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Diagnosis: Poverty [Marcella Wilson, PhD] on leondumoulin.nl *FREE* shipping on qualifying offers. Poverty has reached epidemic proportions, and the current.
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TB is no exception. As a disease of poverty, TB is associated with many patients never attending health services, attending late, or dropping out after initiation of the diagnostic process [ 10 , 15 , 16 ]. As TB diagnostic services are not available in all health facilities, patients often express concerns about multiple consultations, service fees, travel expenses and lost time and opportunity costs [ 17 ].

This analysis confirms that the direct costs sustained by patients undergoing a diagnosis of TB across multiple settings are substantial. A large component of these are associated with clinic costs, transport and patients attending the services with company. According to the Multidimensional Poverty Index, of the four countries Yemen, ranked as the least poor at the time of the study, followed by Nigeria, Nepal and Ethiopia [ 2 ].

Although it is difficult to compare costs and expenditure directly between countries, as living costs and income were very different across study settings, our findings identified remarkable similarities. Clinic user fees comprised a common and significant cost. These fees are known to have a negative impact on general health service utilisation and this is likely to be more prominent in TB patients with limited financial resilience [ 18 ]. Clinic costs for attending TB clinics in the study comprised consultation fees, smear microscopy, X-rays and blood tests to screen for other diseases [ 19 ].

Furthermore, although not captured in the study, bacteriologically negative cases may undergo further consultation and testing, pay for further visits and have higher expenditure than smear-positive cases. Furthermore, we have documented elsewhere that patients are often overcharged or pay under-the-counter fees to speed up test results or to be seen earlier than others [ 20 ].

These expenses are not documented in their receipts and where reimbursement does occur, patients are often only partially reimbursed. Transport costs also contribute significantly to expenditure in Ethiopia, Nigeria and Yemen, where a high number of patients travel from other towns and rural areas and use buses and taxis. In Ethiopia, the costs reflect the predominantly rural population of the country and the cost of transport from areas with limited road and public transport infrastructure.

In Yemen, collective public transport is limited to the main towns and women often rely on private vehicles to attend the fairly centralised diagnostic services. In Nigeria, buses were very limited within the metropolitan areas of the Federal Capital at the time of the study and people relied on share minibuses or taxis to move from the slums surrounding the metropolitan areas. Although transport costs were incurred for different reasons in each location, they represented more than half of patient expenditure to attend diagnostic centres and are thus a major barrier.

Addressing these issues would require long term infrastructural development. However interim solutions such as recruiting community volunteers or community workers to organise transport and the provision of support funds that facilitate transport could be explored [ 21 ]. A high proportion of patients attended with company in all study settings. This was especially prominent in Yemen, where 4 out of 5 patients came accompanied, and significantly increased the costs associated with displacement.

In Yemen, gender norms meant that women in particular were required to be accompanied by a male relative and faced particular challenges in accessing a TB diagnosis [ 20 ].

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The need for company also reflects cultural practices underpinning support to a person perceived to have a mortal illness - in Ethiopia, for example, TB is equated with lung cancer - and the frailty of patients with chronic and debilitating conditions. Rural residents were more likely to attend with company in all countries, which is probably the reason why these patients had higher expenditure in Ethiopia and Yemen than patients from urban areas [ 11 ].

Our findings indicate that despite the differences in the settings, patients across LMICs experience many similarities in the type of costs associated with clinic attendance and that it might be feasible to identify patients at risk of high expenditure by conducting a simple questionnaire when they present to diagnostic centres. This is particularly relevant in the context of the Global Plan to Stop TB —, which aims to eliminate the number of families facing catastrophic costs due to TB [ 1 , 22 ].

In the study context, additional support made available by NTPs could be channelled to those most at risk of high costs, including illiterate patients, those originating from rural areas or attending with company. This approach could also reimburse expenses to all patients investigated for TB; independently of whether the diagnosis is confirmed.

This analysis, however, has several limitations, beginning with the sampling strategy, which carried a risk of selection bias.

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Participants were recruited using systematic random sampling, rather than randomly, as this suited the objectives of the larger clinical trial [ 14 ]. Patients arriving at the beginning of the day might have had different characteristics from those arriving later. We can hypothesise that the former might have resided more locally, or conversely, have travelled the previous day from afar and stayed overnight. Patients arriving early might have been better prepared. Moreover, all costs were self-reported, rather than observed by investigators. Actual and predicted expenditure might have been expressed differently by different subgroups of the population and different cultures, as mediated by established social hierarchies, gender roles, economic standing and the distribution of power, to name but a few modifiers.

For example, costs which might be overstated by patients in one setting in the hope of financial remuneration might be underreported in another out of individual pride.

Women who do not have access to household finances might also be unaware of the full cost of attendance. Calculation of costs as a proportion of individual income would have provided a more complete picture of the economic burden for the individual and their family, however including the many variables involved in these calculations was not possible within the confines of a short addition to a large survey and asking participants to disclose their income was considered unreliable. Opportunity costs tend to be higher for people living in poverty, who for the most part work in the informal sector and are vulnerable to loss of income or dismissal from work [ 27 ].

In countries with high HIV prevalence, this vulnerability is heightened, as the population perceives that patients with TB are likely to be co-infected with HIV [ 28 ]. Furthermore, a large proportion of symptomatic adults do not attend diagnostic centres and these individuals often have fewer financial and social resources at their disposal [ 20 ]. Poverty constitutes a major access barrier for symptomatic adults in low income countries, as recently recognised by the Sustainable Development Goals SMGs [ 32 ].

Poverty is often compounded by low education and health information, leading to misconceptions of the disease and disempowerment. Rural and urban residence also determines access to diagnostic services. Addressing poverty is likely to be the most crucial factor in determining the success or failure of the Global Health Plan to Stop TB — as a significant public health problem [ 1 ] and recognised as major impediment for the achievement of the TB component of the SMGs [ 17 , 33 ].

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