福建省山区农村DOTS策略执行现状分析

目的评价福建省山区农村DOTS策略执行现状。方法采用定量与定性相结合的方法，对肺结核病人问卷调查，并对知情人员及肺结核病人深入访谈，内容包括：结核病患者发现和治疗管理过程，相关部门对结核病控制的相关策略措施等；从政府承诺、病人发现过程、督导管理落实三方面分析评价。结果调查的3个县政府承诺落实较好；在村卫生室／私人诊所首次就诊的病人占53．5％，在结防机构的首次就诊仅占6．9％；有26．4％的病人就诊延迟，且59．9％的病人存在确诊延迟；94．9％的涂阳病人治疗过程中有医生上门访视，但72．9％的涂阳病人认为没有必要由医生看着吃药。仅有47．3％的病人在医务人员直接面视督导下服药。结论政府承诺及领导重视能保证结防工作顺利开展；应引导疑似肺结核病人和可疑症状者到结防机构就诊，提高归口管理工作的效率，减少卫生服务提供方造成的确诊延迟。直接面视下的短程督导化疗是DOTS策略的关键，应加强对村卫生室／私人诊所等乡村医生培训，提高认识，并制定适合我国农村地区并且符合医学伦理的策略。     

福建省山区农村DOTS策略执行现状分析

目的评价福建省山区农村DOTS策略执行现状。方法采用定量与定性相结合的方法,对肺结核病人问卷调查,并对知情人员及肺结核病人深入访谈,内容包括:结核病患者发现和治疗管理过程,相关部门对结核病控制的相关策略措施等;从政府承诺、病人发现过程、督导管理落实三方面分析评价。结果调查的3个县政府承诺落实较好;在村卫生室/私人诊所首次就诊的病人占53.5%,在结防机构的首次就诊仅占6.9%;有26.4%的病人就诊延迟,且59.9%的病人存在确诊延迟;94.9%的涂阳病人治疗过程中有医生上门访视,但72.9%的涂阳病人认为没有必要由医生看着吃药,仅有47.3%的病人在医务人员直接面视督导下服药。结论政府承诺及领导重视能保证结防工作顺利开展;应引导疑似肺结核病人和可疑症状者到结防机构就诊,提高归口管理工作的效率,减少卫生服务提供方造成的确诊延迟。直接面视下的短程督导化疗是DOTS策略的关键,应加强对村卫生室/私人诊所等乡村医生培训,提高认识,并制定适合我国农村地区并且符合医学伦理的策略。     

农村贫困地区肺结核患者就诊延迟及其原因分析

目的分析农村贫困地区肺结核患者就诊延迟,及供需双方因素对就诊延迟的影响,为提高病人发现提供参考。方法福建、河南、辽宁和新疆4省各3个经济欠发达县,定量与定性方法结合,调查就诊延迟及其影响因素。对象包括病人、医务人员和管理人员。以首发症状到就医的时间在14 d以上为就诊延迟。结果肺结核病人就诊延迟比例高,有33．6％的病人存在就诊延迟。综合分析供需方的因素:(1)农民群众普遍存在结核病知识的缺乏。(2)医疗服务供给方健康促进工作不够。结论我国农村贫困地区还普遍存在结核病就诊延迟的现象,应该通过有针对性地健康促进工作提高结核病知晓率,并采用多种方式改变就医行为。     

Gender difference in delays to diagnosis and health care seeking behaviour in a rural area of Nepal.

SETTING: Directly observed treatment for tuberculosis using a short-course regimen (DOTS) was introduced in a rural area of Nepal. All new patients assigned to DOTS from mid-December 1997 to mid-June 1999 were eligible for the study. OBJECTIVE: To examine delays in tuberculosis (TB) diagnosis and compare health care seeking behaviour between men and women. DESIGN: A cross-sectional analysis of patient interviews. RESULTS: Women were found to have a significantly longer total delay before diagnosis of tuberculosis (median 2.3 months for men, 3.3 months for women). When they visited traditional healers first, women had a significantly longer delay than men from the first visit to health care providers to diagnosis (median 1.5 months for men, 3.0 months for women). More women (35%) visited traditional healers before diagnosis than men (18%), and were more likely to receive more complicated charms from traditional healers. Men tended to visit the government medical establishment first if they knew that free TB treatment was available, but women did not. CONCLUSION: Women were more likely to visit and to believe in traditional healers; this might lead to the longer delays experienced before TB diagnosis.     

