| BACKGROUD AND AIMSTuberculosis (TB) disease is one of the public health problems that severely threatened the global people's health. Following the prevalence of AIDS and the increase of resistance to anti-tuberculosis medicines, the number of the TB patients is still increasing in the world. As one of the 22 higher TB disease burden countries in the world, China ranks the second following the India in terms of the amount of TB patients. About 80% of TB patient lived in the rural areas in China. TB disease is one of the main diseases that cause the rural population into poverty and impoverishment.Directly Observed Treatment, Short Course strategy (DOTS) was the most cost-effectiveness strategy recommended by WHO for achieving the goal of global TB control.Even great achievement has made through the implementation of DOTS globally, there are still many factors undermining the effect of DOTSCurrently the key points of gloable TB control are focused on how to detect the potential patients timely, and how to further improve the quality of DOTS strategy. In the DOTS strategy the patients' early presentation to TB treatment and good adherence to DOTS treatment are the two key factors that ensuing the implementation of DOTS strategy successfully. The research results from developed and developing countries have showed the poor adherence to DOTS treatment and delayed treatment severely weakened the effectiveness of DOTS strategy. Poor adherence and delayed treatment would increase the spread of TB and drug resistance, which have been recognized and accepted by the whole world. In China, the emphasis of TB control will also focus on enhancing the detection rate of TB patients, especiall for rural TB patients, and on improving the quality of DOTS strategy through further regulating the implementation of DOTS.The aim of this project is to provide scientific interventions and recommendations for further developing a sustainable TB control mechanism through studying the health-seeking behavior of Shandong rural TB patients, the patient's therapeutic behavior in the DOTS treatment.METHODOLOGYThis was a retrospective case study and consisted of two individual studies: delayed presentation to DOT treatment and adherence to treatment.Total 7 counties in Shandong Province were selected as study sites according to the geography and economic distribution. The smear-positive TB patients registered in the county TB dispensaries were recruited into this study, which included the patients who were being treated and who had finished the treatment within one year. Total 247 TB patients were investigated in the delayed presentation study, and 404 patients in adherence study. Meanwhile the directors, clinical doctors of county TB dispensaries, and village doctors were interviewed as key informants for understanding their perceptions on rural TB patient's health-seeking behavior and treatment behavior. Literature reviews, patient survey by face to face and key informant interview were the main data sources. The researchers and graduated students in Shandong University are the data collectors. The Intercooled STATA 9.0 was used to analyze the data, and the descriptive statistical analysis, signal factors analysis and logistic regression analysis were the main analyzing methodsRESULTSThe rural TB patients had poor knowledge on TB prevention and treatment, themain knowledge source were from their families, relatives and friends. The health education didn't play enough roles on helping patients to get the right knowledge.Over 50% of TB patients had cough at onset, 58% of them selected the village doctors as their first visit health facilities, and closer to their home was the main perceived reason by them. Marriage status, economic level and the severity of symptom at onset were the factors that impacted on their first selection on health institution. The married patients would like to go to the health institutions over village level, the patients with debt preferred to go to village doctors, and the patient with mild symptom, such as cough, sweat at night, had more opportunity to see the village doctors.Without considering the repeated visit to a health institution, the average number of health institutions visited by per patient before they went to the county TB dispensary was 2. The patient's health-seeking behavior was not developed in line. The county hospital, township health center and village doctors were the most used health institutions by rural TB patients. The multi-regression results showed that the counties difference and the first selected health institutions has significant associaton with the difference of health-seeking behavior.The median days of patient delay for Shandong rural TB patients were 10 days, and the median days of health system delay were 24 days, which was the major contributor to the delayed presentation to treatment. The severity of symptom at onset would decide whether the patients would seek health care timely or not. The patients with severe symptoms would seek health care in time. Gender, economic status and the TB knowledge source were the main significant factors that impacted on the extent of patient delays. Female patients showed the shorter patient delay, the poorer the patients were, the longer the patient delays were. The patients whose knowledge mainly came from health promotion showed longer patient delays.Although the female patients had a shorter patient delay, they indeed showed a longer health system delay compared with male patients. The patients with more family members had shorter health system delays, and the patients who firstly went to county hospital had shorter health system delays compared with the patient firstly selected village doctors.37% of the patients had the stigma after they got TB disease, or they felt the change of attitude of their friends or the peers. The distribution of the patients with stigma in the four counties was significant different, the proportion of patients with stigma in Cangshan and Zhangqiu County was higher than the other two counties, which may be related with the local culture. The female patients showed more stigma than male patients, but there weren't significant difference between the age and between the education levels. 