{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T03:15:18Z","timestamp":1790824518514,"version":"4.1.0"},"reference-count":59,"publisher":"Public Library of Science (PLoS)","issue":"11","license":[{"start":{"date-parts":[[2025,11,21]],"date-time":"2025-11-21T00:00:00Z","timestamp":1763683200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"German Ministry for Education and Research","award":["LMU-IMPH-TB Sequel-01"],"award-info":[{"award-number":["LMU-IMPH-TB Sequel-01"]}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Pulmonary tuberculosis (PTB), remains one of the leading causes of death from infectious diseases worldwide, its burden is disproportionately affecting low- and middle-income countries (LMICs), including Tanzania. This study aimed to examine the direct and indirect costs incurred by patients and their families prior to PTB diagnosis, and how such costs influence patients\u2019 health-seeking behaviours.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A mixed-methods approach was employed, integrating qualitative and quantitative methods for data collection, analysis, and interpretation. The study was part of a longitudinal observational cohort that included 261 adults diagnosed with PTB. Quantitative data were collected using a structured questionnaire adapted from the WHO\u2019s generic patient cost survey tool, administered after TB diagnosis was confirmed. To gain deeper insights, additional data were gathered through, in-depth interviews (IDIs) with purposively selected participants, aimed at identifying both financial and non-financial challenges experienced by patients and their family supporters before to diagnosis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of the 261 respondents, 59% were men, 48% were married, and 51% were living with HIV, with a median age of 35 years. The majority 185(72.8%) delaying visiting a healthcare facility (HCF) by more than four weeks following the onset of symptoms. The average total pre-treatment cost per patient was USD 28.8, comprising direct medical, direct non-medical, and indirect costs. These costs varied based on the number and type of healthcare providers consulted. Qualitative findings indicated that participants frequently associated this pre-treatment costs with delays in seeking formal care, often influenced by self-medication, limited awareness of TB symptoms, and long distances to formal HCFs.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This study highlights the significant financial and non-financial barriers faces by patients diagnosed with PTB and their families before diagnosis. Delays in care-seeking not only worsen health outcomes but also increase the overall economic burden. Addressing these challenges requires a comprehensive, multisectoral approach to improve early diagnosis, reduce patients costs and strengthen TB control efforts in high-burden settings.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0336270","type":"journal-article","created":{"date-parts":[[2025,11,21]],"date-time":"2025-11-21T18:24:21Z","timestamp":1763749461000},"page":"e0336270","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["Implications of pre-diagnosis costs incurred by patients and their families for tuberculosis-related health-seeking behaviors in Mbeya and Songwe regions, Tanzania"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6792-0990","authenticated-orcid":true,"given":"Stella","family":"Kilima","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kamban","family":"Hirasen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Godfrey","family":"Mubyazi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aneesa","family":"Moolla","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nyanda","family":"Ntinginya","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Issa","family":"Sabi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Simeon","family":"Mwanyonga","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Denise","family":"Evans","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,11,21]]},"reference":[{"key":"pone.0336270.ref001","first-page":"1","volume-title":"Global tuberculosis report 2021","author":"WHO","year":"2021"},{"key":"pone.0336270.ref002","first-page":"6","volume-title":"Global tuberculosis report 2019","year":"2019"},{"issue":"12","key":"pone.0336270.ref003","doi-asserted-by":"crossref","first-page":"1395","DOI":"10.1016\/S1473-3099(23)00372-9","article-title":"Burden of tuberculosis among vulnerable populations worldwide: an overview of systematic reviews","volume":"23","author":"S Litvinjenko","year":"2023","journal-title":"Lancet Infect Dis"},{"issue":"1","key":"pone.0336270.ref004","doi-asserted-by":"crossref","DOI":"10.1016\/S2666-5247(22)00359-7","article-title":"WHO\u2019s global tuberculosis report 2022","volume":"4","author":"S Bagcchi","year":"2023","journal-title":"Lancet Microbe"},{"issue":"1","key":"pone.0336270.ref005","doi-asserted-by":"crossref","first-page":"260","DOI":"10.1186\/s12889-024-17713-9","article-title":"Financial burden of tuberculosis diagnosis and treatment for patients in Ethiopia: a systematic review and meta-analysis","volume":"24","author":"DG Assefa","year":"2024","journal-title":"BMC Public