Health seeking behavior of patients in Muzaffarpur-TMRC Health and Demographic Surveillance Site may obstruct Kala-azar elimination in Bihar, India

Abstract

Background: Muzaffarpur-TMRC Health and Demographic Surveillance System (HDSS) is a dedicated platform for visceral leishmaniasis (VL) research established in 2008 in Muzaffarpur district of Bihar state in India. In the 50 VL endemic villages of the HDSS, annual household surveys are conducted and all VL patients are registered and interviewed. We use the HDSS dataset to get more insight into the healthcare seeking behavior of VL patients. Methods & Materials: From the available data we extracted information on number and types of health providers consulted by VL patients, diagnosis and treatment prescribed; and individual and health system delay. We performed the trend analysis to study changes occurred in the health seeking behavior of the villagers over a period of 8 years. Results: Between March 2007 and July 2015, 332 VL cases were registered (185 men (56%) and 147 women (44%)). We observed declining trend in annual incidence (15 per 10000 in 2007 to 0.82 in 2014). Most patients (73%) first consulted unqualified providers; only 3% opted government hospitals. Mean patient delay was 7.3 days and on average each patient visited more than three health facilities before being diagnosed. These trends did not improve much over the study period. During the course of health seeking, only 17% of the time government hospitals were consulted. Mean total health system delay (constituted as diagnosis delay: 37.7 days + treatment delay 6.3 days) was 44 days. Patients (93.7%) were diagnosis by rK39 rapid test, Amphotericin-B (45.5%) and Miltefosine (23.5%) were the most common treatments while 19.3% received some combination therapy, 11.8% received abandoned antimonial treatment. Of 332 patients, though 35.5% were diagnosed at public hospitals, only 22.3% of them took final treatment there. Remaining patients moved to either NGOs (47%) or private qualified doctors (30.72%). Conclusion: Incidence of VL in the HDSS area sharply declined over the past 8 years. Patients usually present early but mostly to unqualified providers despite free diagnosis, treatment and wage loss compensation provided by public hospitals. They still incur alarmingly long health system's delays which increases risks for further transmission of infection.