Barriers in the access, diagnosis and treatment completion for tuberculosis patients in central and western Nepal: A qualitative study among patients, community members and health care workers

Autoři: Sujan Babu Marahatta aff001;  Rajesh Kumar Yadav aff001;  Deena Giri aff001;  Sarina Lama aff001;  Komal Raj Rijal aff002;  Shiva Raj Mishra aff003;  Ashish Shrestha aff004;  Pramod Raj Bhattrai aff004;  Roshan Kumar Mahato aff005;  Bipin Adhikari aff006
Působiště autorů: Manmohan Memorial Institute of Health Sciences, Soaltee mode, Kathmandu, Nepal aff001;  Central Department of Microbiology, Tribhuwan University, Kirtipur, Kathmandu, Nepal aff002;  University of Queensland, Queensland, Australia aff003;  National Tuberculosis Centre, Bhaktapur, Nepal aff004;  Dhulikhel Hospital, Dhulikhel, Nepal aff005;  Nepal Community Health and Development Centre, Kathmandu, Nepal aff006;  Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, United Kingdom aff007
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article



Nepal has achieved a significant reduction of TB incidence over the past decades. Nevertheless, TB patients continue to experience barriers in access, diagnosis and completion of the treatment. The main objective of this study was to explore the factors affecting the access to the health services, diagnosis and the treatment completion for TB patients in central and western Nepal.


Data were collected using in-depth interviews (IDI) with the TB patients (n = 4); Focus Group Discussions (FGDs) with TB suspected patients (n = 16); Semi Strucutred Interviews (SSIs) with health workers (n = 24) and traditional healers (n = 2); and FGDs with community members (n = 8). All data were audio recorded, transcribed and translated to English. All transcriptions underwent thematic analysis using qualitative data analysis software: Atlas.ti.


Barriers to access to the health centre were the long distance, poor road conditions, and costs associated with travelling. In addition, lack of awareness of TB and its consequences, and the belief, prompted many respondents to visit traditional healers. Early diagnosis of TB was hindered by lack of trained health personnel to use the equipment, lack of equipment and irregular presence of health workers. Additional barriers that impeded the adherence and treatment completion were the need to visit health centre daily for DOTS treatment and associated constraints, complex treatment regimen, and the stigma.


Barriers embedded in health services and care seekers’ characteristics can be dealt by strengthening the peripheral health services. A continuous availability of (trained) human resources and equipment for diagnosis is critical. As well as increasing the awareness and collaborating with the traditional healers, health services utilization can be enhanced by compensating the costs associated with it, including the modification in current DOTS strategy by providing medicine for a longer term under the supervision of a family member, peer or a community volunteer.

Klíčová slova:

Equipment – Health economics – Health education and awareness – Health systems strengthening – Nepal – Transportation – Tuberculosis – Tuberculosis diagnosis and management


1. WHO. Global Tuberculosis Report 2018. Available online at: (Accessed 16th April, 2019). 2018.

2. WHO. Tuberculosis. Available online at: (Accessed 16th April, 2019). 2019.

3. Waisbord S. Behavioral barriers in tuberculosis control: A literature review. Available online at: (Accessed on 16th September, 2019). Washington, DC. 2004.

4. Piot P, Greener R, Russell S. Squaring the circle: AIDS, poverty, and human development. PLoS Med. 2007;4(10):1571–5. Epub 2007/10/26. doi: 10.1371/journal.pmed.0040314 17958469; PubMed Central PMCID: PMC2039763.

5. Osei E, Akweongo P, Binka F. Factors associated with DELAY in diagnosis among tuberculosis patients in Hohoe Municipality, Ghana. BMC Public Health. 2015;15:721. Epub 2015/07/30. doi: 10.1186/s12889-015-1922-z 26220804; PubMed Central PMCID: PMC4517499.