Health"},{"key":"pone.0336270.ref006","volume-title":"Global tuberculosis report 2023","author":"WHO","year":"2023"},{"issue":"1","key":"pone.0336270.ref007","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1186\/s41043-018-0146-0","article-title":"Pre- and post-diagnosis costs of tuberculosis to patients on Directly Observed Treatment Short course in districts of southwestern Ethiopia: a longitudinal study","volume":"37","author":"A Asres","year":"2018","journal-title":"J Health Popul Nutr"},{"issue":"1","key":"pone.0336270.ref008","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1186\/s40249-016-0187-9","article-title":"Tuberculosis care strategies and their economic consequences for patients: the missing link to end tuberculosis","volume":"5","author":"B Getahun","year":"2016","journal-title":"Infect Dis Poverty"},{"issue":"1","key":"pone.0336270.ref009","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1186\/s12879-023-08069-3","article-title":"Implementation of evidence-based multiple focus integrated intensified TB screening to end TB (EXIT-TB) package in East Africa: a qualitative study","volume":"23","author":"K Isangula","year":"2023","journal-title":"BMC Infect Dis"},{"key":"pone.0336270.ref010","unstructured":"STOP TB Partnership. 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Active TB case finding approaches: Tanzania experience. 2022."},{"issue":"6","key":"pone.0336270.ref028","doi-asserted-by":"crossref","first-page":"601","DOI":"10.4097\/kjae.2017.70.6.601","article-title":"Introduction of a pilot study","volume":"70","author":"J In","year":"2017","journal-title":"Korean J Anesthesiol"},{"issue":"3","key":"pone.0336270.ref029","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1007\/s11111-019-0314-1","article-title":"Assessing recall bias and measurement error in high-frequency social data collection for human-environment research","volume":"40","author":"A Bell","year":"2019","journal-title":"Popul Environ"},{"issue":"3","key":"pone.0336270.ref030","first-page":"241","article-title":"Understanding the implications of social and financial burdens of pulmonary tuberculosis on patients, survivors and their family caregivers on care seeking and treatment in Tanzania: Feedback from a qualitative study in Mbeya and Songwe regions","volume":"24","author":"SP Kilima","year":"2023","journal-title":"Tanzan J Health Res"},{"key":"pone.0336270.ref031","doi-asserted-by":"crossref","first-page":"114523","DOI":"10.1016\/j.socscimed.2021.114523","article-title":"Sample sizes for saturation in qualitative research: a systematic review of empirical tests","volume":"292","author":"M Hennink","year":"2022","journal-title":"Soc Sci Med"},{"issue":"7","key":"pone.0336270.ref032","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001675","article-title":"Defining catastrophic costs and comparing their importance for adverse tuberculosis outcome with multi-drug resistance: a prospective cohort study, Peru","volume":"11","author":"T Wingfield","year":"2014","journal-title":"PLoS Med"},{"key":"pone.0336270.ref033","unstructured":"Registration P, In N, Patient THE, Of AGE, Patient THE. Nationwide generic TB patient cost survey\/\/ Enqu\u00eate nationale sur les co\u00dbts support\u00e9s par les patients atteints de tuberculose (g\u00e9n\u00e9rique)\/\/ Encuesta nacional para establecer los costos soportados por los pacientes enfermos de tuberculosis (gen\u00e9rico):1\u201314."},{"key":"pone.0336270.ref034","first-page":"5","volume-title":"Minimum Wage \u2013 Mainland - Domestic and Hospital Services","year":"2023"},{"key":"pone.0336270.ref035","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1186\/1478-4505-9-43","article-title":"Quality assurance of qualitative research: a review of the discourse","volume":"9","author":"J Reynolds","year":"2011","journal-title":"Health Res Policy Syst"},{"key":"pone.0336270.ref036","unstructured":"NTLP. Manual for management of Tuberculosis and Leprosy in Tanzania. 2020;120-124:285\u20137."},{"key":"pone.0336270.ref037","unstructured":"Africa HR Solution. Minimum wage across 54 African countries. 2025."},{"key":"pone.0336270.ref038","unstructured":"Country Data. Skip to main content Main navigation Top menu NMW-National Minimum Wage. 2024."},{"key":"pone.0336270.ref039","first-page":"5","author":"Wageindicator.org","year":"2023"},{"issue":"4","key":"pone.0336270.ref040","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1136\/thoraxjnl-2020-215338","article-title":"The long term effect of pulmonary tuberculosis on income and employment in a low income, urban setting","volume":"76","author":"J Meghji","year":"2021","journal-title":"Thorax"},{"issue":"19","key":"pone.0336270.ref041","doi-asserted-by":"crossref","first-page":"10404","DOI":"10.3390\/ijerph181910404","article-title":"Knowledge, beliefs, and perceptions of TB and Its treatment amongst TB patients in the Limpopo Province, South Africa","volume":"18","author":"H Matakanye","year":"2021","journal-title":"Int J Environ Res Public Health"},{"key":"pone.0336270.ref042","doi-asserted-by":"crossref","first-page":"476","DOI":"10.1186\/s12913-015-1138-z","article-title":"What can dissaving tell us about catastrophic costs? 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