We examined the healthcare seeking behaviour of adult TB patients as well as treatment delays and its determinants in a low-resource setting with a high burden of TB/HIV. More than nine-tenth of the patients reported a walking distance of more than one hour to the nearest public healthcare facility to their homes. This reflects poor availability of public health facilities in rural settings in the state. In addition, it suggests that efforts should be made to expand and sustain such public health facilities. This will in turn form the bedrock in achieving the TB millennium development goal and universal health coverage .
Two-thirds of the patients in the study sought treatment more than four weeks after onset of symptoms, higher than in Malaysia (52%) , Iran (12%) , Ethiopia (41%) , Spain (43%) , Zambia (35%)  and the Philippines (50%) , but lower than in urban Nigeria (83%) . This suggests that although the proportion of patients who sought treatment more than four weeks after onset of TB symptoms were higher in Nigeria compared to other countries, overall, with the current public enlightenment campaigns [12, 13], there have been a reduction in the proportion of patients who delayed for more than a month before consulting the health system.
The median patient delay observed was consistent with findings from southwest Nigeria [10, 11], but higher than the average patient delay of 31.7 days documented in low-and-middle income countries . However, the median health system delay observed was lower than the average of 28.4 days found in low-and-middle income countries . The total delay found in this study was longer than those reported in the Philippines and South Africa [23, 26] but agrees with previous findings in high incidence settings [10, 25]. Given the high coverage of DOTS in Nigeria, and the very low case detection rate , our findings suggest that TB patients face major barriers to care and many of them remain undetected.
Patients who first sought care at a NTP-provider made an average of 3 visits required by the diagnostic pathway compared to those who didn’t. The average number of visits made before commencing treatment after an initial visit to a non-NTP provider was higher because TB might not have been considered during the first visit to the informal providers, as a result; the patients might have been given inappropriate care which led to several other visits before reaching the appropriate health facility for TB care. However, median number of visits made irrespective of the source of care in this study were similar to what was found in South Africa , but less than what was found in Tajikistan and urban Zambia, where TB patients made on the average 4.8 and 6.7 visits respectively [27, 28]. Additional strategies to shorten the interval between HCP visits in the diagnostic pathway may further reduce health system delay in our setting and improve TB control.
Factors associated with diagnostic and treatment delays have not always been replicated in all settings, populations, and may differ among countries [3–5]. In a systematic review of studies on TB diagnostic and treatment delay by Storla et al. , factors associated with delays in the health seeking pathway included HIV infection, older age, low educational level, longer walking distance to the nearest public facility, male gender, an initial visit to a non-NTP provider, rural residence and smear-negative sputum test; except for urban residence and HIV infection, these were consistent with our findings. The reason for higher delays among patients living in urban area may be because the study health facilities were located in the rural areas, and in order to probably avoid the stigma associated with TB care seeking in urban hospitals, they opted for care in a rural hospital. HIV positive patients had shorter patient delay probably because of the collaborative TB/HIV activities exiting in the health institutions which ensures early TB screening among HIV patients and vice versa .
To reduce delays in TB care in our setting, a high index of suspicion for TB needs to be maintained by all HCPs. To date, Nigeria has made several organised efforts to involve the private sector in TB care, through public-private mix initiatives . These include involvement of non-governmental organisations, private (mission/for-profit) hospitals in TB care, which contributed to 39% of total TB case notification in 2010 . Our study suggests that the next steps in this process would include involving pharmacy/drug shops and traditional healers in rural low-resource settings. There is a potential for earlier detection of TB in these patients if they would refer all coughing patients to a diagnostic clinic. In Malawi and Nigeria, drug shop owners and traditional healers have respectively indicated willingness to play a role in tuberculosis control [30, 31].
Our study has several limitations. It was conducted in a rural, high TB/HIV under-resourced setting. Thus, our findings may not be generalisable to all settings. It would be valuable to obtain data on settings with different cultural and socio-economic characteristics in the future. A further limitation found in studies on TB treatment delays, is that they rely on patient recall. We reduced this by collecting data as soon as possible after the patient initiated TB treatment, and by helping them in their recall efforts. Another limitation is that we do not report on patient knowledge and stigma, and its effects on TB treatment delay. These factors have been shown to be associated with patient delay in other studies [3, 4] and must be further investigated in order to design appropriate educational interventions for our setting.