Factors associated with patient and health care system delay among migrant and local tuberculosis patients in Istanbul: a cross-sectional study

Abstract

Background

Effective tuberculosis (TB) management requires timely diagnosis and immediate treatment initiation. The urgency for diagnosing and treating TB is particularly acute among immigrants, who face heightened health risks due to factors such as poverty, hazardous working conditions, and limited healthcare access. The objective of this study was to examine the characteristics of patient and health care delays among migrant and local TB patients in Istanbul and to identify factors associated with delays in the diagnosis and treatment of TB in both migrant and local patients.

Methods

This cross-sectional study was conducted in six Tuberculosis Control Dispensaries (TCDs) in Istanbul, the city with the highest number of TB cases in Turkey. A total of 211 TB patients, including 140 local residents and 71 migrants, participated. Data were collected through interviews via a structured questionnaire and patient files, following the patients’ consent.

Results

Among migrant patients, the time from the onset of TB-related symptoms to the first contact with a health institution (patient delay) was 4.7 times longer (95% Confidence Interval [CI] = 1.1–20.9) than that in local resident patients. Compared with local patients, migrant patients were predominantly male, younger, had lower education levels, had a history of previous TB, and were less likely to smoke. Additionally, the frequency of working without insurance and unemployment was greater among migrant patients than among those employed with insurance.

Conclusion

Our research underscores the importance of focusing on the migrant community to achieve tuberculosis control goals, potentially through interventions to increase knowledge of healthcare system access and the significance of working conditions, including health insurance. While we profiled migrant TB patients, qualitative research is needed to elucidate the underlying reasons for delays in diagnosis and treatment.

Introduction

Tuberculosis (TB) constitutes a substantial global public health challenge, with approximately 10.6 million cases reported annually by the World Health Organization (WHO). Globally, TB ranks as the 13th most common cause of mortality and the second leading infectious disease killer following COVID-19. It primarily afflicts adults during their most productive years, although all age groups remain at risk. Additionally, it is crucial to underscore that over 80% of TB cases occur in low- and middle-income nations [1].

In contrast to TB infection, the onset of TB disease is characterized by noticeable symptoms. These symptoms, albeit often mild, can persist for an extended duration, thus facilitating the unintentional transmission of TB by individuals who may remain unaware of their infectious status. Approximately 5–10% of individuals infected with TB eventually experience symptoms leading to active TB disease. Several underlying factors increase an individual’s TB risk, including compromised immune function (e.g., HIV/AIDS), diabetes, malnutrition, and tobacco use. The primary focus of TB control efforts lies in early diagnosis, anti-TB drug prophylaxis for risk groups, effective treatment, and transmission control by tracing contacts and screening vulnerable groups [1].

To provide active TB control in societies, the WHO recommends focusing on protecting the poor and fragile population against TB by developing programs for immigrants in the National TB Control Programs of the member countries with the “End TB Strategy”. Its emphasis lies in catering to demographics, particularly infections, and facing challenges in accessing adequate health care, such as migrant populations. The world’s immigrant population is increasing due to globalization, economic, and climate crises [2, 3]. Critical health risk factors during migration include poverty, hazardous working conditions, limited health care access, and social exclusion [2, 4]. Migrants, who frequently bear a significantly greater TB burden than the general population, exhibit heightened vulnerability [5]. Moreover, the migrant population has varying tuberculosis burdens based on immigration status [6]. However, their diverse and highly mobile characteristics make them particularly challenging to access and treat [3]. The legal status of immigrants often plays a crucial role in determining their access to health care. Undocumented or unauthorized immigrants may face barriers to accessing health care services.

As the most up-to-date official epidemiological data for TB in Türkiye, the number of new patients in 2020 was 8.830, and the incidence was 10.6 per hundred thousand. It was reported that 12.8% of the cases were born outside Türkiye. The “Türkiye-wide Tuberculosis Data” report reported that 25.6% of multidrug-resistant TB (MDR-TB) cases were born outside Türkiye. Furthermore, when provinces examine the distribution of cases, it has been reported that Istanbul has the highest number of cases (33%) [7, 8].

