shanghai (17) to 8 days (median) in Shandong province 11 12 (12) to 13 days (median) in Changning District of Shanghai (15). Factors 13 14 including age, economic status, TB symptoms, health insurance, educational 15 level, working time,For the specificpeer health facilitiesreview first visited byonly the TB 16 17 patients were found to be associated with the patient and diagnosis delays 18 19 (12, 15 19). Management of TB patients among migrants which involves 20 early diagnosis and timely initiation of treatment is crucial to reduce 21 22 transmission, morbidity, mortality and development of drug resistance (8 11). 23 24 Many studies have reported the length of time from onset of symptoms 25 related to TB to diagnosis of PTB and risk factors for the delay (12 15). 26 27 However, to the author’s knowledgement, few studies have documented the 28 29 length of time from the time of PTB diagnosis to the start of 30 anti tuberculosis treatment among migrant PTB patientsreatment delay, and 31 32 few have reported onidentified risk factors for this treatment delay. 33
34 HenceTherefore, treatment delay among migrants is of a high priority among http://bmjopen.bmj.com/ 35 topics for study in China TB control. 36 37 The objective of this study is to describe treatment delay among migrant 38 39 PTB patients in Shandong, China, and to identify factors associated with 40 41 treatment delay, so as to provide an evidence for the strategy development 42 and improvement of TB control strategy among migrants in China. on September 30, 2021 by guest. Protected copyright. 43 44 Materials and Methods 45 46 Study design 47 48 This study was conducted in Shandong Province, which consists of 140 49 counties (districts) with a total population of nearly 100 million. By the end 50 51 of 2008, Shandong had about 6.91 million migrants. The DOTS strategy for 52 53 TB was introduced in the 1990s and is now 100% available in 100% of all 54 5 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 42 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 counties (districts) in Shandong province. In China, TB cases are usually 9 10 diagnosed and treated in local TB dispensaries (LTD). However, service 11 12 providers at other levels, especially the lowest level providers (such as 13 14 township health centers and clinics) cannot diagnose and treat the TB cases, 15 only to identifyFor suspected peer TB cases and review refer them to the only LTD. All 16 17 diagnosed TB cases (including new and relapsed patients) are required to be 18 19 registered in the LTD and reported to upper level health authorities. 20 By the end of 2008, Shandong had about 6.91 million migrants.A total of 21 22 12 counties/districts (including Huaiyin District, Lixia District, Dongying 23 24 District, Guangrao County, Penglai County, Laizhou County, Zouping 25 County, Chengyang District, Jimo County, Luozhuang District, Lanshan 26 27 District, Gaomi County) were selected as study sites after considering the 28 29 larger number of migrants in these counties (districts) and the feasibility of 30 the study implementation. 31 32 The participants should meet the following selection criteria: 1) They 33
34 were smear positive migrant pulmonary PTB patients registered in county http://bmjopen.bmj.com/ 35 TB dispensary(CLTD ) of the 12 sampling sites during the period from 36 37 August 1 st 2007 to July 31st 2008; 2) If the patients were being treated, the 38 39 treatment time must be over 1 month; 3) If the patients had finished normal 40 41 treatment, the closure end of treatment must happen within 6 months. 42 Table.1. Economic status and distribution of cases of study sites on September 30, 2021 by guest. Protected copyright. 43 44 Sites GDP per capita 45 No. of Participants 46 (RMB)* 47 Huaiyin 34511 25 48 49 Lixia 75148 25 50 Dongying 48163 25 51 Guangrao 41125 26 52 53 54 6 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 42 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 Penglai 54584 34 9 10 Laizhou 26936 26 11 Zouping 47566 25 12 13 Chengyang 97426 22 14 Jimo 39011 27 15 For peer review only 16 Luozhuang 34706 26 17 Lanshan 31111 26 18 Gaomi 22093 27 19 20 *The data of the GDP per capita sourced from Shandong Statistical Yearbook 2007. 21 22 23 There were a total of 418 migrant TB patients registered in the 12 24 sampling sites during the period, 372 of which met the above criteria. Of the 25 26 372 eligible cases, 20 individuals were unreachable because they had left the 27 28 area, 16 individuals were unresponsive to contact, 11 individuals refused to 29 30 participate in the study, and 11 individuals did not participate for other 31 reasons.There were 314 patients finally successfully recruited into this the 32 33 study. Table 1 presents the economic status and distribution of the patients in
34 http://bmjopen.bmj.com/ 35 different sites. Formatted: Font color: Red 36 Data collection 37 38 A cross sectional study was conducted between August 2nd 2008 and 39 th 40 October 17 2008. The participants were contacted and recruited by staff of 41 the LTD and All the participants were interviewed face to face at local 42 on September 30, 2021 by guest. Protected copyright. 43 CTDthe LTD of the study site using self making questionnaires which 44 45 included socio demographic characteristics, household income, health 46 insurance status, health service geographic accessibility, knowledge about 47 48 TB and its related policies, and patient health seeking experiences from 49 50 diagnosis to the initiation of treatment. The interviews were undertaken by 51 52 trained postgraduates from the School of public Public health Health of 53 54 7 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 42 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 Shandong University and physicians from the Shandong Centre Center for 9 10 TB Prevention and Control. 11 12 Definitions 13 14 In this study, “migrants” were non local residents who had already lived 15 or intended to stayplannedFor topeer live in our study review areas a certain area only for more 16 17 thanat least 3 months (1620). The “diagnosis symptoms severity” was 18 19 divided into three categories: mild, moderate and severe. The “mild 20 symptoms” included the initial symptoms of cough, sputum, and night 21 22 sweats;, the “moderate symptoms” referred to the initial symptoms of the 23 24 chest pain, weight loss, and fever; and the “severe symptoms” included high 25 fever and haemoptysis (12). Treatment time was the period from the 26 27 diagnosis of PTB to the initiation of treatment. Using the median (1 day) as 28 29 the cut off point, a period of longer than 1 day was defined as a treatment 30 delay. 31 32 Data analysis 33
34 The data was double entered using EPI Data 6.04, and the two copies http://bmjopen.bmj.com/ 35 were verified. We used SPSS 13.0 for Windows to analyze the data. Gender, 36 37 age, educational level, marital status, residence and health insurance status 38 39 were presented as percentages. Descriptive and inferential analyses were 40 41 performed as appropriate. Univariate logistic regression was used to analyze 42 the association of each variable with treatment delay across different on September 30, 2021 by guest. Protected copyright. 43 44 subgroups ofamong migrant PTB patients. The identified risk factors 45 46 (P<0.05) were included into a Multimulti logistic regression model was 47 developed to further assess the impact of variables on treatment delay. The 48 49 magnitude of the association was measured by the odds ratio (OR) with 95% 50 51 confidence interval (95% CI). A P value of <0.05 was considered Formatted: Font: Italic 52 statistically significant. 53 54 8 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 28 of 42 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 Ethical consideration 9 10 The Ethical Committee of School of Public Health of Shandong 11 12 University approved this study. All participants provided signed written 13 14 informed consents to participate in the study. The investigation was 15 conducted after For obtaining thepeer informed consentsreview of all participants only .for 16 17 participation prior to the start of study activities. 18 19 Results 20 21 Of the 314 respondents, 63.4% were male. The age of the participants 22 ranged from 15 to 70 years, with a mean age of 31.8 years, and 53.8% are 23 24 were from 15 to 29 years, 31.5% were from 30 to 44 years, 14.7% are were 25 26 45 years old and above. As for educational level,About 18.8% had were with 27 primary education or illiteratebelow, 40.1% with had junior high education 28 29 and 41.1% with had senior high school education and above. With regards to 30 31 marital status, 44.6% of the respondents were single (never married), while 32 51.9% were married, and 3.5% were divorced or widowed. 88.2% of the 33
34 respondents are from rural areas, and 11.8% were from urban areas. 64.6% http://bmjopen.bmj.com/ 35 36 of the patients did not have any kind of health insurance plans (Table 12). 37 38 39 Table.2. 1 Socio demographic characteristics of the participants 40 41 Characteristic No. of Patients % 42 on September 30, 2021 by guest. Protected copyright. 43 No. 44 Gender 45 Male 199 63.4 Formatted: Font: 12 pt 46 Formatted: Font: 12 pt 47 Female 115 36.6 48 Age(in years) Formatted: Font: 12 pt 49 15~29 169 53.8 Formatted: Font: 12 pt 50 30~44 99 31.5 Formatted: Font: 12 pt 51 Formatted: Font: 12 pt 52 ≥45 46 14.7 53 54 9 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 29 of 42 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 Formatted: Font: 12 pt 9 Educational level 10 Primary school and or below 59 18.8 Formatted: Font: 12 pt 11 Junior schoolhigh 126 40.1 Formatted: Font: 12 pt 12 Senior High school and above 129 41.1 Formatted: Font: 12 pt 13 Formatted: Font: 12 pt 14 Marital Status 15 Single For peer140 review44.6 only Formatted: Font: 12 pt 16 Married 163 51.9 Formatted: Font: 12 pt 17 Divorced/ bereft of spouse 11 3.5 Formatted: Font: 12 pt 18 19 Household originResidence Formatted: Font: 12 pt 20 Rural 277 88.2 Formatted: Font: 12 pt 21 Urban 37 11.8 Formatted: Font: 12 pt 22 Formatted: Font: 12 pt 23 Health insurance status 24 yes 111 35.4 Formatted: Font: 12 pt 25 no 203 64.6 Formatted: Font: 12 pt 26 27 28 29 The median of treatment delay was 1 day, with a mean of 2.5 days, 30 31 ranging from 0 to 90 days. When we examined the treatment delay at the 32 33 individual level, During the study periodwe found that, 65.6% of the
34 subjects experienced treatment delay during the study period. The treatment http://bmjopen.bmj.com/ 35 36 delay was compared among across different subgroups using univariate 37 38 logistic regression analysis. We found that migrant TB patients who were 39 younger (PPP＜0.05), who were single (PPP＜0.05), whose household income 40 41 level were lower(PPP＜0.01),who had a debt (PPP＜0.01), who were from 42 on September 30, 2021 by guest. Protected copyright. 43 guarantee Dibao household (Low income households identified and Formatted: Font: Italic 44 45 subsidized by local bureau of civil affairs—PPP ＜ 0.05),who were not 46 47 companied by migrated without families (PPP ＜ 0.01),whose diagnosis 48 49 symptoms were mild (PPP＜0.01), who thought TB was incurable(PPP＜0.01) 50 51 and who didn’t know about the free TB free treatment policy (PPP＜0.01 ) 52 were more likely to experience treatment delay (Table 23). 53 54 10 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 30 of 42 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 9 10 Table.3. 2 Univariate analysis of the risk factors for treatment delay (T-delay) among Formatted: Centered 11 migrant PTB patients in Shandong, China 12 13 T-delay No T-delay 14 Variables OR 95% CI P 15 Forn peer % n review % only 16 SexGender 0.38 Formatted: Font: 12 pt 17 Male 127 63.8 72 36.2 1.0 Formatted: Font: 12 pt 18 Female 79 68.7 36 31.3 1.24 0.76 2.03 Formatted: Font: 12 pt 19 Formatted: Font: 12 pt 20 Age(in years) 0.01 21 15~29 124 73.4 45 26.6 1.0 Formatted: Font: 12 pt 22 30~44 56 56.6 43 43.4 0.47 0.28 0.80 Formatted: Font: 12 pt 23 ≥45 26 56.5 20 43.5 0.47 0.24 0.93 Formatted: Font: 12 pt 24 Formatted: Font: 12 pt 25 Educational level 0.26 26 Primary school and or 35 59.3 24 40.7 1.0 Formatted: Font: 12 pt 27 below 28 Junior schoolhigh 89 70.6 37 29.4 1.65 0.87 3.15 Formatted: Font: 12 pt 29 30 Senior High school and above 82 63.6 47 36.4 1.20 0.64 2.25 Formatted: Font: 12 pt 31 Marital Status 0.04 Formatted: Font: 12 pt 32 Single 102 72.9 38 27.1 1.0 Formatted: Font: 12 pt 33 Married 96 58.9 67 41.1 0.53 0.33 0.87 Formatted: Font: 12 pt
34 http://bmjopen.bmj.com/ 35 Divorced/ bereft of spouse 8 72.7 3 27.3 0.99 0.25 3.94 Formatted: Font: 12 pt 36 Household originResidence 0.64 Formatted: Font: 12 pt 37 Rural 183 66.1 94 33.9 1.0 Formatted: Font: 12 pt 38 Formatted: Font: 12 pt 39 Urban 23 62.2 14 37.8 0.84 0.42 1.72 40 Household income level 0.00 Formatted: Font: 12 pt 41 Lowest group 60 75.0 20 25.0 1.0 Formatted: Font: 12 pt 42 Formatted: Font: 12 pt Lower group 54 76.1 17 23.9 1.06 0.50 2.23 on September 30, 2021 by guest. Protected copyright. 43 Formatted: Font: 12 pt 44 Higher group 58 63.0 34 37.0 0.57 0.29 1.10 45 Highest group 34 47.9 37 52.1 0.31 0.15 0.61 Formatted: Font: 12 pt 46 Debt status 0.00 Formatted: Font: 12 pt 47 No 135 60.3 89 39.7 1.0 Formatted: Font: 12 pt 48 Formatted: Font: 12 pt 49 ≤10000 Yuan(RMB) 44 77.2 13 22.8 2.23 1.14 4.38 50 ＞10000Yuan(RMB) 27 81.8 6 18.2 2.97 1.18 7.48 Formatted: Font: 12 pt 51 Guaranteeing Dibao household** 0.03 52 Yes 16 94.1 1 5.9 1.0 Formatted: Font: 12 pt 53 54 11 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 42 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 Formatted: Font: 12 pt 9 No 190 64.0 107 36.0 0.11 0.02 0.85 10 Working hours per day 0.65 Formatted: Font: 12 pt 11 ≤8 134 64.7 73 35.3 1.0 Formatted: Font: 12 pt 12 ＞8 72 67.3 35 32.7 1.12 0.68 1.84 Formatted: Font: 12 pt 13 Formatted: Font: 12 pt 14 Working days per week 0.22 15 ≤5 For93 peer69.4 41 review 30.6 1.0 only Formatted: Font: 12 pt 16 ＞5 113 62.8 67 37.2 0.74 0.46 1.20 Formatted: Font: 12 pt 17 Companied byMigrating with 0.00 Formatted: Font: 12 pt 18 19 families or not 20 No 126 78.3 35 21.7 1.0 Formatted: Font: 12 pt 21 Yes 80 52.3 73 47.7 0.30 0.19 0.50 Formatted: Font: 12 pt 22 Formatted: Font: 12 pt 23 Health insurance status 0.97 24 Yes 73 65.8 38 34.2 1.0 Formatted: Font: 12 pt 25 No 133 65.5 70 34.5 0.99 0.61 1.61 Formatted: Font: 12 pt 26 Distance to local CTD (Kms) 0.56 Formatted: Font: 12 pt 27 0 51 68.0 24 32.0 1.0 Formatted: Left 28 Formatted: Font: 12 pt 5 48 67.6 23 32.4 0.98 0.49 1.97 29 Formatted: Font: 12 pt 30 10 73 67.0 36 33.0 0.95 0.51 1.79 Formatted: Font: 12 pt 31 20 34 57.6 25 42.4 0.64 0.32 1.30 Formatted: Font: 12 pt 32 Formatted: Font: 12 pt 33 Diagnosis symptom severity 0.001 Formatted: Font: 12 pt
