With the vertical TB control system, DOTS program characterized by the free TB diagnosis and anti-tuberculosis treatment is only available in TB dispensary. In rural areas, the lowest level of TB control system is the county TB dispensary where patients with cough and/or other TB symptoms do not routinely visit. In the context of China's TB control policy, it's not possible to see this system being replaced by the non-specialized health facilities in a near future. So the accessibility of DOTS in China relies on referral by doctors in general hospitals, and/or self-referral by patients. To empower patients, and to make people understand when and where they should seek health-care, Chinese government has initiated a massive education program on TB in general population, especially people living in the rural areas. One of the objectives of this education program is to help potential TB patients identify the suspicious symptoms and go to the right place for treatment in time. Either in the urban hospitals or in the remote rural health facilities (even in the village health station), there are posters on the wall, such as 'If coughed for more than 3 weeks, you are suspect for TB', 'The government provides free treatment for communicable TB' and 'Local CDC (TB dispensary) provides free service for sputum smear test, chest X-ray and anti-tuberculosis medicines'. This information also spread through other vivid and dramatic manners such as newspaper, website, television, broadcast, brochure and leaflet. People would argue that it does not sound reasonable to expect non-patients and/or potential patients to know where to go for TB diagnosis and treatment, but it's a compromise to the vertical TB control system. Theoretically, the health staff that TB patients encounter should refer them to the correct place for diagnosis and treatment, where DOTS program is available. However, this referral system does not work well in many places [5, 19]. As we know, under China's health system reforms, hospitals and other health facilities have adopted fee for service and bonus-related revenue systems to encourage their medical staffs to make more money [4]. It is not surprising, therefore, that these health facilities have been developing a variety of means to attract patients in order to generate more revenues by providing more services and selling more drugs [4]. It is also common to see that, repeated outpatient visits before diagnosis, over-prescription of drugs and prolonged treatments instead of referral to appointed health facilities in time [17]. Admittedly, the heavy financial burden on TB patients is one of the major problems in China's TB control which has been the main reason for poor access to TB care and treatment compliance. Pressure to generate revenue and competence of health workers at different levels cause diagnostic delay and high economic burden to TB patients and ultimately impede effective TB control in China [20]. But, if patients know TB diagnosis and treatment should be free, they would have more chances to ask why they should pay for TB care and what cost should be covered by the free care. Therefore, on one hand, regulating doctors' referral could be effective to shorten diagnosis delay for TB; on the other hand, educating general population to seek health-care in an appropriate way is also an alternative.
Massive health education programs in China have been proved to make a great impact on the enhancement on people's knowledge about TB. From the current study, we are also glad to find that almost all people have heard about TB and more than 92% knew it was a transmissible disease. However, knowledge about TB linked with health-care seeking behaviors still seems unsatisfactory. Only 16% of them knew that cough lasting for more than 3 weeks was a suspicious symptom for TB and less than half of them knew the free policy for TB diagnosis and treatment. The incomprehensive perception on TB among general population after the massive education program arouses our consideration on the health educations in China: whether it is a successful campaign and what is the cost-effective way?
One interesting result in our study is that the gender disparity of knowledge towards TB among men and women was inconsistent with the health-care seeking behaviors. Compared with men, women lacked knowledge about TB symptoms and the pro-poor service policy. However, they were more likely than men to seek health-care after the onset of TB suspicious symptoms. As proved in several studies, deficient knowledge in women and patient's recognition of TB were statistically significant factors of diagnostic delay for TB [11, 21]. A study in rural Inner Mongolia of China also reported that women with less education tended to be less knowledgeable about TB and were less likely to seek care than men though gender difference was not statistically significant in the quantitative survey [22]. In our current study, lack of knowledge among women did not show negative impacts on their health-care seeking. This phenomenon could also be found in South India that despite facing greater stigma and inconvenience, women were more likely than men to access health services and adhere to treatment [23]. However, when we take a deep look on the data and further explore their health seeking experiences, it is not surprised to find that men and women have different preference on the health-care service. Men preferred to visit upper level health facilities – the hospitals, whereas women preferred to visit lower level health facilities such as village health stations. As proved by other studies, patients who chose the village clinic or private providers as their first health facility usually experienced a much longer health system delay than that of those choosing other formal heath facilities [16, 24]. Thus though women were more likely to seek health-care for TB suspicious symptoms, it might not help shorten the health system delay due to the weakness in diagnosis in non-formal health facilities. There are several explanations for this phenomenon. One might be the deficient knowledge on TB we discussed above. Another might be the special role of women in China. In rural areas of China, most work in the household is undertaken by women in addition to agricultural work, which may mean that they have less time seek health-care in a township health center or general hospital. Women may therefore prefer to visit facilities that are geographically accessible such as village health stations or private practitioners.
Another intriguing phenomenon found from this study also need to be further studied, which was that, though free service was provided to the identified cough patients, some of them were still not willing to get further examination. When inquired about the potential reasons, some patients answered "Free? I don't believe it. After examination, I am sure they will administrate many drugs and charge me a lot", and others said "That is only cough. I know it will not be a serious disease..." More reasons undermining this aspect need further studies.
One of the limitations in this study is that data were only collected from one county, which might not truly reflect the vision of the whole population in China. Though the study is very small, and findings from this study may not be comprehensive, it does have impacts on gender equity in TB control of China. Another limitation is that information depended on self-reported data and the survey on health-care seeking behavior was based on recall history. To minimize recall bias, some strategies had been taken, such as questionnaires were pre-tested and all questions were set to be easy understood; investigators were carefully trained and supervised. Ten percent of subjects were re-interviewed through telephone and the consistency was more than 95%.