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For Peer Review Only 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 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 <b>Primary Subject Health services research Heading</b>: Secondary Subject Heading: Health services research, Health policy, Infectious diseases HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Health policy < Keywords: HEALTH SERVICES ADMINISTRATION & MANAGEMENT, Tuberculosis < INFECTIOUS DISEASES http://bmjopen.bmj.com/ on September 30, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 18 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from 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 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 18 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from 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 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 18 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from 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 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 18 BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from 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 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 18 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2014-005805 on 22 December 2014. Downloaded from 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.
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