34 mild 21 42.9 28 57.1 1.0 http://bmjopen.bmj.com/ Formatted: Font: 12 pt 35 moderate 122 67.0 60 33.0 2.71 1.42 5.17 36 Formatted: Font: 12 pt severe 63 75.9 20 24.1 4.20 1.97 8.96 37 Formatted: Font: 12 pt Cognition onUnderstanding of whether TB is curable 0.009 Formatted: Font: 12 pt 38 39 or not 01 Formatted: Left 40 Yes 182 63.2 106 36.8 1.0 Formatted: Font: 12 pt 41 Formatted: Font: 12 pt, Bold No 24 92.3 2 7.7 6.99 1.62 30.16 42 Formatted: Font: 12 pt Knowledge about the free TB free treatment policy 0.001 on September 30, 2021 by guest. Protected copyright. 43 Formatted: Font: 12 pt 44 Yes 139 59.9 93 40.1 1.0 Formatted: Font: 12 pt 45 No 67 81.7 15 18.3 2.99 1.61 5.55 Formatted: Left 46 *:Household income level: 1) Lowest group (≤10000 RMB Yuan per year); 2) Lower Formatted: Font: 12 pt 47 group(10001 20000 RMB Yuan per year); 3) Higher group (20001 30000 RMB Yuan per year ); 4) Formatted: Font: 12 pt 48 Highest group (＞30000 RMB Yuan per year)；**：Guaranteeing Dibao household：：： the Formatted: Font: 12 pt 49 lLow income households identified and subsidized by local bureau of civil affairs. 50 Formatted: Font: 10.5 pt 51 Formatted: Font: 10.5 pt 52 The output of multivariate logistic regression model showed indicated Formatted: Font: 10.5 pt 53 54 12 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 42 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 that patients’ household income level, diagnosis symptom severity, cognition 9 10 onunderstanding of whether TB was curable or not and knowledge about the 11 12 free TB free treatment policy were factors significantly associated with 13 14 treatment delay. None of the others entered the model (Table 34). 15 For peer review only Formatted: Normal, Indent: First line: 1.5 ch, 16 Line spacing: 1.5 lines Table.4. 3 Multivariate logistic regressionFinal model of the risk factors for treatment 17 Formatted: Centered delay (T-delay) among migrant PTB patients in Shandong, China 18 19 Variables OR adj 95% CI P 20 Age(in years) Formatted 21 ≥45 1.0 Formatted: Font: 12 pt 22 Formatted: Font: 12 pt 23 15~29 1.56 0.55 4.42 0.40 24 30~44 1.03 0.43 2.48 0. 95 25 Marital Status Formatted: Font: 12 pt 26 Single 1.0 Formatted: Font: 12 pt 27 28 Married 1.37 0.56 3.34 0.49 29 Divorced/ bereft of spouse 0.97 0.14 6.70 0.97 30 Household income level* Formatted: Font: 12 pt 31 Highest group 1.0 Formatted: Font: 12 pt 32 33 Lowest group 3.79 1.55 9.29 0.00
34 Lower group 2.37 0.96 5.81 0.06 http://bmjopen.bmj.com/ 35 Higher group 1.42 0.66 3.07 0.37 36 Debt status 37 38 No 1.0 Formatted: Font: 12 pt 39 ≤10000 Yuan(RMB) 1.91 0.84 4.32 0.12 Formatted: Font: 12 pt 40 ＞10000Yuan(RMB) 2.23 0.76 6.52 0.14 41 Formatted: Font: 12 pt 42 Guaranteeing Dibao household** on September 30, 2021 by guest. Protected copyright. 43 Yes 1.0 44 No 0.14 0.02 1.24 0.08 45 Companied byMigrating with families 46 Formatted: Font: 12 pt 47 or not 48 No 1.0 49 Yes 0.21 0.11 0.43 0.00 50 Diagnosis symptom severity Formatted: Font: 12 pt 51 52 mild 1.0 53 54 13 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 42 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 9 moderate 7.00 2.91 16.84 0.00 10 severe 13.35 4.87 36.63 0.00 11 Cognition onUnderstanding of whether TB is curable Formatted: Font: 12 pt 12 Formatted: Left or not 13 Formatted: Font: 12 pt 14 No 1.0 15 Yes For peer review0.04 0.01 0.23 only0.00 16 Knowledge about the free TB free treatment policy Formatted: Justified 17 Formatted: Font: 12 pt No 1.0 18 Formatted: Font: 12 pt 19 Yes 0.22 0.10 0.50 0.00 20 *:Household income level: 1) Lowest group (≤10000 RMB Yuan per year); 2) Lower Formatted: Font: 10.5 pt 21 group(10001 20000 RMB Yuan per year); 3) Higher group (20001 30000 RMB Yuan per year ); 4) ＞ ； ： ： Formatted: Font: 10.5 pt 22 Highest group ( 30000 RMB Yuan per year) ** Guaranteeing Dibao household：： the lLow income households identified and subsidized by local bureau of civil affairs. Formatted: Font: 10.5 pt 23 24 Formatted: Font: 10.5 pt 25 Discussion Formatted: Font: 10.5 pt 26 27 Providing timely treatment after diagnosis is a key intervention to 28 29 prevent the spread of TB among migrantstransmission in community. 30 Therefore, understanding the risk factors for treatment delay is of high 31 32 significance.to identify risk factors for treatment delay among migrant PTB 33
34 patients is of high significance. The median treatment delay in our study was http://bmjopen.bmj.com/ 35 36 1 day, which was similar to the reported median (1 day) among permanent 37 residents in research conducted in Ghana (1721) and Ethiopia (1813), and 38 39 the median (1 day) of the studydelay found in another study among 40 41 permanent residents conducted in the same province study area among 42 permanent residents(Shandong Province—1922), but it was a little slightly on September 30, 2021 by guest. Protected copyright. 43 44 longer delay than the 0 day median reported among migrant TB patientss in 45 46 Changning District,Shanghai City(1315). 47 Similar to the findings of other studies, this study also indicated that 48 49 economic status of migrant PTB patients was a key barrier to accessing TB 50 51 treatment (2023 2225). The policy implemented by the Chinese government 52 to provide free treatment for TB patients has reached migrants and hashad 53 54 14 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 34 of 42 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 covered migrants. The free policy, to a certain extent, had reduced the 9 10 financial burden of migrant TB patients. However, there were are also some 11 12 items that are critical to treating TB among migrants that have not yet been 13 14 being not included in the free packagepolicy, such as transport costs 15 occurring in theFor care seeking peer process and review additional treatment only for side 16 17 effectsancillary drugs for treatment. Those high out of pocket medical health 18 19 expenditures would probably affectmay hinder migrant PTB patients’ 20 fromto seeking timely TB treatment after diagnosis. Therefore, in order to 21 22 efficiently reach migrants and make these polices more pro poor, the free TB 23 24 control program me for migrants should address the economic factors to 25 maximize its efficiency by expanding the free package or making 26 27 pro poverty policies to extend the range of reimbursement for TB related 28 29 health services for the poor among migrant PTB patients. 30 As When compared with migrant patients who had migrated with 31 32 companied bytheir families, we found that patients living along in the study 33
34 sites were more vulnerable to have treatment delay. Some previous studies http://bmjopen.bmj.com/ 35 found that lack of social support was a positively associated risk factor of 36 37 TB related health seeking behavior (2326 2427). As the most important 38 39 source of social support for migrant TB patients, family members played an 40 41 important role,which could not be replaced by any other sources, in 42 encouraging them to seek timely treatment after TB diagnosis. on September 30, 2021 by guest. Protected copyright. 43 44 We found that migrant PTB patients with mild and moderate diagnosis 45 46 symptoms were more easily likely to experience treatment delay than those 47 with severe diagnosis symptoms ones. In China, 80% of migrants are 48 49 rural to urban workers (28). Among this population the average educational 50 51 level is rather low (28), which may result in poor understanding of TB 52 symptoms, the importance of timely treatment and the free TB treatment 53 54 15 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 35 of 42 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 policy. An explanation for such phenomenon might be patients’ deficient 9 10 knowledge on TB symptoms and thus manyThus, the migrant TB patients 11 12 would may delay to in seeking timely treatment after diagnosis based ondue 13 14 to their poor understanding of these factors.subjective cognition on mild 15 diagnosis symptoms,For then treatment peer delay wouldreview easily appear. only 16 17 A clear association was observed between treatment delay and patient 18 19 understanding s cognition onof the possibility of curing TB cure. The 20 pPatients who thought TB was incurable would bewere more likely to 21 22 experience treatment delay than those who thought TB was curable. We also 23 24 found that the patients had who did not know about the freen TB free 25 treatment policy were more easily likely to experience treatment delay. As 26 27 The National TB Control Program Implementation Guide in China (2008) 28 29 proposed that to improvinge TB related cognitive understanding level 30 among PTB patients was a crucial measure to controlling TB in China(2529). 31 32 These findings should therefore give an impetus to carry out TB related 33
34 health education and also publicize the free TB treatment policy promotion http://bmjopen.bmj.com/ 35 among migrants PTB patients. 36 37 We were somewhat surprised to observe that health insurance status had 38 39 no significant effect on the treatment delay among migrant TB patients. One 40 41 possible explanation for this finding is the weakness of health insurance 42 policies towards the migrants. In China, the health insurance system is on September 30, 2021 by guest. Protected copyright. 43 44 tightly tied to the hukou (household registration) system. Due to localized 45 46 management, health insurance is generally not transferrable to a new 47 location. This means that insured migrants are generally unable to utilize 48 49 local health services. Instead, insured migrants are usually required to return 50 51 to their hometowns (hukou registered locations) if they want to make use of 52 these benefits. Given general poor financial conditions among the migrant 53 54 16 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 42 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 population, it is unlikely that insured migrants would travel all the way back 9 10 to their hometowns to utilize these health services (30). Therefore, the true 11 12 financial protection level among migrants through health insurance is 13 14 relatively low, even if they had been covered by some kind of health 15 insurance plans For in their hometowns. peer This review finding underlies the only need for 16 17 policymakers to make health insurance plans transferable for migrants. 18 Formatted: Font: 14 pt 19 This study had potential limitations. First, One limitation was that the Formatted: Default, Left, First line: 0 ch, Line 20 spacing: single 21 selection of migrant PTB patients might be biased. The target population of 22 23 this study were was the patientsose who had registered in local a CTDLTD. 24 25 This means, but the cases who were that undetected TB patients, patients 26 who had or had nonot registration registratered in local a CTD LTD or and 27 28 patients who had left the sample counties (districts) during the period of the 29 30 survey were not included, . This thus affected affects to some extent the 31 32 representativeness of our result. Second, Another limitation was that the 33 measure of treatment delay was self reported, and recall bias was
34 http://bmjopen.bmj.com/ 35 unavoidable. 36 37 Conclusions 38 In this study, 65.6% of the participants experienced treatment delay (＞ 39 40 1 day). The study indicates that treatment delay was associated with the 41 42 economic status of migrant patients, which implicated suggests that future on September 30, 2021 by guest. Protected copyright. 43 44 policies for policymakers that pro poverty policies should be made to should 45 extend the range of reimbursement for TB related health services for the 46 47 poor among migrant PTB patients to make them more pro poor.. We also 48 49 founind that TB patients’ poor cognition understanding on of TB was 50 significantly associated with higher cure might have negative impact on 51 52 treatment delay. It This suggests that for policy makers to should carry out 53 54 17 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 37 of 42 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 extensive TB related health education among migrant TB patients. 9 10 Furthermore, wWe also found fInd that factors including diagnosis symptom 11 12 severity and whether migrants lived with companied bytheir families or not 13 14 were associated with treatment delay, . Understanding these risk factors may 15 which would beFor helpful for peer policymakers toreview make more effective only policies 16 17 target policiesthe most at risk patients. 18 19 Competing interests 20 21 The authors declare there are no competing interests. 22 Contributorship statement 23 24 CZ, LX and HG conceived the idea, CZ and HG implemented the field 25 26 study. JC and XW participated in the statistical analysis and interpretation of 27 28 the results. CZ wrote the manuscript. All authors read and approved the final 29 manuscript. 30 31 Funding 32 33 This study was supported by the National Science Foundation of China
34 http://bmjopen.bmj.com/ 35 (71473152), Department of Science and Technology of Shandong Province 36 (BS2012SF010) and Independent Innovation Foundation of Shandong 37 38 University (2012DX006). 39 40 Data sharing 41 42 Extra No additional data is available by emailing CZ. on September 30, 2021 by guest. Protected copyright. 43 Acknowledgements 44 45 We would like to thank all participants and staffs at the study sites for 46 47 their cooperation and also thank Miss Natalie Johnson from REAP of 48 49 Stanford University for her contribution to polish this paper. 50 51 52 53 54 18 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 38 of 42 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 References 9 10 1.WHO.Global Tuberculosis Control：Surveillance，Planning，Financing．In：Communicable Formatted: Line spacing: Exactly 17 pt 11 Diseases．World Health Organization,Geneva,2002. 12 2.Ministry of Health of People’s Republic of China. National Tuberculosis Control Program 13 14 (1991–2000).Chinese Journal of Public Health. , 1992,8(4):1 5 (in Chinese) 15 3.Xianyi C, FengzengFor Z, Hongjin D, Liyapeer W, Lixia W, Xin review D, Chin DPet al. The DOTS only strategy in 16 China: Results and lessons after 10 years. Bull World Health Organ. 2002;80: 430 436. 17 4.Zhou C, Chu J, Liu J, Gai Tobe R, Gen H, Wang X, Zheng W, Xu Let al. Adherence to tuberculosis Field Code Changed 18 treatment among migrant pulmonary tuberculosis patients in Shandong, China: a quantitative survey Field Code Changed 19 Field Code Changed study.PLoS One,. 2012;7(12):e52334. doi: 10.1371/journal.pone.0052334. 20 Field Code Changed 5.Tobe RG, Xu L, Zhou C, Yuan Q, Geng H, Wang Xet al. Factors affecting patient delay of diagnosis 21 Field Code Changed and completion of Direct Observation Therapy, Short course (DOTS) among the migrant population 22 Field Code Changed 23 in Shandong, China. Biosci Trends. Biosci Trends, 2013 Jun;7(3):122 8 Field Code Changed 24 6. National Health and Family Planning Commission of People’s Republic of China. Report on Field Code Changed 25 National Developments of Migrants in China in 2013.Beijing,China,2013(in Chinese) Formatted: Font: 10.5 pt 26 27 National Population and Family Planning Commission,China. Report on National Developments of 28 Migrants in China in 2012.Beijing,China,2012(in Chinese) Formatted: Font: 10.5 pt 29 7.Li X, Zhang H, Jiang S, Wang J, Liu X, Li W, Yao H, Wang Let al. Active Pulmonary Tuberculosis Field Code Changed 30 Case Detection and Treatment Among Floating Population in China: An Effective Pilot. J Immigrant Field Code Changed 31 Field Code Changed Minority Health (2010) 12:811–815 32 33 8.WHO: Global Tuberculosis Control: report.: 2011.World Health Organization,2012. 9.Whitehorn J, Ayles H, Godfrey Fausset P. Extra pulmonary and smear negative forms of 34 http://bmjopen.bmj.com/ 35 tuberculosis are associated with treatment delay and hospitalization. Int J Tuberc Lung Dis Dis,2010, ; 36 4:741–744. 37 10. Liam CK, Tang BG: .Delay in the diagnosis and treatment of pulmonary tuberculosis in patients 38 39 attending a university teaching hospital. Int J Tuberc Lung Dis, 1997, ;1:326–332. 40 11. Madebo T, Lindtjorn B: . Delay in treatment of pulmonary tuberculosis: ananalysis of symptom 41 duration among Ethiopian patients. Med Gen Med,1999, ; 18:E6. 42 Field Code Changed