6. WHO. Global Tuberculosis Report. Available online at: (Accessed on 16th September, 2019). 2018.

7. Banstola A. Issues and threats of Tuberculosis in Nepal. Available online at (Accessed on 16th September, 2019). 2012.

8. National Tuberculosis Centre, Ministry of Health, Government of Nepal. National Tuberculosis Program Nepal. Available online at: (Accessed online 16th April, 2019). 2018.

9. Munro SA, Lewin SA, Smith HJ, Engel ME, Fretheim A, Volmink J. Patient adherence to tuberculosis treatment: a systematic review of qualitative research. PLoS Med. 2007;4(7):e238. Epub 2007/08/07. doi: 10.1371/journal.pmed.0040238 17676945; PubMed Central PMCID: PMC1925126.

10. Kliner M, Canaan M, Ndwandwe SZ, Busulwa F, Welfare W, Richardson M, et al. Effects of financial incentives for treatment supporters on tuberculosis treatment outcomes in Swaziland: a pragmatic interventional study. Infectious diseases of poverty. 2015;4:29. Epub 2015/06/09. doi: 10.1186/s40249-015-0059-8 26052440; PubMed Central PMCID: PMC4456807.

11. Jaiswal A, Singh V, Ogden JA, Porter JD, Sharma PP, Sarin R, et al. Adherence to tuberculosis treatment: lessons from the urban setting of Delhi, India. Trop Med Int Health. 2003;8(7):625–33. Epub 2003/06/28. doi: 10.1046/j.1365-3156.2003.01061.x 12828545.

12. Sreeramareddy CT, Qin ZZ, Satyanarayana S, Subbaraman R, Pai M. Delays in diagnosis and treatment of pulmonary tuberculosis in India: a systematic review. Int J Tuberc Lung Dis. 2014;18(3):255–66. Epub 2014/03/29. doi: 10.5588/ijtld.13.0585 24670558; PubMed Central PMCID: PMC4070850.

13. Cai J, Wang X, Ma A, Wang Q, Han X, Li Y. Factors associated with patient and provider delays for tuberculosis diagnosis and treatment in Asia: a systematic review and meta-analysis. PLoS One. 2015;10(3):e0120088. Epub 2015/03/26. doi: 10.1371/journal.pone.0120088 25807385; PubMed Central PMCID: PMC4373856.

14. Marahatta SB, Shrestha A, Bhattarai PR, Thapa A, Lamichinnae B, Chhetri C. TB: Barrier in access, diagnosis and treatment completion. Journal of Manmohan Memorial Institute of Health Sciences. 2016;2:76–80.

15. Mahato RK, Laohasiriwong W, Vaeteewootacharn K, Koju R, Bhattarai R. Major Delays in the Diagnosis and Management of Tuberculosis Patients in Nepal. J Clin Diagn Res. 2015;9(10):LC05–9. Epub 2015/11/12. doi: 10.7860/JCDR/2015/16307.6633 26557545; PubMed Central PMCID: PMC4625264.

16. Makwakwa L, Sheu ML, Chiang CY, Lin SL, Chang PW. Patient and heath system delays in the diagnosis and treatment of new and retreatment pulmonary tuberculosis cases in Malawi. BMC Infect Dis. 2014;14:132. Epub 2014/03/13. doi: 10.1186/1471-2334-14-132 24606967; PubMed Central PMCID: PMC3976046.

17. Demissie M, Lindtjorn B, Berhane Y. Patient and health service delay in the diagnosis of pulmonary tuberculosis in Ethiopia. BMC Public Health. 2002;2:23. Epub 2002/09/26. doi: 10.1186/1471-2458-2-23 12296975; PubMed Central PMCID: PMC130033.

18. Saifodine A, Gudo PS, Sidat M, Black J. Patient and health system delay among patients with pulmonary tuberculosis in Beira city, Mozambique. BMC Public Health. 2013;13:559. Epub 2014/02/07. doi: 10.1186/1471-2458-13-559 24499197; PubMed Central PMCID: PMC3680113.

