Care seeking in tuberculosis: results from a countrywide cluster randomised survey in Bangladesh

OBJECTIVES To explore systematically the care seeking trajectories of tuberculosis (TB) cases up to four subsequent places of care and to assess the type of services provided at each place. METHODS TB cases detected actively during the 2007-2009 national TB prevalence survey and passively under the routine programme in the same period were interviewed by administering a standardised questionnaire. Care seeking and services provided up to four subsequent points were explored. Care seeking was further explored by categorising the providers into formal, informal and 'self-care' groups. RESULTS A total of 273 TB cases were included in this study, of which 33 (12%) were detected during the survey and 240 (88%) from the TB registers. Out of the 118 passively detected cases who first sought care from an informal provider, 52 (44.1%) remained in the informal sector at the second point of care. Similarly, out of the 52, 17 (32.7%) and out of the 17, 5 (29.4%) remained in the informal sector at the third and fourth subsequent points of care, respectively. All the 33 actively detected cases had 'self-care' at the first point, and 27 (81.8%) remained with 'self-care' up to the fourth point of care. Prescribing drugs (59-99%) was the major type of care provided by the formal and informal care providers at each point and was limited to the non-existent practice of investigation or referrals. CONCLUSIONS Free TB services are still underutilised by TB cases and informal caregivers remained the major care providers for such cases in Bangladesh. In order to improve case detection, it is necessary that the National Tuberculosis Programme immediately takes effective initiatives to engage all types of care providers, particularly informal providers who are the first point of care for the majority of the TB suspects.