{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T00:45:11Z","timestamp":1785804311349,"version":"3.56.0"},"reference-count":36,"publisher":"PAGEPress Publications","license":[{"start":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T00:00:00Z","timestamp":1785715200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Monaldi Arch Chest Dis"],"abstract":"<jats:p>Tuberculosis (TB) caused by acid-fast bacilli is one of the leading causes of morbidity and mortality in developing countries. Pakistan has the world's fifth-largest prevalence of TB, with 276\/100,000 cases in prevalence and a mortality of 34\/100,000. Delayed diagnosis, disruptions in treatment continuity and a lack of awareness are the key issues leading to multidrug-resistant TB. The current study aimed to find out the determinants of delayed pulmonary TB in a rural district of Khyber Pakhtunkhwa Province, Pakistan. The cross-sectional study was conducted in six TB control program centers designated by the National TB Control Program from March to December 2024. Data were collected from 250 eligible patients, and after removal of incomplete questionnaires, the data of 229 patients were analyzed. The study was approved by the district TB officer, and participants' consent was obtained before data collection. A delay of &gt;21 days was considered the cutoff point for delayed TB diagnosis. Among 229 patients, 51.1% were male and 48.9% female participants, with a mean age of 33.31\u00b121.32 years. The mean diagnostic delay was 23.66\u00b114.94 days. Descriptive analysis of data showed 52% of delayed TB diagnosis cases; 92.2% of the studied patients were from rural areas, in which 80% of delayed TB diagnosis cases were reported. Male gender [odds ratio (OR)=2.31], getting treatment from public hospitals (OR=4.13), age group 31-45 years (OR=3.10), presence of acute extrapulmonary symptoms of cough, fever, and weight loss (OR=2.84), perception that the symptoms will be relieved by oneself (OR=9.99), economic constraints (OR=6.58), and perception of the poor quality of healthcare services at hospitals (OR=7.32) were found to be significant factors of delayed TB diagnosis. Primary school- (OR=0.20), college- or university-level education (OR=0.42) and high-income groups (OR=0.39) were significant protective factors against delayed TB diagnosis. Marital status, occupation, residence, comorbidities, distance from healthcare facility, previous exposure to TB patients, fever, weight loss, chronic cough, hemoptysis, fear of diagnosis, fear of social isolation, and bad experience of the healthcare staff behavior were found to be non-significant factors for delayed TB diagnosis. The study only focused on delayed diagnosis and did not report healthcare system-related or total delay in tuberculosis management. The study affirmed the significant impact of patient perceptions and socioeconomic status on delayed TB diagnosis.<\/jats:p>","DOI":"10.4081\/monaldi.2026.3782","type":"journal-article","created":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T00:01:58Z","timestamp":1785801718000},"source":"Crossref","is-referenced-by-count":0,"title":["Determinants of delayed pulmonary tuberculosis diagnosis in a rural district of Pakistan"],"prefix":"10.4081","author":[{"given":"Amin Ur","family":"Rahman","sequence":"first","affiliation":[{"name":"Department of Public Health, Institute of Management Sciences, Peshawar"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zia","family":"Qamar","sequence":"additional","affiliation":[{"name":"Jinnah International