The Study On Health System Delay And Influential Factors Of The Rural Tuberculosis Patient In Shandong Province

BACKGROUND AND OBJECTIVESTuberculosis (TB) disease is not only a growing public health problem, but also a socio-economic problem. The increase of floating population, Multidrug-Resistant Tuberculosis (MDR TB) and TB/HIV co-infection are three challenges to TB control. TB disease increases the burden of the patients. China is one of the 22 higher TB disease burden countries in the world, 80% of TB patients lived in the rural areas, which limited the improvement of the rural areas.Directly Observed Treatment, Short Course strategy(DOTS)was the most cost-effectiveness strategy recommend by WHO ,which had got obvious achievements, there were still many factors undermining the effect of DOTS. The new Stop TB strategy recommended by WHO in the year of 2006 started to pay attention to strengthening health service and engaging all care providers.The increase of case detection rate is quite necessary to the TB control, therefore analyzing how to detect more patients and finding out the factors of influencing patient delay are of importance to TB control. Currently the key points of research focused on patient delay and health system delay. The behaviors of health service provider played important role in patient's health-seeking process.The main aim is to provide scientific recommendations for shortening health system delay in order to enable successful DOTS expansion through examining the extent of health system delay, the burden of disease and the behavior of the health service provider. The specific objectives are:(l)to examine the extent of health system delay of rural TB patients in Shandong province .(2)to explore the relationship between behavior of health service providers and health system delay.(3)to analyze the burden of the TB patients. METHODOLOGYThis project analyzed through pathways of pulmonary TB patients and health service providers' behavior. Total 3 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 health system delay study. Key informant interviews were conducted on the key informants who were in charge of DOTS strategy coming from CTBDs , township hospitals were interviewed. Meanwhile Focus Group Discussion were also conducted among village health providers for understanding their perceptions on rural TB patients health system delay. Literature reviews, institution-based survey, patient survey by face to face and key informant interview were the main data sources. The graduated students in Shandong Uniersity were the data collectors. The SPSS13.0 was used to analyze the data, and the descriptive statistical analysis,signal facors analysis were the main analyzing methods.RESULTS1. The median days of health system delay for Shandong rural TB patients were 21 days, and health system delay of the county of jiaonan,jinxiang,changqing in turn were 32 days, 12 days and 23 days. County and patients' first selection on health institution has significant associaton with the extent of health system delay.2. Health financing mechanisms, the cooperatation between health departments, referral arrangement and incentive impacted diagnosis and treatment leading to differentce of the extent of health system delay. Different level of health service providers' behavior impacted health institute interval. The institute interval of village clinical,township hospitals and county hospitals in turn were 15 days,2days and 1day. Only 8% of village health providers,about 68% of township health providers,and 82%of county hospital health providers's dignosis were "be suspicious of TB"; the main treatment of village health providers were"pills and injection", township health provider and county hospital health provider's treament were both" check-up".3. Patients' first selection impacted the complexity of health-seeking pathway,then further impacted the extent of health system delay. The village clinics,township hospitals ,county hospitals were the most used health institudions by rural TB patients. The pathway of patients choosing village clinics as first selection were most complex, and the median days of these patients' health system delay were longest. The median days of village clinics ,township hospitals and county hospitals in turn were 28days,15 days and 3days.4. The main reason of choosing village clinics,township hospitals and county hospitals in turn were" shorter distance'7'shorter distance and higher quality"and"higher quality".5. The disease burden of rural TB patients were high. The average of all of investigated patients'cost was 2016yuan account for 30% of net income in 2005. The average cost of patients from county of jiaonanjinxiang and changqing in turn were 2860yuan,756yuan and 2325yuan. It was highest in hospitals' payment. The average cost of patients in village clinics,township hospitals and county hospitals in turn were 373yuan,297yuan and 709yuan.RECOMMENDATIONS1. Increasing the input scale of the government , insuring high quality of health human resources and health equipment, and fufiling sufficient incentives for referral from general and primary services toTB dispensaries to improve TB case finding.2. Taking effort to raise awareness about TB symptoms and service provided by village clinics and township hospitals, stanarding referral arrangement and strengthening network information construction.3. Enhanceing county health providers' understanding of DOTS, prompting their diagnosis, strengthening cooperation between county general hospitals and county TB dispensaries and ensuring to shorten patients' interval in general hospitals.