Chagas disease is the leading cause of nonischemic cardiomyopathy in Latin America. Timely access to diagnosis and trypanocidal treatment and preventive tools for millions of infected people continues to be a challenge. The purpose of this study was to identify potential barriers for the diagnosis of Chagas disease in Colombia from the perspective of healthcare providers. Using a simultaneous mixed-methods study design, we analyzed trends in access to screening and diagnosis for Chagas disease in Colombia and assessed the national barriers to access. The main barriers to access at the national level included a limited governmental public health infrastructure for the diagnosis of Chagas disease and limited physician awareness and knowledge of the disease. Data indicate that 1.5% of total expected cases based on national prevalence estimates were reported. Few public health laboratories have the capacity to perform complementary tests for the diagnosis of Chagas disease and almost 6 months elapse between the requests of the tests and the confirmation of the disease. This study shows that infected people must overcome a number of barriers to achieve diagnosis. Reducing barriers to early diagnosis of Chagas disease is an important goal in the fight against the disease.
Timely access to diagnosis and anti-
The diagnosis of Chagas disease is complex due to the dynamics of parasitemia in the phases of the disease [
Recently, molecular techniques such as polymerase chain reaction (PCR) have been considered as supportive diagnostic tests due to their ability to determine parasitic loads of
In Colombia, Chagas disease testing has not been broadly promoted, as well as the etiological treatment [
This research aimed to identify potential barriers to healthcare access for Chagas disease in Colombia, defined as diagnosis, from the perspective of healthcare providers, and, additionally, to systematically review the literature on the views of healthcare professionals to the access to healthcare for Chagas disease and to identify potential barriers.
A simultaneous mixed-methods study design was conducted, involving (i) a systematic review of the literature to identify published papers describing the views on the barriers to access to healthcare for Chagas disease from the perspective of health managers and health professionals, (ii) a cross-sectional survey, and (iii) semistructured in-depth interviews, to collect data from healthcare providers and policymakers at the national level in Colombia. In addition, (iv) key documentary information was examined. The results of the four stages of data collection were formally triangulated.
This review was carried out as per PRISMA guidelines (Table
Identified articles were initially filtered with a title search by two investigators independently. Publications were included if they reported on views of health managers and health professionals on access barriers to healthcare for Chagas disease. The concept of access to healthcare was defined as the degree to which people are able to reach and obtain adequate care from the healthcare system in a timely manner [
The extraction of the results from the primary studies in this review was done manually in a matrix (Access 2007, Microsoft Inc., Redmond, WA), which included data on authors, year of publication, country of origin, aims, research design, characteristics of the scenarios and participants of studies, data recognition tools, method of data analysis, and specific results presented by the researchers. Data were extracted by one reviewer and checked by two others for omissions and accuracy. The data analysis in this review was carried out following the approaches for the generation of qualitative metasynthesis suggested by
Qualitative data were collected via interviews (Appendix
Qualitative and quantitative data were collected via self-report. A self-administered questionnaire was created to assess the perception of these key informants about their own services in relation to barriers to access to diagnosis for Chagas disease and to evaluate the awareness and knowledge about the recommendations on the diagnosis of Chagas disease according to Colombian clinical practice guidelines (Appendix
Key documentary information was examined, for example, annual reports of confirmed cases of Chagas disease between 2008 and 2015, clinical practice guidelines, and protocols and reports of the national network of public and private laboratories in Colombia, including blood banks. A range of information was obtained from websites related to the National Institute of Health and the Ministry of Health of Colombia. The information regarding the location of the different laboratories with the capacity to diagnose
All quantitative survey data were doubly entered into a computerized relational database (Access 2007, Microsoft Inc., Redmond, WA). Means and standard deviations (SD) were determined for quantitative variables. Data were analyzed using Fisher’s exact test to compare categorical variables and an unpaired
Examination was based on framework analysis and thematic analysis methods. All qualitative data obtained from in-depth interviews and policy documents were described and organized according to the Health System Reform Framework [
Three triangulation techniques were used for the integration of research components [
Approvals were granted by the Technical Research Committee and Ethics Research Board at the National Health Institute in Bogotá, Colombia, Protocol CTIN-014-11, Minute 9 of December 11, 2012. Participation was voluntary and informed consent was obtained from all interviewees.
