Table 3.

Emerged themes and synthesized findings from qualitative studies

Themes	Countries	Quotes
Patient delay
Perceived stigma and discrimination at the workplace, within the family and the community against women, and associating TB with HIV deterred people with presumptive TB from seeking TB diagnosis and care	Bangladesh [115, 116], Brazil [129, 130], Cambodia [117], China [135, 136], Ethiopia [110], India [115, 121], Nigeria [125], Philippines [126], Russia [137], South Africa [139–144], Tanzania [114], Zambia [127], Zimbabwe [128]	“When someone says, ‘I have TB’ others will say that the person has three words [HIV].’’ [143]
		“The person would be scared that she would lose her job and that people and friends would avoid her.” [126]
Long distance to health facilities and language barrier led to delay in care-seeking and TB diagnosis	Brazil [131], Cambodia [48, 117], China [136], Ethiopia [111, 112], Philippines [126], Russia [137], South Africa [140, 142], Tanzania [114], Thailand [145]	“Well, I didn’t come to the health centre early because it is far from my village.” [111]
		“I don't understand the language, so I don't know what to do next after I finished the 15 days medication. The problem for me is the language because I can't speak Thai.” [145]
Long chains of care-seeking through multiple providers and the lack of trust in the health care system providing TB care led to delay in care-seeking and TB diagnosis	Bangladesh [115, 116], Brazil [131], Cambodia [117], China [134–136], Ethiopia [110–112], India [115, 118–122], Indonesia [123, 124], Mozambique [113], Nigeria [125], Philippines [126], Russia [137, 138], South Africa [139, 140, 142–144], Tanzania [114], Zambia [127], Zimbabwe [128]	“Government doctor did not show any interest, neither he responded to my questions. They never spoke to me at all. We went there 1–3 days and became fed-up. Even the 4th day, they did not say anything. They asked me to go here and there. It was really a horrible experience to run around there. So, finally, we decided and went to private” [122]
		“We usually try many other methods first, and the hospital is the last choice.” [117]
Gender-specific factors such as men dominating and owning the decision-making power in the family, more economic constraints for women to seek healthcare, and men concealing health issues or denying disease severity by substance (alcohol and nicotine) abuse led to delay in care-seeking and TB diagnosis	Bangladesh [115, 116], India [115], Nigeria [125], Russia [137, 138], South Africa [144], Thailand [145], Zimbabwe [128] (alcohol and nicotine) abuse led to delay in care-seeking and TB diagnosis	“There are very few women in my community who can afford the costs of transportation to the hospital and to pay the hospital fees.” [125]
		“My husband told me to go to my parent’s home. He refused to give me money for the cost of treatment. My neighbour did not help me that much either.” [115]
		“When I drink, nothing is bad for me! Illness flies out with alcohol. You don’t feel it. Alcohol softens everything, all diseases. When you drink, you do not pay attention to illness. Well, today you sneeze, cough, but it will pass! In the morning, you wake up, something squeaks, whistles; you groan but go anyway, then you forget about it during work.” [138]
Competing priorities of livelihood, work, and family led to delay in care-seeking and TB diagnosis	Cambodia [48], China [134], Nigeria [125], Philippines [126], Russia [138], Thailand [145], Zambia [127]	“They had to earn money for their families and had no time for illness and examinations.” [138]
		“I work almost every day except on market days on the farm and Sundays or if there are special occasions. I usually return in the late afternoon to cook for my husband and children. So, if I should go to the hospital in the morning hours as I am told that is when they open and return in the afternoon, that whole day is gone.” [125]
Poor knowledge regarding TB symptoms and treatment and the availability of free treatment policy were barriers to early healthcare-seeking	Brazil [129], China [134, 135], Ethiopia [110, 112], India [121], Indonesia [123], Philippines [126], Russia [138], South Africa [140, 142], Tanzania [114], Zambia [127], Zimbabwe [128]	“TB is not yet a disease that people recognise, then any respiratory problem is associated with virus diseases, flu, smoke, the dust of the street, all but a disease like TB.” [129]
		“Some participants in rural areas were sceptical whether the free treatment actually existed” [123]
People with presumptive TB delayed care-seeking due to low perceived severity of symptoms, low perceived susceptibility to TB, believed that TB is hereditary or retribution for sinful behaviour, blame others for the delay and then overpowered by hopelessness	Bangladesh [115], Cambodia [48, 117], Ethiopia [110], India [115, 119], Indonesia [124], Mozambique [113], Philippines [126], Russia [137], Tanzania [114]	“They also don’t take the symptoms seriously, they just assume that is a flu.” [142]
		“My uncle suspected that she [respondent’s mother] had TB. But my mother said that in her family, no one had ever had TB … She still rejected the idea and insisted that no one in her family ever had this TB. She asked us to stop referring her [to get medical help]” [117]