重庆市梁平县肺结核患者就诊延迟及其相关因素分析

目的了解重庆市梁平县肺结核患者就诊延迟情况,探索与就诊延迟相关的主要因素。方法从结核病信息管理系统导出重庆市梁平县2005--2012年登记的结核病患者的个案资料共计3365例,采用描述性分析就诊延迟率;采用秩和检验分析不同性别、年龄、职业、患者来源、登记类型的就诊延迟是否有差异,以P〈0．05为差异有统计学意义;采用logistic回归分析性别、年龄、职业、患者来源、登记类型是否与就诊延迟相关（P〈0．05为差异有统计学意义）。结果重庆市梁平县肺结核患者就诊延迟率为73．14％（2461／3365）,就诊延迟中位数为32d,有52．84％（1778／3365）的肺结核患者就诊延迟在1个月以上。职业、患者来源和登记类型与就诊延迟相关,农民就诊延迟高于其他职业（OR=1．513,95％CI=1．279～1．778,P〈0．05）;因症推荐患者就诊延迟高于转诊患者（OR=2．170,95％CI=1．798~2．618,P〈0．05）;复发患者就诊延迟高于新患者（OR=1．222,95％CI=0．9501．572,P〈0．05）。结论重庆市梁平县肺结核患者就诊延迟率高,就诊延迟与患者职业、来源和登记类型相关,建议采取综合有效措施,减少该地区的肺结核患者就诊延迟现象。     

Diagnostic delays in access to tuberculosis care in counties with or without the National Tuberculosis Control Programme in rural China.

SETTING: A county covered by the National Tuberculosis Control Programme (NTP) (Jianhu) and a nonprogramme county (Funing) in Jiangsu Province, China. OBJECTIVE: To compare diagnostic delays among tuberculosis (TB) patients between counties with and without the NTP, and to study the impact of demographic, socioeconomic and policy factors on the delays. DESIGN: A cohort study of 493 newly diagnosed TB patients registered in the study sites during 2002 was conducted using a structured questionnaire interview. RESULT: The median total diagnostic delay was longer in Jianhu County, 31 (14-68) days, compared to Funing County, 19 (12-34) days, with a shorter patient's delay (10 vs. 16 days, P < 0.05) but a longer doctor's delay (6 vs. 0 days, P < 0.01) in Jianhu than in Funing. Smear-positive TB accounted for 86% of patients in Jianhu, compared to 37% in Funing. Less educated and uninsured patients had longer patient's or doctor's delays in Jianhu, while in Funing poor patients and farmers had both longer patient's and doctor's delays. CONCLUSION: The subsidised NTP leads to a shorter patient's delay, but a longer doctor's delay, with a substantially higher proportion of smear-positive TB diagnosis. Education, medical insurance, poverty and the system of TB control can influence patients' access to TB care.     

Patient and health system delays in the diagnosis and treatment of tuberculosis in Southern Taiwan.

SETTING: Tainan city, Tainan county and 13 townships of Kaohsiung county, Southern Taiwan. OBJECTIVE: To measure delays in the diagnosis and treatment of sputum-positive tuberculosis (TB) and to determine factors associated with delays in seeking health care (patient delay) and in starting anti-tuberculosis treatment (health system delay). DESIGN: A population-based patient interview study. RESULTS: Median patient delay was 7 days (range 0-730). Median health system delay was 23 days (range 0-489), 13 for smear-positive patients and 37 for smear-negative patients (P < 0.005). Median total delay was 44 days (range 0-730). Age <65 years was associated with longer patient delay. Negative smear, absence of haemoptysis, not having a chest radiograph at the first medical consultation and visiting clinics for first consultation were associated with a longer health system delay. Age <65 years, negative smear and cough as the only presenting symptom were associated with longer total delay. CONCLUSION: Patient delay was substantially shorter than health system delay. To reduce health system delay, clinics need to be involved and the referral mechanism must be strengthened. Physicians should maintain high alert for TB and perform prompt sputum smear examinations.     

