© 2025 International Journal of Mycobacteriology | Published by Wolters Kluwer - Medknow232
Abstract
Original Article
IntroductIon
Survival and treatment outcomes in tuberculosis (TB) 
patients have improved over the past two decades.[1] 
However, there is still a high risk of mortality in TB 
patients due to delayed diagnosis.[2,3] Late TB diagnosis 
results in delayed treatment, poorer treatment outcomes, 
increased disease transmission, higher medical costs, and 
poor prognosis.[4,5] TB is highly prevalent in Afghanistan.
[6] Moreover, Afghanistan faces numerous challenges in 
TB care, including high rates of treatment failure and 
TB-related mental health symptoms,[7,8] compounded by 
socioeconomic disparities, limited patient education, and 
inadequate healthcare infrastructure.[6,9,10]
Despite the detrimental effects of diagnostic delay among 
TB patients, it remains prevalent in many low- and 
middle‑income countries (LMICs). For instance, a 
meta-analysis by Fetensa et al. reported a 50% prevalence 
of diagnostic delay among Ethiopian TB patients.[11] 
Similarly, another systematic review of 124 articles from 
TB high-burden countries found that the pooled median 
durations of patient delay and health system delay were 28 
and 14 days, respectively.[12] Other studies in LMICs have 
also reported a high magnitude of diagnostic delay among 
TB patients, ranging from 27% to 65%.[13]
Background: Diagnostic delay among tuberculosis (TB) patients leads to late anti-TB treatment initiation, which is associated with poor 
prognosis and increased TB transmission. Despite its recognized negative consequences, diagnostic delay among TB patients is common 
in developing countries, including Afghanistan, where evidence on its predictors is limited. We aimed to evaluate diagnostic delay and 
its predictors among newly diagnosed TB patients attending healthcare facilities in Kandahar, Afghanistan. Methods: A multicenter, 
cross-sectional study was conducted in Kandahar between February and May 2025. Newly diagnosed TB patients aged 18 years or older 
were randomly recruited from the TB care centers of six healthcare facilities. Delays in TB diagnosis encompassed both patient and 
healthcare system delays. The predictors of diagnostic delay were identified using a multivariable logistic regression model. Results: 
Patient and health system delays were noted in 44% and 59.4% of cases, respectively. Patients’ low education level, extrapulmonary TB, 
longer distance to healthcare facility, and positive history of self‑medication were significant predictors of diagnostic delays. Conclusion: 
Despite the well‑established benefits of early TB diagnosis, this study revealed that delay in TB diagnosis is still a public health challenge 
in Kandahar province. Late presentation for TB care was a result of factors that relate to the patient’s education, TB type, distance to 
healthcare facility, and history of self-medication. Therefore, focusing extra attention on these factors could potentially reduce diagnostic 
delays among TB patients in Afghanistan.
Keywords: Afghanistan, delays, diagnosis, predictors, tuberculosis
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Diagnostic Delay and its Predictors among Tuberculosis Patients 
in Kandahar, Afghanistan: A Cross‑sectional Analytical Study
Hazratullah Bariz1, Muhammad Haroon Stanikzai1, Ghulam Mohayuddin Mudaser2, Khalid Ahmad Stanikzai3, Omid Dadras4
Departments of 1Public Health and 2Para‑Clinic, Faculty of Medicine, Kandahar University, 3Department of Clinic, Faculty of Medicine, Malalay Institute of Higher 
Education, Kandahar, Afghanistan, 4Research Centre for Child Psychiatry, University of Turku, Turku, Finland
Submitted: 01-May-2025    Revised: 22-Jul-2025    Accepted: 23-Aug-2025    Published: 15-Sep-2025
How to cite this article: Bariz H, Stanikzai MH, Mudaser GM, 
Stanikzai KA, Dadras O. Diagnostic delay and its predictors among 
tuberculosis patients in Kandahar, Afghanistan: A cross-sectional analytical 
study. Int J Mycobacteriol 2025;14:232-8.
