Study On Current Status And Countermeasures Of Tuberculosis Patients Health-Seeking Behavior And Treatment Management Among Migrants In Shandong

BackgroundsIn the late 1980s, the increasing incidence of tuberculosis (TB) brought it back to be one of the foci of public health arousing global concerns. As one of the 22 countries of heavy disease burden of TB in the world, China ranks the second just following the India in terms of the number of TB patients.In recent years, with the implementation of DOTS strategy and more attention of government at all levels, epidemic situation of TB in China had been curbed to a certain extent. Even so, China is still facing a good deal of severe challenges, one of which is TB control among migrants in China. In 2009, the number of floating population in China had risen to 211 million. In next 30 years, China will form a "trisection" pattern of 500 million urban populations,500 million floating population and 500 million rural populations. Because of low income, poor working and living conditions, low education level, and weak awareness of health etc., TB epidemic situation among floating population is relatively serious. Rapid increase in the number of floating population is one of the most important reasons of TB epidemic rise. No fixed homes for most of floating population, high mobility, and difficulties in adhering to regular treatments and in treatment management result in increasing proportion of drug-resistant TB and risk of transmission, which brings out many obstacles to the regional TB control. TB control among migrants has become an urgent problem to solve in TB Control Programme of China.Currently, TB control relies mainly on early detection of cases and completed treatment so as to cut transmission and reduce morbidity. Early detection requires a timely manner of identifying patients as suspicious TB cases and a rapid referral to TB dispensaries for diagnosis and treatment after their involvement in health system. Delays occurring in any part of health-seeking process would increase the probability of TB transmission and eventually result in high mortality. Therefore, the ability to detect TB patients among floating population is a key to the success of TB control. After diagnosis, treatment management of active tuberculosis patients and strengthened treatment management of smear-positive patients are necessary, so as to ensure patients complete treatment, otherwise, the success rate of treatment and cure rate would drop, number of drug-resistant TB cases would increase, which furthermore results in high risk of social transmission. Therefore, the effective management of patient treatment is another essential process in TB control among migrants.However, after searching for existing literature, we found no systematic research on behaviors and pathways of migrants'health seeking and relevant factors, as well as special survey on migrant TB patients'treatment management. Therefore, we selected two important processes-behavior of health seeking and treatment management-mentioned above as research focuses.ObjectivesThe general objective of this study is to explore current situation and problems of tuberculosis patients'health-seeking behavior and treatment management among migrants, in order to put forward some suggestions to improve TB case finding and treatment management effectiveness. The specific objectives include:identifying health-seeking behavior and its obstacles; establishing patients health-seeking behavior model based on identifying influencing factors of TB patients health-seeking behavior; evaluating on current situation of TB patients treatment management and relevant factors; identifying key problems in TB patients health-seeking behavior and treatment management among migrants; making strategic suggestion to promote TB case early detection and improve treatment management effectiveness.MethodsQuantitative methods, qualitative methods and literature analysis were comprehensively used in this study so as to analyze the health-seeking behavior and treatment management and its problems to form a multi-angle research.A total of 12 counties (districts) in 7 cities of Shandong province were selected as study sites according to the economic level and geography distribution and the number of smear-positive migrants TB cases registered during the past year. The smear-positive migrants TB cases registered in the 12 sampling counties (districts) TB dispensaries were recruited into the study, including 314 patients who were being treated and had completed normal treatment within 6 months.. Meanwhile, we carried out focus group discussion and in-depth discussion in 6 sites from the 12 sampling counties (districts). And directors, doctors of TB dispensaries, doctors of grass-roots medical institutions and migrants TB patients of the 6 sampling counties (districts) were interviewed as key informants to tell us their cognition on constraints of TB cases health-seeking behavior and problems existed in TB cases treatment management.The data of this study mainly source from Shandong Statistics Yearbook, literature review, face-to-face interview of migrants TB cases and key informants discussion. The researchers and graduate students from School of public health of Shandong University, and some staff from Shandong Centre for TB Prevention and Control