Türkiye has experienced a notable rise in its immigrant population, primarily from Syria and other Middle Eastern and North African countries [9]. The immigration status in Türkiye varies depending on the country of origin of the migrant population, as per the current legislation [10]. Current data show that most of the migrant population in Türkiye is Syrian-born and has a degree of social security under Temporary Protection Status (TPS) [11]. The migrant population, most of whom were born in Iraq, Afghanistan, and Iran and are from countries other than Syria, has an International Protection Status (IPS), which provides access to health care services for free for a limited period. In addition, reports have shown an unregistered migrant population whose numbers exceed the IPS [10]. These legal differences between migrants have practical consequences for accessing preventive and curative health services [12].

Migrant populations face significant and unique challenges in accessing health care, timely diagnosis and treatment. Prolonged delays are notably associated with migrants, with one study reporting a median patient delay of 16 days, which significantly contributed to the total delay [13]. Studies also showed that migrant patients face considerably longer delays in seeking medical care compared to local patients. For example, one study observed a median delay of 13 days among migrants versus 9 days for local patients, with 47% of migrants experiencing delays exceeding 14 days, compared to 30% of locals [14]. Similarly, a study in Italy reported an exceptionally long median delay of 90 days for migrant patients, in contrast to just 10 days for local residents [15].

Previous literature suggested that barriers to health care access play a pivotal role in contributing to these delays. Migrants frequently face challenges such as limited awareness of TB, insufficient social support, language barriers, and difficulties in navigating or accessing healthcare insurance reimbursement systems [14, 16]. Socioeconomic factors such as overcrowded living conditions, discrimination and legal status also plays an important role in determining health-seeking behavior among migrants [15].

Patient and health care system delays and associated factors have been studied within the general population in Türkiye, with the patient delay rate reported at 24.6% [17]. However, data on delays and the specific risk factors affecting the migrant population in Türkiye remains unclarified. This study aims to investigate delays in the diagnosis and treatment of TB, along with the associated factors, among migrants and local residents in Istanbul.

Materials and methods

Study design and setting

We conducted a cross-sectional study, with data collection carried out between October 2022 and July 2023 at six Tuberculosis Control Dispensaries (TCDs) in Istanbul on weekdays from 09:00 to 16:00. Of the six dispensaries selected in Istanbul, two are located on the Anatolian side, and four are on the European side (Fig. 1). The study was conducted across various districts to achieve a highly representative and heterogeneous population sample. All recently diagnosed TB cases must be officially recorded via local TCD and reported to higher-level health authorities. It should be noted that the Ministry of Health assigns patients to dispensaries based on their residential district. Therefore, dispensaries in districts with a high immigrant population can be expected to serve more immigrant patients. The six TCDs where this study was conducted had the highest number of immigrant patients.

Fig. 1

Among the six TCDs selected in Istanbul, two are located on the Anatolian side, and four are on the European side. TCD = Tuberculosis Control Dispensary

