Lost in care pathway: a qualitative investigation on the health system delay of extra pulmonary TB patients in Bangladesh

Health system delay of extra pulmonary tuberculosis (TB) patients in Bangladesh was a qualitative study funded by BRAC’s TB control programme and was conducted in two different geographical areas: rural and urban. During early 2014, a research team comprising of six interviewers collected data on the healthcare seeking pathways of extra pulmonary tuberculosis (EPTB) patients in both rural and urban locations of Bangladesh. For rural locations, a coastal, a hilly, and a plain land area were chosen for intervention, whilst two urban slums in Dhaka were selected as the urban locations. We purposely selected different geographical areas assuming that there might be some difference in health care seeking practice among the EP TB patients.

The general research objective of this study was to understand the health care seeking practice of extra pulmonary tuberculosis patients before they were enrolled to BRAC’s TB treatment programme. The findings from this study revealed that the rural EPTB patients encountered a significant delay in diagnosis when compared to the urban patients, even though the average number of healthcare providers consulted by the rural and urban EPTB patients did not significantly vary. This study also showed that the healthcare seeking journey of both rural and urban EPTB patients will usually start either from pharmacies or from private facilities.

While exploring the detailed nature of the pathway, this study revealed the beneficial role of non-medical informants (mainly family and friends) to TB patients. The study concluded with a suggestion that the private and informal healthcare providers should receive appropriate training on the diagnosis of EPTB which could effectively shorten the long healthcare seeking pathways of EPTB patients.

• From January-March 2014, data was collected via single, face-to-face, in-depth interviews with EPTB patients using semi-structured guidelines.
• Interviewers were trained in qualitative data collection procedures before conducting interviews in private on-site.
• The respondents were selected from the register of BRAC’s TB control programme with the assistance of BRAC staff. Altogether, 36 in-depth interviews were conducted with people in rural areas and with 24 people in urban areas
• An initial categorising system was developed using thematic analysis, based on the study objectives and guidelines. Then research team identified these themes and sub-themes which emerged from the data analysis to finally produce a thematic index to code all the data.

• BRAC TB control programme
• GFATM TB Global Fund to Fight AIDS, Tuberculosis and Malaria

• The study findings in 2014 were submitted to BRAC’s TB control programme.
• A manuscript was submitted to BMC Public Health and is currently under peer review.