The literature search identified 964 records. After screening titles and abstracts, 14 met inclusion criteria and were eligible. After full-text review and manual review of references, 3 publications were included; a PRISMA flow diagram of study selection is presented in Figure
PRISMA flow diagram describing the review process and study selection.
The revision of the articles included in this study reported that patients with Chagas disease face a variety of barriers to obtaining adequate and timely access to care for this disease, mainly barriers associated with diagnosis and treatment. Most of the views expressed about access to healthcare for a person infected with
Main characteristics and study design of the articles included in this review.
Authors (Ref) | Year of publication | Country | Study design | Key findings | CAPS |
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Manne-Goehler et al. [ |
2015 | United States of America | Mixed methods | (1) An inability to place orders for Chagas disease diagnostic tests in institutional laboratory ordering systems, (2) heterogeneity in available diagnostic tests, (3) a limited capacity to conduct definitive confirmatory diagnostic testing, (4) poor follow-up of positive blood donors, (5) diagnostic and institutionalized referral and care processes, (6) lack of financing for patient-care activities, and (7) limited awareness and training among providers | Mixed methods |
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Manne-Goehler et al. [ |
2014 | Mexico | Mixed methods | (1) Lack of market authorization for benznidazole, (2) long waiting times for medicine importation, and (3) limited awareness of the disease among both physicians and patients | Mixed methods |
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Manne et al. [ |
2013 | Mexico | Mixed methods | (1) Exclusion of antitrypanosomal medicines from the national formulary, (2) historical exclusion of Chagas disease from the social insurance package, (3) absence of national clinical guidelines, (4) limited provider awareness, (5) no national clinical guidelines for Chagas disease treatment, (6) global supply chain problems: long waiting times, and (7) insufficient training and education of providers about Chagas disease and its diagnosis and treatment | Mixed methods |
Ref: reference; CAPS: Critical Appraisal Skills Programme checklist.
The most frequent barriers reported were limited diagnostic and institutionalized referral and care processes, lack of laboratories that perform confirmatory tests, lack of financing for patient-care activities, limited awareness and training among providers, lack of licensing of drugs for Chagas disease, absence of national clinical guidelines, and limited provider awareness.
Interviews with health managers and health professionals provided information on the routes for access to the diagnosis of Chagas disease in the health system (see Figure
Generalized flow diagram of Chagas disease diagnosis in Colombia.
Key informants unanimously declared that although the diagnosis of the disease was provided within their organization, community services and issues beyond their control also affected access to health and integration they were able to provide. Barriers to access that emerged from the key informant interviews were described and organized according to the Health System Reform Framework [
Summary of barriers to diagnosis access for Chagas disease in Colombia.