Tuberculosis control dispensaries in Türkiye

In Türkiye, tuberculosis is designated a notifiable disease, and its treatments are bestowed without charge to all individuals, irrespective of their health insurance status. Directly observed treatment (DOT) is available in all provinces, TCDs are institutions authorized to provide TB diagnosis, treatment, and case management. Eight out of the 29 TCDs situated in Istanbul extend health-related amenities in affiliation with the Istanbul Tuberculosis Control Association (ITCA), and our study was conducted in TCDs affiliated with the association [18]. Since the 1940s, the Turkish state has encouraged the fight against tuberculosis by supporting nongovernmental organizations (NGOs). ITCA, as an entity affiliated with the Ministry of Health, operates on a nonprofit basis, and its personnel are formally associated with the NGO. The TCD staff, who are permanent, seasoned, motivated, immigrant-sensitive, and socially supportive, contribute significantly to the health care system. Moreover, the districts where TCDs affiliated with the association are located are in places with a large migrant population. Given the robust network of associations with other NGOs, effective communication channels exist for patient referrals from diverse NGOs operating in various domains. This robust NGO network facilitates streamlined access to TCDs, even for irregular migrants. Additionally, tuberculosis drugs can be obtained only through government agencies. Patients registered with TCDs, even for medication supply, undergo DOT. Furthermore, TCDs affiliated with ITCA, which provide immigrant-centric services, offer social assistance to support the treatment trajectory [19]. It should be underlined that there is no difference between ITCA-affiliated TCDs and other TCDs in terms of TB diagnosis or treatment; all are affiliated with the Ministry of Health.

Data collection and variables

A questionnaire was administered to patients receiving treatment who were diagnosed with active tuberculosis in the TCDs. (Additional file 1) Pulmonary TB is defined as the presence of radiological lung lesions, sputum smear positivity, or positive sputum culture. Nonpulmonary TB diagnoses were obtained only in hospital settings. We excluded patients with MDR-TB, who accounted for 2.2% of the cases [7]. This subgroup presents particular complexities, including a higher likelihood of treatment discontinuation, which could have introduced bias into our definitions of patient and healthcare system delays.

At the outset of the data collection, a pilot study involving seven patients was conducted to assess the clarity and comprehensibility of the questions. The interviews were conducted with six trained medical school students from the Faculty of Medicine of Istanbul University. We provided standardized training and supervision to all researchers involved in data collection. Training sessions were organized by the authors Z.K., Ş.K., and M.E. All students were under supervision within their first 3 days of data collection by the researchers Ş.K., M.E., and D.G. Additionally, periodical meetings with all the researchers were organized weekly to monitor and support the data collection. To overcome a possible language barrier for the migrant population, two of the researchers who collected data were of Syrian origin and were directly involved in data collection and translation when necessary, as their mother tongue was Arabic. All the researchers were fluent in English, and a French translator accompanied them when required.

The DOT method is implemented in TCDs, and active TB patients attend local TCDs on scheduled days to receive their drug treatments. During these visits, the questionnaire, including the sociodemographic and TB diagnosis questions, were prepared in three languages, Turkish, Arabic, and French, and were administered face-to-face. Examples in the literature were evaluated, and sociodemographic factors such as age, sex, educational status, literacy, occupation, social security status, housing conditions such as household characteristics, and medical background information such as smoking status and duration, such as pack-years, alcohol consumption, comorbidities, and TB history, were collected by the researcher. In addition to the variables determined for the study in the questionnaire, information such as the dates of the first complaint, the first contact with any health facility, the number of health facilities attended, the use of other treatments or remedies, and TB contact was obtained verbally from the participant and verified against health records. Bacille Calmette-Guérin (BCG) vaccination history was assessed verbally and confirmed by checking for a vaccination scar during a physical examination. Information about the patients was recorded from their health record files after obtaining consent, including details such as the healthcare institution where the TB diagnosis was made, the date of the initial diagnosis, the treatment start date, and the result of HIV serology. For child patients (n = 5), the questionnaire was completed with the assistance of their parents.

To ensure the data quality and security measures were taken, all data was entered into a secure, electronic database in Microsoft Excel, version 2021 program linked using hospital record numbers. All data was de-identified for analysis. Duplicate verification of the records was completed to identify errors and missing data. Implausible entries were verified against the set as missing if incomplete.

Study population and definitions

In this study, “migrants” were defined as nonlocal residents who lived away from their permanent places of residence across the international border for more than three months. The delay in diagnosing and treating TB, especially pulmonary tuberculosis, is an essential indicator for evaluating disease control practices because of the associated risk of transmission over time [20]. The time from the onset of TB-related symptoms to first contact with the health institution was defined as “patient delay,” the time from first contact to diagnosis was defined as “diagnostic delay,” and the time from diagnosis to the start of anti-TB treatment was defined as “treatment delay” (presented in Fig. 2). The total duration of diagnostic and treatment delays is expressed as “health care system delay” [14, 21].

