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Research Article

Indu J Ekka1 ,Pallavi

Treatment Seeking Behavior and Factors
R Shidhaye2 , DM Associated with Its Delay among Newly
Saxena3 , Vishal
Bankwar4 Diagnosed Pulmonary Tuberculosis Patients
1 2
PG Student, Assistant
Professor , Professor &
in Bhopal, Madhya Pradesh
HOD, Associate
Professor, Department of Abstract
Community Medicine, L.
N. Medical College, Background: Tuberculosis (TB) is a major public health challenge for various reasons,
Bhopal, Madhya Pradesh, with patient delay in the diagnosis of TB being one of the important hurdles in TB
control. Early treatment of TB cases is important for reducing transmission, morbidity
Correspondence to: and mortality associated with TB.
Dr. Indu J Ekka,
Department of Objectives: (a) To study the treatment seeking behavior among TB patients attending
Community Medicine, DOTS Centers; (b) to determine any delay in seeking treatment among patients; and (c)
L.N. Medical College, to identify reasons and associated factors responsible for patient’s delay.
Bhopal, M.P. India.
Materials and Methods: This was a cross-sectional study conducted among newly
E-mail Id: dr.indujyotsna
diagnosed pulmonary TB patients who were registered under the Revised National TB
control program (RNTCP) in Jai Prakash TU of Bhopal, Madhya Pradesh. Patients were
interviewed using a pre-tested semi-structured questionnaire which was designed to
elicit the treatment-seeking behavior and factors associated with patient delay. SPSS
software was used for analysis and chi-square statistical test was used to compare two
groups for proportions.

Results: Overall mean delay to seek treatment for tuberculosis was 27 days. Out of total
493 patients, 242 patients had reported delay, i.e., 49.1% had not reported to doctor or
health center for diagnosis when they had cough with more than 2 weeks’ duration.
Sixty-five percent patients had no awareness about TB. Fifty-four percent patients first
sought care in private health facilities, followed by government health facility 22.5%
after they developed symptoms of TB.

Conclusion: Unsatisfactory knowledge of TB may be contributing to patient’s delay.

There is a need for an active and ongoing IEC campaign, with special focus on an early
diagnosis. Building partnerships with the private health sector for reducing delays in the
diagnosis of TB would be useful.

How to cite this article: Keywords: Treatment-seeking behavior, Pulmonary tuberculosis, Patient delay, DOTS
Ekka IJ, Shidhaye PR, center.
Saxena DM et al.
Treatment Seeking
Behavior and Factors
Associated with Its Delay
among Newly Diagnosed Tuberculosis (TB) causes enormous social and economic disruption and it hampers a
Pulmonary Tuberculosis nation’s development.1Tuberculosis is a major cause of illness and death worldwide,
Patients in Bhopal, especially in Asia.2 Though the second-most populous country in the world, India has
Madhya Pradesh. Epidem more new TB cases annually than any other country. India and China alone accounted
Int 2016; 1(3) 26-31. for 24% and 11% of global cases, respectively.3 Although the RNTCP (Revised National
TB Control Program) was expanded to cover the whole country, a substantial number of
ISSN: 2455-7048 patients with TB are still treated within the private sector.4To provide access to the
RNTCP for these ‘missing patients’, it is important to involve private practitioners (PPs)

© ADR Journals 2016. All Rights Reserved.

