Factors associated with tuberculosis diagnosis and treatment delays in Middle East and North Africa: a systematic review

Background: Political instability, economic sanctions and substandard quality of health care negatively affect tuberculosis (TB) control in the Middle East and North Africa (MENA) region. Aims: We aimed to elucidate factors contributing to delays in TB diagnosis and treatment in MENA countries. Methods: Two reviewers independently appraised eligible articles identified through comprehensive searching and extracted data which were subjected to meta-analysis. Results: Delays in TB diagnosis were associated with older age and low income [(OR = 1.49; 95% CI: 1.31-1.70) and (OR = 1.26; 95% CI: 1.09-1.45)] respectively (n = 17 studies). Being female was associated with patient delay and health system delay [(OR = 1.24; 95% CI: 1.02-1.50) and (OR = 1.68; 95% CI: 1.18-2.38)] respectively. Knowledge and perception of TB, having employment and low levels of crowding were each protective against patient delay. The GRADE system rated the evidence as of low quality. Conclusion: This review provides evidence for facilitators and barriers to TB diagnosis and health system delays. For successful TB control in the MENA region, TB awareness and interventions targeting the elderly and those from lower-income settings, particularly directed at gender differences, are essential.