Fig. 2

The diagram of diagnostic and treatment delays in tuberculosis. (Adapted from Li, 2018)

Sample size calculation and data analysis

In the existing literature, we observed a broad spectrum of delay rates among migrants and local residents. A domestic study in our country reported a patient delay rate of 24.6% [17]. Based on a sample size calculation, 285 patients were required, assuming an alpha error rate of 0.05 and a statistical power of 80%. However, we could access data from 211 patients, constituting 74% of our targeted sample size owing to limited active TB patients who receive DOTs in TCDs and the planned data collection duration.

Data were analyzed with IBM Statistical Package for the Social Sciences (SPSS) software (version 23.0; IBM Corporation, Armonk, NY, USA). Descriptive statistics used measures of central distribution and tendency, frequencies, and percentages. The conformity of the measurement variables to a normal distribution was examined via visual (histogram) and analytical methods (Kolmogorov‒Smirnov/Shapiro‒Wilk tests). While the chi-square test and Fisher’s exact test were performed to compare categorical variables, Student’s t test and the Mann–Whitney U test were used to compare two independent groups. Multivariate logistic regression analysis was used further to assess the impact of the variables on the delays. To identify factors associated with patient and diagnostic delays, we used 14 days as the cutoff point (delay: >14 days; no delay: ≤14 days) based on previous studies that established this cutoff value. Patient delay was reported as median of 14 days in and determined as cut-off in various studies [14, 22,23,24]. The variables included in the multivariate analysis were selected based on their relevance for adjusting patient delay and/or their statistical significance in the univariate analysis. Although sex was not statistically significant, it was added into the model due to its role as a crucial confounding factor. Certain variables, despite demonstrating significance in the univariate analysis, were excluded from the multivariate model because of their correlation with other variables (e.g., tobacco exposure). Additionally, variables such as HIV testing status post-tuberculosis diagnosis were omitted, as they do not represent factors requiring adjustment for patient delay.

Ethical considerations

Ethical approval was obtained from the Ethics Committee of the Istanbul University Faculty of Medicine (2022/1666), and research permission was obtained from the Istanbul Tuberculosis Control Association for TCDs. Informed consent, provided in three languages (Turkish, Arabic, and French) was obtained from all participants. For illiterate participants; appropriate representatives, such as family members or translators, facilitated the consent process. In the case of child patients, consent was obtained from their parents.

Results

Sociodemographic and clinical characteristics

Among the 211 TB patients included in the study, 140 were local residents, and 71 were migrants. Table 1 summarizes the sociodemographic characteristics of the participants. Migrants were significantly younger than local residents (p ≤ 0.001). Both groups had a male majority, with no significant difference in gender distribution (p = 0.432). However, a higher proportion of migrants were single, divorced, or widowed compared to local residents (p = 0.009).

Table 1 Sociodemographic characteristics and medical history of the patients

Migrants also had significantly lower rates of smoking and tobacco exposure (in packs per year), employment, health insurance coverage, comorbidities, and BCG vaccination (p values: 0.008, ≤ 0.001, ≤ 0.001, ≤ 0.001, 0.004, and 0.007, respectively). On the other hand, migrants were more likely to live with others, have a history of previous TB treatment, self-medicate before diagnosis, and incur out-of-pocket expenses for TB treatment before visiting the dispensary (p values: 0.007, 0.008, 0.005, and ≤ 0.001, respectively). Significant differences were observed in the choice of initial healthcare facilities between the two groups (p ≤ 0.001), with local residents more likely to use public health services than migrants.