Hospital, Abbottabad"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Afnan","family":"Fayaz","sequence":"additional","affiliation":[{"name":"Hayatabad Medical Complex, Peshawar"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bushra","family":"Arif","sequence":"additional","affiliation":[{"name":"Ayub Teaching Hospital, Abbottabad"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ihtisham","family":"Habib","sequence":"additional","affiliation":[{"name":"Hayatabad Medical Complex, Peshawar"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wareesha Naeem","family":"Aurakzai","sequence":"additional","affiliation":[{"name":"Afridi Medical Complex, Peshawar"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2549","published-online":{"date-parts":[[2026,8,3]]},"reference":[{"key":"84279","doi-asserted-by":"crossref","unstructured":"Mohammadnabi N, Shamseddin J, Emadi M, et al. Mycobacterium tuberculosis: the mechanism of pathogenicity, immune responses, and diagnostic challenges. J Clin Lab Anal 2024;38:e25122.","DOI":"10.1002\/jcla.25122"},{"key":"84280","doi-asserted-by":"crossref","unstructured":"Fort\u00fan J, Navas E. Latent tuberculosis infection: approach and therapeutic schemes. Rev Esp Quimioter 2022;35:94-6.","DOI":"10.37201\/req\/s03.20.2022"},{"key":"84281","doi-asserted-by":"crossref","unstructured":"Vk V. Latent TB infection in children and adolescents: scientific rationale and programmatic management. Indian J Tuberc 2023;70:35-8.","DOI":"10.1016\/j.ijtb.2023.09.001"},{"key":"84282","doi-asserted-by":"crossref","unstructured":"Kanabalan RD, Lee LJ, Lee TY, et al. Human tuberculosis and Mycobacterium tuberculosis complex: a review on genetic diversity, pathogenesis and omics approaches in host biomarkers discovery. Microbiol Res 2021;246:126674.","DOI":"10.1016\/j.micres.2020.126674"},{"key":"84283","doi-asserted-by":"crossref","unstructured":"Kontsevaya I, Cabibbe AM, Cirillo DM, et al. Update on the diagnosis of tuberculosis. Clin Microbiol Infect 2024;30:1115-22.","DOI":"10.1016\/j.cmi.2023.07.014"},{"key":"84284","doi-asserted-by":"crossref","unstructured":"Mirijello A, Ritrovato N, D\u2019Agruma A, et al. Abdominal lymphadenopathies: lymphoma, brucellosis or tuberculosis? Multidisciplinary approach-case report and review of the literature. Medicina 2023;59:293.","DOI":"10.3390\/medicina59020293"},{"key":"84285","doi-asserted-by":"crossref","unstructured":"Sarkar M, Sarkar J. Transmission of Mycobacterium Tuberculosis. J Assoc Physicians India 2025;73:91-6.","DOI":"10.59556\/japi.73.1113"},{"key":"84286","doi-asserted-by":"crossref","unstructured":"Klingm\u00fcller A, Steinke J, Rybniker J, Su\u00e1rez I. Extrapulmonary tuberculosis. Dtsch Med Wochenschr 2025;150:1189-96. [Article in German].","DOI":"10.1055\/a-2597-9679"},{"key":"84287","doi-asserted-by":"crossref","unstructured":"Chin KL, Anibarro L, Chang ZY, et al. Impacts of MDR\/XDR-TB on the global tuberculosis epidemic: Challenges and opportunities. Curr Res Microb Sci 2024;7:100295.","DOI":"10.1016\/j.crmicr.2024.100295"},{"key":"84288","unstructured":"World Bank Group. Incidence of tuberculosis (per 100,000 people). Available from: https:\/\/data.worldbank.org\/indicator\/SH.TBS.INCD."},{"key":"84289","unstructured":"UK Health Security Agency. GOV.UK 2024. Available from: https:\/\/www.gov.uk\/government\/publications\/tuberculosis-in-england-2024-report\/tuberculosis-incidence-and-epidemiology-england-2023."},{"key":"84290","unstructured":"CDC. Tuberculosis Data. Provisional 2025 tuberculosis data, United States. Available from: https:\/\/www.cdc.gov\/tb-data\/aboutprovisionaldata\/2025-provisional-data.html."