多部门合作开展结核病防治健康促进活动的效果评价

目的评价多部门合作在农村地区开展结核病健康促进活动的效果。方法综合项目报表数据,同时在我国中部和西部各一个项目省地区开展村民、患者的随机专项问卷调查,并对相关项目资料进行统计分析。结果项目地区选择的合作部门排在前4位的是妇联、教委、宣传部门和村委会,分别有69.7%、63.7%、60.7%和59.2%的项目县认为合作的效果较好。宣传家户覆盖率86.1%,接受过面对面宣传的村民中有78.8%的村民接受过妇联干部的宣传。接受过宣传的村民对6项结核病相关问题的知晓率要高于未接受过宣传的村民,分别为67.8%和52.3%(P0.01)。患者就医行为调查发现主动就诊者中有66.1%的患者是因村医或妇联宣传而就诊。结论农村地区多部门合作开展健康促进活动提高了村民的结核病知晓率,促进了可疑者的主动就医行为,在结核病防治工作起重要作用。     

2010年我国城乡肺结核患者就诊报告过程及其相关因素分析

目的分析2010年中国结核病流行病学抽样调查（简称“流调”）发现患者在调查前出现症状、就诊、确诊、报告至开始治疗的全过程并比较城乡差异。方法以2010年在全国77个城镇调查点、99个乡村调查点进行结核病调查发现的≥15岁的肺结核患者作为研究对象,采用统一结构化的问卷,以面对面询问的形式进行社会经济情况及发病、就诊、治疗过程中相关因素的问卷调查,按照1301例患者（其中城乡患者分别为373例、928例）自然就诊报告过程进行分析,采用y。检验（显著性水平设为0．05）比较城乡差异并探讨其原因。结果城镇患者中49．3％（184／373）在流调前出现了肺结核相关症状,低于乡村患者（59．9％,556／928）,差异有统计学意义（x2=12．15,P〈O．01）。城乡有症状者中就诊者分别占47．3％（87／184）、46．6％（259／556）,城乡有症状就诊者中确诊肺结核者分别占41．4％（36／87）、34．0％（88／259）,确诊结核病后进行了传染病报告者分别占69．4%（25／36）、70．5％（62／88）,开始了抗结核治疗者分别占91．7％（33／36）、88．6G（78／88）,以上差异均无统计学意义（x2=1．52、0．01、0．03,P值均〉0．05）。总结患者在流调前发病、就诊、诊断、治疗全过程,可见患者分流的最主要环节是无症状不就诊、有症状未就诊、有症状就诊诊断为其他疾病,分别占所有患者的42．1％（548／1301）、30．3％（394／1301）、17．1％（222／1301）,最终仅有8．5％（111／1301）的患者出现了症状后确诊并开始了抗结核治疗,另有1.0％（13／1301）的患者虽未出现症状但因为其他原因确诊患了肺结核。结论患者有症状不就诊、就诊未确诊、确诊未治疗应被视为防控策略需重点注意的薄弱环节,城乡患者主要在出现症状的比例上存在差异,乡村患者无症状比例较低,其有症状就诊、就诊者确诊、确诊者治疗比例与城镇患者差异无统计学意义。     

Health care seeking behaviour for tuberculosis symptoms in Kiev City, Ukraine.

SETTING: Tuberculosis (TB) doctors in Kiev City have the impression that TB patients often present with advanced TB disease, and the mortality rate among TB patients is high. Delay in seeking health care may explain these observations. OBJECTIVE: To assess the magnitude of patient delay and evaluate risk factors for delay. DESIGN: We included 190 newly diagnosed pulmonary TB patients. For each patient, information was gathered through interviews and from the medical records. RESULTS: The median time between the start of symptoms and the first visit to a health care provider (patient delay) was 30.0 days. Individuals reporting unemployment, cough or loss of weight before seeking health care had a longer patient delay. The same applies to individuals with the risk factors homelessness, joblessness or alcohol abuse. The main reasons for delay among those who presented late were 'thought symptoms would go away' and 'symptoms not considered serious'. CONCLUSION: For most TB patients, the time between start of symptoms and first health care seeking action was acceptable. Long patient delay was reported by individuals who were homeless, jobless or abused alcohol. Specific activities will have most effect if they are targeted at these vulnerable and difficult to reach groups.     