Table 2 highlights key characteristics related to migrant patients. Among migrants, the largest subgroup consisted of Syrian individuals (25%), followed by Afghans (13%) and Somalis (13%). Regarding migration status, 25% of migrants were unregistered, 24% had temporary protection status (TPS), and 17% were in the application process for temporary residence. Furthermore, 14% of migrants reported language barriers in accessing healthcare services.

Table 2 Sociodemographic characteristics of the migrant patients

A subgroup analysis (not shown in tables) compared Syrian and non-Syrian migrants. No significant differences were found in patient, diagnostic, treatment, or healthcare system delays, nor in out-of-pocket expenses. However, a significant difference was noted in social security status (p = 0.041). Among Syrians, 70% were unemployed, compared to 52% of non-Syrians. Unregistered employment was reported by 17% of Syrians and 43% of non-Syrians.

Comparison of delays between migrants and local residents

Table 3 shows comparisons of patient, diagnosis, treatment and healthcare delays between the migrant and local groups. Patient delay among migrants was significantly longer than that among local residents (p = 0.002). No statistically significant difference was found between the groups in terms of diagnosis, treatment and healthcare delays.

Table 3 Patient and healthcare delays among migrant and local patients

Logistic regression analysis (Table 4) revealed that migrant status was associated with a 4.7-fold higher likelihood of patient delay compared to local residents (95% CI: 1.1–20.9). Migrants were also younger (adjusted odds ratio [aOR] = 0.8; 95% CI: 0.7–0.9) and had a higher prevalence of previous TB history (aOR = 11.2; 95% CI: 1.7–74.4).

Table 4 Examination of patient delay and other influencing factors among migrants and local residents via logistic regression analysis

Other factors more common among migrants included being male (aOR = 6.6; 95% CI: 1.4–31.6), lacking health insurance (aOR = 1171.5; 95% CI: 48.9–28057.6), unemployment (aOR = 31.8; 95% CI: 3.3–307.2), having a high school diploma (aOR = 121.5; 95% CI: 2.3–6354.1) compared to university education, and being a current smoker (aOR = 0.08; 95% CI: 0.01–0.61) compared to those who never smoked.

Discussion

This is the first study in Türkiye that compares patient and health care delays and risk factors between migrant and local residents. In this study, migrant patients with TB were found to be predominantly male, younger, less educated, have limited social security, be smokers less frequently, and be more likely to have a previous history of TB, which is consistent with the findings of previous studies [14, 25].

Our study revealed an increased delay in TB in migrant patients compared with local patients, which is consistent with the findings of previous studies [13, 21, 24, 26]. No significant difference in patient delay was observed between the Syrian and non-Syrian migrant populations. Our finding of a median patient delay of 24 days (range: 0–379) among migrant patients was consistent with the findings of previous studies [14, 26]. In a review, the average patient delay in high-income countries was found to be 25.8 days among migrant patients, similar to our findings [27]. There has been no study on patient delay among migrant patients with TB in Türkiye. A recent study from Türkiye reported that the median patient delay was 14 days and 10 days among smear-positive and smear-negative local patients, respectively. These durations were shorter than our results for migrant patients but longer than those reported for local patients [17]. In a study conducted on TCDs in Istanbul in 2012 [28], the median diagnostic delay was 30 days, the median treatment delay was 0 days, and the average was 3.8 ± 11.2 days. In this study, which was conducted only with local residents, a delay period similar to that of local residents was reported. A study reported shorter delays for migrant patients, with a median of 13 days [14]. Certain studies from different countries have revealed that migrant patients encounter extended delays, with a median of 25 days (11–49) in the Kyrgyz Republic and 40 days in Portugal [14, 26]. The disparities in study outcomes may be influenced by migrants’ countries of origin, which affect TB suspicion. For example, Syrian migrants in our study came from a country with lower TB prevalence, unlike the African population in the Portuguese study, which had higher TB rates [29]. These prolonged delays may stem from lower socioeconomic status, a lack of familial and social support, and difficulties associated with medical insurance reimbursement. Other contributing factors include concerns regarding the legalization process and deportation, the stigma and misconceptions surrounding TB diagnosis and treatment, and personal and structural obstacles hindering access to health care services, such as a history of TB, limited awareness, and language barriers [14, 24, 27, 29]. This finding highlights the importance of potential public health interventions in migrant populations to decrease patient delay.