12. Zhou C, Tobe RG, Chu J, Gen H, Wang X, Xu Let al. Detection delay of pulmonary tuberculosis on September 30, 2021 by guest. Protected copyright. 43 patients among migrants in China: a cross sectional study. Int J Tuberc Lung Dis. Int J Tuberc Lung Field Code Changed 44 Field Code Changed Dis, 2012 Dec;16(12):1630 6. doi: 10.5588/ijtld.12.0227. 45 Field Code Changed 13.Belay M, Bjune G, Ameni G,et al. Diagnostic and treatment delay among Tuberculosis patients in 46 Field Code Changed Afar Region, Ethiopia: a cross sectional study. BMC Public Health, 2012 May 23;12:369. doi: 47 Field Code Changed 48 10.1186/1471 2458 12 369. Field Code Changed 49 14.Solomon Yimer, Gunnar Bjune,Getu Alene. Diagnostic and treatment delay among pulmonary Field Code Changed 50 tuberculosis patients in Ethiopia: a cross sectional study.BMC Infectious Diseases,2005,5:112 51 52 53 54 19 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 39 of 42 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 9 1315. Huang LQ,Wang WB,Li HD,Xu B,Yang Het al.A descriptive study on diagnostic delay and 10 factors impacting accessibility to diagnosis among TB patients in floating population in Changning 11 District,Shanghai City.Chinese Journal of Antituberculosis. ,2007;29(2):127 129(in Chinese) Formatted: Font color: Red 12 16.Xi HF, Li JJ. Analysis on patient delay among new pulmonary tuberculosis patients among urban 13 migrants.Modern Journal of Integrated Traditional Chinese and Western Medicine,2011,20(6):682 4 14 17.Deng HJ, Zheng YH, Zhang YY, Xu B.Study on diagnosis delay and its influencing factors among Formatted: Left, Line spacing: Exactly 17 pt 15 For peer review only 16 migrant tuberculosis patients in Putuo District of Shanghai.Chin J Epidemiol,2006,27(4):311 315(in 17 Chinese) Formatted: Font color: Red 18 1418. Long Q, Wang Y, Tang S, Rachel T, Zhan S, Yue Y, Li Y.et al. Study on patient delay and the Formatted: Line spacing: Exactly 17 pt 19 influencing factors of TB suspect patients among rural to urban migrants in Chongqing. Modern Prev 20 Med, 2007; 34:810 812. (in Chinese) 21 22 1519.Xu B, Jiang Q W, Xiu Y, Diwan V Ket al. Diagnostic delays in access to tuberculosis care in 23 counties with or without the National Tuberculosis Control Programme in rural China. Int J Tuberc 24 Lung Dis ,2005; 9: 784–790. 25 1620. China Global Fund Project Office. The Implementation of Floating Population TB Control Pilot 26 Project (China Global Fund TB Program Round 5), Beijing,China, 2006. (in Chinese) 27 28 1721.Lawn SD, Afful B, Acheampong JW: . Pulmonary tuberculosis: diagnostic delay in Ghanaian 29 adults. Int J Tuberc Lung Dis ,1998, ; 2(8):635–640. 30 18. Belay M, Bjune G, Ameni G, Abebe F. Diagnostic and treatment delay among Tuberculosis 31 patients in Afar Region, Ethiopia: a cross sectional study. BMC Public Health. 2012 May 23;12:369. 32 doi: 10.1186/1471 2458 12 369. 33 1922.Zhao X, Xu L, Guo Z, Zheng W, Zhou C, Wang X, Yu X, Qi H, Yang Pet al. Analysis on
34 http://bmjopen.bmj.com/ 35 treatment delay of tuberculosis patients and its influencing factors. Chinese Journal of Health 36 Statistics,2013,;30(2):187 189(in Chinese) 37 2023.Liu Q,Wang Y. Study on the floating population tuberculosis prevalence and Control 38 Countermeasures. Journal of Preventive Medicine Information.,2005;21(6):680 682(in Chinese) Field Code Changed 39 Field Code Changed 2124.Cambanis A, Yassin MA, Ramsay A, Bertel Squire S, Arbide I, Cuevas LEet al.Rural poverty 40 Field Code Changed and delayed presentation to tuberculosis services in Ethiopia.Trop Med Int Health. Trop Med Int 41 Field Code Changed 42 Health, 2005,;10(4):330 5 Field Code Changed on September 30, 2021 by guest. Protected copyright. 43 2225.Enarson DA.Conquering tuberculosis:dream or reality?Int J Tuberc Lung Dis.,2002;6:369 370. Field Code Changed 44 2326.Lin HP, Deng CY, Chou P. Diagnosis and treatment delay among pulmonary tuberculosis Field Code Changed 45 patients identified using the Taiwan reporting enquiry system, 2002 2006. BMC Public Health. BMC Field Code Changed 46 Field Code Changed 47 Public Health, 2009 Feb 12;9:55. doi: 10.1186/1471 2458 9 55. 48 2427.Kirwan DE, Nicholson BD, Baral SC, Newell JNet al.The social reality of migrant men with Field Code Changed Field Code Changed 49 tuberculosis in Kathmandu: implications for DOT in practice. Trop Med Int Health. Trop Med Int Field Code Changed 50 Health, 2009 Dec;14(12):1442 7. Field Code Changed 51 28.National Population and Family Planning Commission,China. Report on National Developments of 52 Formatted: Font: 10.5 pt Migrants in China in 2012.Beijing,China,2012.(in Chinese) 53 Formatted: Font color: Red 54 20 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 40 of 42 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 4 5 6 7 8 9 2529.Ministry of Health of PRC. National TB Control Program Implementation Guide in China (2008 10 Edition).Beijing,2009.(in Chinese) 11 30. Zhao Y, Kang B, Liu Y, et al. Health insurance coverage and its impact on medical cost: 12 observations from the floating population in china. PLoS One. 2014 Nov 11;9(11):e111555. doi: 13 10.1371/journal.pone.0111555. eCollection 2014. 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
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1 2 STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies 3 Item Reported on 4 No Recommendation page # 5 Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the 2，5 6 7 title or the abstract 8 (b) Provide in the abstract an informative and balanced summary 2 9 of what was done and what was found 10 11 Introduction 12 Background/rationale 2 Explain the scientific background and rationale for the 4，5 13 investigation being reported 14 Objectives 3 State specific objectives, including any prespecified hypotheses 4，5 15 For peer review only 16 Methods 17 Study design 4 Present key elements of study design early in the paper 5 18 Setting 5 Describe the setting, locations, and relevant dates, including 5 19 periods of recruitment, exposure, follow-up, and data collection 20 21 Participants 6 (a) Give the eligibility criteria, and the sources and methods of 5 22 selection of participants 23 Variables 7 Clearly define all outcomes, exposures, predictors, potential 6 24 confounders, and effect modifiers. Give diagnostic criteria, if 25 26 applicable 27 Data sources/ 8* For each variable of interest, give sources of data and details of 28 measurement methods of assessment (measurement). Describe comparability of 29 assessment methods if there is more than one group 30 31 Bias 9 Describe any efforts to address potential sources of bias 5 32 Study size 10 Explain how the study size was arrived at 5 33 Quantitative variables 11 Explain how quantitative variables were handled in the analyses. 6
34 If applicable, describe which groupings were chosen and why http://bmjopen.bmj.com/ 35 Statistical methods 12 (a) Describe all statistical methods, including those used to control 6 36 37 for confounding 38 (b) Describe any methods used to examine subgroups and 39 interactions 40 (c) Explain how missing data were addressed 41 d 42 ( ) If applicable, describe analytical methods taking account of on September 30, 2021 by guest. Protected copyright. 43 sampling strategy 44 (e) Describe any sensitivity analyses 45 46 Results 47 Participants 13* (a) Report numbers of individuals at each stage of study—eg 7 48 numbers potentially eligible, examined for eligibility, confirmed 49 eligible, included in the study, completing follow-up, and analysed 50 (b) Give reasons for non-participation at each stage 51 52 (c) Consider use of a flow diagram 53 Descriptive data 14* (a) Give characteristics of study participants (eg demographic, 7 54 clinical, social) and information on exposures and potential 55 confounders 56 57 (b) Indicate number of participants with missing data for each 58 variable of interest 59 Outcome data 15* Report numbers of outcome events or summary measures 8 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml1 BMJ Open Page 42 of 42 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 Main results 16 (a) Give unadjusted estimates and, if applicable, confounder- 8-11 3 adjusted estimates and their precision (eg, 95% confidence 4 interval). Make clear which confounders were adjusted for and 5 why they were included 6 7 (b) Report category boundaries when continuous variables were 8 categorized 9 (c) If relevant, consider translating estimates of relative risk into 10 absolute risk for a meaningful time period 11 12 Other analyses 17 Report other analyses done—eg analyses of subgroups and 13 interactions, and sensitivity analyses 14 Discussion 15 For peer review only 16 Key results 18 Summarise key results with reference to study objectives 11-13 17 Limitations 19 Discuss limitations of the study, taking into account sources of 13 18 potential bias or imprecision. Discuss both direction and 19 magnitude of any potential bias 20 Interpretation 20 Give a cautious overall interpretation of results considering 11-13 21 22 objectives, limitations, multiplicity of analyses, results from 23 similar studies, and other relevant evidence 24 Generalisability 21 Discuss the generalisability (external validity) of the study results 25 26 Other information 27 Funding 22 Give the source of funding and the role of the funders for the 14 28 present study and, if applicable, for the original study on which 29 the present article is based 30 31 32 *Give information separately for exposed and unexposed groups. 33
34 Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and http://bmjopen.bmj.com/ 35 published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely 36 37 available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at 38 http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is 39 available at www.strobe-statement.org. 40 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml2 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
Pulmonary tuberculosis among migrants in Shandong, China: Factors associated with treatment delay
ForJournal: peerBMJ Open review only Manuscript ID: bmjopen-2014-005805.R2
Article Type: Research
Date Submitted by the Author: 03-Dec-2014
Complete List of Authors: Zhou, Chengchao; School of Public Health, Shandong Univeristy Chu, Jie; Shandong Centre for Disease Control and Prevention, Geng, Hong; Shandong Center for Tuberculosis Prevention and Control, Wang, Xingzhou; School of Public health, Shandong University, Xu, Lingzhong; Shandong University, School of Public health
Primary Subject Health services research Heading:
Secondary Subject Heading: Health services research, Health policy, Infectious diseases
HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Health policy < Keywords: HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Tuberculosis < INFECTIOUS DISEASES
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1 2 3 4 Pulmonary tuberculosis among migrants in Shandong, China: 5 6 Factors associated with treatment delay 7 8 9 10 Chengchao Zhou1, Jie Chu2, Hong Geng3, Xingzhou Wang1, Lingzhong Xu1 11 12 13 14 1. Department of Health Management and Maternal and Child Healthcare, 15 For peer review only 16 School of Public Health, Shandong University, Ji’nan, China; 17 18 2. Shandong Centre for Disease Control and Prevention, Ji’nan, China; 19 20 3. Shandong Center for Tuberculosis Prevention and Control, Ji’nan, China 21 22 23 24 25 *Corresponding Author: Chengchao Zhou (Associate Prof.), Department of 26 27 Health Management and Maternal and Child Healthcare, School of Public 28 29 Health, Shandong University, Wen-hua-xi Road No.44, Jinan City, 250012, 30 31 China 32 33 E-mail address: [email protected]
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1 2 3 4 Abstract 5 6 Objective A timely initiation of treatment is crucial to better control 7 8 tuberculosis (TB).The aim of this study is to describe treatment delay among 9 10 migrant TB patients and to identify factors associated with treatment delay, 11 12 so as to provide evidence for strategy development and improvement of TB 13 14 control among migrants in China. 15 For peer review only 16 Design A cross-sectional study was conducted in Shandong province of 17 18 China. A total of 314 confirmed smear positive migrant pulmonary TB 19 20 patients were included. Univariate logistic regression was used to analyze 21 22 23 the association of variables with treatment delay among migrant TB patients. 24 25 Multi-logistic regression model was developed to further assess the effect of 26 27 variables on treatment delay. 28 29 Results Of 314 migrant TB patients, 65.6% experienced treatment delay (＞ 30 31 1day). Household income level, diagnosis symptom severity, understanding 32 33 of whether TB is curable or not and knowledge about the free TB treatment
34 http://bmjopen.bmj.com/ 35 policy are factors significantly associated with treatment delay. 36 37 Conclusions Economic status and knowledge about TB are key barriers to 38 39 accessing TB treatment. An integrated policy of carrying out TB-related 40 41 health education and publicizing the free TB treatment policy among 42 on September 30, 2021 by guest. Protected copyright. 43 44 migrants is needed. Health insurance schemes for migrants should be 45 46 modified to make them transferrable and pro-poor. 47 48 49 50 Key Words 51 52 Tuberculosis, migrant, treatment delay, cross-sectional study, China 53 54 55 56 57 58 59 60 2
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1 2 3 4 5 6 Strengths and limitations of this study 7 8 9 10 11 This study is one of the first to try to analyze treatment delay among 12 13 migrant pulmonary TB patients in China. 14 15 For peer review only 16 17 A cross-sectional study to examine the treatment delay and its risk 18 19 factors was conducted in Shandong province of China with a recruitment 20 21 of 314 confirmed smear positive migrant TB patients. 22 23 24 25 Economic status and knowledge about TB are key barriers to accessing 26 27 timely TB treatment among migrants. 28 29 30 31 The measurement of treatment delay was self-reported, and reporting 32 33 bias was unavoidable.