46% of the patients felt better after 2 months treatment, and there were not difference between gender and age. Nearly 60% of them had side-effects during the treatment, and 71% of patients showed the side-effects within 1 month. 82% of TB patients stored the medicines at home. Over 60% of them didn't get any visit by county TB dispensaries or township health centers. Shorter of professionals and traffic tools were the main reasons resulting in the low proportion of visits.21% of patient were monitored by village doctors when they swallowed the medicines, 22% of them were surveillanced by there family members, but over 60% of the family members didn't get and training on how to help the TB patients in the treatment period.33% of rural TB patients didn't go to county TB dispensary to get drugs per month, and among of them, 45% of patients had the irregular drug-gotten behavior after two months treatment. Gender, education level, stigma, with surveillance or not and whether patients know the right DOTS treatment time had significant impact on patients' drug-gotten behavior. Female patients were easier to get drugs irregularly; the patients with higher education could strictly follow the treatment guide to get drugs regularly. And the patients who swallowed the drugs under the surveillance of village doctors showed better regularity of drug-gotten behavior. The patients who knew the right treatment time had better drug-gotten behavior compared with the patients who didn't know it, and stigma would have significant influence on patient's drug-gotten behavior.Only 20% of the patients forgot to swallow their medicines at least one time during the treatment course. The first time of omitting to swallow medicines for nearly half of patients was in the first two months; this period also matched with the time when patients appeared the side-effect and when patients felt better firstly. The perceived reasons by patients for forgetting to swallow drugs timely were the side-effects and lack of reminding. The regression results showed that age, education level, whether patients knew the free treatment policy, whether patients had side-effect and with surveillance or not had significant effects on patients' drug-taken behavior. The younger patients showed higher possibility to forget to swallow medicines timely, and the patients with side-effect would be easier to omit to take medicines on time. The patients who were monitored by village doctors showed better drug-swallowed behavior.CONCLUSION AND RECOMMENDATIONSThe health-seeking behaviors of Shandong rural TB patients were complexes non-line development process. The selection of health care providers had significant association with the complexity of health-seeking behavior. Village clinics were the main firstly visited by rural patients when they got cough at onset, but most of them were diagnosed by catching a cold. The health system delay was the main contributor which resulting in patients' delayed treatment. The patients who visited village clinics had significant longer health system delays. Most of the rural patients were lack of surveillance in the course of DOTS treatment. Very few of them were monitored by village doctors when they swallowed medicines. Although family members have participated into the management of TB patients, the proportion of patients monitored by their family member was very low, and most of their family member didn't get any training. The rural TB patients had the situation of non-adherence to DOTS treatment in terms of regular drug-gotten and swallowing medicines timely, providing support for the patients, such as monitoring patients swallowing medcines, can improve their adherence to DOTS treatment.This study concluded that the key to the success of DOTS strategy is how to play the roles of health care providers on the TB control, rather than the patient's side. The specific recommendations include that improve their capability of TB diagnosis by establishing a long-term village doctors' training mechanism is essential, and through establishment of incentive mechanism encourages village doctors to participate into the TB control actively and accountable; establishing new patient-centered TB management mechanism and flexibly and targeted implementing DOTS strategy; setting up the community-based rural TB control scheme by encouraging the involvement of community and expanding the supervisors to family members with essential training; carring out the TB health education to the public by strengthening the education on TB basic knowledge. Health eduation should be targeteted and be with a long-term design.
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