喀麥隆兩個地區的患者到結核病診斷的地理模式

Abstract

背景 結核病從發病到康復需要很長的路程。在高負擔環境中，重複訪問結核病中心進行診斷和治療是常見的。在此期間，地理障礙可能是患者是否最終能夠完成治療的一個重要決定因素。但是卻很少有研究使用地理信息系統來評估結核病服務的可及性。本研究旨在評估結核病診斷的地理格局及其在喀麥隆的決定因素。 方法 我們根據2015年至2016年喀麥隆西北和西南地區40個診斷和治療單位中的39個來估計所有通報的結核病患者（n = 1870）的行程距離。通過ArcGIS中的路網並使用研究區域的道路信息，分析估算每位結核病患者的行程距離。我們計算了兩種類型的旅行距離，一種是基於患者地址與最近的TB中心之間的距離（作為地理障礙的代理測量），另一種是基於患者實際上與患者地址到TB中心的距離參觀。如果患者沒有訪問最近的肺結核中心並且兩種類型的距離之間的差異大於5公里，則定義為“跨中心”訪問。我們使用邏輯回歸分析來評估跨中心訪問的因素。 結果 根據39個結核病診斷和治療單位，到最近的結核病中心的中位數旅行距離是5.23公里（IQR = 13.14），但到實際訪問的結核病中心的中位數距離是兩倍（11.82公里，IQR = 27.21） ）。總共1946名結核病患者中有609名（31.3％）進行了跨中心就診。在單變量邏輯回歸分析中，結核病中心的區域（西南vs西北，OR = 0.60,95％CI：0.50-0.74），DTU的類型（基於信仰vs公立，OR = 3.72,95％CI：3.04） -4.57），婚姻狀況（已婚vs單身，OR = 1.38,95％CI：1.03-1.84）是與跨中心就診相關的重要因素。 結論 為了改善區域結核病控制設施的可及性，建立結核病中心很重要，但這樣還不夠。在本分析中發現的跨中心就診的現象，表示存在隱藏因素（可能與護理質量相關），這些因素增加了接受結核病治療的障礙，因此迫切需要努力了解跨中心訪問的原因，以提高結核病診斷和治療網絡的效率。

Background There is a long journey from getting tuberculosis (TB) to recovery. Repetitive visits to TB centers for diagnosis and treatment is common in high-burden settings. During this period, the geographic barriers can be one important determinant of whether the patient could eventually complete the treatment. Few studies used geographic information systems to assess accessibility to TB service. The present study aims to evaluate the geographic barriers of TB diagnosis and treatment and their determinants in Cameroon. Methods We estimated the travel distance for all notified TB patients (n=1870) from 39 out of 40 diagnostic and treatment units in the northwest and southwest regions of Cameroon between 2015 and 2016. Travel distance of notified TB patients was estimated by network analysis in ArcGIS using the road information in the study area. We calculated two types of travel distances, one based on the distance between the patient’s address to the nearest TB center (as a proxy measurement of geographic barrier), the other based on the distance between the patient’s address to the TB center that the patient actually visited. A “cross-center” visit is defined if a patient did not visit the nearest TB center and the difference between the two types of distances was greater than 5 kilometers. We used logistic regression analyses to evaluate the factors of cross-center visit. Results Based on 39 tuberculosis diagnostic and treatment unit locations, the median travel distance to the nearest TB center was 5.23 kilometers (IQR=13.14), but the median travel distance to the TB center actually visited was two times greater (11.82 kilometers, IQR=27.21). 609 out of 1946 (31.3%) TB patients had cross-center visit. In the univariable logistic regression analysis, region of the DTU (Southwest vs. Northwest, OR=0.60, 95%CI: 0.50-0.74), type of the DTU (faith-based vs public, OR=3.72, 95%CI: 3.04-4.57), marital status (married vs single, OR=1.38, 95%CI: 1.03-1.84) are the significant factors associated with cross-center visit. Conclusions To improve accessibility to TB control facilities in areas, the establishment of TB centers is important, but not enough. The prevailing phenomenon of cross-center visit identified in the present analysis suggested that there were hidden factors (probably associated with quality of care) that added to the barriers to receiving TB care. Efforts are needed urgently to understand the reasons of cross-center visit in order to improve the efficiency of TB diagnostic and treatment network.