CAUSES OF DELAY IN THE DIAGNOSIS, AND TREATMENT OF PULMONARY TUBERCULOSIS, IN GUJRAT, PAKISTAN A case of Basic health Unit Joura Jalal Pur and Aziz Bhati Shaheed Hospital By ANSAR touseef September 2011 A Thesis Presented to the Higher Degree Committee Of Ritsumeikan Asia Pacific University In Partial Fulfillment of the Requirements for the Degree of Master of Science in International Cooperation Policy (Public Health Management) ACKNOWLEDGEMENTS I would like to express my deepest gratitude to my thesis advisor, Prof. GHOTBI Nader, Ritusmeikan Asia Pacific University for his endless support and insightful comments, criticism, guidance, encouragement and supervision throughout the period of my study. I would also like to thank Prof. UCHIDA Yasuo, and Prof. MEIRMANOV Serik for their support and guidance throughout the course. Also I am deeply indebted to Prof. GUNARTO Hary, and Prof. MAJUMDAR A.A.K Ritsumeikan Asia Pacific University. I would like to thank the Joint Japan/World bank Graduate Scholarship Program for providing me a great opportunity to join this prestigious program at Ritsumeikan Asia Pacific University. Without this golden chance, I would have never been at this point. I extend my heartfelt thanks to Ritsumeikan Center for Asia Pacific Studies (RCAPS) for providing the generous financial assistance to my research trip. Without this financial support, my fieldwork in Pakistan could have never been achieved. i I am grateful to the Japanese people for their kind contribution through taxation and ethical and moral support. Without their contribution, I would not be here for the higher degree of my education and to learn about this beautiful nation in the world. I would also like to convey my warm gratitude to Govt. District Health Department Gujrat, Pakistan where I worked for 2 years before coming to APU. The experience of working there inspired me to study Public Health Management and to work for my community. Without this inspiration, this degree would have not been accomplished. I would like to thank Dr. Munir Ahmed EDO health, Dr. Azhar Ch. DOH and Dr. Sabeer Mirza from Aziz bhati shaheed hospital Gujrat for their endless support and encouragement. Finally, I am deeply grateful to my parents, sister, and brother, also thanks to my wife for her love, inspiration, sacrifice and support to realize my dream. Also I want to give my love to my lovely baby angel daughter Shantul Zahra. I would like to dedicate this work to her. I also wish to thank my friends, seminar classmates, and other APU students who have been supportive during my two-year study in Japan. ii TABLE OF CONTENTS Acknowledgement………………………………………………………….................i Table of Contents…………………………………………………………………….iii List of Tables………………………………………………………………………..xiii List of Figures……………………………………………………………………… xv List of Acronyms…………………………………………………………………..xviii Abstract…………………………………………………………………………….xxii CHAPTER 1: INTRODUCTION 1.1 Introduction to Pakistan………………………………………………………..…1 1.1.1Location and History……………………………………………………..…1 1.1.2 Geography and Climate………………………………………………….....2 1.1.3 Demography………………………………………………………………..3 1.1.4 Economy……………………………………………………………...…….5 1.1.5 Education and Literacy……………………………………………….….....7 iii 1.2 Global Tuberculosis Situation………………………………………………..….10 1.3 Tuberculosis Situation in Pakistan……………………………………………....13 1.3.1 Indicators of National Tuberculosis Control Program in Pakistan……...…16 1.3.1.1 Absolute Number of TB cases……….…….…….……………...…17 1.3.1.2 Age Distribution of Total cases………………………....................18 1.3.1.3 Age Distribution of Females…………………...……………….….18 1.3.1.4 Age distribution of Males………………………...…………….….19 1.3.1.5 Case Detection rate of all types and NSS+………………………...20 1.3.1.6 Case Notification rate of all types/100,000 population…………....22 1.3.2 Challenges of TB management in Pakistan……………………….………23 1.4 Rational of Study………………………………………………….……………..24 1.5 Research Objectives………………………………………………….…………..28 1.6 Research Questions……………………………………………………….……...30 1.7 Research Hypothesis………………………………………………………….….31 1.8 Research Framework…………………………………………………………….32 1.9 Research Methodology……………………………………………….………….35 iv 1.10 Limitations and Constrains…………………………………………….……….36 1.11 Organization of Thesis…………………………………………………….……38 CHAPTER 2: PRIMARY HEALTH CARE SYSTEM AND LADY HEALTH WORKERS PROGRAM IN PAKISTAN 2.1 Health Indicators of Pakistan………………….