Healthcare diagnostic delay of Tuberculosis in Portugal – is education the key?

<bold>Introduction:</bold> Tuberculosis (TB) remains a global health concern and the COVID-19 pandemic has impacted the fight against TB, with delays in diagnosis. Timely diagnosis is crucial, with experts suggesting that diagnostic delay reflects the efficacy of TB programs. Despite the advances, diagnosis is often delayed due to clinicians' low suspicion. Our study aims to assess the healthcare diagnostic delay of TB in Portugal, identifying linked factors. <bold>Methods:</bold> Retrospective analysis of TB notifications in Portugal (2008-2017), analyzing socio-demographic and medical data. Patients with missing/incorrect data were excluded. Analysis was performed with R software, employing multiple imputation and studying associated factors through a generalized additive model <bold>Results:</bold> Among 15359 TB notifications, male sex comprised 70.4%, and 45.1% were aged 20-44. Approximately 7% originated in a high TB incidence country, while 84% were Portuguese. The developed model identified significant diagnostic delays in females and those aged>45, contrasting with lower delays in alcohol abusers and residents in community settings. Additionally, shorter delays were associated with higher education levels and social income <bold>Discussion:</bold> Most factors contributing to diagnostic delay overlap with those described in studies from other countries, namely female gender, older age, and shorter delay in groups with higher stigma. To our knowledge, the fact that a higher education level contributes to a shorter healthcare delay has not been previously described <bold>Conclusion:</bold> Our study provides a robust assessment of diagnostic delays in Portugal. Known factors (gender, age, social factors) affect delay, but the novel observation that higher education levels reduce delay suggests a potential target for enhancing TB program performance