In this study, treatment delay was not notably different between migrant and local patients. These findings are consistent with those of a previous study conducted in the Kyrgyz Republic [26]. The median health care system delay, including the term treatment delay, was 26 days in migrant patients, while the median delay in local patients was 31 days, and no statistically significant difference was found. A study revealed a similar interval, with a median of 21.5 days (range: 7.2–36) in health care delay among the general population of high-income countries [27]. A study from Türkiye health care system delays of 16 and 41 days among smear-positive and smear-negative local patients, respectively [17]. One study reported a median healthcare system delay of 9 days among migrant patients, which is higher than the findings of other studies (range: 0–25) [14]. A Portuguese study revealed a significantly lower health care delay among migrant patients [29]. The China study showed otherwise, with significantly longer patient delays among migrants [14]. The varying outcomes may be linked to a high suspension index caused by the differing migrant profiles across the studies. Another contributing factor that influences health care delays might be the availability of health care services. The parallelism observed in the treatment processes or health care delays among migrant and local patients in our study may be attributed to the provision of free health care services by TCDs, which benefits the vulnerable population. Another factor contributing to the similarity in health care delays between migrant and local residents is the exclusive availability of tuberculosis medications through government entities (i.e., TCDs, hospitals) and their noncommercial distribution. The structure of TCDs, bolstered by these facets, has culminated in the absence of discernible delays in health care for migrants, affirming the efficacy of the health care system.

In the present study, 33% of the patient cohort consisted of the migrant population, which exceeded the 21% reported in a previous study conducted in China but fell below the 65% reported in a study conducted in the United Kingdom [14, 25]. This observed variability can be ascribed to disparities in the epidemiological distribution of TB within diverse socioeconomic contexts across nations and differences in the composition of their populations.

The findings of this study reveal that the primary countries of origin for the migrant population were Syria, Somalia, and Afghanistan. Türkiye currently hosts nearly 4 million refugees [9, 30]. While Syrians make up nearly 80% of the migrant population in Türkiye, they accounted for only 25% of the migrants in our study [31]. Notably, the Somali and other African populations were more prominent in our study than reported in national statistics [9]. This discrepancy could be explained by the specific settlement patterns of migrants within the study region [12]. The country of origin is particularly relevant to our population and hypothesis due to differences in social security coverage among different migrant groups. Accordingly, our analysis categorized migrants into Syrian and non-Syrian groups for further evaluation; however, no significant differences were identified, likely due to the limited sample size.

The availability of health insurance was lower for migrant patients than for local patients. This situation is associated with working without social insurance due to unregistered employment. This disparity was particularly evident in non-Syrian migrants compared with Syrian migrants. Comparable research has also documented decreased health insurance rates among immigrant patients [23]. Previous studies have shown that unemployment and, therefore, a lack of social insurance are risk factors for delays in seeking treatment [29]. Our study revealed that the number of initial admissions and diagnoses to private hospitals was greater among migrant patients. Moreover, 47% of migrant patients preferred private health institutions as their first application, and 17% of local patients applied to private institutions. For health care services other than emergency health care and TB treatment, patients without health insurance must pay out-of-pocket in public and private health care institutions. Additionally, this can be attributed to several factors, including inadequate social security coverage leading to out-of-pocket costs in public and private hospitals, limited understanding of the health care system, concerns about document checks in public hospitals due to undocumented immigration status, and language barriers in public hospitals. Factors identified in previous literature, supported by our findings, highlight the need for potential interventions such as language support services, improved housing conditions, expanded social security coverage, and more accessible healthcare services for all patients.