…………………………………41 2.1.1 Major Health Indicators…………………….……………………………...41 2.1.2 Child Health Indicators…………………….………………………………43 2.1.3 Family Planning Indicators…………………….…………………………..43 2.1.4 Women`s Health Indicators……………………….……………………….44 2.2 Primary Healthcare Services in Pakistan…………..…………………………….44 2.3 Primary Healthcare System…………………………….………………………..46 2.4 Structure of Primary Healthcare at District Level………….……………………47 2.5 Lady Health Worker Program in Pakistan…………………….………………....49 2.6 Management Structure of Lady Health worker Program………………………..51 2.7 Activities of Lady Health Workers………………………………….…………...53 v 2.8 Impact of Lady Health Workers on Health…………………………….………...55 2.9 Referral of TB Patients in PHC System with the help of LHWs………….……..56 2.10 Chapter Summary………………………………………………………………59 CHAPTER 3: LITERATURE REVIEW 3.1 Definitions and concept of delay in the diagnosis and treatment of TB…………60 3.2 Overview of delay in the diagnosis and treatment of TB……………………......63 3.3 Results of previous studies in the World………………………………………...67 3.4 Previous studies on diagnostic and treatment delay in Pakistan and there Results………………………………………………………….………………..77 3.5 Risk Factors associated with different types of delays in TB……………………80 3.5.1 Risk factors of Patient`s delay…………………………………………......80 3.5.2 Risk factors of Healthcare system delay…………………………………...82 3.5.3 Risk factors of Total delay…………………………………………………83 3.6 Chapter Summary…..............................................................................................84 vi CHAPTER 4: CHARACTERISTICS OF STUDY AREA 4.1 Location………………………………………………………………………….85 4.2 Climate…………………………………………………………………………...86 4.3 Population and Area information………………………………………………...87 4.4 Key Indicators of district Gujrat…………………………………………………87 4.5 Gujrat Primary Healthcare model………………………………………………..88 4.6 Aziz Bhati Shaheed Hospital Gujrat……………………………………………..92 4.7 Basic Health Unit Joura Jalal Pur Gujrat………………………………………...93 4.8 Chapter Summary………………………………………………………………..95 CHAPTER 5: RESEARCH METHODOLOGY 5.1 Research Design…………………………………………....……………………96 5.2 Sampling Methods……………………………………………….………………97 5.3 Data Collection Methods…………………………………………….................100 5.3.1 Questionnaire Design…………………………………..…………………101 5.3.1.1 Pulmonary Tuberculosis Patient`s Questionnaire……...…………...101 vii 5.3.1.2 Lady Health Worker`s Questionnaire……………………...……….105 5.3.2 Interview Process…………………………………………………….........109 5.3.2.1 The Interview with Pulmonary tuberculosis Patients…………...….109 5.3.2.1 The Interview with Lady Health Workers……………………….....111 5.3.3 Data Processing and Analysis……………..………………………………112 5.3.3.1 Descriptive Analysis…………………….………………………….113 5.3.3.2 Chi-Square test of Independence…………..……………………….114 5.4 Chapter Summary………………………………………………………………115 CHAPTER 6: FINDINGS AND DISCUSSION 6.1 Pulmonary Tuberculosis Patients Findings and Results…….………………….116 6.1.1 Socio-demographic Characteristics of Respondents……………………...116 6.1.1.1 Distribution of Respondents by Age group………………………..117 6.1.1.2 Distribution of Respondents by Gender…………………………...118 6.1.1.3 Distribution of Respondents by Residence Status………...……….119 6.1.1.4 Distribution of Respondents by Civil Status………………...…….120 viii 6.1.1.5 Distribution of Respondents by Education Level…………….........122 6.1.1.6 Distribution of Respondents by Occupation……………………….123 6.1.1.7 Distribution of Respondents by Number of Household………..….124 6.1.1.8 Interpretations from Socio-demographic Characteristics……….....127 6.1.2 Results of Descriptive Statistical Analysis…………………………….....128 6.1.2.1 Correctness of patient`s knowledge about Tuberculosis…….….....130 6.1.2.2 Perceived Stigma related to Tuberculosis……………..…….…….132 6.1.2.3 Frequency of Risk factors of PTB among Patients…………..…….134 6.1.2.4 Symptoms of Patients with PTB ………………………….…….....136 6.1.2.5 Patients attitude with the onset of symptoms…………………...…138 6.1.2.6 Facility of healthcare provider from whom patients first sought Consultation……………...................................................................140 6.1.2.7 Specialty of HCP from whom patients first sought consultation….142 6.1.2.8 Reasons of First Consultation with the HCF with the onset of Symptoms…………………………………………….………….....143 6.1.2.9 Reasons for not consulting the PHC facility with the onset of ix