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1 2 3 4 Introduction 5 6 China has one of the highest burdens of tuberculosis (TB) worldwide 7 8 and it ranks second among the 22 high-burden countries in the world (1). 9 10 Since 1991, China has implemented the Directly Observed Treatment-Short 11 12 Course (DOTS) strategy and has provided universal coverage for TB 13 14 patients (2). As a result, the cure rate of active TB cases has reached over 15 For peer review only 16 90% (3). However, the implementation of DOTS for the migrant population 17 18 remains one of the main challenges in China for controlling TB (4-5). 19 20 As of 2012, the migrant population in China has reached 236 million, 21 22 23 and is expected to increase continuously in the up-coming decades (6). As 24 25 reported in other studies, TB case management among migrants is more 26 27 difficult than among local residents due to their “migratory” nature, poor 28 29 financial conditions, low education level and minimal awareness of TB (4-5, 30 31 7). The challenge of administering to the migrant population presents an 32 33 important barrier for National TB Control Program in China. Early detection
34 http://bmjopen.bmj.com/ 35 of cases and timely treatment of TB are essential for effective TB control 36 37 (8-11). Delays occurring in any part of the health-seeking process would 38 39 increase the probability of TB transmission and eventually result in a higher 40 41 disease burden (12). Studies of delays have been conducted in many 42 on September 30, 2021 by guest. Protected copyright. 43 countries, most of which explain the delays in terms of patient delay, 44 45 diagnosis delay and treatment delay (13-14). 46 47 In China, a number of studies have reported the length of the patient 48 49 delay among migrant TB patients to last from 10 days (median) in Shandong 50 51 52 province (12) to 20 days (median) in Changning District of Shanghai (15) to 53 54 43 days (median) in Shijiazhuang city (16). Previous studies have also 55 56 reported diagnosis delays among migrant TB patients of 5 days (median) in 57 58 Putuo District of Shanghai (17) to 8 days (median) in Shandong province 59 60 4
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1 2 3 4 (12) to 13 days (median) in Changning District of Shanghai (15). Factors 5 6 including age, economic status, TB symptoms, health insurance, educational 7 8 level, working time, the specific health facilities first visited by the TB 9 10 patients were found to be associated with the patient and diagnosis delays 11 12 (12, 15-19). However, to the author’s knowledge, few studies have 13 14 documented the length of treatment delay, and few have identified risk 15 For peer review only 16 factors for treatment delay. Therefore, treatment delay among migrants is of 17 18 a high priority among topics for study in China TB control. 19 20 The objective of this study is to describe treatment delay among migrant 21 22 TB patients in Shandong, China, and to identify factors associated with 23 24 treatment delay, so as to provide evidence for strategy development and 25 26 improvement of TB control among migrants in China. 27 28 29 Materials and Methods 30 31 Study design 32 33 This study was conducted in Shandong Province, which consists of 140
34 http://bmjopen.bmj.com/ 35 counties (districts) with a total population of nearly 100 million. By the end 36 37 of 2008, Shandong had about 6.91 million migrants. The DOTS strategy for 38 39 TB was introduced in the 1990s and is now available in 100% of counties 40 41 (districts) in Shandong province. In China, TB cases are usually diagnosed 42 on September 30, 2021 by guest. Protected copyright. 43 and treated in local TB dispensaries (LTD). However, service providers at 44 45 other levels, especially the lowest level providers (such as township health 46 47 centers and clinics) cannot diagnose and treat the TB cases, only to identify 48 49 suspected TB cases and refer them to the LTD. All diagnosed TB cases 50 51 52 (including new and relapsed patients) are required to be registered in the 53 54 LTD and reported to upper level health authorities. 55 56 A total of 12 counties/districts (including Huaiyin District, Lixia District, 57 58 Dongying District, Guangrao County, Penglai County, Laizhou County, 59 60 5
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1 2 3 4 Zouping County, Chengyang District, Jimo County, Luozhuang District, 5 6 Lanshan District, Gaomi County) were selected as study sites after 7 8 considering the larger number of migrants in these counties (districts) and 9 10 the feasibility of the study implementation. The participants should meet the 11 12 following selection criteria: 1) They were smear-positive migrant pulmonary 13 14 TB patients registered in LTD of the 12 sampling sites during the period 15 For peer review only 16 from August 1 2007 to July 31 2008; 2) If the patients were being treated, 17 18 the treatment time must be over 1 month; 3) If the patients had finished 19 20 normal treatment, the end of treatment must happen within 6 months. 21 22 Table.1. Economic status and distribution of cases of study sites 23 24 Sites GDP per capita 25 No. of Participants 26 (RMB)* 27 28 Huaiyin 34511 25 29 30 Lixia 75148 25 31 32 Dongying 48163 25 33 Guangrao 41125 26
34 http://bmjopen.bmj.com/ 35 Penglai 54584 34 36 37 Laizhou 26936 26 38 39 Zouping 47566 25 40 41 Chengyang 97426 22 42 Jimo 39011 27 on September 30, 2021 by guest. Protected copyright. 43 44 Luozhuang 34706 26 45 46 Lanshan 31111 26 47 48 Gaomi 22093 27 49 50 *The data of the GDP per capita sourced from Shandong Statistical Yearbook 2007. 51 52 53 There were a total of 418 migrant TB patients registered in the 12 54 55 sampling sites during the period, 372 of which met the above criteria. Of the 56 57 372 eligible cases, 20 individuals were unreachable because they had left the 58 59 60 6
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1 2 3 4 area, 16 individuals were unresponsive to contact, 11 individuals refused to 5 6 participate in the study, and 11 individuals did not participate for other 7 8 reasons. There were 314 patients successfully recruited into the study. Table 9 10 1 presents the economic status and distribution of the patients in different 11 12 sites. 13 14 Data collection 15 For peer review only 16 A cross-sectional study was conducted between August 2 2008 and 17 18 October 17 2008. The participants were contacted and recruited by staff of 19 20 the LTD and were interviewed face-to-face at the LTD of the study site using 21 22 questionnaires which included socio-demographic characteristics, household 23 24 income, health insurance status, health service geographic accessibility, 25 26 knowledge about TB and its related policies, and patient health-seeking 27 28 experiences from diagnosis to the initiation of treatment.The interviews were 29 30 31 undertaken by trained postgraduates from the School of Public Health of 32 33 Shandong University and physicians from the Shandong Center for TB
34 http://bmjopen.bmj.com/ 35 Prevention and Control. 36 37 Definitions 38 39 In this study, “migrants” were non-local residents who had already lived 40 41 or intended to stay in our study areas for at least 3 months (20). The 42 on September 30, 2021 by guest. Protected copyright. 43 “diagnosis symptoms severity” was divided into three categories: mild, 44 45 moderate and severe. The “mild symptoms” included the initial symptoms of 46 47 cough, sputum, and night sweats; the “moderate symptoms” referred to the 48 49 initial symptoms of chest pain, weight loss, and fever; and the “severe 50 51 symptoms” included high fever and haemoptysis (12). Treatment time was 52 53 the period from the diagnosis of TB to the initiation of treatment. Using the 54 55 median (1 day) as the cut-off point, a period of longer than 1 day was 56 57 defined as a treatment delay. 58 59 60 7
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1 2 3 4 Data analysis 5 6 The data was double entered using EPI Data 6.04 and the two copies 7 8 were verified. We used SPSS 13.0 for Windows to analyze the data. Gender, 9 10 age, educational level, marital status, residence and health insurance status 11 12 were presented as percentages. Univariate logistic regression was used to 13 14 analyze the association of each variable with treatment delay across different 15 For peer review only 16 subgroups of migrant TB patients. The identified risk factors (P<0.05) were 17 18 included into a multivariate logistic regression model to further assess the 19 20 impact of variables on treatment delay. The magnitude of the association was 21 22 measured by the odds ratio (OR) with 95% confidence interval (95% CI). A 23 24 P-value of <0.05 was considered statistically significant. 25 26 Ethical consideration 27 28 The Ethical Committee of School of Public Health of Shandong 29 30 31 University approved this study. All participants signed written informed 32 33 consents for participation prior to the start of study activities.