Epidem. Int. 2016; 1(3) Ekka IJ et al.

in the RNTCP.4 Several studies have also shown that the diagnosis of TB were asked as open-ended questions
patients quite often ‘shopped around’ for a diagnosis, and the answers were then subsequently coded and
before they were started on treatment under the entered. All the patients who met the eligibility criteria
program.5 Many patients are treated by private were interviewed after obtaining a written informed
providers, and these are not notified to the health consent from them at the DOTS center.
Patient was a new sputum-positive and new sputum-
Studies have also shown that the mean patient delay in negative PTB case initiated on category I (cat-I)
seeking care was from 25 to 120 days6 and that the treatment regimen as per DOTS at the time of study
patients met several health care providers before period. Provider was a qualified healthcare provider
getting diagnosed and starting with the TB treatment.6-8 (HCP) or facility approached by the patient for relief
A delay in TB diagnosis could lead to worsening of the from their symptoms suggestive of TB. Treatment delay
disease and an increased transmission of TB in the was considered when the interval was >14 days
community. Further, the delays in the diagnosis can be between the first onset of symptoms suggestive of TB
associated with increased costs to the patients in the and first consultation with a healthcare provider.
form of out-of-pocket payments for medications, special Treatment-adherent patient was the eligible patient
foods, tests, and lost work time.8 In a passive case- who did not interrupt ATT any time for >1 month.
finding program, this is dependent on the treatment- Treatment non-adherent patient was the eligible
seeking behavior among individuals with chest patient who interrupted ATT any time during the course
symptoms and the interval between first contact with a for >1 month.
provider and initiation of treatment. Knowledge about
the patient delay and the facilities which are visited is Ethical approval for the study was obtained from the
very crucial for subsequent implementation of Institutional Ethics Committee of the College. The data
awareness and communication activities and these will was validated throughout the interview by repeated
influence the type of stakeholders who are needed to questioning. Subsequently, the data was verified,
be involved for a successful TB program. entered and analyzed by using MS Office and SPSS (19
version). Pearson’s chi-square test was used as a test of
The present study was undertaken among TB patients to significance. A p-value of <0.05 was considered as
detect the delay in seeking treatment at DOTS centers statistically significant.
and where they visit first for TB symptoms. It was also
interesting to know the factors associated with Results
treatment-seeking delay for tuberculosis.
In the Tuberculosis Unit, 493 patients were interviewed
Methods over a period of one year.

A cross-sectional study was done among all newly Profile of the Respondents
diagnosed Category-I pulmonary tuberculosis (PTB)
patients (both new sputum-positive and new sputum- Most of the patients were males 294 (60%) and
negative patients). The TB patients who were registered maximum respondents belonged to age group 18–32
in the Jai Prakash Tuberculosis Unit (TU) of Bhopal years, i.e., 230 (47%) and 163 (33%) had primary school
between January 2014 and December 2014 were education, while 209 (42%) were illiterate. About 17
included for the study. Adult TB patients of both sexes, (3.4%) of the respondents were involved in skilled work.
who were registered under RNTCP and who came to the Socioeconomic status of the respondents revealed that
TU for direct observed treatment, were considered majority of them belonged to lower classes constituting
eligible for the study. Data was collected from directly 444 (90.06%) (Table 1). The new sputum-positive
observed treatment short-course (DOTS) centers under patients were 317 (64%) and new sputum-negative
designated microscopy centers (DMC) of Jai Prakash patients were 176 (36%).
Tuberculosis Unit. A pre-tested, semi-structured
questionnaire was used to collect information on socio- Patients’ Delay in Seeking Treatment
demographic characteristics of the patients and on their Overall mean delay of seeking treatment for
delay in seeking treatment. The delay in seeking tuberculosis was 27 days. Out of total 493 patients, 242
treatment was defined as the duration in days from the had treatment-seeking delay, i.e., 49.1%. The delay was
onset of the symptoms to the first treatment-seeking more among males 156 (53%) as compared to females
incident with a health provider. Questions which were
86 (43.2%). Out of 137 (28%) respondents in the age
related to the perception of the patients to the