19. Law S, Piatek AS, Vincent C, Oxlade O, Menzies D. Emergence of drug resistance in patients with tuberculosis cared for by the Indian health-care system: a dynamic modelling study. Lancet Public Health. 2017;2(1):e47–e55. Epub 2017/12/19. doi: 10.1016/S2468-2667(16)30035-4 29249480.

20. Ten Asbroek AH, Bijlsma MW, Malla P, Shrestha B, Delnoij DM. The road to tuberculosis treatment in rural Nepal: A qualitative assessment of 26 journeys. BMC Health Serv Res. 2008;8:7. Epub 2008/01/15. doi: 10.1186/1472-6963-8-7 18190698; PubMed Central PMCID: PMC2257948.

21. Kumar G, Jha N, Niraula S, Yadav D, Bhattarai S, Pokharel P. Gender based barriers in accessing tuberculosis treatment: A qualitative study from Eastern Nepal. SAARC Journal of Tuberculosis, Lung Diseases and HIV/AIDS. 2013;10(2):15–20.

22. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International journal for quality in health care. 2007;19(6):349–57. doi: 10.1093/intqhc/mzm042 17872937

23. Starks H, Brown Trinidad S. Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qualitative health research. 2007;17(10):1372–80. doi: 10.1177/1049732307307031 18000076

24. Glasser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research. New York: Aldine Publishing Company; 1967.

25. Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52(4):1893–907. Epub 2018/06/26. doi: 10.1007/s11135-017-0574-8 29937585; PubMed Central PMCID: PMC5993836.

26. Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. International journal of qualitative methods. 2006;5(1):80–92.

27. Dussault G, Dubois CA. Human resources for health policies: a critical component in health policies. Human resources for health. 2003;1(1):1. Epub 2003/08/09. doi: 10.1186/1478-4491-1-1 12904254; PubMed Central PMCID: PMC166115.

28. Hongoro C, McPake B. How to bridge the gap in human resources for health. Lancet. 2004;364(9443):1451–6. Epub 2004/10/19. doi: 10.1016/S0140-6736(04)17229-2 15488222.

29. Devkota B, Ghimire J, Devkota A, Gupta RP, Mahato RK, Thapa N, et al. Health governance at local level from human resource for health perspectives: the case of Nepal. J Nepal Health Res Counc. 2013;11(24):133–7. Epub 2013/12/24. 24362600.

30. McPake B, Witter S, Ensor T, Fustukian S, Newlands D, Martineau T, et al. Removing financial barriers to access reproductive, maternal and newborn health services: the challenges and policy implications for human resources for health. Human resources for health. 2013;11:46. Epub 2013/09/24. doi: 10.1186/1478-4491-11-46 24053731; PubMed Central PMCID: PMC3849922.

31. Sherchand J. Human Resources for Health (HRH) and challenges in Nepal. Journal of Institute of Medicine. 2013;35(2).

32. Khan MA, Walley JD, Witter SN, Shah SK, Javeed S. Tuberculosis patient adherence to direct observation: results of a social study in Pakistan. Health Policy Plan. 2005;20(6):354–65. Epub 2005/09/27. doi: 10.1093/heapol/czi047 16183735.

33. Guneylioglu D, Yilmaz A, Bilgin S, Bayram U, Akkaya E. Factors affecting delays in diagnosis and treatment of pulmonary tuberculosis in a tertiary care hospital in Istanbul, Turkey. Med Sci Monit. 2004;10(2):CR62–7. Epub 2004/01/23. 14737045.

34. Desalegn DM, Kitila KT, Balcha HM, Gebeyehu CS, Kidan YW, Amare K, et al. Misdiagnosis of pulmonary tuberculosis and associated factors in peripheral laboratories: a retrospective study, Addis Ababa, Ethiopia. BMC Res Notes. 2018;11(1):291. Epub 2018/05/13. doi: 10.1186/s13104-018-3414-6 29751778; PubMed Central PMCID: PMC5948669.