Despite the availability of translators in public hospitals, some migrant populations might prefer private hospitals that employ health care workers from migrant communities [12]. Additionally, the immigrant population reported higher out-of-pocket expenses than local patients did. Although non-Syrian immigrants have more limited social security coverage, there is no significant difference between Syrians and other immigrant groups in terms of out-of-pocket spending. This could be due to migrant patients’ knowledge of their health care access and practical barriers that may have discouraged them from seeking care at public health care facilities. This finding highlights the significant impact of charging for health care services before diagnosis despite the free services provided by TCDs after diagnosis.

HIV serology data were available for only 55% of local patients and 34% of migrant patients. This study revealed an HIV prevalence of 3% across all patients. Notably, HIV positivity was more prevalent in the local population, which contrasts with findings in similar studies [26]. The WHO report indicated that the global incidence of HIV positivity among TB patients is 6.7% [1]. Official data from Türkiye in 2018 revealed a 71.1% frequency of HIV serology testing and a 0.6% prevalence of HIV positivity among TB patients [8]. The inconsistencies observed in our findings with epidemiological data may be attributed to the low frequency of HIV serology testing. Our study’s HIV-positivity prevalence exceeded that of a Chinese study (0.1%) [13] but was lower than that of a similar study in Zimbabwe, which reported a prevalence as high as 7.3% [32]. These variations are likely the result of differing HIV prevalence rates across countries.

The results of the logistic regression revealed that the frequency of previous TB was 11 times greater in migrant patients. Not surprisingly, in Türkiye, as in the world, the prevalence of TB is higher in the migrant population, and this finding is similar to those of other studies [20]. The absence of treatment continuity in the country of origin for migrants could lead to heightened challenges. In the absence of a control program, rates of treatment abandonment, relapse, and the prevalence of chronic cases may escalate.

Strengths and limitations

This research focuses on an urgent public health issue concerning a particularly vulnerable group. With the increasing prevalence of tuberculosis post-COVID-19 and the global initiative to “End TB strategy”, it has become more critical to handle the risk factors that impact this specific population. The study was conducted in the city with the highest number of tuberculosis patients in Türkiye. This research is centered in Istanbul, home to one-sixth of Türkiye’s migrant population [31]. Consequently, we expect this study to provide valuable insights into the health status and health care access of the migrant population in Türkiye, particularly with respect to TB. Incorporating TCDs further improved the quality of data collection, as these facilities adhered to the guidelines of the “End TB strategy” and the “International Standards for Tuberculosis Care” supported by the WHO [33]. TCDs continue to operate extensively through collaboration between the Ministry of Health, Tuberculosis Control Associations, and various nongovernmental organizations [8].

The limitation of this study was its cross-sectional design, which limits the capacity to infer causality. This requires further research using longitudinal data. Furthermore, although patients from six dispensaries were included in the study, the small sample size constitutes a limitation. To minimize the impact of this limitation, we avoided dividing our variables into too many subgroups. We employed multivariate analysis methods to achieve accurate and reliable results. Future studies with larger sample sizes are essential to extend our findings. The comprehensive confidence interval results from the logistic regression analyses further highlight the necessity for studies with larger sample sizes. Additionally, addressing recall bias is crucial, as the data on patient delay depends on patients’ recollections of symptom onset.

Conclusion

Patient delay, which manifests as a delay in the first contact with the health care system after the onset of symptoms, was significantly greater among migrant patients with TB than among local residents. There was no significant difference in health care system delay between migrant and local patients. Our research highlights the importance of directing attention toward the migrant community to attain tuberculosis control goals, potentially through interventions aimed at enhancing knowledge of access to the health care system, facilitating formal employment, and thus providing health insurance. Further studies could be undertaken to discern differences among various migrant groups, defining their migration status, social security, concerns regarding health care admission expenses, and household circumstances. A longitudinal study design could offer crucial insights into causality. Additionally, a qualitative investigation of patient delay among migrants could address fundamental issues influencing this delay.