Patient care seeking barriers and tuberculosis programme reform: a qualitative study

The patient's perspective, including his/her socio-economic and cultural environment, is an important consideration for tuberculosis control programmes. Through semi-structured interviews, this qualitative research studies the barriers to successful care seeking faced by 202 adult patients with pulmonary tuberculosis in urban Zambia. Three common, interdependent themes explain patient barriers to successful care seeking: (1) number of health care encounters and duration of illness prior to diagnosis; (2) existing financial constraints and additional unrecognized patient costs; and (3) travel distances. On average, patients have 6.7 health care encounters prior to being diagnosed with tuberculosis. Within a resource-poor setting, patients face financial constraints and unrecognized costs associated with their illness. Specifically, travel distances and related transportation costs create a significant burden on patients. In addition, 'special food' expenditures add to their financial constraints. The implications of these patient barriers from this study are then discussed in the context of three tuberculosis programme reforms occurring in sub-Saharan Africa: (1) decentralization of tuberculosis services; (2) integration of tuberculosis and other services; and (3) evaluation of diagnostic techniques. The patient's perspective and related care seeking barriers should be considered in reviewing existing tuberculosis programmes and policy, evaluating potential programme reform and assessing new tuberculosis interventions.