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Ekka IJ et al. Epidem. Int. 2016; 1(3)

group 33–47 years, which was the most productive age Treatment delay was more in smokers 103 (66%) and in
group the treatment delay was more, i.e., 80 (58.4%) alcoholics 187 (90%). Delay was more in patients who
(p<0.05). 209 (42%) were illiterate and of them 140 were not aware about TB (57%) and also among those
(67%) had treatment delay. Delay is more in lower who travelled more than 2 km distance from health
classes (84.3%) than in upper classes patients (15.7%) facility, i.e. 52.5% (Table 1).
Table 1.Distribution of Factors of Treatment Delay among TB Patients
Variable Treatment No Treatment Total n (%) X2 P Value
Delay n (%) Delay n (%) Value
Sex Male 156 (53%) 138 (47%) 294 (60%) 4.60 <0.05*
Female 86 (43.2%) 113 (56.8%) 199 (40%)
Age 18–32 96 (41.7%) 134 (58.3%) 230 (47%) 10.3 <0.05*
33–47 80 (58.4%) 57 (41.6%) 137 (28%)
≥48 66 (52.4%) 60 (47.6%) 126 (25%)
Education Illiterate 140 (67%) 69 (33%) 209 (42%) 69.4 <0.001*
Primary 51 (31.3%) 112 (68.7%) 163 (33%)
Middle 40 (54.8%) 33 (45.2%) 73 (15%)
Higher Secondary 11 (41%) 16 (59%) 27 (6%)
Graduate 0 (0%) 12 (100%) 12 (2%)
Post graduate 0 (0%) 9 (100%) 9 (2%)
Socioeconomic Upper 12 (5%) 7 (2.8%) 19 (4%) 51.2 <0.0001*
Status Upper middle 26 (10.7%) 4 (1.6%) 30 (6%)
Lower middle 42 (17.3%) 78 (31%) 120 (24%)
Upper lower 108 (44.6%) 144 (57.3%) 252 (51%)
Lower class 54 (22.3%) 18 (7.2%) 72 (15%)
Smoking Yes 103 (66%) 53 (34%) 156 (32%) 26.2 <0.0001*
Status No 139 (41%) 198 (59%) 337 (68%)
Alcohol Yes 187 (90%) 20 (10%) 207 (42%) 243.25 <0.0001*
Consumption Status No 55 (19%) 231 (81%) 286 (58%)
Awareness Yes 56 (33%) 114 (67%) 170 (35%) 27.1 <0.0001*
regarding TB (in No 186 (57%) 137 (43%) 323 (65%)
patients )
Distance between <2 km 73 (43%) 98 (57%) 171 (35%) 4.29 <0.05*
Home and DOTS >2 km 169 (52.5%) 153 (47.5%) 322 (65%)

In our study out of total 493 patients, a majority of the and 7 (4.1%) came with other symptoms (Table 2). For
patients 408 (83%) were treatment-adherent of which majority of the respondents most preferred a private
201 (49%) had treatment delay. Out of 85 (17%) doctor 268 (54.3%) followed by government health
patients who were not adherent to TB treatment facility 111 (22.5%), 58 (11.8%) took self-treatment and
41(48%) had patient delay but there was no significant 56 (11.4%) took treatment from pharmacy (Table 3).
difference found in patient delay in patients who were
treatment adherent and non-adherent to TB treatment. Reasons for the Patient Delay

Treatment Seeking-Behavior Out of 242 (49.1%) patients, majority of the patients

had delayed the treatment as they were not aware of
Out of 493 respondents, 322 (65.31%) patients sought the severity of the problem (71%); followed by 39 (16%)
treatment for cough of which 124 (38.5%) came late and who were delayed as the treatment was expensive in
171 (34.69) patients came to doctor when they had non-government health facilities; and 22 (9%) were
other associated symptoms. Out of 171 respondents, 71 delayed due to inconvenient transport and long distance
(41.5%) came to doctor with fever, 28 (16.4%) came and 10 (4%) were delayed due to lack of time (Table 4).
with blood in sputum, 12 (7%) came with weight loss

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Epidem. Int. 2016; 1(3) Ekka IJ et al.