undertook the task of data collection. The data were entered using software EPI Data 6.04, then analyzed by using software SPSS 13.0. The methods of descriptive analysis, t-test, analysis of variance, Mann-Whitney U test, Kruskal-Wallis H test and multinomial logistic regression were applied in the research. The qualitative data were analyzed by descriptive analysis and case analysis.Main resultsTB core knowledge points among migrants TB cases were as follows:"what are the transmissions of tuberculosis", "what causes TB", "what are main symptoms of tuberculosis ", and "TB free treatment policy". TB cases awareness rate of all the four points were less than 75%. Over 90% of patients hold the view that TB could be curative. Education level and family type (from rural areas or urban areas) affected the level of migrants TB cases cognition.The median of patient delay for migrants TB patients was 10 days, with an average of 18.84 days. Patients with a patient delay over 14 days accounted for 40.8%. The median of diagnosis delay was 8 days, with an average of 15.62 days. Patients with a diagnosis delay over 14 days accounted for 44.6%. The median of treatment delay was 1 days, with an average of 2.51 days. Patients with a treatment delay over 1 day accounted for 65.6%. TB patients with low household income, from poor/minimum living households, working over 5 days per week, without health insurance, taking over 30 minutes to the nearest township/street hospitals, with mild and moderate initial symptoms, with poor cognition on TB experienced longer patient delay. TB patients from younger group, working over 5 days per week, with a closer distance to local TB dispensaries, with mild initial symptoms, with first visit to clinics,under poor economic conditions experienced longer diagnosis delay. TB patients with low individual annual income, with accompany of relatives, with moderate and severe symptoms when diagnosed, with more severe symptoms when diagnosed compared with the initial symptoms, with the knowledge that TB cannot be cured and with little knowledge about TB free treatment policy experience longer treatment delay.Nearly 70% of patients had cough at onset.48.73% of them selected health institutions of county level and above as their first visit health facilities, and 32.8% of them selected the grass-root clinics as their first visit health facilities. Education level, household debt status and initial symptom severity were factors affecting patients' selection of first visit health institutions. Patients with education level of junior high school and above preferred to go to health institutions of county level and above as their first visit health facilities, the patients with debt preferred to go to grass-root clinics as their first visit health facilities. The patients with initial symptoms of hemoptysis or bloody sputum preferred to go to county health institutions and above as their first visit health facilities.Before the arrival at TB dispensaries (including the county TB dispensaries), TB patients'visit times ranged from 1 to 9, an average of 2.96 visits. Without considering repeated visits to the same health institutions, the average of health institutions visited was 2.44. The facilities involved in the process of migrant patients health-seeking behavior included health clinics, township (community) health centers, county (district) hospitals and above, and other hospitals or TB dispensaries, etc. TB patients'first visit health facilities had impact on the complexity of the process of health-seeking behavior. Patients'health-seeking pathways were associated with diagnosis delay. With the increase in the number of health facilities involved in the pathway, the median of diagnosis delay extended.The number of patients who received TB-related health education prior to the chemotherapy accounted for 81.5%.58.3% of the patients experienced whole-process supervisory management,13.7% monitoring management during strengthening period of chemotherapy,1.0% whole-process management, and 27.1% self-medication. Patient supervisory management rate was 72.0%. Supply side factors were associated with patient supervisory management rate. Additionally, patients'working condition (including the type of occupation, working hours) was also an important factor that affected patients' supervisory management rate.92.0% of patients kept anti-TB drugs by themselves,8.0% of patients gave their drugs to local primary physicians to keep. Primary physicians'pursuits of profits and patients' fear of discrimination caused the lowly drug-keeping percentage of primary physicians. 