Address for correspondence: Dr. Muhammad Haroon Stanikzai, 
Department of Public Health, Faculty of Medicine, Kandahar University, 
District #10, 3801, Kandahar, Afghanistan. 
E‑mail: haroonstanikzai1@gmail.com
ORCID: 
Muhammad Haroon Stanikzai: https://orcid.org/0000‑0003‑2757‑1965
Bariz, et al.: Diagnostic delay and its predictors among TB patients in Kandahar, Afghanistan
International Journal of Mycobacteriology ¦ Volume 14 ¦ Issue 3 ¦ July-September 2025 233
Research has attributed several factors to the heightened 
risk of diagnostic delay among TB patients in LMICs. For 
example, a mixed-methods systematic review found that 
poor TB knowledge, TB stigma, financial difficulties, poor 
access to healthcare, and lack of resources at healthcare 
facilities were associated with diagnostic delays among 
TB patients in high-burden countries.[12] Other factors such 
as female sex, rural residence, illiteracy, unemployment, 
and long distance to healthcare facilities have been linked 
with diagnostic delay among TB patients in the pertinent 
literature.[13]
Meanwhile, diagnostic delays among TB patients can be 
considerably reduced.[14,15] Several interventions have been 
implemented to reduce diagnostic delays among TB patients, 
including active case finding, rapid testing, patient benefit 
schemes, behavior change campaigns, health education, 
private-sector interventions, and capacity-building and 
skill development of healthcare professionals.[14,16] These 
interventions have shown varying influences across different 
settings.[14]
In Afghanistan, the context of diagnostic delay among TB 
patients has been underexplored,[17] particularly in the southern 
part of the country. Therefore, this study aims to evaluate 
diagnostic delays and their predictors among TB patients in 
Kandahar, Afghanistan. These findings will provide valuable 
information for evidence-based decision-making in TB control 
at the provincial and national levels.
Methods
Ethical Consideration
Ethical clearance for this study was obtained from the Research 
and Ethics Committee at the Faculty of Medicine, Kandahar 
University (Letter No. 115, dated January 10, 2025). The 
study strictly adhered to the ethical guidelines outlined in the 
Declaration of Helsinki.
Types of sampling and reasons for selection
We calculated our sample size using the formula commonly 
applied in cross-sectional studies for estimating proportions, 
based on a 50% prevalence rate of diagnostic delay (maximum 
estimate), a 95% confidence level, and a Z = 1.96. After adding 
a 10% nonresponse rate, a sample size of 422 TB patients was 
deemed adequate. Data from 441 patients were included in the 
analysis. We allocated the sample size proportionally to the TB 
patient load at each facility over the past 3 months.
Study design and settings
This  cross-sect ional  s tudy was conducted f rom 
February to May 2025 in six public healthcare facilities 
in Kandahar, Afghanistan: Kandahar TB Center, Mirwais 
Regional Hospital (MRH), Spin Boldak District Hospital, 
Allama Rashad Comprehensive Healthcare Facility (CHC), 
Zahari District CHC, and Panjwai District CHC. The healthcare 
facilities are being equipped to provide basic diagnostic and 
curative services to TB patients.
Inclusion criteria
Our study population consisted of TB patients attending the TB 
care centers of the abovementioned healthcare facilities. Based 
on our inclusion criteria, we only recruited newly diagnosed 
TB patients aged 18 years and above.
Exclusion criteria
Severely ill and nonconsenting TB patients were excluded 
from the study.
One hundred and ten patients were recruited from MRH, 
followed by the Kandahar TB Center (65), Spin Boldak District 
Hospital  (52), Allama Rashad CHC (43), Zahari District 
CHC  (39), and Panjwai District CHC (39). The patients 
were randomly recruited at each healthcare facility using the 
lottery method.
Study variables
The outcome variable was diagnostic delay among TB patients, 
which consisted of patient delay, health system delay, and total 
delay. We assumed the patient was delayed if they visited a 
professional health provider more than 30 days after the onset 
of TB symptoms.[18,19] Health system delay was confirmed if a 
TB diagnosis was confirmed more than 4 days after the patient 
presented to a professional health provider.[18,19] Total delay 
was equal to the sum of patient and health system delays. We 
recorded delay periods in days.