Health care seeking pattern of tuberculosis patients attending an urban TB clinic in Delhi

The study of pattern of health care seeking of tuberculosis patients is important for identification of factors which might influence delayed reporting of tuberculosis cases, especially the open pulmonary cases. Consecutive 301 pulmonary TB patients, belonging to any of the categories under RNTCP, diagnosed at New Delhi Tuberculosis Centre or its sub-centres over a six-month period were assessed for health care seeking pattern. "Delay" was defined as the time over 3 weeks that a case took to report to the area TB facility. 43.2% patients reported to the TB health facility on their own and others were referred by government hospitals (34.9%) and general practitioners (21.9%). Median delay over 3 weeks was 2.69 weeks for all three categories combined, with a significantly higher delay (3.41 weeks) for retreatment cases as compared to new cases (2.13 weeks). No significant differences were observed in health seeking delay in relation to sex, income, literacy status and source of referral and sputum status. Extensive health education activities can reduce this period of delay in health seeking and result in reduction of transmission of tuberculosis to healthy members of the family and community.     

Increasing TB case detection through intensive referral of TB suspects by village doctors to county TB dispensaries.

OBJECTIVE: To explore new approaches to increase the detection of tuberculosis cases (TB). DESIGN: Thirty counties participated in the study. Patients with TB symptoms were surveyed and referred by trained village doctors to county dispensaries, designated township health centres or general hospitals for free sputum examination. TB patients and suspects notified by general hospitals were traced by TB staff if they defaulted during the transfer. RESULTS: A total of 12,091 new smear-positive TB cases were detected. The registration rate of new smear-positives increased from 36.2 per 100,000 population before the project to 49.9/100,000 after the project, and the case detection rate under the DOTS strategy reached 86%. Of 43,464 registered TB suspects, 15,363 (35.3%) were referred by village and hospital doctors. The referral rate increased significantly (P < 0.01). Of the 15,363 referred patients, 3870 were diagnosed as new smear-positive TB cases. Among three different microscopy centres, there was a statistically significant difference in the sputum examination rates of TB suspects and in the smear-positive rates among the suspects examined. The follow-up rate was 70.9%, but the follow-up success rate was only 33.1%. CONCLUSIONS: Intensive referral of patients with TB symptoms by village doctors to TB dispensaries is an effective way of increasing detection. At the same time, incentives are necessary for patients and village doctors.     

Help-seeking behavior of marginalized groups: a study of TB patients in Harlem, New York.

SETTING: Harlem Hospital Directly Observed Therapy (DOT) Program, New York City. OBJECTIVE: To identify various pathways to tuberculosis (TB) diagnosis, and determine time to diagnosis and reasons for delay, to ensure rapid diagnosis of TB and prompt initiation of appropriate treatment. DESIGN: Cross-sectional survey of the help-seeking behavior of TB patients within 2 months of their enrollment into DOT from May 2001 to December 2004. RESULTS: The average total delay between symptom onset and a patient's diagnosis of TB was 18 weeks among 39 patients. The average delay to diagnosis attributed to patient delay and health care system delay were 10.5 and 7.5 weeks, respectively. Patients visited on average 1.6 sources of care prior to receiving a TB diagnosis. Foreign-born patients in particular were found to have more complex paths to diagnosis. The most common reason for delaying seeking care reported by patients was that they didn't think it was serious' (29.1%). CONCLUSION: There was a substantial time interval between the onset of symptoms and TB diagnosis due to both patient and health care system delay. Foreign-born status, economic and social factors, and missed opportunities for diagnosis by the health care system played important roles in delaying TB diagnoses for the marginalized patients in this study.     

