Confusion, caring and tuberculosis diagnostic delay in Cape Town, South Africa.

OBJECTIVE: To explore the ways in which provider and patient behaviours interact to exacerbate diagnostic delay in Cape Town, South Africa. DESIGN: Eight focus group discussions were conducted in four urban communities, all with high tuberculosis (TB) prevalence, including two with high human immunodeficiency virus co-prevalence. Groups were stratified by sex, ethnicity and TB status. Findings were elicited inductively from the dataset using a combination of grounded theory and thematic analysis. RESULTS: Diagnostic delay was caused by delays in care seeking, provider failure to diagnose TB at first contact, use of the private sector which did not treat TB and multiple care seeking within and between sectors. CONCLUSION: Patient behaviour interacts with institutional arrangements in a way that materially exacerbates TB diagnostic delay. Care seeking in pluralistic settings needs to be understood as a complex process involving a range of providers across sectors. Strategies to smooth the flow of patients within and between sectors and improve perceptions of both service quality and levels of privacy will reduce diagnostic delays and improve both the efficiency and the effectiveness of the current TB treatment programme.