The independent variables examined were sociodemographic 
characteristics and clinical factors. The sociodemographic 
factors included age, sex, education level, residential area 
(urban vs. rural), marital status, employment status, household 
size, monthly income, and distance to healthcare facility. 
Clinical variables comprised TB type, family history of TB, 
knowledge of TB, self-perceived severity, self-medication, 
current smoking, TB-related stigma, and history of depression 
symptoms were also included as independent factors of 
interest. Depression symptoms were assessed by the patient’s 
self-reported dichotomized questions with a yes or no response 
to “Did you experience any depression symptoms during 
disease?”
Data collection
We used a paper-based, structured, and pretested questionnaire 
to collect data. A 30-min face-to-face interview was conducted 
with newly diagnosed TB patients at their exit in a private 
room. Female interviewers interviewed female patients. We 
checked all questionnaires for completeness, consistency, and 
accuracy.
Patient consent statement
We obtained verbal informed consent from all participants in 
the study.
Statistical analysis
To assess the distribution of sociodemographic characteristics 
and clinical factors of patients, descriptive statistics were 
provided using frequency and percentage. To examine the 
likelihood of patient and health system delays across the 
Bariz, et al.: Diagnostic delay and its predictors among TB patients in Kandahar, Afghanistan
International Journal of Mycobacteriology ¦ Volume 14 ¦ Issue 3 ¦ July-September 2025234
categories of explanatory variables, bivariate and multivariable 
binary logistic regression models were used. To determine the 
inclusion of explanatory variables in the multivariable analysis, 
we included the explanatory variable in the multivariable 
regression analysis if it had P < 0.25 for all categories of 
the explanatory variable from the bivariate model. All data 
analyses were performed using STATA version 17 (StataCorp 
LLC, College Station, Texas, USA.).
results
Demographic characteristics
In total, we enrolled 441 newly diagnosed TB patients in 
the study. Among them, 148 (33.6%) were aged >50 years, 
more than half (53.7%) were females, two-thirds (63.9%) 
had no formal education, 272 (61.7%) were urban residents, 
and the majority (70.5%) were married. Moreover, patients 
were most likely to live in households with more than five 
members (83.2%) and had to travel more than 1 h to reach 
the nearest health facility (54.6%). Regarding income, 
239 (54.2%) had a monthly household income exceeding 
10,000 Afghanis [Table 1].
Clinical characteristics
Of all the patients, 287 (65.1%) had pulmonary TB, 
one-third (33.1%) had a family history of TB, and 
283 (64.2%) had poor knowledge of TB. The majority of 
patients had TB-related stigma (67.6%) and depression 
symptoms (89.1%). About half of the patients (49.7%) 
reported self-medication before a diagnosis was made. 
Details on the first health facility contacted by patients are 
presented in Table 2.
Prevalence of patient, health system, and diagnostic 
delays among tuberculosis patients
Figure 1 shows that the median (mean) patient delay 
was 30.1 (68.9) days, with 44% of patients experiencing 
prolonged patient delay. Moreover, the median (mean) health 
system delay was 10.3 (27.4) days, with 59.4% of patients 
experiencing prolonged health system delay [Figure 1].
Factors associated with patient delay among tuberculosis 
patients
The likelihood of patient delay was higher in patients with 
no formal education (adjusted odds ratio [AOR]: 1.60, 95% 
confidence interval [CI]: 1.02–2.49), in extrapulmonary TB 
patients (AOR: 1.82, 95% CI: 1.19–2.77), patients with longer 
distance to the nearest health facility (AOR: 1.56, 95% CI: 
1.05–2.33), and those with a history of self-medication (AOR: 
2.27, 95% CI: 1.51–3.40) [Table 3].
Factors associated with health system delay among 
tuberculosis patients
Similarly, the patient’s education level, type of TB, 
time to reach the nearest health facility, and history of 
self-medication were predictors of health system delay. 