Barriers to access diagnosis |
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(i) Lack of diagnostic tests in hospitals in primary care |
(ii) Few centers that perform confirmatory tests |
(iii) Lack of awareness and knowledge about the disease among physicians |
(iv) Lack of validation of rapid tests |
(v) High heterogeneity in test reliability |
(vi) Nonintegration of diagnosis and treatment of Chagas disease |
(vii) Prior authorizations by health insurance institutions |
(viii) Difficulty for physicians to interpret test results |
(ix) The recruitment of medical and nursing staff |
(x) Lack of insurance reimbursement for services rendered |
(xi) Budget cuts |
(xii) The lack of more diverse staff to serve language minority communities |
(xiii) The multihiring services in different locations |
(xiv) Space limitations for medical equipment |
(xv) Cultural barriers |
(xvi) Internal armed conflict |
In total, 16 key informants were included. All questionnaires were completed and returned. The mean age of the respondents surveyed was 48.4 and the average number of years as an administrator or physician was 11.4. The majority of the respondents were male (12, 66.7%). All respondents were familiar with the existence of a guideline for the diagnosis and management of Chagas disease; the score obtained was associated with age and experience of the respondent; see Table
Distribution and comparison of knowledge scores about access to care for Chagas disease according to demographic characteristics of the respondents (
Characteristics | Knowledge score | |
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Mean ± SD |
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Administrator | 3.55 ± 0.50 | 0.629 |
Physician | 3.67 ± 0.53 | |
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40–45 | 4.00 ± 0 | 0.043 |
46–50 | 3.54 ± 0.52 | |
51–55 | 3.50 ± 0.57 | |
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Endemic | 3.87 ± 0.35 | 0.057 |
Nonendemic | 3.40 ± 0.52 | |
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9-10 | 4.00 ± 0 | 0.028 |
11-12 | 3.50 ± 0.53 | |
13-14 | 3.40 ± 0.55 |
The group (health professionals and health managers) evaluated that 100% of the population that they cover have access to the diagnosis for
The health managers refer that their institutions have an e-mail, telephone, and access to the Internet and this allows physicians to review the diagnostic and management guideline. The institutions do not have the infrastructure or economic resources to acquire the necessary equipment to confirm the diagnosis. They report that they have heard of other diagnostic methods such as rapid tests, but these are not recommended by the guidelines. In addition, they believe that other strategies should be used to explain the content of the guidelines because doctors “are saturated with clinical practice guidelines.” They perceive resistance from physicians to consider this diagnosis and they refer discomfort to research projects that screen for Chagas disease and do not disclose the results to the participants.
The health professionals feel that the diagnosis of Chagas disease is difficult because of the lack of specific signs or symptoms, especially in the adult population that generally has other comorbidities, and also the report of the results is not standardized and changes according to the laboratory, making the interpretation of the results difficult, especially “indeterminate results.” With regard to guidelines, they consider that these are rarely applicable to clinical practice and that the recommendations are not explicit and contain many tests that are not available in their region. They feel uneasy with research projects that perform specialized tests that they cannot interpret and that are not considered as diagnostic tests.
In Colombia, it is estimated that there are 4,813,543 people at high risk for getting Chagas disease and 437,960 cases infected with
In addition, a predominance of cases with chronic Chagas disease was observed in the main cities of Colombia. However, the data from the blood banks come from a selected population and these do not represent the distribution of the disease in the country. Unfortunately, there is no information on cases confirmed by blood banks and their referral to primary care centers.
Regarding the clinical practice guideline [
With regard to the diagnosis of Chagas disease in Colombia, all 33 public health laboratories have the capacity to carry out direct parasitological methods (thick and thin peripheral blood drop). However, of the 33 public health laboratories, only twenty have the structural and technological capacity to perform at least one indirect parasitological test (ELISA, IFA, or IHA), five laboratories perform 2 diagnostic techniques, and three laboratories perform 3 indirect parasitological tests. Eighteen public health laboratories perform ELISA, seven laboratories perform IFA, and three laboratories perform IHA. Distribution of indirect parasitological methods for diagnosis of Chagas disease in Colombia is shown in Figure
Distribution of laboratories according to department with the capacity to perform indirect parasitological tests (ELISA, IFA, and IHA) for diagnosis of Chagas disease in Colombia.
A total of 14 key findings were identified and the level of agreement among the sources of information is shown in Table
Integration of the main findings across the constitutive studies.