},{"key":"84291","unstructured":"World Bank Group. Incidence of tuberculosis (per 100,000 people) - Pakistan. Available from: https:\/\/data.worldbank.org\/indicator\/SH.TBS.INCD?locations=PK."},{"key":"84292","unstructured":"NIH Islamabad. National Tuberculosis control Program. 2025. Available from: https:\/\/www.nih.org.pk\/national-tb-control-program."},{"key":"84293","doi-asserted-by":"crossref","unstructured":"Khaliq A, Ashraf U, Chaudhry MN, et al. Spatial distribution and computational modeling for mapping of tuberculosis in Pakistan. J Public Health 2023;45:338-46.","DOI":"10.1093\/pubmed\/fdac125"},{"key":"84294","doi-asserted-by":"crossref","unstructured":"Yao F, Zhang R, Lin Q, et al. Plasma immune profiling combined with machine learning contributes to diagnosis and prognosis of active pulmonary tuberculosis. Emerg Microbes Infect 2024;13:2370399.","DOI":"10.1080\/22221751.2024.2370399"},{"key":"84295","doi-asserted-by":"crossref","unstructured":"Garg K, Chopra P, Garg J, et al. Psychological morbidity and quality of life of patients with pulmonary tuberculosis. Monaldi Arch Chest Dis 2024;95:3171.","DOI":"10.4081\/monaldi.2024.3171"},{"key":"84296","doi-asserted-by":"crossref","unstructured":"Zhou G, Luo Q, Luo S, et al. Interferon-\u03b3 release assays or tuberculin skin test for detection and management of latent tuberculosis infection: a systematic review and meta-analysis. Lancet Infect Dis 2020;20:1457-69.","DOI":"10.1016\/S1473-3099(20)30276-0"},{"key":"84297","doi-asserted-by":"crossref","unstructured":"Kim SH, Min J, Cho JY, et al. Clinical profiles and outcomes of pulmonary tuberculosis patients with delayed treatment at a tertiary hospital in South Korea. Ann Palliat Med 2021;10:2948-57.","DOI":"10.21037\/apm-20-1521"},{"key":"84298","doi-asserted-by":"crossref","unstructured":"Santos JA, Leite A, Soares P, et al. Delayed diagnosis of active pulmonary tuberculosis - potential risk factors for patient and healthcare delays in Portugal. BMC Public Health 2021;21:2178.","DOI":"10.1186\/s12889-021-12245-y"},{"key":"84299","doi-asserted-by":"crossref","unstructured":"Jiang Y, Luo L, Gui M, et al. Duration and determinants of delayed diagnosis with tuberculosis in Shenzhen, China: a cross-sectional study. Risk Manag Healthc Policy 2022;15:1473-81.","DOI":"10.2147\/RMHP.S367998"},{"key":"84300","doi-asserted-by":"crossref","unstructured":"Saqib MA, Awan IN, Rizvi SK, et al. Delay in diagnosis of tuberculosis in Rawalpindi, Pakistan. BMC Res Notes 2011;4:165.","DOI":"10.1186\/1756-0500-4-165"},{"key":"84301","doi-asserted-by":"crossref","unstructured":"Kunjok DM, Mwangi JG, Mambo S, Wanyoike S. Assessment of delayed tuberculosis diagnosis preceding diagnostic confirmation among tuberculosis patients attending Isiolo County level four hospital, Kenya. Pan Afr Med J 2021;38:51.","DOI":"10.11604\/pamj.2021.38.51.21508"},{"key":"84302","unstructured":"Crowder R, Thangakunam B, Andama A, et al. Diagnostic accuracy of TB screening tests in a prospective multinational cohort: chest-X-ray with computer-aided detection, Xpert TB host response, and C-reactive protein. Clin Infect Dis 2026;82:e239-47."