Table 1: Sociodemographic characteristics of the study 
participants (n=441)
Variables Frequency, n (%)
Age
18–20 38 (8.6)
21–30 110 (24.9)
31–40 78 (17.7)
41–50 67 (15.2)
>50 148 (33.6)
Sex
Male 204 (46.3)
Female 237 (53.7)
Residence
Urban 169 (38.3)
Rural 272 (61.7)
Marital status
Single 94 (21.3)
Married 311 (70.5)
Widowed/divorced 36 (8.2)
Educational status
No formal education 282 (63.9)
Religious 72 (16.3)
Primary 50 (11.3)
Secondary 9 (2.0)
High school graduate 20 (4.5)
Higher studies 8 (1.8)
Employment status
Public employed 41 (9.3)
Private employed 37 (8.4)
Homemaker 182 (41.3)
Unemployed 181 (41.0)
Household members
2–5 74 (16.8)
>5 367 (83.2)
Distance to a health facility (h)
≤1 200 (45.4)
>1 241 (54.6)
Monthly household income (Afghanis)
5000–10,000 202 (45.8)
>10,000 239 (54.2)Figure 1: Prevalence of patient, health system, and total delays
Bariz, et al.: Diagnostic delay and its predictors among TB patients in Kandahar, Afghanistan
International Journal of Mycobacteriology ¦ Volume 14 ¦ Issue 3 ¦ July-September 2025 235
The crude and AOR for health system delay are presented 
in Table 4.
dIscussIon
The aim of this was to evaluate diagnostic delay and its 
predictors among TB patients in Kandahar, Afghanistan. We 
found that 44% and 59.4% of patients experienced prolonged 
delays within the patient and health system, respectively. 
In addition, we found that patients’ low education level, 
longer distance to health facilities, extrapulmonary TB, and 
self‑medication were significantly associated with diagnostic 
delay among TB patients.
We found that 44% of participants had prolonged patient delay, 
with a median (mean) of 30.1 (68.9) days. This finding aligns 
with earlier studies conducted in India (44.6%)[15] and southern 
Ethiopia (median: 30 days).[20] However, our finding is higher 
than studies conducted in Ethiopia (median: 20–24 days)[21,22] 
and China (median: 16.8 days).[23] No recent study has 
assessed diagnostic delay among TB patients in Afghanistan. 
Nonetheless, the previous studies have shown poor TB 
knowledge and high TB-related stigma among Afghan TB 
patients.[7,24] These findings, together, underscore a critical need 
for integrated policy action, embedding TB awareness into the 
community’s literacy and vocational programs, and mobilizing 
community health workers in active TB case finding.
We also observed an alarming magnitude (59.4%) of health 
system delay in the current study. The previous studies have 
also documented prolonged health system delays among TB 
patients in LMICs.[14,25,26] Limited resources, a shortage of 
the health workforce, and poor capacity among healthcare 
professionals are some of the reasons linked to health system 
delays in LMICs.[14] Earlier studies have shown that TB care 
faces significant challenges in Afghanistan, particularly in the 
postconflict scenario.[6,8,27] Considering the negative health 
consequences and higher medical and nonmedical costs 
associated with late TB diagnosis, there is an urgent need for 
resource allocation, the provision of rapid diagnostic tools, 
and the capacity-building and skill development of healthcare 
professionals in Afghanistan.
Education has long been considered a significant predictor of 
optimal healthcare utilization. We also observed that patients 
with no formal education encountered substantial delays 
in TB diagnosis. This finding is in agreement with studies 
conducted in Indonesia[28] and Ethiopia.[22] Previous studies in 
Afghanistan have also revealed high prevalence of TB-related 
stigma, depression symptoms, and nonadherence to anti-TB 
medications among patients with no formal education.[8,9] 
Taking these findings together, TB programs and policies should 
prioritize individuals with limited education in Afghanistan.