34 http://bmjopen.bmj.com/ 35 Results 36 37 Of the 314 respondents, 63.4% were male. The age of the participants 38 39 ranged from 15 to 70 years, with a mean of 31.8 years, and 53.8% were from 40 41 15 to 29 years, 31.5% were from 30 to 44 years, 14.7% were 45 years and 42 on September 30, 2021 by guest. Protected copyright. 43 above. As for educational level, 18.8% had primary education or below, 44 45 40.1% had junior high education and 41.1% had high school education and 46 47 above. With regards to marital status, 44.6% of the respondents were single 48 49 (never-married), while 51.9% were married, and 3.5% were divorced or 50 51 52 widowed. 88.2% of the respondents were from rural areas and 11.8% were 53 54 from urban areas. 64.6% of the patients did not have any kind of health 55 56 insurance plans (Table 2). 57 58 59 60 8
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1 2 3 4 5 6 Table.2. Socio-demographic characteristics of the participants 7 8 9 Characteristic No. of Patients % 10 Gender 11 12 Male 199 63.4 13 Female 115 36.6 14 15 Age(inFor years) peer review only 16 15~29 169 53.8 17 18 30~44 99 31.5 19 ≥45 46 14.7 20 21 Educational level 22 23 Primary or below 59 18.8 24 Junior high 126 40.1 25 26 High school and above 129 41.1 27 Marital Status 28 29 Single 140 44.6 30 Married 163 51.9 31 32 Divorced/ bereft of spouse 11 3.5 33 Residence
34 http://bmjopen.bmj.com/ 35 Rural 277 88.2 36 Urban 37 11.8 37 38 Health insurance status 39 40 yes 111 35.4 41 no 203 64.6 42 on September 30, 2021 by guest. Protected copyright. 43 44 The median of treatment delay was 1 day, with a mean of 2.5 days, 45 46 ranging from 0 to 90 days. When we examined the treatment delay at the 47 48 49 individual level, we found that 65.6% of the subjects experienced treatment 50 51 delay during the study period. The treatment delay was compared across 52 53 different subgroups using univariate logistic regression analysis. We found 54 55 that migrant TB patients who were younger (PPP＜0.05), who were single (PPP＜ 56 57 0.05), whose household income level were lower (PPP＜0.01),who had a debt 58 59 60 9
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1 2 3 4 (PPP＜0.01), who were from Dibao household (Low-income households 5 6 identified and subsidized by local bureau of civil affairs—PPP＜0.05), who 7 8 migrated without families (PPP＜0.01), whose diagnosis symptoms were mild 9 10 11 (PPP＜0.01), who thought TB was incurable (PPP＜0.01) and who didn’t know 12 13 about the free TB treatment policy (PPP＜0.01 ) were more likely to experience 14 15 treatment delayFor (Table peer 3). review only 16 17 Table.3. Univariate analysis of the risk factors for treatment delay (T-delay) among 18 19 migrant TB patients in Shandong, China 20 21 T-delay No T-delay 22 Variables OR 95%CI P 23 n % n % 24 Gender 0.38 25 26 Male 127 63.8 72 36.2 1.0 -- 27 Female 79 68.7 36 31.3 1.24 0.76-2.03 28 29 Age(in years) 0.01 30 31 15~29 124 73.4 45 26.6 1.0 -- 32 30~44 56 56.6 43 43.4 0.47 0.28-0.80 33 ≥45 26 56.5 20 43.5 0.47 0.24-0.93 34 http://bmjopen.bmj.com/ 35 Educational level 0.26 36 37 Primary and below 35 59.3 24 40.7 1.0 -- 38 Junior high 89 70.6 37 29.4 1.65 0.87-3.15 39 40 High school and above 82 63.6 47 36.4 1.20 0.64-2.25 41 Marital Status 0.04 42 on September 30, 2021 by guest. Protected copyright. 43 Single 102 72.9 38 27.1 1.0 -- 44 Married 96 58.9 67 41.1 0.53 0.33-0.87 45 46 Divorced/ bereft of spouse 8 72.7 3 27.3 0.99 0.25-3.94 47 Residence 48 0.64 49 Rural 183 66.1 94 33.9 1.0 -- 50 51 Urban 23 62.2 14 37.8 0.84 0.42-1.72 52 Household income level 0.00 53 54 Lowest group 60 75.0 20 25.0 1.0 55 Lower group 54 76.1 17 23.9 1.06 0.50-2.23 56 57 Higher group 58 63.0 34 37.0 0.57 0.29-1.10 58 59 60 10
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1 2 3 4 Highest group 34 47.9 37 52.1 0.31 0.15-0.61 5 Debt status 0.00 6 7 No 135 60.3 89 39.7 1.0 8 ≤10000 Yuan(RMB) 44 77.2 13 22.8 2.23 1.14-4.38 9 10 ＞10000Yuan(RMB) 27 81.8 6 18.2 2.97 1.18-7.48 11 12 Dibao household** 0.03 13 Yes 16 94.1 1 5.9 1.0 14 15 No For peer 190 64.0review 107 36.0 only 0.11 0.02-0.85 16 Working hours per day 0.65 17 18 ≤8 134 64.7 73 35.3 1.0 19 ＞8 72 67.3 35 32.7 1.12 0.68-1.84 20 21 Working days per week 0.22 22 ≤5 93 69.4 41 30.6 1.0 23 24 ＞5 113 62.8 67 37.2 0.74 0.46-1.20 25 Migrating with families or not 0.00 26 27 No 126 78.3 35 21.7 1.0 28 29 Yes 80 52.3 73 47.7 0.30 0.19-0.50 30 Health insurance status 0.97 31 32 Yes 73 65.8 38 34.2 1.0 33 No 133 65.5 70 34.5 0.99 0.61-1.61
34 http://bmjopen.bmj.com/ 35 Distance to local CTD (Kms) 0.56 36 0- 51 68.0 24 32.0 1.0 37 38 5- 48 67.6 23 32.4 0.98 0.49-1.97 39 10- 73 67.0 36 33.0 0.95 0.51-1.79 40 41 20- 34 57.6 25 42.4 0.64 0.32-1.30 42 Diagnosis symptom severity 0.00 on September 30, 2021 by guest. Protected copyright. 43 44 mild 21 42.9 28 57.1 1.0 45 46 moderate 122 67.0 60 33.0 2.71 1.42-5.17 47 severe 63 75.9 20 24.1 4.20 1.97-8.96 48 49 Understanding of whether TB is curable or not 0.01 50 Yes 182 63.2 106 36.8 1.0 51 52 No 24 92.3 2 7.7 6.99 1.62-30.16 53 Knowledge about the free TB treatment policy 0.00 54 55 Yes 139 59.9 93 40.1 1.0 56 No 67 81.7 15 18.3 2.99 1.61-5.55 57 ≤ 58 *:Household income level: 1) Lowest group ( 10000 RMB Yuan per year); 2) Lower 59 60 11
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1 2 3 group(10001-20000 RMB Yuan per year); 3) Higher group (20001-30000 RMB Yuan per year ); 4) 4 Highest group (＞30000 RMB Yuan per year)；**：Dibao household：：：Low-income households 5 identified and subsidized by local bureau of civil affairs. 6 7 8 9 The multivariate logistic regression model indicated that household 10 11 income level, diagnosis symptom severity, understanding of whether TB was 12 13 curable or not and knowledge about the free TB treatment policy were 14 15 factors significantlyFor associatedpeer with review treatment delay only (Table 4). 16 17 Table.4. Multivariate logistic regression model of the risk factors for treatment delay 18 among migrant TB patients in Shandong ,China 19 20 Variables OR adj 95%CI P 21 22 Age(in years) 23 ≥45 1.0 24 25 15~29 1.56 0.55-4.42 0.40 26 30~44 1.03 0.43-2.48 0. 95 27 28 Marital Status 29 Single 1.0 30 31 Married 1.37 0.56-3.34 0.49 32 Divorced/ bereft of spouse 0.97 0.14-6.70 0.97 33
34 Household income level* http://bmjopen.bmj.com/ 35 Highest group 36 1.0 37 Lowest group 3.79 1.55-9.29 0.00 38 39 Lower group 2.37 0.96-5.81 0.06 40 Higher group 1.42 0.66-3.07 0.37 41 42 Debt status on September 30, 2021 by guest. Protected copyright. 43 No 1.0 44 45 ≤10000 Yuan(RMB) 1.91 0.84-4.32 0.12 46 ＞10000Yuan(RMB) 2.23 0.76-6.52 0.14 47 48 Dibao household** 49 Yes 1.0 50 51 No 0.14 0.02-1.24 0.08 52 Migrating with families or not 53 54 No 1.0 55 56 Yes 0.21 0.11-0.43 0.00 57 Diagnosis symptom severity 58 59 60 12
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1 2 3 4 mild 1.0 5 moderate 7.00 2.91-16.84 0.00 6 7 severe 13.35 4.87-36.63 0.00 8 Understanding of whether TB is curable or not 9 10 No 1.0 11 12 Yes 0.04 0.01-0.23 0.00 13 Knowledge about the free TB treatment policy 14 15 No For peer review1.0 only 16 Yes 0.22 0.10-0.50 0.00 17 *:Household income level: 1) Lowest group (≤10000 RMB Yuan per year); 2) Lower 18 group(10001-20000 RMB Yuan per year); 3) Higher group (20001-30000 RMB Yuan per year ); 4) 19 20 Highest group (＞30000 RMB Yuan per year)；**：Dibao household: Low-income households 21 identified and subsidized by local bureau of civil affairs. 22 23 24 25 Discussion 26 27 Providing timely treatment after diagnosis is a key intervention to 28 29 prevent TB transmission in community. Therefore, understanding the risk 30 31 factors for treatment delay is of high significance. The median treatment 32 33 delay in our study was 1 day, which was similar to the reported median (1
34 http://bmjopen.bmj.com/ 35 day) among permanent residents in research conducted in Ghana (21) and 36 37 Ethiopia (13), and the median (1 day) of delay found in another study among 38 39 permanent residents in the same study area (Shandong Province—22), but it 40 41 was a slightly longer delay than the 0 day median reported among migrant 42 on September 30, 2021 by guest. Protected copyright. 43 TB patients in Changning District of Shanghai (15). 44 45 Similar to the findings of other studies, this study also indicated that 46 47 economic status of migrant TB patients was a key barrier to accessing TB 48 49 50 treatment (23-25). The policy implemented by the Chinese government to 51 52 provide free treatment for TB patients has reached migrants and has, to a 53 54 certain extent, reduced the financial burden of migrant TB patients. However, 55 56 there are also some items that are critical to treating TB among migrants that 57 58 59 60 13
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1 2 3 4 have not yet been included in the free policy, such as transport costs 5 6 occurring in the care-seeking process and ancillary drugs for treatment. 7 8 Those high out-of-pocket health expenditures may hinder migrant TB 9 10 patients from seeking timely TB treatment after diagnosis. Therefore, in 11 12 order to efficiently reach migrants and make these policies more pro-poor, 13 14 the free TB control program should address the economic factors. 15 For peer review only 16 When compared with migrant patients who had migrated with their 17 18 families, we found that patients living along in the study sites were more 19 20 vulnerable to treatment delay. Some previous studies found that lack of 21 22 social support was a positively-associated risk factor of TB-related health 23 24 seeking behavior (26-27). As the most important source of social support for 25 26 migrant TB patients, family members played an important role, which could 27 28 not be replaced by any other sources, in encouraging them to seek timely 29 30 31 treatment after TB diagnosis. 32 33 We found that migrant TB patients with mild and moderate diagnosis
34 http://bmjopen.bmj.com/ 35 symptoms were more likely to experience treatment delay than those with 36 37 severe diagnosis symptoms. In China, 80% of migrants are rural-to-urban 38 39 workers (28). Among this population the average educational level is rather 40 41 low (28), which may result in poor understanding of TB symptoms, the 42 on September 30, 2021 by guest. Protected copyright. 43 importance of timely treatment and the free TB treatment policy. Thus, the 44 45 migrant TB patients may delay in seeking timely treatment after diagnosis 46 47 due to their poor understanding of these factors. 48 49 A clear association was observed between treatment delay and patient 50 51 understanding of the possibility of curing TB. Patients who thought TB was 52 53 incurable were more likely to experience treatment delay than those who 54 55 thought TB was curable. We also found that the patients who did not know 56 57 about the free TB treatment policy were more likely to experience treatment 58 59 60 14
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1 2 3 4 delay. The National TB Control Program Implementation Guide in China 5 6 (2008) proposed that improving TB-related understanding level among TB 7 8 patients was crucial to controlling TB in China (29). These findings should 9 10 therefore give an impetus to carry out TB-related health education and also 11 12 publicize the free TB treatment policy among migrants. 13 14 We were somewhat surprised to observe that health insurance status had 15 For peer review only 16 no significant effect on the treatment delay among migrant TB patients. One 17 18 possible explanation for this finding is the weakness of health insurance 19 20 policies towards the migrants. In China, the health insurance system is 21 22 tightly tied to the hukou (household registration) system. Due to localized 23 24 management, health insurance is generally not transferrable to a new 25 26 location. This means that insured migrants are generally unable to utilize 27 28 local health services. Instead, insured migrants are usually required to return 29 30 31 to their hometowns (hukou registered locations) if they want to make use of 32 33 these benefits. Given general poor financial conditions among the migrant
34 http://bmjopen.bmj.com/ 35 population, it is unlikely that insured migrants would travel all the way back 36 37 to their hometowns to utilize these health services (30). Therefore, the true 38 39 financial protection level among migrants through health insurance is 40 41 relatively low, even if they had been covered by some kind of health 42 on September 30, 2021 by guest. Protected copyright. 43 insurance plans in their hometowns. This finding underlies the need for 44 45 policymakers to make health insurance plans transferable for migrants. 46 47 This study had potential limitations. First, the measure of treatment 48 49 delay was self-reported and recall bias was thus a serious threat to the 50 51 estimate of the treatment delay. Similar with other studies, we minimized the 52 53 estimation error by helping the migrant TB patients in their recall efforts , 54 55 and also collecting data from LTD registration system. FirstSecond, the 56 57 selection of migrant TB patients might be biased. The target population of 58 59 60 15
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1 2 3 4 this study was the patients who had registered in a LTD. This means that 5 6 undetected TB patients, patients who had not registered in a LTD and 7 8 patients who had left the sample counties (districts) during the period of the 9 10 survey were not included. This thus affects to some extent the 11 12 representativeness of our result. Second, the measure of treatment delay was 13 14 self-reported and recall bias was unavoidable. 15 For peer review only 16 17 18 Conclusions 19 20 In this study, 65.6% of the participants experienced treatment delay (＞ 21 22 23 1 day). The study indicates that treatment delay was associated with the 24 25 economic status of migrant patients, which suggests that future policies 26 27 should extend the range of reimbursement for TB-related health services for 28 29 the poor among migrant TB patients to make them more pro-poor. We find 30 31 that TB patients’ poor understanding of TB was significantly associated with 32 33 higher treatment delay. This suggests that policymakers should carry out
34 http://bmjopen.bmj.com/ 35 extensive TB-related health education among migrant TB patients. We also 36 37 find that factors including diagnosis symptom severity and whether migrants 38 39 lived with their families were associated with treatment delay. 40 41 Understanding these risk factors may be helpful for policymakers to make 42 on September 30, 2021 by guest. Protected copyright. 43 more effective policies targeting the most at-risk patients. 44 45 Competing interests 46 47 48 The authors declare there are no competing interests. 49 50 Contributorship statement 51 52 CZ, LX and HG conceived the idea, CZ and HG implemented the field 53 54 study. JC and XW participated in the statistical analysis and interpretation of 55 56 the results. CZ wrote the manuscript. All authors read and approved the final 57 58 59 60 16
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1 2 3 4 manuscript. 5 6 Funding 7 8 This study was supported by the National Science Foundation of China 9 10 (71473152), Department of Science and Technology of Shandong Province 11 12 (BS2012SF010) and Independent Innovation Foundation of Shandong 13 14 University (2012DX006). 15 For peer review only 16 17 Data sharing 18 19 No additional data available. 20 21 Acknowledgements 22 23 We would like to thank all participants and staffs at the study sites for 24 25 their cooperation and also thank Miss Natalie Johnson from REAP of 26 27 Stanford University for her contribution to polish this paper. 28 29 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 17