35. Pedrazzoli D, Abubakar I, Potts H, Hunter PR, Kruijshaar ME, Kon OM, et al. Risk factors for the misdiagnosis of tuberculosis in the UK, 2001–2011. Eur Respir J. 2015;46(2):564–7. Epub 2015/04/18. doi: 10.1183/09031936.00227914 25882811.

36. Raut S, Adhikari B. Ceftazidime-avibactam in ceftazidime-resistant infections. Lancet Infect Dis. 2016;16(9):997. Epub 2016/09/30. doi: 10.1016/S1473-3099(16)30194-3 27684335.

37. Pokharel S, Raut S, Adhikari B. Tackling antimicrobial resistance in low-income and middle-income countries. BMJ Global Health. 2019;4(6):e002104. doi: 10.1136/bmjgh-2019-002104 31799007

38. Khan MS, Hutchison C, Coker RJ, Yoong J, Hane KM, Innes AL, et al. Preventing emergence of drug resistant tuberculosis in Myanmar's transitioning health system. Health Policy Plan. 2017;32(suppl_2):i43–i50. Epub 2017/10/14. doi: 10.1093/heapol/czx093 29028228.

39. Marahatta SB, Adhikari B, Mishra SR, Raut S, Ramasoota P, Malla P, et al. Association of Previous Smoking Habit and Perceived Social Discrimination with the Risk of Multi-Drug Resistant Tuberculosis in Central Nepal. J Nepal Health Res Counc. 2015;13(29):95–101. 26411721.

40. Adhikari B, Mishra SR, Babu Marahatta S, Kaehler N, Paudel K, Adhikari J, et al. Earthquakes, Fuel Crisis, Power Outages, and Health Care in Nepal: Implications for the Future. Disaster Med Public Health Prep. 2017:1–8. doi: 10.1017/dmp.2016.195 28416042.

41. Acharya J, Kaehler N, Marahatta SB, Mishra SR, Subedi S, Adhikari B. Hidden Costs of Hospital Based Delivery from Two Tertiary Hospitals in Western Nepal. PLoS One. 2016;11(6):e0157746. doi: 10.1371/journal.pone.0157746 27308836; PubMed Central PMCID: PMC4911061.

42. Mishra P, Hansen EH, Sabroe S, Kafle KK. Socio-economic status and adherence to tuberculosis treatment: a case-control study in a district of Nepal. Int J Tuberc Lung Dis. 2005;9(10):1134–9. Epub 2005/10/19. 16229225.

43. Adhikari B, Phommasone K, Pongvongsa T, Koummarasy P, Soundala X, Henriques G, et al. Treatment-seeking behaviour for febrile illnesses and its implications for malaria control and elimination in Savannakhet Province, Lao PDR (Laos): a mixed method study. BMC Health Serv Res. 2019;19(1):252. Epub 2019/04/26. doi: 10.1186/s12913-019-4070-9 31018855.

44. Adhikari B, Kaehler N, Chapman RS, Raut S, Roche P. Factors affecting perceived stigma in leprosy affected persons in western Nepal. PLoS Negl Trop Dis. 2014;8(6):e2940. doi: 10.1371/journal.pntd.0002940 24901307; PubMed Central PMCID: PMC4046961.

45. Adhikari B, Shrestha K, Kaehler N, Raut S, Chapman RS. Community attitudes towards leprosy affected persons in Pokhara municipality of western Nepal. J Nepal Health Res Counc. 2013;11(25):264–8. 24908528.

46. Adhikari B, Kaehler N, Raut S, Marahatta SB, Gyanwali K and Chapman RS. Risk factors of stigma related to leprosy—A systematic review. Journal of Manmohan Memorial Health Sciences. 2013;1(2):3–11.

