title: Barriers to accessing TB diagnosis for rural-to-urban migrants with chronic cough in Chongqing, China: a mixed methods study.
abstract: BACKGROUND
  China is facing a significant tuberculosis epidemic among rural-to-urban migrants, which poses a threat to TB control. This study aimed to understand the health seeking behaviour of and health systems responses to migrants and permanent urban residents suffering from chronic cough, in order to identify the factors influencing delays for both groups in receiving a TB diagnosis in urban China.
  
  
  METHODS
  Combining a prospective cohort study of adult suspect TB patients and a qualitative study, the Piot model was used to analyze the health seeking behaviour of TB suspects among migrants and permanent urban residents, the factors influencing their decision and the responses by general health providers. Methods included a patient survey, focus group discussions with migrants in the general population, qualitative interviews with migrant and permanent resident TB suspects and TB patients as well as key stakeholders related to TB control and the management of migrants.
  
  
  RESULTS
  Sixty eight percent of migrants delayed for more than two weeks before seeking care for symptoms suggestive of TB, compared to 54% of residents (p < 0.01). When they first decided to seek professional care, migrants were 1.5 times more likely than residents to use less expensive, community-level health services. Only 5% were ultimately referred to a TB dispensary. Major reasons for both patient and provider delay included lack of knowledge and mistrust of the TB control programme, lack of knowledge about TB (patients), and profit-seeking behaviour (providers). In the follow up survey, 61% of the migrants and 41% of the residents who still had symptoms gave up continuing to seek professional care, with a statistically significant difference between the two groups (p < 0.05).
  
  
  CONCLUSIONS
  Rural-to-urban migrants are more likely than permanent residents to delay in seeking care for symptoms suggestive of TB in urban Chongqing. 'Patient-' and 'provider-' related factors interact to pose barriers to TB diagnosis for migrants, including: low awareness, and poor knowledge among both the general public and TB suspects about TB as a disease and about the TB control programme; low financial capacity to pay for care and diagnostic tests; and inadequate use of diagnostic tests and referral to TB dispensaries by general health providers.
authors.affiliation: School of Public Health, Chongqing Medical University, No.1 Yixueyuan Road, Chongqing, PR China. longqian620@163.com
authors.forename: Qian
authors.initials: Q
authors.lastname: Long
authors.forename: Ying
authors.initials: Y
authors.lastname: Li
authors.forename: Yang
authors.initials: Y
authors.lastname: Wang
authors.forename: Yong
authors.initials: Y
authors.lastname: Yue
authors.forename: Cheng
authors.initials: C
authors.lastname: Tang
authors.forename: Shenglan
authors.initials: S
authors.lastname: Tang
authors.forename: S Bertel
authors.initials: SB
authors.lastname: Squire
authors.forename: Rachel
authors.initials: R
authors.lastname: Tolhurst
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002681:China; D003371:Cough / Q000175:diagnosis / Q000209:etiology; D005260:Female; D017144:Focus Groups; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D017064:Process Assessment, Health Care / Q000379:methods; D011446:Prospective Studies; D036301:Qualitative Research; D012424:Rural Population; D011795:Surveys and Questionnaires; D014171:Transients and Migrants / Q000523:psychology* / Q000706:statistics & numerical data; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000517:prevention & control; D014505:Urban Population