BMC Public Health 2009, 9:53 http://www.biomedcentral.com/1471-2458/9/53 Background Delayed presentation is a major problem contributing to the high burden and transmission of tuberculosis (TB) in most developing countries: Ethiopia, where fewer than half the estimated sputum smear positive pulmonary tuberculosis (PTB) cases are detected [1,2], is no excep- tion. Nearly 10% of TB patients on treatment die each year from complications arising partly from delayed presenta- tion and/or Human Immunodeficiency Virus (HIV) co- infection [1-3]. Patient delay, the time from onset of symp- toms to first consultation to modern health care, is alarm- ingly prolonged with studies reporting from 2 to 4 months [4,5]. Patient delay represents 77% of the total delay period from onset of symptoms to initiation of treatment [6,7]. A key challenge of any TB control programme is to improve detection of sputum smear positive PTB cases. Normal practice is to use a passive case finding strategy. Patients' decisions on seeking health care however, depend on several factors, some common to many coun- tries and settings, and some context-specific. In Ethiopia, inadequate awareness of TB, illiteracy, long distances to health services and the use of informal care from alterna- tive providers have been associated with patient delay [4- 6,8]. The HIV epidemic is counteracting TB control efforts by increasing TB incidence and contributing to delays in treatment seeking because of the stigma associated with HIV, and by association with TB [9]. Very little is known regarding the pattern of TB patients' health seeking behav- iour from onset of symptoms to first consultation at a for- mal health facility. Identifying the sources, magnitude and risk factors of patient delay will help improve TB con- trol. This cross sectional study was therefore developed to assess patterns of PTB patients' health seeking behaviour, the percent of patients who delayed seeking treatment and the risk factors for patient delays from onset of symptoms to seeking care at a public health facility, in Ethiopia. Methods The study was carried out in Tigray Region, northern Ethi- opia. The population of the region is estimated at 4.4 mil- lion, 86% of whom are rural. The region has five administrative zones comprising 36 districts. Public health institutions are the main sources of health care for most people: health services access, as defined by resi- dence within 10 kilometres of any health institution, is about 65%. The TB control programme operates as an integral part of the public health system with control pro- gramme structures at national, regional and district levels. Patients have free access to TB diagnostic services and treatment in public health facilities. TB diagnostic services are only available in health centres and hospitals which are located at district urban centres. Rural patients pre- senting to clinics with symptoms suggestive of TB must therefore be referred to a health centre or a district hospi- tal for diagnosis. Health centres can diagnose smear posi- tive pulmonary TB using sputum microscopy, but must refer patients with negative sputum smears to district hos- pitals for further investigation. District hospitals are equipped with x-ray facilities and serve as the only diag- nostic units for sputum smear negative PTB. Our primary intention was to calculate a reliable estimate of the prevalence of patient delay in Tigray region. A com- mon cut-off used to determine patient delay is 30 days. Previous reports from Ethiopia give crude estimates of the prevalence of patient delay as follows: 58% [4], 65% [8], 75% [5] and 79% [6]. To estimate the prevalence of patient delay with a 95% CI of width ± 5%, a sample size of 374 is needed, assuming a prevalence of 58% (i.e. the prevalence that gives the largest sample size) [10]. To improve the validity of our findings, we increased this sample size by a factor of 2.4 to allow for drop-out and to permit reliable estimates to be made for gender and other potential risk factors. To achieve this sample size, we ran- domly selected 10 districts from the total of 36 in Tigray region. Over a one year period, all newly diagnosed pul- monary TB patients ≥ 15 years of age from the study dis- tricts were recruited at the time of diagnosis. All suspected cases referred to the diagnostic centres (11 health centres and 10 hospitals) for diagnosis from all clinics (n = 48) in the study districts were included prospectively from Janu- ary 12, 2005 to January 12, 2006. Ethical approval was obtained from the Tigray Regional Ethical Committee for Biomedical Research. Informed consent was obtained from each patient by interviewers (trained nurses). Patients were interviewed using a pre-tested questionnaire translated into the local language regarding their health seeking behaviour and actions taken from onset of symp- toms to first consultation. Patients were asked about the time of onset of cough and other major constitutional symptoms [11] and the types of treatment sought prior to first consultation at public health institutions. The number of days of treatment from informal sources was collected to quantify the magnitude of patient delays. Potential risk factors assessed included: socio-demo- graphic factors (age, sex, marital status, literacy, area of residence), economic status (monthly income of house- hold head, eligibility status for government food aid pro- gramme), health status (type of TB diagnosis, nutritional status, HIV sero-status), health seeking behaviour (use of alternative treatment/providers, type of health facility first visited, one way walking time to visit the first-visited health facility, how the decision was made to visit first-vis- ited public health facility), perception and awareness of PTB (knowledge of cause of PTB, patient's perception of cause of his/her illness, patient's perception of potential risk of transmitting TB to family members, level of fear of Page 2 of 10 (page number not for citation purposes)