Comparing Accessibility And Equity To TB Diagnosis Between Rural-To-Urban Migrants And Permanent Residents In Urban Chongqing

Objective To investigate and analyze the current situation and influencing factors of the delay in the TB diagnosis between rural-to-urban migrants and permanent residents in urban Chongqing, and assess the accessibility and equity to TB diagnosis.Methods (1) Data collection: several methods were used in data collection including questionnaire study and in-depth interview with the new patients, observational study in the general hospital, clinic and pharmacy observation with simulated clients and literature review; (2) Data analysis: quantitative data analysis approach with SPSS13.0 and qualitative approach with MAXqda2 for the data collected in the in-depth interview and observation study,framework analysis mainly be used,also analyzed and concluded the related literature materials.Results (1) quantitative questionnaire survey: 185 new TB cases were investigated. It was found that the rural-to-urban migrants'propotion not to seek healthcare were higher than the permanent residents because of busy work.For the examination condition, the permanent residents were better, such as, the times of radiograph, sputum examination and the times, the permanent residents'times were higher than rural-to-urban migrants, but the cost before the first visit in rural-to-urban migrants were nealy three times than the permanent residents. For the reasons of the delay, univariate analysis found that the first symptom was hemoptysis and if medicare insurance had were the significant effecting factors in rural-to-urban migrants'diagnosis delay; Multivariate analysis found that gender is the rural-to-urban migrants'significant factor in provider delay. In the patients suffering from tuberculosis, when asked them what problems they worryed about, majority of the answers was that they were afraid of transmitting to their families. The rural-to-urban migrants were more worried than the permanent residents in some aspects, such as fear of health condition,family estrangement and can't find work or lose job.When asked if told their families, friends, colleagues or neighbors, the majority of TB cases choosed to tell their families. And the others were less informed, the rural-to-urban migrants and permanent residents in this aspect was no significant difference. (2) Qualitative in-depth interviews: 17 newly diagnosed TB cases were interviewed. Delay was existed both in rural-to-urban migrants and permanent residents, which was mainly affected by the patients and medical institutions: patients'poor economic conditions, no medical insurance, lack of health awareness and knowledge of TB; The staffs in pharmacies, private clinics, general Hospitals were lack of TB awareness, they should be included in the TB control system further. In additional, the social support for patients also was the mainly impact factor on delay, whether relatives or friends of the patient played a very important role in improving diagnosis delay. Most of interviewers lacked of knowledge about TB, even after illness. They were suffering from TB in many worries, the main concern were the economic problem and physical health. Only a few people were not suffering from the disease that had a better understanding of TB and also had better economic ability. When asked if they would tell the other people their disease, most of them said they would not tell others except their relatives, mainly the spouse.The reasons were: worried about other people feared him and away from him, despised them by the surrounding people, losed their jobs or hard to find work. (3) Observational study: one week's concealed observation was carried out both in respiratory outpatient department and general outpatient department; we found both rural-to-urban migrants and permanent residents exited different levels of delay, the delay ranges were from a few days to several months, even years.There were no significant differences between rural-to-urban migrants and permanent residents in the delay. First, the economy's capacity to pay is the main factor to affect the health seeking behavior: comparatively speaking, patients with poor economic capacity to pay more prone to diagnosis delay, the compliance are relatively poor, especially for rural-to-urban migrants. Second, the patient's improper self-medical also led to the delay. Third, the responsibility of the doctors was also important factors affecting the diagnosis delay of tuberculosis. In additional, patients'register and report also existed many problems. Lack of the publicity on TB knowledge also affected the TB patients'timely diagnosis. (4) Simulated patients observation: with two"rural-to-urban migrants"as simulated patients, 12 general hospitals and 13 clinics and pharmacies were observed. No significant discrimination acts to simulated patients were found. When simulated patients refused the examination and asked the doctor to prescribe some medications directly, only 1 doctor in 11 hospitals refused the patients'request; the remaining 10 doctors at the hospital were prescribed drugs as "flu" and "bronchitis". In the 12 hospitals, there were no health education materials for the TB patient. In the pharmacies, most shop assistants asked the patient: if coughed with sputum? After this question, most staff began to suggest the patient a lot of drugs, only a few staff asked more detail symptoms, even several pharmacies'staff did not ask the patient and just recommended the drugs, the attitude of the staff was different in 13 pharmacies. There was no pharmacy staff referral the patient to the hospital, even the patient said he/she had already sputum with blood. Conclusions The study found that there were 67.1% of the migrant TB patients existed patient delay, 30.3% of the migrant TB patients existed provider delay, the proportion of patient delay is higher than the provider delay. There were four major factors affecting the delay: TB patients themselves, medical insurance, social support and medical institutions. (1) Before seeking healthcare, whether patients with suspected symptoms of tuberculosis would go to see the doctor in time was an important factor affecting delay; In the process of the treatment, the drop out and the poor patient's compliance to the doctor was also an important reason for delay in the diagnosis. In these processes, the migrants had much misbehavior in healthcare seeking. (2) Although the rural-to-urban migrants and some poor permanent residents had higher healthcare demand, their healthcare insurance was poor. This seriously affected the accessibility and equity of the healthcare. (3) Social support for patients had significant influencing on the delay, whether the relatives or friends of patients played a big role in preventing from diagnosis delay. People with lower social support had the higher level delay. (4) The awareness of the doctor in the general hospital on TB and responsibility played an important role. One of the reasons was that the doctor was lack of knowledge, especially in TB management related policies; another was the issue of financial compensation for doctors to participate in the work of tuberculosis. In addition, the sputum examination also impacted the diagnosis delay. Policy suggestions (1) to solve TB patients, especially migrant patients'financial difficulties in TB diagnosis; (2) enhancing publicity and training to improve people's awareness of TB; (3) the general hospitals and pharmacies should be integrated into the TB control system; (4) the leading of the government,and the participation of the whole society.