Key finding | Health professionals | Health managers | Literature review | Documentation |
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Diagnosis not considered by physicians | Agreement | Agreement | Agreement | Silence |
Unclear screening recommendations | Agreement | Agreement | Agreement | Agreement |
Lack of diagnostic tests in hospitals in primary care | Agreement | Agreement | Agreement | Agreement |
Few laboratories that perform confirmatory tests | Agreement | Agreement | Agreement | Agreement |
Lack of awareness and knowledge among physicians and patients | Agreement | Agreement | Agreement | Silence |
Positive blood donors not referred to the primary care centers | Agreement | Agreement | Agreement | Partial agreement |
Lack of validation of rapid tests | Agreement | Agreement | Agreement | Agreement |
High heterogeneity in test reliability | Agreement | Agreement | Agreement | Partial agreement |
Prior authorizations by health insurance institutions | Agreement | Agreement | Agreement | Agreement |
Difficulty for physicians to interpret test results | Agreement | Agreement | Silence | Silence |
The lack of more diverse staff to serve language minority communities | Partial agreement | Agreement | Agreement | Silence |
The multihiring services in different locations | Agreement | Agreement | Agreement | Silence |
Cultural barriers | Agreement | Agreement | Agreement | Silence |
Internal armed conflict | Agreement | Agreement | Silence | Silence |
PRISMA Checklist.
Section/topic | # | Checklist item | Reported on page # |
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Title | 1 | Identify the report as a systematic review, meta-analysis, or both. | |
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Structured summary | 2 | Provide a structured summary including, as applicable, background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number. | |
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Rationale | 3 | Describe the rationale for the review in the context of what is already known. | |
Objectives | 4 | Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS). | |
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Protocol and registration | 5 | Indicate if a review protocol exists and if and where it can be accessed (e.g., web address) and, if available, provide registration information including registration number. | |
Eligibility criteria | 6 | Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, and publication status) used as criteria for eligibility, giving rationale. | |
Information sources | 7 | Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched. | |
Search | 8 | Present a full electronic search strategy for at least one database, including any limits used, such that it could be repeated. | |
Study selection | 9 | State the process of selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis). | |
Data collection process | 10 | Describe method of data extraction from reports (e.g., piloted forms, independently, and in duplicate) and any processes for obtaining and confirming data from investigators. | |
Data items | 11 | List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made. | |
Risk of bias in individual studies | 12 | Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level) and how this information is to be used in any data synthesis. | |
Summary measures | 13 | State the principal summary measures (e.g., risk ratio, difference in means). | |
Synthesis of results | 14 | Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., |
This study provides evidence to suggest a wide gap in access to the diagnosis of Chagas disease in Colombia. To measure the gap in access to diagnosis, this research shows that from 2008 to 2015 only a small percentage (1.5%) of the estimated cases in Colombia were identified through the public health surveillance system [
This research also clearly shows the barriers to access to health services faced by patients with Chagas disease in different regions of the world, in particular, the barriers related to access to diagnosis and treatment of the disease. The interviewees confirmed that almost 6 months elapse between the requests of the tests and the confirmation of the diagnosis of the disease. The health system barriers that explain the gaps in access to care for patients with Chagas disease can be divided into three main barriers: (1) limited diagnosis of Chagas disease, (2) funding, and (3) limited physician awareness and knowledge of the disease.
The first is related to the limitations of access to diagnosis, a barrier identified in several regions of the world like the United States [
In order to reduce this barrier, countries have marketed rapid tests. However, in Mexico and the United States, great heterogeneity has been observed in the results [
The second limitation is funding. Financial barriers, not surprisingly, played a central role as demonstrated by several studies in the United States [
The third limitation is the lack of awareness and knowledge among physicians and patients about the disease. According to the interviewees, the lack of awareness of the disease represents one of the great barriers that limit access to diagnosis. If the physicians are not aware of the existence of the disease, they will not consider it as a potential diagnosis in the population at risk and will not order the needed diagnostic tests. This finding is similar to others reported in the United States [
Moreover, key informants perceived the inadequate implementation of clinical practice guidelines for Chagas disease. Most of the respondents mentioned that the guidelines are available on the website of the Ministry of Health of Colombia, but they lacked detailed knowledge of them probably because the guidelines as well as control programs were not widely disseminated. The respondents agreed that education about Chagas disease and control programs should be integrated in the training curricula, especially in medical schools and primary schools in endemic regions.