湖南省农村不同性别传染性肺结核病人求医模式研究

目的　探讨农村不同性别传染性肺结核病人的求医模式。方法 采取横断面调查方法 ,根据不同经济状况在湖南省随机抽取4个县为研究现场。运用自制的调查问卷,在知情同意的前提下对到抽样县结核病防治所诊治、年龄在15岁及以上的涂阳肺结核病人逐一面谈。结果 共318例传染性肺结核病人接受了面谈并完成调查问卷,其中男229例(72.0%),女89例(28.0%);平均年龄(38.2±12.0)岁。在结核病发病后直接到当地结核病防治机构就诊者仅占5.4%,其中以县级综合性医院为首次就诊单位者为33.3%,乡镇卫生院和个体村医等占54.8%;男性患者较多以综合医院为首诊单位,女性多选择个体诊所。分别有24.8%和34.9%的被访者发病后有迷信求治和民间偏方求治行为,女性多于男性。经统计分析,因病住院和就诊次数的性别比较无显著性差异。结论 在结核病防治规划的实施中,需考虑不同性别的求医模式,特别是在平等诊治服务方面。结核病健康教育应优先指向目前得不到结核病信息的特殊人群如女性、低文化程度和低社会经济地位者等。     

新发涂阳肺结核患者就诊和诊断延误的影响因素研究

目的 分析新发涂阳肺结核患者就诊和诊断延误的影响因素，为制定减少延误发生的干预措施提供科学依据。方法 采取典型调查的方法，在东、中、西部各选择1个县作为研究现场，采用编制的《新发涂阳肺结核患者诊疗过程调查表》对研究现场结核病防治（简称“结防”）机构2010年5-9月登记发现的329例初治涂阳肺结核患者全部进行了面对面的问卷调查，获得有效个案调查表329份。使用t检验比较就诊延误、诊断延误等不同指标间差异有无统计学意义，使用Cox比例风险回归模型分析影响患者就诊延误的因素，使用非参数检验比较不同医疗机构患者的发现和转诊延误。结果 患者就诊延误15d(0~594d)，诊断延误10d(0~429d)，就诊延误与诊断延误的差异无统计学意义(t=1.596, P=0.111)。与自费相比较，有其他医疗保险（除外新农合）的患者就诊延误更短（β=0.701，Waldχ²=6.223，P=0.013，RR=2.015），有发热症状的患者更易就诊（β=0.430，Waldχ²=11.556，P=0.001，RR=1.537），而有咳嗽症状（β=-0.711，Waldχ²=9.314，P=0.002，RR=0.491）或咯痰症状（β=-0.429，Waldχ²=8.549，P=0.003，RR=0.651）的患者就诊延误更长。不同医疗机构发现结核病可疑者的能力差异有统计学意义（χ²=115.134，P=0.000），其中药店的延误时间最长（26d，四分位间距66.5d），县级及以上医院(0d，四分位间距0d)、乡镇卫生院(0d，四分位间距6d)和结防机构(0d，四分位间距0d)延误时间最短；不同医疗机构转诊结核病可疑者的能力上差异有统计学意义（χ²=55.476，P=0.000），其中结防机构延误时间最短（0d，四分位间距1d），个体诊所延误时间最长（9d，四分位间距19.5d）。结论 新发涂阳肺结核患者的延误包括患者和医疗机构两方面的因素，其中缺乏对结核病可疑症状的相关知识或对症状不重视是导致患者延误的主要因素，而基层医疗机构结核病可疑者的发现和转诊延误是导致医疗机构延误的主要因素。     

新疆维吾尔自治区喀什地区肺结核就诊及确诊延迟调查分析

目的 分析新疆喀什地区肺结核患者就诊与确诊延迟的原因,为提高就诊和确诊的措施提供依据。 方法 对喀什地区除塔什库尔干县（高海拔偏远小县）外其他所有11个县（市）2005年1月1日至2010年9月30日登记的所有活动性肺结核患者43 832例（其中有7622例因出现症状至初次就诊日期填写不详而无法评价,占17.39%）就诊延迟和确诊延迟进行统计,结合每个县面对面问卷调查不少于20例2010年结束疗程的肺结核患者对防治结核病知识的认知、就医行为等进行调查分析;同时对被调查乡卫生院及村卫生室的状况进行调查了解。 结果 患者出现症状到第一次就诊平均间隔106.5 d,91.98%（33 305/36 210）就诊延迟;就诊前了解相关信息者延迟率为51.43%（18/35）,而不了解者为98.11%（52/53）,差异有统计学意义（χ²=28.24,P<0.01）;患者初诊至确诊平均间隔80.1 d,33.25%（12 102/36 393）确诊延迟;乡医院痰菌检出率为13.15%（43/327）、诊断符合率93.58%（306/327）;X线胸片合格率72.64%（146/201）、诊断符合率76.03%（111/146）;村医无诊断结核病的能力。 结论 就诊延迟和确诊延迟现象在喀什地区农村中普遍存在。强化少数民族人口结核病防治策略和措施的宣传,提高乡村级诊断能力和转送意识,是当前喀什地区亟待解决的问题。     