We found that TB patients who had to travel more than 
1 h to reach the nearest health facility were more likely to 
experience both patient and health system delays than their 
counterparts. Studies in LMICs have revealed that longer 
distance to healthcare facilities contributes to late diagnosis, 
nonadherence to medication, higher medical and nonmedical 
costs, and poor prognosis.[29] In Afghanistan, earlier research 
has shown that a longer distance is a contributing factor to poor 
healthcare utilization.[30,31] Therefore, policymakers should 
prioritize expanding access to decentralized TB diagnostic 
and treatment services in remote areas to reduce both patient 
and health system delays.
Extrapulmonary TB has been identified as a risk factor for 
delayed TB diagnosis.[32,33] Similarly, we found that the 
odds of patient and health system delays were greater in 
patients diagnosed with extrapulmonary TB compared to 
those diagnosed with pulmonary TB. This finding is echoed 
in earlier studies conducted in LMICs.[19,22,34] No study has 
investigated diagnostic delay among extrapulmonary TB 
patients in Afghanistan. In addition, there is a limited focus 
on extrapulmonary TB in the Afghan health system.[6] These 
findings call for resource allocation and the capacity building 
of Afghan healthcare professionals in the diagnosis of 
extrapulmonary TB.
Finally, this study noted that self-medication is strongly 
associated with both patient and health system delays in 
Table 2: Clinical and other related characteristics (n=441)
Variables Frequency, n (%)
Type of TB
Pulmonary TB 287 (65.1)
Extrapulmonary TB 154 (34.9)
Self-perceived severity
Mild 55 (12.5)
Moderate 145 (32.9)
Severe 241 (54.6)
TB awareness
Yes 158 (35.8)
No 283 (64.2)
Family history of TB
Yes 146 (33.1)
No 295 (66.9)
TB-related stigma
Yes 298 (67.6)
No 143 (32.4)
Depression symptoms
Yes 393 (89.1)
No 48 (10.9)
Currently smoking
Yes 62 (14.1)
No 379 (85.9)
Type of health facility first contacted
Public hospital/clinic 164 (37.2)
Private hospital/clinic 114 (25.8)
Pharmacy 163 (41.0)
Self-medication
Yes 219 (49.7)
No 222 (50.3)
TB: Tuberculosis
Bariz, et al.: Diagnostic delay and its predictors among TB patients in Kandahar, Afghanistan
International Journal of Mycobacteriology ¦ Volume 14 ¦ Issue 3 ¦ July-September 2025236
TB patients. Self‑medication is known to be a significant 
barrier to timely TB diagnosis and results in various adverse 
consequences.[35] It also contributes to prediagnosis costs 
linked with TB.[36,37] Studies have also shown that prediagnosis 
costs comprise a significant portion of the total medical and 
nonmedical expenses associated with TB.[38] No study has 
reported on self-medication among Afghan TB patients. 
Therefore, the magnitude and predictors of self-medication 
among Afghan TB patients warrant further investigation.
conclusIon
Diagnostic delay among TB patients is an increasingly recognized 
basis for disease transmission and poor prognosis. About 44% and 
59.4% of TB patients in our cohort had prolonged patient delay 
and health system delay, respectively. In addition, we found that 
patients’ low education level, longer distance to the nearest health 
facility, extrapulmonary TB, and self‑medication were significantly 
associated with diagnostic delay among TB patients. Therefore, 
focusing extra attention on these factors could potentially reduce 
diagnostic delays among TB patients in Afghanistan.
Outcomes of the study
About 44% and 59.4% of patients had prolonged patient delay 
and health system delay, respectively. Low education level, 
extrapulmonary TB, longer distance, and self-medication predicted 
diagnostic delay among TB patients. The high magnitude of 
diagnostic delays in the study area is a cause for concern and action.