This study has some limitations; first, the review of the literature only chose articles published in English or Spanish. Secondly, the data on the prevalence of Chagas disease are limited worldwide. Third, there is little information on control programs and education of Chagas disease. Fourthly, the results for Colombia were based on opinions and experiences of key informants. However, high levels of agreement between the different key informants suggest reliability of the findings. The views and opinions of key informants may not be representative of all experts of Chagas disease in Colombia.
In conclusion, this study shows that the barriers to access to healthcare for patients with Chagas disease are a global problem; vast majority of people were diagnosed late due to these gaps in access to care. The limited awareness and knowledge of physicians about the disease and the limited number of laboratories with the capacity to perform confirmatory tests are the main barriers to accessing the diagnosis of Chagas disease. Rapid tests are techniques that could help reduce the diagnostic gap. However, having rapid tests is not enough, as many barriers may prevent their successful implementation, for which we recommend qualitative research on diagnostic practices that may help identify potential barriers. In Colombia, the results of this study show that infected people must overcome a number of barriers to achieve the diagnosis. Reducing barriers to early diagnosis of Chagas disease is an important goal in the fight against the disease. However, the current barriers must be addressed in order to provide widespread access to early diagnosis.
Chagas disease: 11555
Healthcare disparities: 10891 Health services accessibility: 94450 Quality of healthcare: 5777583 Healthcare quality, access, and evaluation: 6269340 Chagas disease/diagnosis: 1840 Delivery of healthcare: 913929 Health services accessibility/organization and administration: 16540 Quality of healthcare/organization and administration: 157674 Healthcare quality, access, and evaluation/organization and administration: 294747 Delivery of healthcare/organization and administration: 162632 Qualitative research: 31691 (1) or (2) and (4): 15 (1) or (2) and (5): 2766 (1) or (2) and (6): 2807 (1) or (2) and (8): 96 (1) or (2) and (9): 4 (1) or (2) and (10): 23 (1) or (2) and (11): 35 (1) or (2) and (12): 11 (1) or (2) and (13): 3 (1) or (2) and (4) or (5) or (6) or (8): 6349697 (1) or (2) and (4) or (5) or (6) or (8) and (13): 27929 (1) or (2) and (9) or (10) or (11) or (12): 325121 (1) or (2) and (9) or (10) or (11) or (12) and (13): 3366 (1) or (2) and (4) or (5) or (6) or (8) and (9) or (10) or (11) or (12): 297991 (1) or (2) and (4) or (5) or (6) or (8) and (9) or (10) or (11) or (12) and (13): 968 Limit (28) to English and Spanish languages and humans: 850
Chagas disease: 22906
Healthcare disparities: 18859 Health services accessibility: 5453 Quality of healthcare: 446069 Healthcare quality, access, and evaluation: 5778 Chagas disease/diagnosis: 6754 Delivery of healthcare: 29166 Health services accessibility/organization and administration: 124 Quality of healthcare/organization and administration: 10781 Healthcare quality, access, and evaluation/organization and administration: 11003 Delivery of healthcare/organization and administration: 5709 Qualitative research: 115133 (1) or (2) and (4): 5 (1) or (2) and (5): 40 (1) or (2) and (6): 171 (1) or (2) and (8): 17 (1) or (2) and (9): 5 (1) or (2) and (10): 5 (1) or (2) and (11): 5 (1) or (2) and (12): 5 (1) or (2) and (13): 5 (1) or (2) and (4) or (5) or (6) or (8): 612803 (1) or (2) and (4) or (5) or (6) or (8) and (13): 19359 (1) or (2) and (9) or (10) or (11) or (12): 14716 (1) or (2) and (9) or (10) or (11) or (12) and (13): 416 (1) or (2) and (4) or (5) or (6) or (8) and (9) or (10) or (11) or (12): 36356 (1) or (2) and (4) or (5) or (6) or (8) and (9) or (10) or (11) or (12) and (13): 634 Limit (28) to English and Spanish languages and humans: 543
Chagas OR Healthcare OR Sistemas OR Disparities OR Disparidad OR Access OR Acceso OR Barriers OR Barrera.
