Exploring barriers and motivators to tuberculosis care-seeking among late presenters in rural Hhohho, Eswatini

Abstract

Introduction: Tuberculosis (TB) remains the second leading cause of death from a single infectious agent worldwide, after COVID-19. Africa and South-East Asia account for approximately 70% of the global TB burden, with HIV/AIDS continuing to drive TB morbidity and mortality in sub-Saharan Africa. In high-burden settings such as Eswatini, effective TB control depends on both quality health services and timely care-seeking. This study explored attitudes, perceptions, and socio-cultural beliefs influencing TB care-seeking behaviour among late-presenting patients at a rural health centre in the Hhohho region of Eswatini. Methods: The study was conducted at a rural health centre serving a catchment population of approximately 30,000 people, including referrals from satellite clinics, within a low-income, semi-subsistence farming area. An exploratory qualitative design was used. Fourteen adults enrolled in TB care as late presenters between January 2020 and December 2021 were purposively sampled. Semi-structured interviews were conducted in siSwati or English in private settings sensitive to TB-related stigma. Interviews were audio-recorded, transcribed verbatim, and analysed thematically using a reflexive approach. Results: Three main themes emerged: perceived individual-level barriers to timely care-seeking, perceived health system barriers, and perceived motivators for care-seeking. Individual-level barriers included limited or inaccurate TB knowledge, misinterpretation of symptoms, and socio-economic and geographic constraints that delayed health facility attendance. Health system barriers included anticipated and internalised stigma, insufficient community education and health promotion, and negative or apprehensive experiences with healthcare workers. Motivators for care-seeking included worsening symptoms and perceived threat to health, as well as encouragement from family members and social networks. Conclusion: Delayed TB care-seeking in rural Eswatini is driven by a combination of knowledge gaps, symptom misattribution, socio-economic constraints, stigma, and health system challenges. Strengthening community-based TB education, reducing stigma, improving patient-provider interactions, and decentralising TB services could promote earlier care-seeking and improve TB outcomes in rural settings.