title: The road to tuberculosis treatment in rural Nepal: A qualitative assessment of 26 journeys.
abstract: BACKGROUND
  The fact that tuberculosis can be treated with the DOTS strategy (Directly Observed Treatment, Short-course) is not enough to control the disease. Patients have to find their way to tuberculosis treatment first. To better understand the route to tuberculosis treatment in rural Nepal we interviewed twenty-six patients under treatment.
  
  
  METHODS
  In semi-structured interviews patients shared their disease history and health seeking behaviour. The analysis focused on the encounters with the health care system before enrolment in the tuberculosis treatment program.
  
  
  RESULTS
  Patient routes often started in the medical shop and led via intricate routes with multiple providers to facilities with higher qualified and more competent staff where tuberculosis was diagnosed. Several factors influenced the route to tuberculosis treatment. Besides known patients factors (such as severity of complaints, the ability to pay for services, availability of services and peer support for choosing a provider) specific health services factors were also identified. These included the perceived quality, costs and service level of a provider, and lack of provider initiated referral. Self referral because of waned trust in the provider was very common. In contrast, once tuberculosis was considered a possible diagnosis, referral to diagnostic testing and tuberculosis treatment was prompt.
  
  
  CONCLUSIONS
  Patient routes towards tuberculosis treatment are characterised by self referral and include both private and public health care providers. Once tuberculosis is suspected referral for diagnosis and treatment is prompt. Given the importance of the private practitioners in the patient routes, quality improvement initiatives need to address not only the public sector but the private health care sector as well.
authors.affiliation: Department of Social Medicine J2-216, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, The Netherlands. g.tenasbroek@gmail.com
authors.forename: Augustinus H A
authors.initials: AH
authors.lastname: Ten Asbroek
authors.forename: Merijn W
authors.initials: MW
authors.lastname: Bijlsma
authors.forename: Puspha
authors.initials: P
authors.lastname: Malla
authors.forename: Binjwala
authors.initials: B
authors.lastname: Shrestha
authors.forename: Diana M J
authors.initials: DM
authors.lastname: Delnoij
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D003266:Continuity of Patient Care; D023801:Directly Observed Therapy / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D033262:Narration; D009313:National Health Programs; D009390:Nepal / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011331:Private Practice / Q000592:standards / Q000706:statistics & numerical data; D017064:Process Assessment, Health Care / Q000379:methods*; D011635:Public Health Administration / Q000592:standards; D036301:Qualitative Research; D012017:Referral and Consultation; D019035:Rural Health Services / Q000592:standards / Q000706:statistics & numerical data*; D014397:Tuberculosis, Pulmonary / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*