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1 2 3 References 4 5 1.WHO.Global Tuberculosis Control：Surveillance，Planning，Financing．In：Communicable 6 7 Diseases．World Health Organization, Geneva, 2002. 8 9 2.Ministry of Health of People’s Republic of China. National Tuberculosis Control Program 10 (1991–2000).Chinese Journal of Public Health, 1992,8(4):1-5 (in Chinese) 11 12 3.Xianyi C, Fengzeng Z, Hongjin D, et al. The DOTS strategy in China: Results and lessons after 10 13 years. Bull World Health Organ, 2002;80: 430-436. 14 15 4.Zhou C, ChuFor J, Liu J, peer et al. Adherence review to tuberculosis treatment only among migrant pulmonary 16 tuberculosis patients in Shandong, China: a quantitative survey study.PLoS One, 2012;7(12):e52334. 17 18 doi: 10.1371/journal.pone.0052334. 19 5.Tobe RG, Xu L, Zhou C, et al. Factors affecting patient delay of diagnosis and completion of Direct 20 21 Observation Therapy, Short-course (DOTS) among the migrant population in Shandong, China. 22 23 Biosci Trends, 2013 Jun;7(3):122-8 24 6.National Health and Family Planning Commission of People’s Republic of China. Report on 25 26 National Developments of Migrants in China in 2013.Beijing,China,2013(in Chinese) 27 7.Li X, Zhang H, Jiang S,et al. Active Pulmonary Tuberculosis Case Detection and Treatment Among 28 29 Floating Population in China: An Effective Pilot. J Immigrant Minority Health (2010) 12:811–815 30 31 8.WHO: Global Tuberculosis Control: report.: 2011.World Health Organization,2012. 32 9.Whitehorn J, Ayles H, Godfrey-Fausset P. Extra-pulmonary and smear negative forms of 33 tuberculosis are associated with treatment delay and hospitalization. Int J Tuberc Lung Dis, 2010, 34 http://bmjopen.bmj.com/ 35 4:741–744. 36 37 10. Liam CK, Tang BG. Delay in the diagnosis and treatment of pulmonary tuberculosis in patients 38 attending a university teaching hospital. Int J Tuberc Lung Dis ,1997, 1:326–332. 39 40 11. Madebo T, Lindtjorn B.Delay in treatment of pulmonary tuberculosis: ananalysis of symptom 41 duration among Ethiopian patients. Med Gen Med,1999, 18:E6. 42 on September 30, 2021 by guest. Protected copyright. 43 12. Zhou C, Tobe RG, Chu J, et al. Detection delay of pulmonary tuberculosis patients among 44 migrants in China: a cross-sectional study. Int J Tuberc Lung Dis, 2012 Dec;16(12):1630-6. doi: 45 46 10.5588/ijtld.12.0227. 47 48 13. Belay M, Bjune G, Ameni G, et al. Diagnostic and treatment delay among Tuberculosis patients in 49 Afar Region, Ethiopia: a cross-sectional study. BMC Public Health, 2012 May 23;12:369. 50 51 14.Solomon Yimer, Gunnar Bjune,Getu Alene. Diagnostic and treatment delay among pulmonary 52 tuberculosis patients in Ethiopia: a cross sectional study.BMC Infectious Diseases,2005,5:112 53 54 15. Huang LQ,Wang WB,Li HD,et al.A descriptive study on diagnostic delay and factors impacting 55 accessibility to diagnosis among TB patients in floating population in Changning District,Shanghai 56 57 City.Chinese Journal of Antituberculosis, 2007;29(2):127-129(in Chinese) 58 59 60 18
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1 2 3 16.Xi HF, Li JJ. Analysis on patient delay among new pulmonary tuberculosis patients among urban 4 5 migrants.Modern Journal of Integrated Traditional Chinese and Western Medicine,2011,20(6):682-4 6 17.Deng HJ, Zheng YH, Zhang YY, Xu B.Study on diagnosis delay and its influencing factors among 7 8 migrant tuberculosis patients in Putuo District of Shanghai.Chin J Epidemiol,2006,27(4):311-315(in 9 10 Chinese) 11 18. Long Q, Wang Y, Tang S, et al. Study on patient delay and the influencing factors of TB suspect 12 13 patients among rural to urban migrants in Chongqing. Modern Prev Med,2007; 34:810-812. (in 14 Chinese) 15 For peer review only 16 19.Xu B, Jiang Q-W, Xiu Y, et al. Diagnostic delays in access to tuberculosis care in counties with or 17 without the National Tuberculosis Control Programme in rural China. Int J Tuberc Lung Dis,2005; 9: 18 19 784–790. 20 20. China Global Fund Project Office. The Implementation of Floating Population TB Control Pilot 21 22 Project (China Global Fund TB Program Round 5), Beijing,China, 2006. (in Chinese) 23 21.Lawn SD, Afful B, Acheampong JW. Pulmonary tuberculosis: diagnostic delay in Ghanaian adults. 24 25 Int J Tuberc Lung Dis,1998, 2(8):635–640 26 27 22.Zhao X, Xu L, Guo Z,et al. Analysis on treatment delay of tuberculosis patients and its influencing 28 factors. Chinese Journal of Health Statistics,2013,30(2):187-189(in Chinese) 29 30 23.Liu Q,Wang Y. Study on the floating population tuberculosis prevalence and Control 31 Countermeasures. Journal of Preventive Medicine Information,2005;21(6):680-682(in Chinese) 32 33 24.Cambanis A, Yassin MA, Ramsay A,et al.Rural poverty and delayed presentation to tuberculosis
34 services in Ethiopia.Trop Med Int Health,2005,10(4):330-5 http://bmjopen.bmj.com/ 35 36 25.Enarson DA.Conquering tuberculosis:dream or reality?Int J Tuberc Lung Dis,2002;6:369-370. 37 26.Lin HP, Deng CY, Chou P. Diagnosis and treatment delay among pulmonary tuberculosis patients 38 39 identified using the Taiwan reporting enquiry system, 2002-2006. BMC Public Health, 2009 Feb 40 41 12;9:55. doi: 10.1186/1471-2458-9-55. 42 27.Kirwan DE, Nicholson BD, Baral SC, et al.The social reality of migrant men with tuberculosis in on September 30, 2021 by guest. Protected copyright. 43 44 Kathmandu: implications for DOT in practice. Trop Med Int Health, 2009 Dec;14(12):1442-7. 45 28.National Population and Family Planning Commission,China. Report on National Developments of 46 47 Migrants in China in 2012.Beijing,China,2012(in Chinese) 48 49 29.Ministry of Health of PRC. National TB Control Program Implementation Guide in China (2008 50 Edition).Beijing,2009.(in Chinese) 51 52 30. Zhao Y, Kang B, Liu Y, et al. Health insurance coverage and its impact on medical cost: 53 observations from the floating population in china. PLoS One. 2014 Nov 11;9(11):e111555. doi: 54 55 10.1371/journal.pone.0111555. eCollection 2014. 56 57 58 59 60 19
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1 2 3 4 Pulmonary tuberculosis among migrants in Shandong, China: 5 6 Factors associated with treatment delay 7 8 9 10 Chengchao Zhou1, Jie Chu2, Hong Geng3, Xingzhou Wang1, Lingzhong Xu1 11 12 13 14 1. Department of Health Management and Maternal and Child Healthcare, 15 For peer review only 16 School of Public Health, Shandong University, Ji’nan, China; 17 18 2. Shandong Centre for Disease Control and Prevention, Ji’nan, China; 19 20 3. Shandong Center for Tuberculosis Prevention and Control, Ji’nan, China 21 22 23 24 25 *Corresponding Author: Chengchao Zhou (Associate Prof.), Department of 26 27 Health Management and Maternal and Child Healthcare, School of Public 28 29 Health, Shandong University, Wen hua xi Road No.44, Jinan City, 250012, 30 31 China 32 33 E mail address: [email protected]
34 http://bmjopen.bmj.com/ 35 Tel: (+86) 531 8838 1567 36 37 Fax: (+86) 531 8838 2553 38 39 40 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1
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1 2 3 4 Abstract 5 6 Objective A timely initiation of treatment is crucial to better control 7 8 tuberculosis (TB).The aim of this study is to describe treatment delay among 9 10 migrant TB patients and to identify factors associated with treatment delay, 11 12 so as to provide evidence for strategy development and improvement of TB 13 14 control among migrants in China. 15 For peer review only 16 Design A cross sectional study was conducted in Shandong province of 17 18 China. A total of 314 confirmed smear positive migrant pulmonary TB 19 20 patients were included. Univariate logistic regression was used to analyze 21 22 23 the association of variables with treatment delay among migrant TB patients. 24 25 Multi logistic regression model was developed to further assess the effect of 26 27 variables on treatment delay. 28 29 Results Of 314 migrant TB patients, 65.6% experienced treatment delay (＞ 30 31 1day). Household income level, diagnosis symptom severity, understanding 32 33 of whether TB is curable or not and knowledge about the free TB treatment
34 http://bmjopen.bmj.com/ 35 policy are factors significantly associated with treatment delay. 36 37 Conclusions Economic status and knowledge about TB are key barriers to 38 39 accessing TB treatment. An integrated policy of carrying out TB related 40 41 health education and publicizing the free TB treatment policy among 42 on September 30, 2021 by guest. Protected copyright. 43 44 migrants is needed. Health insurance schemes for migrants should be 45 46 modified to make them transferrable and pro poor. 47 48 49 50 Key Words 51 52 Tuberculosis, migrant, treatment delay, cross sectional study, China 53 54 55 56 57 58 59 60 2
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1 2 3 4 5 6 Strengths and limitations of this study 7 8 9 10 11 This study is one of the first to try to analyze treatment delay among 12 13 migrant pulmonary TB patients in China. 14 15 For peer review only 16 17 A cross sectional study to examine the treatment delay and its risk 18 19 factors was conducted in Shandong province of China with a recruitment 20 21 of 314 confirmed smear positive migrant TB patients. 22 23 24 25 Economic status and knowledge about TB are key barriers to accessing 26 27 timely TB treatment among migrants. 28 29 30 31 The measurement of treatment delay was self reported, and reporting 32 33 bias was unavoidable.
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 3
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1 2 3 4 Introduction 5 6 China has one of the highest burdens of tuberculosis (TB) worldwide 7 8 and it ranks second among the 22 high burden countries in the world (1). 9 10 Since 1991, China has implemented the Directly Observed Treatment Short 11 12 Course (DOTS) strategy and has provided universal coverage for TB 13 14 patients (2). As a result, the cure rate of active TB cases has reached over 15 For peer review only 16 90% (3). However, the implementation of DOTS for the migrant population 17 18 remains one of the main challenges in China for controlling TB (4 5). 19 20 As of 2012, the migrant population in China has reached 236 million, 21 22 23 and is expected to increase continuously in the up coming decades (6). As 24 25 reported in other studies, TB case management among migrants is more 26 27 difficult than among local residents due to their “migratory” nature, poor 28 29 financial conditions, low education level and minimal awareness of TB (4 5, 30 31 7). The challenge of administering to the migrant population presents an 32 33 important barrier for National TB Control Program in China. Early detection
34 http://bmjopen.bmj.com/ 35 of cases and timely treatment of TB are essential for effective TB control 36 37 (8 11). Delays occurring in any part of the health seeking process would 38 39 increase the probability of TB transmission and eventually result in a higher 40 41 disease burden (12). Studies of delays have been conducted in many 42 on September 30, 2021 by guest. Protected copyright. 43 countries, most of which explain the delays in terms of patient delay, 44 45 diagnosis delay and treatment delay (13 14). 46 47 In China, a number of studies have reported the length of the patient 48 49 delay among migrant TB patients to last from 10 days (median) in Shandong 50 51 52 province (12) to 20 days (median) in Changning District of Shanghai (15) to 53 54 43 days (median) in Shijiazhuang city (16). Previous studies have also 55 56 reported diagnosis delays among migrant TB patients of 5 days (median) in 57 58 Putuo District of Shanghai (17) to 8 days (median) in Shandong province 59 60 4
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1 2 3 4 (12) to 13 days (median) in Changning District of Shanghai (15). Factors 5 6 including age, economic status, TB symptoms, health insurance, educational 7 8 level, working time, the specific health facilities first visited by the TB 9 10 patients were found to be associated with the patient and diagnosis delays 11 12 (12, 15 19). However, to the author’s knowledge, few studies have 13 14 documented the length of treatment delay, and few have identified risk 15 For peer review only 16 factors for treatment delay. Therefore, treatment delay among migrants is of 17 18 a high priority among topics for study in China TB control. 19 20 The objective of this study is to describe treatment delay among migrant 21 22 TB patients in Shandong, China, and to identify factors associated with 23 24 treatment delay, so as to provide evidence for strategy development and 25 26 improvement of TB control among migrants in China. 27 28 29 Materials and Methods 30 31 Study design 32 33 This study was conducted in Shandong Province, which consists of 140
34 http://bmjopen.bmj.com/ 35 counties (districts) with a total population of nearly 100 million. By the end 36 37 of 2008, Shandong had about 6.91 million migrants. The DOTS strategy for 38 39 TB was introduced in the 1990s and is now available in 100% of counties 40 41 (districts) in Shandong province. In China, TB cases are usually diagnosed 42 on September 30, 2021 by guest. Protected copyright. 43 and treated in local TB dispensaries (LTD). However, service providers at 44 45 other levels, especially the lowest level providers (such as township health 46 47 centers and clinics) cannot diagnose and treat the TB cases, only to identify 48 49 suspected TB cases and refer them to the LTD. All diagnosed TB cases 50 51 52 (including new and relapsed patients) are required to be registered in the 53 54 LTD and reported to upper level health authorities. 55 56 A total of 12 counties/districts (including Huaiyin District, Lixia District, 57 58 Dongying District, Guangrao County, Penglai County, Laizhou County, 59 60 5
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1 2 3 4 Zouping County, Chengyang District, Jimo County, Luozhuang District, 5 6 Lanshan District, Gaomi County) were selected as study sites after 7 8 considering the larger number of migrants in these counties (districts) and 9 10 the feasibility of the study implementation. The participants should meet the 11 12 following selection criteria: 1) They were smear positive migrant pulmonary 13 14 TB patients registered in LTD of the 12 sampling sites during the period 15 For peer review only 16 from August 1 2007 to July 31 2008; 2) If the patients were being treated, 17 18 the treatment time must be over 1 month; 3) If the patients had finished 19 20 normal treatment, the end of treatment must happen within 6 months. 21 22 Table.1. Economic status and distribution of cases of study sites 23 24 Sites GDP per capita 25 No. of Participants 26 (RMB)* 27 28 Huaiyin 34511 25 29 30 Lixia 75148 25 31 32 Dongying 48163 25 33 Guangrao 41125 26
34 http://bmjopen.bmj.com/ 35 Penglai 54584 34 36 37 Laizhou 26936 26 38 39 Zouping 47566 25 40 41 Chengyang 97426 22 42 Jimo 39011 27 on September 30, 2021 by guest. Protected copyright. 43 44 Luozhuang 34706 26 45 46 Lanshan 31111 26 47 48 Gaomi 22093 27 49 50 *The data of the GDP per capita sourced from Shandong Statistical Yearbook 2007. 51 52 53 There were a total of 418 migrant TB patients registered in the 12 54 55 sampling sites during the period, 372 of which met the above criteria. Of the 56 57 372 eligible cases, 20 individuals were unreachable because they had left the 58 59 60 6
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1 2 3 4 area, 16 individuals were unresponsive to contact, 11 individuals refused to 5 6 participate in the study, and 11 individuals did not participate for other 7 8 reasons. There were 314 patients successfully recruited into the study. Table 9 10 1 presents the economic status and distribution of the patients in different 11 12 sites. 13 14 Data collection 15 For peer review only 16 A cross sectional study was conducted between August 2 2008 and 17 18 October 17 2008. The participants were contacted and recruited by staff of 19 20 the LTD and were interviewed face to face at the LTD of the study site using 21 22 questionnaires which included socio demographic characteristics, household 23 24 income, health insurance status, health service geographic accessibility, 25 26 knowledge about TB and its related policies, and patient health seeking 27 28 experiences from diagnosis to the initiation of treatment.The interviews were 29 30 31 undertaken by trained postgraduates from the School of Public Health of 32 33 Shandong University and physicians from the Shandong Center for TB
34 http://bmjopen.bmj.com/ 35 Prevention and Control. 36 37 Definitions 38 39 In this study, “migrants” were non local residents who had already lived 40 41 or intended to stay in our study areas for at least 3 months (20). The 42 on September 30, 2021 by guest. Protected copyright. 43 “diagnosis symptoms severity” was divided into three categories: mild, 44 45 moderate and severe. The “mild symptoms” included the initial symptoms of 46 47 cough, sputum, and night sweats; the “moderate symptoms” referred to the 48 49 initial symptoms of chest pain, weight loss, and fever; and the “severe 50 51 symptoms” included high fever and haemoptysis (12). Treatment time was 52 53 the period from the diagnosis of TB to the initiation of treatment. Using the 54 55 median (1 day) as the cut off point, a period of longer than 1 day was 56 57 defined as a treatment delay. 58 59 60 7
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1 2 3 4 Data analysis 5 6 The data was double entered using EPI Data 6.04 and the two copies 7 8 were verified. We used SPSS 13.0 for Windows to analyze the data. Gender, 9 10 age, educational level, marital status, residence and health insurance status 11 12 were presented as percentages. Univariate logistic regression was used to 13 14 analyze the association of each variable with treatment delay across different 15 For peer review only 16 subgroups of migrant TB patients. The identified risk factors (P<0.05) were 17 18 included into a multivariate logistic regression model to further assess the 19 20 impact of variables on treatment delay. The magnitude of the association was 21 22 measured by the odds ratio (OR) with 95% confidence interval (95% CI). A 23 24 P value of <0.05 was considered statistically significant. 25 26 Ethical consideration 27 28 The Ethical Committee of School of Public Health of Shandong 29 30 31 University approved this study. All participants signed written informed 32 33 consents for participation prior to the start of study activities.