Rationale of the study
No previous study has assessed diagnostic delay among TB 
patients in Southern Afghanistan. Therefore, this study aimed 
Table 3: Logistic regression analysis on results of patient delay; crude and adjusted odds ratios with 95% confidence 
interval
Variables Categories Patient delay COR (95% CI) P AOR (95% CI) P
Yes No
Age 18–40 101 125 Reference 0.762 - -
>40 93 122 0.93 (0.64−1.37)
Sex Male 80 124 Reference 0.061 Reference 0.846
Female 114 123 1.43 (0.98−2.09) 1.04 (0.68−1.59)
Residence Rural 120 152 Reference 0.946 - -
Urban 74 95 0.98 (0.67−1.45)
Marital status Currently married 138 173 Reference 0.80 - -
Currently unmarried 56 74 0.94 (0.62−1.43)
Education status Educated 55 104 Reference 0.003 Reference 0.038
Uneducated 139 143 1.83 (1.23−2.74) 1.60 (1.02−2.49)
Employment Employed 35 43 Reference 0.86 − −
Unemployed 159 204 0.95 (0.58−1.56)
Household size 2–5 35 43 Reference 0.86 − −
>5 159 204 0.95 (0.58−1.56)
Distance to healthcare 
facility (h)
≤1 76 124 Reference 0.021 Reference 0.026
>1 118 123 1.56 (1.06−2.29) 1.56 (1.05−2.33)
Monthly income 5000–10,000 85 117 Reference 0.45 − −
>10,000 109 130 0.86 (0.59−1.26)
Type of TB Pulmonary 114 173 Reference 0.014 Reference 0.005
Extrapulmonary 80 74 1.64 (1.10−2.43) 1.82 (1.19−2.77)
Self-perceived disease 
severity
Not severe 22 33 Reference 0.524 - -
Severe 172 214 1.20 (0.67−2.14)
TB awareness No 126 157 Reference 0.763 - -
Yes 68 90 0.94 (0.63−1.39)
Family history of TB No 132 163 Reference 0.650 - -
Yes 62 84 0.91 (0.61−1.36)
TB-related stigma No 65 78 Reference 0.668 - -
Yes 129 169 0.91 (0.61−1.36)
Depression symptoms No 18 30 Reference 0.337 - -
Yes 176 217 1.35 (0.72−2.50)
Currently smoking No 169 210 Reference 0.530 - -
Yes 25 37 0.84 (0.48−1.45)
Self-medication No 75 147 Reference <0.001 Reference <0.001
Yes 119 147 2.33 (1.58−3.42) 2.27 (1.51−3.40)
TB: Tuberculosis, COR: Crude odds ratio, AOR: Adjusted odds ratio, CI: Confidence interval
Bariz, et al.: Diagnostic delay and its predictors among TB patients in Kandahar, Afghanistan
International Journal of Mycobacteriology ¦ Volume 14 ¦ Issue 3 ¦ July-September 2025 237
to evaluate diagnostic delays and their predictors among TB 
patients in Kandahar, Afghanistan. These findings will provide 
valuable information for evidence-based decision-making in 
TB control at the provincial and national levels.
Limitations of study
Although this study has provided important information about 
diagnostic delay among TB patients in Afghanistan, it has its 
limitations. First, the cross-sectional nature of the study makes 
it difficult to infer the temporal relationship between predictors 
and diagnostic delay among TB patients. Second, data on 
patient and health system delays were self-reported and are 
prone to information and recall biases. Third, the cutoff point 
for assessing diagnostic delay differs across studies; therefore, 
comparing diagnostic delays and their predictors considering 
various cutoff points seems formidable. Finally, our evaluation 
of predictors for diagnostic delay among TB patients was 
restricted to the information collected by the current study. 
Therefore, future studies include other important determinants, 
such as social and community support systems, media access, 
and doctor–patient communication, in their analyses.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Table 4: Logistic regression analysis on results of health system delay; crude and adjusted odds ratios with 95% 
confidence interval
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Yes No
Age 18–40 140 86 Reference 0.266 - -
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Bariz, et al.: Diagnostic delay and its predictors among TB patients in Kandahar, Afghanistan
International Journal of Mycobacteriology ¦ Volume 14 ¦ Issue 3 ¦ July-September 2025238
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