		“For all patients that had initially thought they were cursed, the fact that their disease was diagnosed in the hospital was perceived as a proof that TB is a punishment of God rather than caused by witchcraft forces. Now I realise it has nothing to do with witchcraft, like I thought in the past. It is a punishment of God. He pushes the wind that contains TB in the direction of the person that will subsequently develop TB.” [114]
		“I had been sick for two years. I went to a traditional healer, but he suggested to me to go to the hospital. Before that, my friend who also had got TB suggested to me to check my sputum because he thought I might have got TB as well. I insisted that it was not TB because I have never lived with TB patients… I have heard about TB, but I did not think I would get TB.” [124]
		“Patients referred to impoverished living conditions, unclean water and insufficient food as the reasons for their TB. These causes were linked to a sense of hopelessness and an inability to improve the conditions of one’s life.” [115]
Health system delay
Poor practice at the health facilities and ignorance of TB led to a delay in TB diagnosis	Bangladesh [116], Brazil [129, 132], China [133, 135], Ethiopia [110, 111], India [118, 122], Indonesia [123, 124], Tanzania [114]	“He had told me to take injections daily, and I was taking it as advised. But he did not tell me anything. He kept on saying it is typhoid. We told him that sputum is coming while coughing. But he said it will happen like this even for typhoid also.” [122]
		“There was poor adherence of the doctors to the recommended algorithm for investigating a patient suspected to have TB.” [118]
Complicated procedures at the health facilities to reach TB diagnosis	Brazil [130, 132], China [133], India [96, 119], Philippines [126], South Africa [144]	“Referrals from the public day or tertiary hospitals to clinics were not managed smoothly and receiving clinics frequently seemed to question the referral and/or diagnosis, sending the patient away without treatment or referring the patient on to another service provider.” [144]
Lack of resources and materials in the health facilities led to a delay in TB diagnosis	Brazil [129, 130, 132], India [96], Russia [138], South Africa [144]	“Very often, we do not have enough doctors or nurses in medical sites. Our doctor is absent very often. Then we go to another one. But she might not know my situation and prescribes something at random.” [138]
		“Where the patient was diagnosed at a centre without microscopy or had to be referred for treatment to a local DOTS centre, the delay was more likely to occur.” [96]
Treatment delay
Self-perception of health and unconvinced of the diagnosis and the effectiveness of TB treatment led to a delay in TB treatment initiation	Cambodia [48], India [96, 119], South Africa [141]	“Sometimes, they argued and denied (their condition). They would say they are healthy. Why did we think they had the disease? They didn't trust us because they were still feeling strong.” [48]
		“Some people distrust that the medication would not be effective. Some commented on such cases where the treatment did not work or where people repeatedly kept getting TB.” [141]
Diagnosis and treatment initiated in different facilities caused a delay in TB treatment initiation	India [119]	“Active referrals by the diagnosing provider to another provider for treatment initiation constituted the major reason for delay.” [119]
Geographical distance to health facilities and other competing priorities delayed TB treatment initiation	South Africa [141]	“Sometimes, respondents were referred for treatment, but because of work-related issues, particularly work hours and the place of work, they could not access care.” [141]
Health system factors such as lack of organization at the facilities to manage patients, poor staff attitude, and logistic issues caused a delay in TB treatment initiation	India [96], South Africa [141]	“A lack of organisation at the facilities causing delays in service and queues.” [141]
		“Complaints included that staff sent a patient away when they assumed that he was not taking treatment, treat patients like children and in a derogatory manner, blame patients for problems for which they are not responsible and for shouting and swearing at patients. These raised anger and irritation at the services. While the fear may motivate patients to remain on treatment, it can make it difficult for them to return if they did not initiate treatment.” [141]
		“Delay in the transport of drugs from the Peripheral Health Institution to the DOTS centres where the patient is supposed to start his DOTS.” [96]
Women experienced stigma due to TB diagnosis resulting in the concealment of diagnosis or being isolated	Zambia [127]	“A TB patient described that she was sent away and that in rural areas, TB treatment was not easily accessible or available. This contributed to her treatment disruption and aggravation of TB.” [127]

DOTS directly observed treatment, short course; HIV human immunodeficiency virus; TB tuberculosis