Understanding treatment initiation pathways and associated costs among people with pulmonary tuberculosis in a peri-urban area of Mozambique: a cross-sectional study

Nhassengo, Pedroso, Atkins, Salla, Nhamuave, Celina, Uanela, Miguel, Matusse, Cristovão, Banze, Denise, Maphossa, Vânia, Hirasen, Kamban, Ivanova, Olena, Evans, Denise, Lönnroth, Knut, Khosa, Celso and Wingfield, Tom ORCID: https://orcid.org/0000-0001-8433-6887 (2025) 'Understanding treatment initiation pathways and associated costs among people with pulmonary tuberculosis in a peri-urban area of Mozambique: a cross-sectional study'. BMC Public Health, Vol 25, Issue 1, p. 1335.

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Abstract

Background
People with tuberculosis (TB) may seek care from healthcare providers without designated TB diagnosis and treatment services. This can lead to missed or delayed diagnosis and erroneous treatment for other diseases before being correctly diagnosed with TB. Such delays can contribute to increased out-of-pocket expenditures and lost income. We described TB treatment initiation pathways, including the type and number of pre-treatment healthcare providers visited, the time to TB treatment initiation, and the associated costs, among adults with pulmonary TB in Maputo, Mozambique.

Methods
We conducted a cross-sectional survey from December 2017 to January 2020 among adults (≥ 18 years) with pulmonary TB initiating TB treatment in health facilities with TB services in Maputo city and Maputo province, Mozambique. We used a locally adapted version of the World Health Organization’s TB Patient Cost Survey tools to collect health and socioeconomic data including symptoms, type and number of pre-treatment healthcare providers visited, and out-of-pocket costs and lost income. Logistic regression models were used to evaluate the associations of health and socioeconomic variables with the number of pre-treatment healthcare providers visited.

Results
Of 416 enrolled participants, 268 (64.4%) were male. Median age was 34.0 (IQR: 27.0–42.0) years, and 172/416 (41.4%) were breadwinners. Nearly two-thirds (61.5%, 256/416) visited two or more healthcare providers before TB treatment initiation. The mean times to first healthcare provider visits and initiation of TB treatment were 1.5 weeks (SD = 4.9) and 7.7 weeks (SD = 5.5), respectively. The mean cost of care-seeking was equivalent to 53.7% (95%CI = 38.8–68.5%) of the monthly household income and increased with additional visits to healthcare providers. Longer duration of TB symptoms prior to TB treatment initiation (aOR 6.0 [95%CI = 3.6–9.9], p < 0.001) and being in the least poor quintile of households (aOR 2.6 [95%CI = 1.3–5.5], p = 0.011) were associated with visiting two or more pre-treatment healthcare providers.

Conclusions
Most people with TB symptoms sought care within two weeks but TB treatment initiation was delayed to nearly two months after symptoms onset. This suggests that delays in TB treatment initiation may be attributable to health system factors rather than the care-seeking behaviour of people with TB in Maputo, Mozambique. Additionally, there was a substantial financial burden of care-seeking exacerbated by additional healthcare provider visits. Evidence on interventions to address delays in diagnosis and treatment, and their associated health and socioeconomic impacts in Mozambique is urgently needed.

Item Type:	Article
Subjects:	WA Public Health > WA 30 Socioeconomic factors in public health (General) WF Respiratory System > Tuberculosis > WF 300 Pulmonary tuberculosis
Faculty: Department:	Clinical Sciences & International Health > Clinical Sciences Department
Digital Object Identifer (DOI):	https://doi.org/10.1186/s12889-025-22333-y
SWORD Depositor:	JISC Pubrouter
Depositing User:	JISC Pubrouter
Date Deposited:	23 Apr 2025 09:39
Last Modified:	23 Apr 2025 09:39
URI:	https://archive.lstmed.ac.uk/id/eprint/26524

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