Barriers and delays in tuberculosis diagnosis and treatment services: does gender matter?

Abstract

Background. Tuberculosis (TB) remains a global public health problem with known gender-related disparities. We reviewed the quantitative evidence for gender-related differences in accessing TB services from symptom onset to treatment initiation. Methods. Following a systematic review process, we: searched 12 electronic databases; included quantitative studies assessing gender differences in accessing TB diagnostic and treatment services; abstracted data; and assessed study validity. We defined barriers and delays at the individual and provider/system levels using a conceptual framework of the TB care continuum and examined gender-related differences. Results. Among 13,448 articles, 137 were included: many assessed individual-level barriers (52%) and delays (42%), 76% surveyed persons presenting for care with diagnosed or suspected TB, 24% surveyed community members, and two-thirds were from African and Asian regions. Many studies reported no gender differences. Among studies reporting disparities, women faced greater barriers (financial: 64% versus 36%; physical: 100% versus 0%; stigma: 85% versus 15%; health literacy: 67% versus 33%; and provider-/system-level: 100% versus 0%) and longer delays (presentation to diagnosis: 45% versus 0%) than men. Conclusions. Many studies found no quantitative gender-related differences in barriers and delays limiting access to TB services. When differences were identified, women experienced greater barriers and longer delays than men.

Figure 1

Study selection process.

Figure 2

Conceptual framework illustrating barriers and delays that limit access to TB diagnostic and treatment services. The figure illustrates the conceptual framework of the tuberculosis (TB) care continuum from symptom onset to treatment initiation that we used to define barriers and delays that limit access to TB diagnostic and treatment services at the individual and provider/system levels. Individual-level barriers impact access to TB services along the full continuum of TB care, and provider-/system-level barriers impact access to TB services from patient presentation to any health care provider through TB treatment initiation. Barriers may contribute to delays between each step along the TB care continuum. Accordingly, we define individual-level delay as the delay between symptom onset and presentation to any health care provider; provider/system delay as the delay between presentation to any health care provider and diagnosis, the delay between presentation to any health care provider and treatment initiation or the delay between diagnosis and treatment initiation; and combined individual/provider/system delay as the delay between symptom onset and diagnosis or the delay between symptom onset and treatment initiation.