37.6% of the patients got visits to the residence from doctors in county TB dispensaries in the process of treatment.39.8% of the patients got visits to the residence from doctors of grass-root preventive doctors in the process of treatment. The low visit rate from county and township levels doctors may be due to lack of health personnel and limited funds.15.9% of patients experienced non-compliance of using anti-TB drug in the process of treatment. Marital status, whether received TB-related health education prior to the chemotherapy or not, patients evaluation on the inventiveness of free treatment policies, treatment supervisor had significant relation to migrant patients compliance in using anti-TB drug. Married patients were easier to take drug regularly than single patients, patients who received TB-related health education prior to the chemotherapy had better compliance in drug-taking behavior than those who didn't, patients who thought the free treatment policy incentive had better compliance in drug-taking behavior than those who didn't, and patients who were supervised by clinic doctors were easier to take drug regularly than patients without supervisor. Among patients who had completed TB treatment, success rate of treatment was 80.5%. Patients who knew TB treatment regulations had higher success rate of treatment than those who didn't.Conclusions and RecommendationsMigrant TB patients'cognition level on TB was rather low, and should be further enhanced. Patient educational level and family types were the factors that affected their cognition level. Diagnosis delay and patient delay had nearly same impact on delayed detection, and diagnosis delay rate was slightly higher than patient delay rate. Poverty was a crucial constraint for TB patients'access to health service among migrants, hi addition, working time, initial symptom severity and geographic accessibility to health service were factors influencing delayed detections. The process of health-seeking behavior among migrant TB patients was very sophisticated, requiring many visits(considering repeated visits to the same health institution) to medical institutions before accepting regular anti-TB treatment. In the first visit, the rate of diagnosing TB patients as suspected one by grass-root clinic doctors was low. Educational level, household debt status and initial symptom severity were factors affecting patients first visit selection of health institutions. To carry out TB-related health education prior to the chemotherapy was conducive to early detection of TB patients, high compliance in using anti-TB drug and high success rate of treatment.27.1% of patients took the medication without monitoring, which had negative effects on treatment outcome. Grass-root clinic doctors played a more important role in TB cases detection, but in fact failed to.92.0% of patients kept the anti-TB drug by themselves. The visit rate to patients'residence of doctors at county and township levels was rather low.16.0% failed to adhere to the regulation of using anti-TB drug in the whole process of treatment.We put forward the following specific recommendations for the improvement of early TB case detection and treatment management effectiveness among migrants:(1) To increase the financial input of special funds for TB control among migrants, and strengthen the monitoring of funds to improve capital efficiency; (2) To adopt comprehensive measures helping the vulnerable poor to break the circle of "poverty-low utilization of TB health services-health damage-more poverty" so as to improve migrants'TB cases health services accessibility; (3) To strengthen training of primary care doctors and improve incentive mechanism, and give them more chances to play their full role in early case detection and treatment management; (4) To carry out targeted health education among floating population, including:strengthening propaganda and education on the floating population before their flowing out from their hometowns, carrying out health education during concentrated period of flowing, developing simple health education materials, carrying out the employer-centered health education, implementing 100% health education before chemotherapy; (5)To strengthen guidance on patients'self-management in the process of treatment.,Innovations and LimitationsInnovations(1) There lacks systematic researches concerning the overall process of diagnosis and treatment of TB patients among floating population at home and abroad. The study analyzes current situation and existing problems of the overall process from observable symptom to treatment among floating population systematically, and explores corresponding barriers, in order to provide essential suggestions to early detection and enhancing efficiency of treatment management;(2) Based on the description of barriers of behaviors and path of seeking medical services, the study initially establishes the models of determinants and path of TB patients among floating population, in order to enhance the comprehensive and systematic understanding of the process of their seeking medical services;(3) This study tries to employ index of delayed treatment so as to grasp the condition of timeliness of receiving treatment after diagnosis, introduces the rate of health education before regular treatment as an indicator to reflect the current situation of treatment management and explores relevant factors of it from the perspective of health service consumers.Limitations(1) There might be selective bias in the study due to the fact that our interviewees are all registered patients in prophylactic-therapeutic institutions.(2) The study is retrospective. Although various measures were taken to control the survey's quality in the field, recall bias, bound to impose a certain effect on the study, is unavoidable.In addition, when interviewed, patients might not tend to provide real sensitive information owing to privacy and biased understanding, in the sense that there is likely to be discrepancy between collected data and real condition in terms of income and expenditure.