BMC Public Health 2009, 9:53 http://www.biomedcentral.com/1471-2458/9/53 imity in terms of walking time to health facilities alone may not improve patients' health seeking behaviour for early TB treatment. This could be due to the fact that most patients consult after their health status is compromised and getting optimal quality of care from tertiary facilities could be a priority to regain their ability to function nor- mally. Perception and stigma Most patients had heard of PTB, but only a few cited the infectious nature of the disease. The majority of patients believed TB to be the result of exposure to cold, evil spirits and God's will. In line with previous studies [4,6,8], patients with poor perception about TB were more likely to delay their first consultation at public health facilities, suggesting that renewed efforts are required to improve awareness of TB. The stigma attached with TB often deters patients from seeking early treatment [2,24]. Nonetheless, most of the patients (88%) were willing to reveal their illness to oth- ers. Only a few patients (12%) preferred not to reveal their illness. Fear of isolation (8%) and lost hope of being cured (4%) were given as explanations. With the spread of HIV, TB-related stigma has been heightened in sub-Saha- ran Africa [26,27]. In Ethiopia, the burden of TB is still increasing with the spread of HIV from urban to rural areas. Earlier studies estimate that HIV co-infection rate in TB patients varies from 20% to 47% [28-30]. Neverthe- less, estimates from these studies could be unreliable since most were conducted in major urban centres. The NTC programme HIV surveillance report indicates that 40% of PTB patients were HIV positive [31]. In this study, 45% of respondents were HIV sero-positive. This was consistent with the national TB programme figures reported for years 2005/2006 [31]. However, only 8% of patients thought that their illness was associated with HIV. This signifies that most respondents had low index of suspicion about the risk of having HIV. These results are consistent with a recent survey from the Southern region of Ethiopia where only 7% patients equated the two diagnoses [8]. Improv- ing awareness about TB and its treatment, and the stigma attached with TB/HIV are crucial to reduce prolonged delays in seeking modern TB care. Limitations of the study The low specificity of the diagnostic methods (radiogra- phy and clinical features) used to detect sputum smear negative PTB could potentially lead to misdiagnosis of patients. Because of atypical clinical presentations among cases with HIV co-infection, the probability of introduc- ing bias could be high. The other potential limitation may arise from patients' inability to recall the exact date of onset of symptoms based on which the study outcomes were measured. However, measures were taken to mini- mize these two limitations. The diagnosis of sputum smear negative PTB cases has been made by experienced clinicians using the recommended diagnostic algorisms [13]. In each district, two clinicians also reviewed records in order to validate patients' history of illness at presenta- tion with their responses from interview, and to evaluate whether patients were diagnosed as per the national diag- nostic standard [11]. Patients were interviewed by experi- enced nurses regarding date of onset of cough and other constitutional symptoms. To minimize variations in esti- mating patient delay, interviewers used major national and local events to define patients' perceived date of onset of symptoms. This study included all patients attending health facilities in the study districts during the study period. That is, this study was of self-referent patients and it is unknown whether there are differences in patients' characteristics with the non-attendant cases. The implications of this on the findings, however, are likely to be limited for a number of reasons. The number of PTB cases recruited constitutes 60% of the total expected adult cases for these districts. The number recruited was 2.4 times the required study size for this study. TB care is only available in public health facilities in these districts (and in Ethiopia in gen- eral), and have no where else to go. This study was con- ducted within operational conditions of the TB control programme. The study approach is consistent with the WHO Stop TB strategy and national TB programme pol- icy. Conclusion The high occurrence of delayed consultation among PTB patients a major challenge for TB control programme in Ethiopia. Illiteracy, rural poverty, poor perception of TB and the use of alternative treatment are key factors con- tributing to delays in seeking modern medical treatment. Delay in seeking allopathic treatment among sputum smear positive PTB patients is a major constraint to cur- tailing the continued transmission of TB. Creating public awareness and the involvement of the private health sec- tor, traditional practitioners and religious institutions in TB control could be important in order to improve early detection of PTB. The findings of the study could also be relevant to other sub-Saharan countries where poverty, illiteracy, HIV and the use of traditional treatment for TB disease are highly prevalent. Competing interests The authors declare that they have no competing interests. Authors' contributions MMM, RJM, and AG participated in the conception and design of the study. MMM, RJM and AG monitored and supervised data collection. MMM, JNN and JDW managed Page 9 of 10 (page number not for citation purposes)