34 http://bmjopen.bmj.com/ 35 Results 36 37 Of the 314 respondents, 63.4% were male. The age of the participants 38 39 ranged from 15 to 70 years, with a mean of 31.8 years, and 53.8% were from 40 41 15 to 29 years, 31.5% were from 30 to 44 years, 14.7% were 45 years and 42 on September 30, 2021 by guest. Protected copyright. 43 above. As for educational level, 18.8% had primary education or below, 44 45 40.1% had junior high education and 41.1% had high school education and 46 47 above. With regards to marital status, 44.6% of the respondents were single 48 49 (never married), while 51.9% were married, and 3.5% were divorced or 50 51 52 widowed. 88.2% of the respondents were from rural areas and 11.8% were 53 54 from urban areas. 64.6% of the patients did not have any kind of health 55 56 insurance plans (Table 2). 57 58 59 60 8
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1 2 3 4 5 6 Table.2. Socio demographic characteristics of the participants 7 8 9 Characteristic No. of Patients % 10 Gender 11 12 Male 199 63.4 13 Female 115 36.6 14 15 Age(inFor years) peer review only 16 15~29 169 53.8 17 18 30~44 99 31.5 19 ≥45 46 14.7 20 21 Educational level 22 23 Primary or below 59 18.8 24 Junior high 126 40.1 25 26 High school and above 129 41.1 27 Marital Status 28 29 Single 140 44.6 30 Married 163 51.9 31 32 Divorced/ bereft of spouse 11 3.5 33 Residence
34 http://bmjopen.bmj.com/ 35 Rural 277 88.2 36 Urban 37 11.8 37 38 Health insurance status 39 40 yes 111 35.4 41 no 203 64.6 42 on September 30, 2021 by guest. Protected copyright. 43 44 The median of treatment delay was 1 day, with a mean of 2.5 days, 45 46 ranging from 0 to 90 days. When we examined the treatment delay at the 47 48 49 individual level, we found that 65.6% of the subjects experienced treatment 50 51 delay during the study period. The treatment delay was compared across 52 53 different subgroups using univariate logistic regression analysis. We found 54 55 that migrant TB patients who were younger (PPP＜0.05), who were single (PPP＜ 56 57 0.05), whose household income level were lower (PPP＜0.01),who had a debt 58 59 60 9
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1 2 3 4 (PPP＜0.01), who were from Dibao household (Low income households 5 6 identified and subsidized by local bureau of civil affairs—PPP＜0.05), who 7 8 migrated without families (PPP＜0.01), whose diagnosis symptoms were mild 9 10 11 (PPP＜0.01), who thought TB was incurable (PPP＜0.01) and who didn’t know 12 13 about the free TB treatment policy (PPP＜0.01 ) were more likely to experience 14 15 treatment delayFor (Table peer 3). review only 16 17 Table.3. Univariate analysis of the risk factors for treatment delay (T-delay) among 18 19 migrant TB patients in Shandong, China 20 21 T-delay No T-delay 22 Variables OR 95%CI P 23 n % n % 24 Gender 0.38 25 26 Male 127 63.8 72 36.2 1.0 27 Female 79 68.7 36 31.3 1.24 0.76 2.03 28 29 Age(in years) 0.01 30 31 15~29 124 73.4 45 26.6 1.0 32 30~44 56 56.6 43 43.4 0.47 0.28 0.80 33 ≥45 26 56.5 20 43.5 0.47 0.24 0.93 34 http://bmjopen.bmj.com/ 35 Educational level 0.26 36 37 Primary and below 35 59.3 24 40.7 1.0 38 Junior high 89 70.6 37 29.4 1.65 0.87 3.15 39 40 High school and above 82 63.6 47 36.4 1.20 0.64 2.25 41 Marital Status 0.04 42 on September 30, 2021 by guest. Protected copyright. 43 Single 102 72.9 38 27.1 1.0 44 Married 96 58.9 67 41.1 0.53 0.33 0.87 45 46 Divorced/ bereft of spouse 8 72.7 3 27.3 0.99 0.25 3.94 47 48 Residence 0.64 49 Rural 183 66.1 94 33.9 1.0 50 51 Urban 23 62.2 14 37.8 0.84 0.42 1.72 52 Household income level 0.00 53 54 Lowest group 60 75.0 20 25.0 1.0 55 Lower group 54 76.1 17 23.9 1.06 0.50 2.23 56 57 Higher group 58 63.0 34 37.0 0.57 0.29 1.10 58 59 60 10
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1 2 3 4 Highest group 34 47.9 37 52.1 0.31 0.15 0.61 5 Debt status 0.00 6 7 No 135 60.3 89 39.7 1.0 8 ≤10000 Yuan(RMB) 44 77.2 13 22.8 2.23 1.14 4.38 9 10 ＞10000Yuan(RMB) 27 81.8 6 18.2 2.97 1.18 7.48 11 12 Dibao household** 0.03 13 Yes 16 94.1 1 5.9 1.0 14 15 No For peer190 64.0review 107 36.0 only 0.11 0.02 0.85 16 Working hours per day 0.65 17 18 ≤8 134 64.7 73 35.3 1.0 19 ＞8 72 67.3 35 32.7 1.12 0.68 1.84 20 21 Working days per week 0.22 22 ≤5 93 69.4 41 30.6 1.0 23 24 ＞5 113 62.8 67 37.2 0.74 0.46 1.20 25 Migrating with families or not 0.00 26 27 No 126 78.3 35 21.7 1.0 28 29 Yes 80 52.3 73 47.7 0.30 0.19 0.50 30 Health insurance status 0.97 31 32 Yes 73 65.8 38 34.2 1.0 33 No 133 65.5 70 34.5 0.99 0.61 1.61
34 http://bmjopen.bmj.com/ 35 Distance to local CTD (Kms) 0.56 36 0 51 68.0 24 32.0 1.0 37 38 5 48 67.6 23 32.4 0.98 0.49 1.97 39 10 73 67.0 36 33.0 0.95 0.51 1.79 40 41 20 34 57.6 25 42.4 0.64 0.32 1.30 42 Diagnosis symptom severity 0.00 on September 30, 2021 by guest. Protected copyright. 43 44 mild 21 42.9 28 57.1 1.0 45 46 moderate 122 67.0 60 33.0 2.71 1.42 5.17 47 severe 63 75.9 20 24.1 4.20 1.97 8.96 48 49 Understanding of whether TB is curable or not 0.01 50 Yes 182 63.2 106 36.8 1.0 51 52 No 24 92.3 2 7.7 6.99 1.62 30.16 53 Knowledge about the free TB treatment policy 0.00 54 55 Yes 139 59.9 93 40.1 1.0 56 No 67 81.7 15 18.3 2.99 1.61 5.55 57 58 *:Household income level: 1) Lowest group (≤10000 RMB Yuan per year); 2) Lower 59 60 11
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1 2 3 group(10001 20000 RMB Yuan per year); 3) Higher group (20001 30000 RMB Yuan per year ); 4) 4 Highest group (＞30000 RMB Yuan per year)；**：Dibao household：：：Low income households 5 identified and subsidized by local bureau of civil affairs. 6 7 8 9 The multivariate logistic regression model indicated that household 10 11 income level, diagnosis symptom severity, understanding of whether TB was 12 13 curable or not and knowledge about the free TB treatment policy were 14 15 factors significantlyFor associatedpeer with review treatment delay only (Table 4). 16 17 Table.4. Multivariate logistic regression model of the risk factors for treatment delay 18 among migrant TB patients in Shandong ,China 19 20 Variables OR adj 95%CI P 21 22 Age(in years) 23 ≥45 1.0 24 25 15~29 1.56 0.55 4.42 0.40 26 30~44 1.03 0.43 2.48 0. 95 27 28 Marital Status 29 Single 1.0 30 31 Married 1.37 0.56 3.34 0.49 32 Divorced/ bereft of spouse 0.97 0.14 6.70 0.97 33
34 Household income level* http://bmjopen.bmj.com/ 35 Highest group 36 1.0 37 Lowest group 3.79 1.55 9.29 0.00 38 39 Lower group 2.37 0.96 5.81 0.06 40 Higher group 1.42 0.66 3.07 0.37 41 42 Debt status on September 30, 2021 by guest. Protected copyright. 43 No 1.0 44 45 ≤10000 Yuan(RMB) 1.91 0.84 4.32 0.12 46 ＞10000Yuan(RMB) 2.23 0.76 6.52 0.14 47 48 Dibao household** 49 Yes 1.0 50 51 No 0.14 0.02 1.24 0.08 52 Migrating with families or not 53 54 No 1.0 55 56 Yes 0.21 0.11 0.43 0.00 57 Diagnosis symptom severity 58 59 60 12
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1 2 3 4 mild 1.0 5 moderate 7.00 2.91 16.84 0.00 6 7 severe 13.35 4.87 36.63 0.00 8 Understanding of whether TB is curable or not 9 10 No 1.0 11 12 Yes 0.04 0.01 0.23 0.00 13 Knowledge about the free TB treatment policy 14 15 No For peer review1.0 only 16 Yes 0.22 0.10 0.50 0.00 17 *:Household income level: 1) Lowest group (≤10000 RMB Yuan per year); 2) Lower 18 group(10001 20000 RMB Yuan per year); 3) Higher group (20001 30000 RMB Yuan per year ); 4) 19 20 Highest group (＞30000 RMB Yuan per year)；**：Dibao household: Low income households 21 identified and subsidized by local bureau of civil affairs. 22 23 24 25 Discussion 26 27 Providing timely treatment after diagnosis is a key intervention to 28 29 prevent TB transmission in community. Therefore, understanding the risk 30 31 factors for treatment delay is of high significance. The median treatment 32 33 delay in our study was 1 day, which was similar to the reported median (1
34 http://bmjopen.bmj.com/ 35 day) among permanent residents in research conducted in Ghana (21) and 36 37 Ethiopia (13), and the median (1 day) of delay found in another study among 38 39 permanent residents in the same study area (Shandong Province—22), but it 40 41 was a slightly longer delay than the 0 day median reported among migrant 42 on September 30, 2021 by guest. Protected copyright. 43 TB patients in Changning District of Shanghai (15). 44 45 Similar to the findings of other studies, this study also indicated that 46 47 economic status of migrant TB patients was a key barrier to accessing TB 48 49 50 treatment (23 25). The policy implemented by the Chinese government to 51 52 provide free treatment for TB patients has reached migrants and has, to a 53 54 certain extent, reduced the financial burden of migrant TB patients. However, 55 56 there are also some items that are critical to treating TB among migrants that 57 58 59 60 13
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1 2 3 4 have not yet been included in the free policy, such as transport costs 5 6 occurring in the care seeking process and ancillary drugs for treatment. 7 8 Those high out of pocket health expenditures may hinder migrant TB 9 10 patients from seeking timely TB treatment after diagnosis. Therefore, in 11 12 order to efficiently reach migrants and make these policies more pro poor, 13 14 the free TB control program should address the economic factors. 15 For peer review only 16 When compared with migrant patients who had migrated with their 17 18 families, we found that patients living along in the study sites were more 19 20 vulnerable to treatment delay. Some previous studies found that lack of 21 22 social support was a positively associated risk factor of TB related health 23 24 seeking behavior (26 27). As the most important source of social support for 25 26 migrant TB patients, family members played an important role, which could 27 28 not be replaced by any other sources, in encouraging them to seek timely 29 30 31 treatment after TB diagnosis. 32 33 We found that migrant TB patients with mild and moderate diagnosis
34 http://bmjopen.bmj.com/ 35 symptoms were more likely to experience treatment delay than those with 36 37 severe diagnosis symptoms. In China, 80% of migrants are rural to urban 38 39 workers (28). Among this population the average educational level is rather 40 41 low (28), which may result in poor understanding of TB symptoms, the 42 on September 30, 2021 by guest. Protected copyright. 43 importance of timely treatment and the free TB treatment policy. Thus, the 44 45 migrant TB patients may delay in seeking timely treatment after diagnosis 46 47 due to their poor understanding of these factors. 48 49 A clear association was observed between treatment delay and patient 50 51 understanding of the possibility of curing TB. Patients who thought TB was 52 53 incurable were more likely to experience treatment delay than those who 54 55 thought TB was curable. We also found that the patients who did not know 56 57 about the free TB treatment policy were more likely to experience treatment 58 59 60 14
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1 2 3 4 delay. The National TB Control Program Implementation Guide in China 5 6 (2008) proposed that improving TB related understanding level among TB 7 8 patients was crucial to controlling TB in China (29). These findings should 9 10 therefore give an impetus to carry out TB related health education and also 11 12 publicize the free TB treatment policy among migrants. 13 14 We were somewhat surprised to observe that health insurance status had 15 For peer review only 16 no significant effect on the treatment delay among migrant TB patients. One 17 18 possible explanation for this finding is the weakness of health insurance 19 20 policies towards the migrants. In China, the health insurance system is 21 22 tightly tied to the hukou (household registration) system. Due to localized 23 24 management, health insurance is generally not transferrable to a new 25 26 location. This means that insured migrants are generally unable to utilize 27 28 local health services. Instead, insured migrants are usually required to return 29 30 31 to their hometowns (hukou registered locations) if they want to make use of 32 33 these benefits. Given general poor financial conditions among the migrant
34 http://bmjopen.bmj.com/ 35 population, it is unlikely that insured migrants would travel all the way back 36 37 to their hometowns to utilize these health services (30). Therefore, the true 38 39 financial protection level among migrants through health insurance is 40 41 relatively low, even if they had been covered by some kind of health 42 on September 30, 2021 by guest. Protected copyright. 43 insurance plans in their hometowns. This finding underlies the need for 44 45 policymakers to make health insurance plans transferable for migrants. 46 47 This study had potential limitations. First, the measure of treatment 48 49 delay was self reported and recall bias was thus a serious threat to the 50 51 estimate of the treatment delay. Similar with other studies, we minimized the 52 53 estimation error by helping the migrant TB patients in their recall efforts, 54 55 and also collecting data from LTD registration system. Second, the selection 56 57 of migrant TB patients might be biased. The target population of this study 58 59 60 15