47. Kaehler N, Adhikari B, Raut S, Marahatta SB, Chapman RS. Perceived Stigma towards Leprosy among Community Members Living Close to Nonsomboon Leprosy Colony in Thailand. PLoS One. 2015;10(6):e0129086. doi: 10.1371/journal.pone.0129086 26047512; PubMed Central PMCID: PMC4457619.

48. Van Brakel WH. Measuring health-related stigma—a literature review. Psychol Health Med. 2006;11(3):307–34. Epub 2006/11/30. doi: 10.1080/13548500600595160 17130068.

49. Marahatta SB, Amatya R, Adhikari S, Giri D, Lama S, Kaehler N, et al. Perceived stigma of leprosy among community members and health care providers in Lalitpur district of Nepal: A qualitative study. PLoS One. 2018;13(12):e0209676. Epub 2018/12/28. doi: 10.1371/journal.pone.0209676 30589875; PubMed Central PMCID: PMC6307718.

50. Baral SC, Karki DK, Newell JN. Causes of stigma and discrimination associated with tuberculosis in Nepal: a qualitative study. BMC Public Health. 2007;7:211. Epub 2007/08/21. doi: 10.1186/1471-2458-7-211 17705841; PubMed Central PMCID: PMC2018718.

51. WHO Tuberculosis Programme. WHO report on the tuberculosis epidemic: 1995, stop TB at the source. Available online at: (Accessed on 5th December, 2019)

52. Cox HS, Morrow M, Deutschmann PW. Long term efficacy of DOTS regimens for tuberculosis: systematic review. BMJ. 2008;336(7642):484–7. Epub 2008/02/06. doi: 10.1136/bmj.39463.640787.BE 18250104; PubMed Central PMCID: PMC2258398.

53. Birch S, Govender V, Fried J, Eyles J, Daries V, Moshabela M, et al. Does treatment collection and observation each day keep the patient away? An analysis of the determinants of adherence among patients with Tuberculosis in South Africa. Health Policy Plan. 2016;31(4):454–61. Epub 2015/09/19. doi: 10.1093/heapol/czv084 26384375.

54. Adhikari B, Pell C, Phommasone K, Soundala X, Kommarasy P, Pongvongsa T, et al. Elements of effective community engagement: lessons from a targeted malaria elimination study in Lao PDR (Laos). Glob Health Action. 2017;10(1):1366136. doi: 10.1080/16549716.2017.1366136 28914184.

55. Adhikari B, James N, Newby G, von Seidlein L, White NJ, Day NP, et al. Community engagement and population coverage in mass anti-malarial administrations: a systematic literature review. Malaria journal. 2016;15(1):523. Epub 2016/11/04. doi: 10.1186/s12936-016-1593-y 27806717; PubMed Central PMCID: PMC5093999.

56. Nakigozi G, Makumbi FE, Bwanika JB, Atuyambe L, Reynolds SJ, Kigozi G, et al. Impact of Patient-Selected Care Buddies on Adherence to HIV Care, Disease Progression, and Conduct of Daily Life Among Pre-antiretroviral HIV-Infected Patients in Rakai, Uganda: A Randomized Controlled Trial. J Acquir Immune Defic Syndr. 2015;70(1):75–82. Epub 2015/06/04. doi: 10.1097/QAI.0000000000000710 26039929; PubMed Central PMCID: PMC4556592.

57. Marino P, Simoni JM, Silverstein LB. Peer support to promote medication adherence among people living with HIV/AIDS: the benefits to peers. Soc Work Health Care. 2007;45(1):67–80. Epub 2007/09/07. doi: 10.1300/J010v45n01_05 17804348; PubMed Central PMCID: PMC5096452.

58. Adhikari B, Mishra SR, Raut S. Rebuilding Earthquake Struck Nepal through Community Engagement. Frontiers in public health. 2016;4:121. doi: 10.3389/fpubh.2016.00121 27379225; PubMed Central PMCID: PMC4904779.

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