Given the targeted 4–5 per cent annual reduction of tuberculosis (TB) cases to reach the “End TB Strategy” by 2020 milestone globally set by WHO, exploration of TB health-seeking behaviour is warranted for insightful understanding. With that in mind, we performed a qualitative study to provide an account of the social, cultural, and socio-economic breadth of TB cases in Bangladesh. Covering both BRAC and non-BRAC TB program coverage areas to get an insight, it was found that underestimation of TB knowledge and lack of awareness among the TB patients along with the opinions from their family members played key roles in their TB health-seeking behaviour. A quick decision on the treatment issue was observed once the diagnosis was confirmed; however, difficulties were in accepting the diseases. Nevertheless, individual beliefs, intrinsic ideologies, financial abilities, and cultural and social beliefs on TB were closely interconnected with the “social perception” of TB that eventually influenced the care-seeking pathways of TB patients in various ways. Individual and community-level public health interventions could increase early diagnosis; therefore, reduce recurrent TB.
Researchers: Dr Md. Akramul Islam; Dr Mahfuzar Rahman; Anita Sharif Chowdhury; Belal Hossain; Shayla Islam, BRAC; Nusrat Khan; Saifur Reja; Tanvir Shatil
Partners: BRAC
Timeline: 2017-2018
Status: Completed
Contact: Tanvir Shatil
tanvir.shatil@bracu.ac.bd
Publication
Journal Article: Estimating Catastrophic Costs Due to Pulmonary Tuberculosis in Bangladesh
Context
Tuberculosis (TB) is a major public health problem; it is the ninth leading cause of death globally with 10.4 million new cases detected worldwide in 2016. To reduce the case fatality rate from 16 to 10 per cent between 2015 and 2020, it is necessary to diagnose and treat patients without any delay. Most TB-burdened countries now provide free treatment facilities through the National Tuberculosis Control Program (NTP). NTP is normally implemented by the government health services of a country’s national health system. Adopting the Directly Observed Treatment Short (DOTS) course strategy, NTP in Bangladesh runs on public-private collaboration with a strong contribution from non-government organisations (NGOs) like BRAC along with the government.
The current TB control strategy is based, among others, on passive case detection. Case detection, in turn, is highly influenced by a patient’s knowledge of TB symptoms, their presence, and severity influence their intention of healthcare-seeking. As a result, the success of this program largely depends on the healthcare-seeking behaviour of TB patients. It is, therefore, important to understand the care-seeking behaviours of TB patients in Bangladesh. We believe that this study will fill that knowledge gap.
Objectives
The objectives of this study were to understand the current healthcare-seeking pathway of pulmonary TB patients and understand duration and delays in TB care-seeking.
Methodology
For this study, a qualitative investigation was carried out to explore the TB care-seeking pathways in Bangladesh in both rural and urban areas. TB patients from four different sub-districts—Nandail Upazila from Mymensingh and Dumuria Upazila from Khulna representing the rural areas and Rajshahi City Corporation and Sylhet City Corporation representing the urban areas were selected. These four different geographical areas were selected on the basis of the good and bad performance of the health workforce (as per TB program’s expectation) of the existing TB care program implemented by BRAC and non-BRAC NGOs. We followed the “snowball sampling technique” starting from the TB service provider to identify the suitable participants from these study areas. The selected participants were then categorised into two groups—one representing the patients and the other representing the health service providers. Data were collected through a total of 32 in-depth interviews (IDIs) and 16 key informant interviews (KIIs).
Findings and Recommendations
Study findings show that the majority of patients tend to seek care within a week. But they sought care from a variety of health care providers—from certified doctors to bogus healers. However, the majority (71 per cent) sought care from drug storekeepers of local drug shop selling medicines. This proportion was about the same across rural BRAC/Non-BRAC and Urban BRAC/Non-BRAC areas. More than half (58 per cent) of the patients consulted two or more health providers before reaching DOTS. The same trend was present in rural BRAC/non-BRAC and urban BRAC/non-BRAC areas. Only nine per cent reported DOT centre as their first health care seeking point. About 98 per cent of the patients, who went elsewhere to seek first care, reported that they were not aware of the DOT provision. These patients also mentioned Family/friends (35 per cent) and BRAC staff (37 per cent) who advised them to seek care from DOT centre later. A quick decision on the treatment issue was observed once the diagnosis was confirmed; however, difficulties were in accepting the diseases. Nevertheless, individual beliefs, intrinsic ideologies, financial abilities, and cultural and social beliefs on TB were closely interconnected with the “social perception” of TB that eventually influenced the care-seeking pathways of TB patients in various ways.
Illiteracy is still a problem in our country; since passive case detection of TB is in place, patients, caregivers, health care providers as well as communities’ awareness regarding TB and its treatment needs to be enhanced through intensive TB communication tools and strategies. Both formal and informal private providers should also come under one standard operational procedure to manage suspected TB cases.