Decentralized DOTS shortens delay to TB treatment significantly in Cambodia

SETTING: Rural districts in Cambodia with and without decentralized health center based DOTS program. OBJECTIVE: To compare delays to treatment and behavior of patients up to diagnosis, between the pilot districts where DOTS is decentralized through the health centers, and the control districts where DOTS is provided through hospitals. DESIGN: A cross sectional study with structured questionnaire interviews to all new smear-positive TB patients aged 15 years or older who were registered in the study sites from May 1st to July 31st in 2002. RESULTS: The total delay in the pilot districts was significantly shorter than that in the control districts (median 58 days vs. 232 days, p < 0.01). The median doctors' delay within TB service in the pilot districts was 10 days and that in the control was 6 days. The period between first consultation to any health care provider and first visit to a TB service center, subsequent contact delay, was longer than any other type of delay and significantly different (24 days in pilot vs. 185 days in control, p < 0.01). The distance and travel costs to a TB service center were the factors associated with delay in seeking diagnosis of tuberculosis. No other variables had any significant association with the delay. CONCLUSION: Decentralizing DOTS to primary care health centers is highly effective in reducing the delay to TB treatment in Cambodia.     

村医集中推荐肺结核可疑症状者检查对提高新涂阳肺结核发现率的研究

目的探讨病人主动发现的新途径,提高新涂阳肺结核发现率。方法选择2003年新涂阳登记率低于全省平均水平的30个县,由经过培训的乡村医生对肺结核可疑症状者进行摸底调查,集中组织他们到县结防科或附近的乡镇、综合医院痰检点进行免费查痰。同时,县结防科对其他非结防机构网络直报但未前来就诊的肺结核和疑似肺结核病人进行追踪调查。结果2004年11月至2005年10月,30个县共发现新涂阳肺结核病人12 091例,新涂阳登记率由项目实施前的36.21/10万,提高到49.94/10万(χ²=101.7,P<0.000 1),发现率达到86.0%。30个县共登记肺结核可疑症状者43 464例,其中村医集中推荐15 363例,占35.3%,村医推荐发现新涂阳病人3 870例,占新涂阳病人发现总数的32.0%。县结防科对传染病网络直报病人的追踪率为70.9%,追踪到位率仅33.1%。结论利用村医集中推荐肺结核可疑症状者到县结防科检查,并给予一定的激励机制,是提高病人发现的有效方法之一。     

Health care seeking among individuals with cough and tuberculosis: a population-based study from rural India.

SETTING: Ujjain district, Madhya Pradesh, India. OBJECTIVE: To describe and compare health care seeking among men and women with cough of >3 weeks, with special focus on the utilisation of private and public health care. DESIGN: A population-based cross-sectional survey including 45 719 individuals aged > or = 15 years. RESULTS: The prevalence of cough was respectively 2.8% and 1.2% among men and women. The majority of men and women reported seeking health care for their symptoms (69% vs. 71%), but only 23% visited a public provider at some point during their illness. A similar health care seeking pattern was found for patients diagnosed with tuberculosis (TB) in our survey. No significant differences in health care seeking were found between men and women. Only 13% of those seeking care reported having had a sputum smear examination since the onset of cough. Factors associated with sputum examination were history of TB, haemoptysis and visiting a public provider. CONCLUSION: The low utilisation of public health care services and the few sputum examinations reported in this rural Indian setting illustrate the need for improved diagnostic practices as well as involvement of private providers in TB control activities.