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1 2 3 4 was the patients who had registered in a LTD. This means that undetected 5 6 TB patients, patients who had not registered in a LTD and patients who had 7 8 left the sample counties (districts) during the period of the survey were not 9 10 included. This thus affects to some extent the representativeness of our 11 12 result . 13 14 15 For peer review only 16 Conclusions 17 18 In this study, 65.6% of the participants experienced treatment delay (＞ 19 20 1 day). The study indicates that treatment delay was associated with the 21 22 23 economic status of migrant patients, which suggests that future policies 24 25 should extend the range of reimbursement for TB related health services for 26 27 the poor among migrant TB patients to make them more pro poor. We find 28 29 that TB patients’ poor understanding of TB was significantly associated with 30 31 higher treatment delay. This suggests that policymakers should carry out 32 33 extensive TB related health education among migrant TB patients. We also
34 http://bmjopen.bmj.com/ 35 find that factors including diagnosis symptom severity and whether migrants 36 37 lived with their families were associated with treatment delay. 38 39 Understanding these risk factors may be helpful for policymakers to make 40 41 more effective policies targeting the most at risk patients. 42 on September 30, 2021 by guest. Protected copyright. 43 Competing interests 44 45 46 The authors declare there are no competing interests. 47 48 Contributorship statement 49 50 CZ, LX and HG conceived the idea, CZ and HG implemented the field 51 52 study. JC and XW participated in the statistical analysis and interpretation of 53 54 the results. CZ wrote the manuscript. All authors read and approved the final 55 56 manuscript. 57 58 59 60 16
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1 2 3 4 Funding 5 6 This study was supported by the National Science Foundation of China 7 8 (71473152), Department of Science and Technology of Shandong Province 9 10 (BS2012SF010) and Independent Innovation Foundation of Shandong 11 12 University (2012DX006). 13 14 Data sharing 15 For peer review only 16 17 No additional data available. 18 19 Acknowledgements 20 21 We would like to thank all participants and staffs at the study sites for 22 23 their cooperation and also thank Miss Natalie Johnson from REAP of 24 25 Stanford University for her contribution to polish this paper. 26 27 28 29 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 17
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1 2 3 References 4 5 1.WHO.Global Tuberculosis Control：Surveillance，Planning，Financing．In：Communicable 6 7 Diseases．World Health Organization, Geneva, 2002. 8 9 2.Ministry of Health of People’s Republic of China. National Tuberculosis Control Program 10 (1991–2000).Chinese Journal of Public Health, 1992,8(4):1 5 (in Chinese) 11 12 3.Xianyi C, Fengzeng Z, Hongjin D, et al. The DOTS strategy in China: Results and lessons after 10 13 years. Bull World Health Organ, 2002;80: 430 436. 14 15 4.Zhou C, ChuFor J, Liu J, peer et al. Adherence review to tuberculosis treatment only among migrant pulmonary 16 tuberculosis patients in Shandong, China: a quantitative survey study.PLoS One, 2012;7(12):e52334. 17 18 doi: 10.1371/journal.pone.0052334. 19 5.Tobe RG, Xu L, Zhou C, et al. Factors affecting patient delay of diagnosis and completion of Direct 20 21 Observation Therapy, Short course (DOTS) among the migrant population in Shandong, China. 22 23 Biosci Trends, 2013 Jun;7(3):122 8 24 6.National Health and Family Planning Commission of People’s Republic of China. Report on 25 26 National Developments of Migrants in China in 2013.Beijing,China,2013(in Chinese) 27 7.Li X, Zhang H, Jiang S,et al. Active Pulmonary Tuberculosis Case Detection and Treatment Among 28 29 Floating Population in China: An Effective Pilot. J Immigrant Minority Health (2010) 12:811–815 30 31 8.WHO: Global Tuberculosis Control: report.: 2011.World Health Organization,2012. 32 9.Whitehorn J, Ayles H, Godfrey Fausset P. Extra pulmonary and smear negative forms of 33 tuberculosis are associated with treatment delay and hospitalization. Int J Tuberc Lung Dis, 2010, 34 http://bmjopen.bmj.com/ 35 4:741–744. 36 37 10. Liam CK, Tang BG. Delay in the diagnosis and treatment of pulmonary tuberculosis in patients 38 attending a university teaching hospital. Int J Tuberc Lung Dis ,1997, 1:326–332. 39 40 11. Madebo T, Lindtjorn B.Delay in treatment of pulmonary tuberculosis: ananalysis of symptom 41 duration among Ethiopian patients. Med Gen Med,1999, 18:E6. 42 on September 30, 2021 by guest. Protected copyright. 43 12. Zhou C, Tobe RG, Chu J, et al. Detection delay of pulmonary tuberculosis patients among 44 migrants in China: a cross sectional study. Int J Tuberc Lung Dis, 2012 Dec;16(12):1630 6. doi: 45 46 10.5588/ijtld.12.0227. 47 48 13. Belay M, Bjune G, Ameni G, et al. Diagnostic and treatment delay among Tuberculosis patients in 49 Afar Region, Ethiopia: a cross sectional study. BMC Public Health, 2012 May 23;12:369. 50 51 14.Solomon Yimer, Gunnar Bjune,Getu Alene. Diagnostic and treatment delay among pulmonary 52 tuberculosis patients in Ethiopia: a cross sectional study.BMC Infectious Diseases,2005,5:112 53 54 15. Huang LQ,Wang WB,Li HD,et al.A descriptive study on diagnostic delay and factors impacting 55 accessibility to diagnosis among TB patients in floating population in Changning District,Shanghai 56 57 City.Chinese Journal of Antituberculosis, 2007;29(2):127 129(in Chinese) 58 59 60 18
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 38 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 3 16.Xi HF, Li JJ. Analysis on patient delay among new pulmonary tuberculosis patients among urban 4 5 migrants.Modern Journal of Integrated Traditional Chinese and Western Medicine,2011,20(6):682 4 6 17.Deng HJ, Zheng YH, Zhang YY, Xu B.Study on diagnosis delay and its influencing factors among 7 8 migrant tuberculosis patients in Putuo District of Shanghai.Chin J Epidemiol,2006,27(4):311 315(in 9 Chinese) 10 11 18. Long Q, Wang Y, Tang S, et al. Study on patient delay and the influencing factors of TB suspect 12 13 patients among rural to urban migrants in Chongqing. Modern Prev Med,2007; 34:810 812. (in 14 Chinese) 15 For peer review only 16 19.Xu B, Jiang Q W, Xiu Y, et al. Diagnostic delays in access to tuberculosis care in counties with or 17 without the National Tuberculosis Control Programme in rural China. Int J Tuberc Lung Dis,2005; 9: 18 19 784–790. 20 20. China Global Fund Project Office. The Implementation of Floating Population TB Control Pilot 21 22 Project (China Global Fund TB Program Round 5), Beijing,China, 2006. (in Chinese) 23 21.Lawn SD, Afful B, Acheampong JW. Pulmonary tuberculosis: diagnostic delay in Ghanaian adults. 24 25 Int J Tuberc Lung Dis,1998, 2(8):635–640 26 27 22.Zhao X, Xu L, Guo Z,et al. Analysis on treatment delay of tuberculosis patients and its influencing 28 factors. Chinese Journal of Health Statistics,2013,30(2):187 189(in Chinese) 29 30 23.Liu Q,Wang Y. Study on the floating population tuberculosis prevalence and Control 31 Countermeasures. Journal of Preventive Medicine Information,2005;21(6):680 682(in Chinese) 32 33 24.Cambanis A, Yassin MA, Ramsay A,et al.Rural poverty and delayed presentation to tuberculosis
34 services in Ethiopia.Trop Med Int Health,2005,10(4):330 5 http://bmjopen.bmj.com/ 35 36 25.Enarson DA.Conquering tuberculosis:dream or reality?Int J Tuberc Lung Dis,2002;6:369 370. 37 26.Lin HP, Deng CY, Chou P. Diagnosis and treatment delay among pulmonary tuberculosis patients 38 39 identified using the Taiwan reporting enquiry system, 2002 2006. BMC Public Health, 2009 Feb 40 41 12;9:55. doi: 10.1186/1471 2458 9 55. 42 27.Kirwan DE, Nicholson BD, Baral SC, et al.The social reality of migrant men with tuberculosis in on September 30, 2021 by guest. Protected copyright. 43 44 Kathmandu: implications for DOT in practice. Trop Med Int Health, 2009 Dec;14(12):1442 7. 45 28.National Population and Family Planning Commission,China. Report on National Developments of 46 47 Migrants in China in 2012.Beijing,China,2012(in Chinese) 48 49 29.Ministry of Health of PRC. National TB Control Program Implementation Guide in China (2008 50 Edition).Beijing,2009.(in Chinese) 51 52 30. Zhao Y, Kang B, Liu Y, et al. Health insurance coverage and its impact on medical cost: 53 observations from the floating population in china. PLoS One. 2014 Nov 11;9(11):e111555. doi: 54 55 10.1371/journal.pone.0111555. eCollection 2014. 56 57 58 59 60 19
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1 2 STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies 3 Item Reported on 4 No Recommendation page # 5 Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the 2，5 6 7 title or the abstract 8 (b) Provide in the abstract an informative and balanced summary 2 9 of what was done and what was found 10 11 Introduction 12 Background/rationale 2 Explain the scientific background and rationale for the 4，5 13 investigation being reported 14 Objectives 3 State specific objectives, including any prespecified hypotheses 4，5 15 For peer review only 16 Methods 17 Study design 4 Present key elements of study design early in the paper 5 18 Setting 5 Describe the setting, locations, and relevant dates, including 5 19 periods of recruitment, exposure, follow-up, and data collection 20 21 Participants 6 (a) Give the eligibility criteria, and the sources and methods of 5 22 selection of participants 23 Variables 7 Clearly define all outcomes, exposures, predictors, potential 6 24 confounders, and effect modifiers. Give diagnostic criteria, if 25 26 applicable 27 Data sources/ 8* For each variable of interest, give sources of data and details of 28 measurement methods of assessment (measurement). Describe comparability of 29 assessment methods if there is more than one group 30 31 Bias 9 Describe any efforts to address potential sources of bias 5 32 Study size 10 Explain how the study size was arrived at 5 33 Quantitative variables 11 Explain how quantitative variables were handled in the analyses. 6
34 If applicable, describe which groupings were chosen and why http://bmjopen.bmj.com/ 35 Statistical methods 12 (a) Describe all statistical methods, including those used to control 6 36 37 for confounding 38 (b) Describe any methods used to examine subgroups and 39 interactions 40 (c) Explain how missing data were addressed 41 d 42 ( ) If applicable, describe analytical methods taking account of on September 30, 2021 by guest. Protected copyright. 43 sampling strategy 44 (e) Describe any sensitivity analyses 45 46 Results 47 Participants 13* (a) Report numbers of individuals at each stage of study—eg 7 48 numbers potentially eligible, examined for eligibility, confirmed 49 eligible, included in the study, completing follow-up, and analysed 50 (b) Give reasons for non-participation at each stage 51 52 (c) Consider use of a flow diagram 53 Descriptive data 14* (a) Give characteristics of study participants (eg demographic, 7 54 clinical, social) and information on exposures and potential 55 confounders 56 57 (b) Indicate number of participants with missing data for each 58 variable of interest 59 Outcome data 15* Report numbers of outcome events or summary measures 8 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml1 BMJ Open Page 40 of 40 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from
1 2 Main results 16 (a) Give unadjusted estimates and, if applicable, confounder- 8-11 3 adjusted estimates and their precision (eg, 95% confidence 4 interval). Make clear which confounders were adjusted for and 5 why they were included 6 7 (b) Report category boundaries when continuous variables were 8 categorized 9 (c) If relevant, consider translating estimates of relative risk into 10 absolute risk for a meaningful time period 11 12 Other analyses 17 Report other analyses done—eg analyses of subgroups and 13 interactions, and sensitivity analyses 14 Discussion 15 For peer review only 16 Key results 18 Summarise key results with reference to study objectives 11-13 17 Limitations 19 Discuss limitations of the study, taking into account sources of 13 18 potential bias or imprecision. Discuss both direction and 19 magnitude of any potential bias 20 Interpretation 20 Give a cautious overall interpretation of results considering 11-13 21 22 objectives, limitations, multiplicity of analyses, results from 23 similar studies, and other relevant evidence 24 Generalisability 21 Discuss the generalisability (external validity) of the study results 25 26 Other information 27 Funding 22 Give the source of funding and the role of the funders for the 14 28 present study and, if applicable, for the original study on which 29 the present article is based 30 31 32 *Give information separately for exposed and unexposed groups. 33
34 Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and http://bmjopen.bmj.com/ 35 published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely 36 37 available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at 38 http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is 39 available at www.strobe-statement.org. 40 41 42 on September 30, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml2