Healthcare seeking behaviour as a link between tuberculosis and socioeconomic factors

Socioeconomic barriers to tuberculosis care-seeking and costs due to care-seeking lead to unfavourable treatment, epidemiological and economic outcomes. Especially in the post-2015 era, socioeconomic interventions for tuberculosis control are receiving increasing attention. In Taiwan, the National Health Insurance programme minimises out-of-pocket expenses for patients, but important delays to tuberculosis treatment still exist. Based on the population and tuberculosis epidemiology in Taiwan, I develop an analysis for profiling the efficacy of tuberculosis care provision and patients' care-seeking pathways. The results highlight that the interrupted tuberculosis evaluation processes and low diagnostic capacity in small local hospitals stands as key causes of extended delays to treatment, unfavourable outcomes, and costs. I analyse socioeconomic status (SES) of employment, vulnerability, and residential contexts, to identify risk factors for different aspects of care-seeking. To link the care-seeking pathways to the nationwide tuberculosis epidemiology, I develop a data-driven hybrid simulation model. The model integrates the advantages of agent-based approaches in representing detail, and equation-based approaches in simplicity and low computational cost. This approach makes feasible Monte-Carlo experiments for robust inferences without over-simplifying the care-seeking details of interest. By comparing the hybrid model simulations with a corresponding equation-based comparator, I confirm its validity. I considered interventions to improve universal health coverage by decentralising tuberculosis diagnostic capacity. I modelled specific interventions increasing the coverage of tuberculosis diagnostic capacity using various SES-targeted scale-up strategies. These show potential benefits in terms of reducing dropouts and reducing the tuberculosis burden, without significant increases in the inequality of care-seeking costs. I suggest considering additional SES variables such as education, health illiteracy, and social segregation to find other care-seeking barriers. Further investigations of SES-related interventions against tuberculosis, including formal impact and health economic evaluation, should be pursued in collaboration with policymakers able to advise on feasibility and patients able to advise on acceptability.