Chagas disease AND Access.
You agree to participate in this project, whose conditions are as follows: The project is aimed to identify the barriers to access for the diagnosis of Chagas disease in Colombia. For this purpose, semi-structured interviews will be conducted with key informants. Interviews will last about 30 minutes and questions will address issues of access to diagnosis. The interview you give and the information it contains will be used only for the purposes defined by the project. At any time, you may refuse to answer certain questions, discuss certain topics, or even put an end to the interview. To facilitate the work of the interviewer, the interview will be recorded. However, recoding will be destroyed as soon as it has been transcribed. All interview data will be handled so as to protect your confidentiality. Therefore, no names will be mentioned and the information will be coded. All data will be destroyed at the end of the project.
What are the routes to access the diagnosis of Chagas disease in Colombia? How is the process in a health care institution for a patient to access the diagnosis of chronic Chagas disease in Colombia? What is the average time it takes for a patient to access the diagnosis of Chagas disease in the Colombian health system? What are the barriers faced by patients to access the diagnosis of Chagas disease in Colombia in terms of financing and payment? What are the barriers faced by patients to access the diagnosis of Chagas disease in Colombia in terms of institutional organization? What are the barriers faced by patients to access the diagnosis of Chagas disease in Colombia in terms of regulation? What are the barriers faced by patients to access the diagnosis of Chagas disease in Colombia in terms of behaviors?
This questionnaire is part of a study whose main purpose is to provide relevant information to contribute to identify the barriers to access for the diagnosis of Chagas disease in Colombia and that can be used in the construction of possible solutions to improve access to diagnosis. We expect the survey to last approximately 15 minutes. All information collected will be kept confidential. Are you willing to participate in this study? Yes □ No □
Date of the interview: _________________ (day/month/year) Initials of the respondent: _________________ Sex Male □ Female □ Age: _______________ Studies carried out Undergraduate: ____________ Postgraduate: _____________________ ___________________________________________________ Institution where you work: _________________________ Place: ______________________ (municipality/department) Years of work experience: _____________________ Start time of interview:_________________
Do you know the guide to clinical care for Chagas disease in Colombia?
Yes □ No □ Is the diagnosis of Chagas disease in the acute phase carried out using direct parasitological methods?
Yes □ No □ Do not know □ Is the diagnosis of Chagas disease in the chronic phase carried out using serological methods?
Yes □ No □ Do not know □ To confirm the diagnosis of Chagas disease in the chronic phase do two tests of different principles be required?
Yes □ No □ Do not know □ Is the Polymerase Chain Reaction (PCR) technique recommended in the diagnostic algorithm for chronic phase Chagas disease in Colombia?
Yes □ No □ Do not know □ Are rapid tests recommended in the diagnostic algorithm for chronic Chagas disease in Colombia?
Yes □ No □ Do not know □
What are the routes for access to the diagnosis of Chagas disease in Colombia? What are the recommended tests for the diagnosis of Chagas’ disease (acute and chronic) in Colombia and which are available in the Health System? What barriers do you consider limit access to the diagnosis of Chagas’ disease in Colombia? What do you think about the coverage of the diagnosis of Chagas disease in your institution? What is your perception about the knowledge about Chagas disease that the directors and/or doctors working in your institution have? End time of interview:_________________
The authors declare that there are no conflicts of interest regarding the publication of this paper.