Table 2.First Symptom for which Respondents Sought Treatment

First Symptoms to Seek Treatment Treatment Delay Total n (%)
Yes n (%) No n (%)
Cough for more than 2 weeks* 124 (38.5%) 198 (61.5%) 322 (65.31%)
Fever** 71 (67.6%) 34 (32.4%) 105 (21.31%)
Sputum with blood$ 28 (80%) 7 (20%) 35 (7.10%)
Weight loss 12 (63.2%) 7 (36.8%) 19 (3.85%)
Others 7 (58.3%) 5 (41.7%) 12 (2.43%)
Total 242 251 493
2 2
*X =41.56, p value=0.0001; **X =18.33 p value=0.0001; $p value=0.001
Table 3.Patient Delay according to First Treatment-Seeking Place when Became Ill
First Treatment Seeking Place Treatment Delay Total n (%)
Yes n (%) No n (%)
Self-treatment 28 (48.3%) 30 (51.7%) 58 (11.8%)
Government* 68 (61.3%) 43 (38.7%) 111 (22.5%)
Private 109 (41%) 159 (59%) 268 (54.3%)
Pharmacy* 37 (66%) 19 (34%) 56 (11.4%)
Total 242 251 493
*p value <0.0001
Table 4.Distribution of Patient Delay according to Reasons Given by Patients
Reasons for Patient Delay Treatment Delay Total n (%)
Yes n (%) No n (%)
Not aware of the severity of the problem* 171 (71%) 139 (55%) 310 (63%)
Expensive 39 (16%) 24 (10%) 63 (13%)
Lack of time 10 (4%) 49 (20%) 59 (12%)
Transportation and long distance 22 (9%) 39 (15%) 61 (12%)
Total 242 251 493
*X =5.7, p value <0.01

Discussion Similar to our study, Madebo T et al. stated that being

illiterate was associated with longer patient delay.12
In the present study, the mean treatment delay was 27 Smoking whether current or ex-smoker was reported as
days which is similar to the study conducted by Selvam significant risk factor for delay. Smokers often do not
et al.,8 where median delay of 28 days was reported. present themselves to health facilities in the belief that
However, it was much higher than mean of 18.4 days their cough is due to smoking. This observation is similar
reported in the systematic review by Sreeramareddy et to the study conducted by Selvam et al.8 A study done
al.9 In the present study, 49% of the study population by Kulkarni et al. found that 34.6% were smokers and
delayed in seeking care from a healthcare practitioner 37.8% (59) were alcoholics.13 Goel et al. found in their
(HCP) compared to 29% in a study done by Tamhane et study that 43% of patients reported alcohol use and
al.10 alcohol dependence as a reason for patient delay.14
Similar to our study, Rajeswari et al.7 found that alcohol
This difference could be because of different population was a significant risk factor associated with delay. In the
and taking definition of patient delay. These studies present study, cough followed by fever was the main
have defined patient delay end-point as consulting a symptom experienced by TB patients which prompted
healthcare practitioner which included traditional them to seek healthcare. Other symptoms were
healers but in present study, HCP did not include reported less frequently. These findings are consistent
traditional healers. Dhanvij et al. 11 reported median with a study by Rajeswari et al.7 where 98% of
delay of 47.2 days. Patient delays can occur during the tuberculosis patients presented with cough and
process of noticing symptoms, determining if one is ill, Salaniponi et al.,15 where 61% of patients presented
assessing the need for professional care and overcoming with cough and 16% with fever. Our study results were
social, personal and physical barriers to obtain the care. also similar to various studies around the world, as
published in a systematic review by Storla et al.16

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Ekka IJ et al. Epidem. Int. 2016; 1(3)