},{"key":"84303","doi-asserted-by":"crossref","unstructured":"Holzinger F, Gehrke-Beck S, Kr\u00fcger K. Acute and chronic cough - differential diagnosis and treatment. Dtsch Med Wochenschr 2022;147:989-1001. [Article in German].","DOI":"10.1055\/a-1716-8101"},{"key":"84304","doi-asserted-by":"crossref","unstructured":"Jaffri SA, Mumtaz M, Rehman A ur, et al. Community awareness and delay in diagnosis of pulmonary tuberculosis. Pak J Med Health Sci 2023;17:801.","DOI":"10.53350\/pjmhs020231712801"},{"key":"84305","doi-asserted-by":"crossref","unstructured":"Khan FU, Khan FU, Hayat K, et al. Impact of protracted displacement on delay in the diagnosis associated with treatment outcomes: a cross-sectional study in internally displaced tuberculosis patients of Pakistan. Int J Environ Res Public Health 2021;18:11984.","DOI":"10.3390\/ijerph182211984"},{"key":"84306","doi-asserted-by":"crossref","unstructured":"Ereso BM, Sagbakken M, Gradmann C, Yimer SA. Total delay and associated factors among tuberculosis patients in Jimma Zone, Southwest Ethiopia. PLoS One 2023;18:e0281546.","DOI":"10.1371\/journal.pone.0281546"},{"key":"84307","doi-asserted-by":"crossref","unstructured":"O\u2019Connell J, Reidy N, McNally C, de Barra E, et al. Delayed tuberculosis treatment and cost of care in a low-incidence country. Open Forum Infect Dis 2022;9:ofac164.","DOI":"10.1093\/ofid\/ofac164"},{"key":"84308","doi-asserted-by":"crossref","unstructured":"Arja A, Bogale B, Gebremedhin M. Health system delay and its associated factors among tuberculosis patients in Gamo Zone public health facilities, Southern Ethiopia: An institution-based cross-sectional study. J Clin Tuberc Other Mycobact Dis 2022;28:100325.","DOI":"10.1016\/j.jctube.2022.100325"},{"key":"84309","doi-asserted-by":"crossref","unstructured":"Etokidem A, Ogaji D. The inverse care law: implications for universal health coverage in Nigerian rural communities. Int J Med Health Dev 2021;26:11.","DOI":"10.4103\/ijmh.IJMH_38_19"},{"key":"84310","doi-asserted-by":"crossref","unstructured":"Alene M, Assemie MA, Yismaw L, et al. Patient delay in the diagnosis of tuberculosis in Ethiopia: a systematic review and meta-analysis. BMC Infect Dis 2020;20:797.","DOI":"10.1186\/s12879-020-05524-3"},{"key":"84311","doi-asserted-by":"crossref","unstructured":"Teo AKJ, Singh SR, Prem K, et al. Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis. Respir Res 2021;22:251.","DOI":"10.1186\/s12931-021-01841-6"},{"key":"84312","doi-asserted-by":"crossref","unstructured":"Saqib SE, Ahmad MM, Amezcua-Prieto C, Virginia MR. Treatment delay among pulmonary tuberculosis patients within the Pakistan National Tuberculosis Control Program. Am J Trop Med Hyg 2018;99:143-9.","DOI":"10.4269\/ajtmh.18-0001"},{"key":"84313","doi-asserted-by":"crossref","unstructured":"Ali SM, Naureen F, Noor A, et al. Loss-to-follow-up and delay to treatment initiation in Pakistan\u2019s national tuberculosis control programme. BMC Public Health 2018;18:335.","DOI":"10.1186\/s12889-018-5222-2"},{"key":"84314","doi-asserted-by":"crossref","unstructured":"Dhami BS, Paneru DP, Parajuli S, et al. Patient and health system delays in the diagnosis and treatment of tuberculosis in Gandaki, Nepal. PLOS Glob Public Health 2025;5:e0004676.","DOI":"10.1371\/journal.pgph.0004676"}],"container-title":["Monaldi Archives for Chest Disease"],"original-title":[],"link":[{"URL":"https:\/\/www.monaldi-archives.org\/macd\/article\/download\/3782\/2251","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.monaldi-archives.org\/macd\/article\/download\/3782\/2251","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T00:02:06Z","timestamp":1785801726000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.monaldi-archives.org\/macd\/article\/view\/3782"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,3]]},"references-count":36,"URL":"https:\/\/doi.org\/10.4081\/monaldi.2026.3782","relation":{},"ISSN":["2532-5264","1122-0643"],"issn-type":[{"value":"2532-5264","type":"electronic"},{"value":"1122-0643","type":"print"}],"subject":[],"published":{"date-parts":[[2026,8,3]]}}}