However, Tamhane et al.10 reported fever to be the compared to inaccessibility and lack of awareness about
most common presenting symptom. It is well known public sector healthcare facilities. Our findings are
that tuberculosis is initially suspected by cough consistent with the findings of Fatiregun et al.21 In the
symptom. It might be that more ‘missed’ cases occur present study, majority of the patients had delayed the
among those who present with other symptoms. With treatment as they were not aware of the severity of the
onset of symptoms, patient took variety of initial action. problem (71%). Hoa et al.22 and Tobgay et al.23 from
Sikkim also had the similar findings. In the current study,
The risk of increased patient delay was higher in those there was no association found in delay in patients who
having lack of awareness and with education less than were adherent and non-adherent to TB treatment. In a
5th standard. In this regard, similar finding was observed study conducted by Kulkarni et al., it was found that the
by Lienhardt et al.17 and may be explained by the fact patients without patient delay were more likely to be
that subjects with lower level of education might have treatment-adherent.13
poor awareness regarding the symptoms and treatment
of TB. In our study, we found that most of the study Limitation
subjects believed that the symptoms were not serious
and would disappear by themselves. This clearly showed In the present study, the data solely relied on the
lack of knowledge among the study subjects with responses given by the patients, which could have been
perceptions and practices that might delay treatment- subjected to recall bias.
seeking in the patient and we found significant
association in our study. This also suggests that the Conclusion
government’s strategy for IEC is not effective to make a
mark on the peoples’ understanding. Similar findings Unsatisfactory knowledge of TB is contributing to
were seen by Rajeswari et al.7 treatment delay. This indicates that the information
about “cough with more than 2 weeks duration maybe
In our study, distance from home to health facility tuberculosis” has not percolated in the population.
played a significant factor for patient delay for Delay in early diagnosis and treatment of TB will
treatment. A WHO study found living more than an hour continue to spread the disease in the community. This
away from a public health facility to be a significant risk study highlighted the need for an active and ongoing IEC
for health system delay.18 A study by Tamhane et al. (information, education and communication) campaign,
stated that travelling to a health center more than 15 with special focus on an early diagnosis. Building
minutes away was problematic particularly for partnerships with the private health sector for reducing
females.10 Rajeswari et al.7 found that patient delay was the delays in the diagnosis of TB would also be very
greater if patient initially consulted a government important.
provider similar to our study. In contrast to our study, a
WHO study18 found that patient delay was significantly Implications
longer if the patient first consulted a private healthcare
Host factor such as treatment seeking-behavior could be
provider and if the diagnosis was made by the private
associated with spread of tuberculosis. Treatment
sector. Datta et al.19 found that 16.5% of patients tried a
seeking itself could be affected by awareness about the
home remedy before proper care seeking in the form of
severity of disease, availability of drug on pharmacy
cough syrup, antibiotics and other over-the-counter
store without prescription, accessibility of health
drugs. In contrast to our study Datta et al.19 found that
services, etc. Therefore, host and environmental factors
69.5% of patients first went to a government health
play significant role in disease-control activities.
facility compared to 30.5% patients who went to private
health facilities. In a study done by Brugha et al.,20 the
reasons for patients presenting to private practitioners
before public doctors are: greater ease of access, We would like to acknowledge the RNTCP state task
shorter waiting periods, longer or more flexible opening force for funding this project under operational research
hours, better availability of staff and drugs, more activities for post graduate dissertation. We would like
sensitive health worker-client attitudes, greater to thank the District TB Officer, Bhopal, for giving us the
confidentiality in dealing with stigmatized conditions permission to conduct the study and medical officers of
such as TB, more compatible with people’s expectations all DOTS centers for helping in this endeavor. We would
and cultural beliefs. Accessibility of private practitioners like to thank the study subjects for their participation in
followed by somebody’s advice were acknowledged as the study.
the prime reasons for seeking care from private sector

ISSN: 2455-7048 30
Epidem. Int. 2016; 1(3) Ekka IJ et al.

Conflict of Interest: None from: http://www.medscape.com/viewarticle/40

7989MedscapeGenera Medicine.
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Date of Submission: 8th Jul. 2016
duration among Ethiopian patients. 1999. Available
Date of Acceptance: 13th Jul 2016

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