Utilizing the standards provided by different literatures: 2-3 weeks ; 28.7 days ; 2 weeks (Chinese Ministry of Health)  as well as the 2 weeks (14 days) ideal health care seeking pace advocated by DOH , there is a considerable delay in the respondents’ health care seeking pace at 59 days. In fact, only 10% of the respondents sought care within the 14-day timeline recommended by DOH. Extended diagnostic and treatment lags like this present serious negative repercussions to the patient as well as the community as these delays can hasten the progression to more complex illness , escalate the risk of complications and mortality  and amplify TB transmission to the community . The generated median HCSP is also long at 49 days, similar to the results found in Hongkong . However, this is shorter than in Ethiopia, 43 weeks  and France 68 days , and longer than in Zimbabwe 36 days  and China 6 days . This delay in health seeking might be due to a number of factors ranging from socioeconomic status, distance to health services, social stigma, personal perception of the disease and severity and seriousness of the disease .
In terms of gender, the proportion of men afflicted by the disease is higher compared to women. Similarly, DOH noted that while both sexes are at risk of contracting tuberculosis, the infectious illness is more prevalent among males . Reasons for this imbalance might include greater prevalence of TB associated with men or it may indicate a persistence of personal barriers, societal inequities and health system challenges disproportionately influencing timely TB diagnosis among women . Less specific clinical TB presentations are also more common among women i.e. fewer characteristic symptoms, such as blood in sputum  which may cause such gender disparities. However, gender is not found to be a significant predictor of HCSP in contrast to a study in Nigeria . Income, tagged in many studies [12, 17, 18] as a good predictor of patient delay, was not a significant determinant in this study. While the majority of the respondents (63%) are living below the poverty threshold whose income falls below Php 9,064 , it did not seem to have an effect on their health care seeking. Furthermore, the results also negate the findings of studies stating that HCSP is dependent on the influence of other patient socio-demographic variables such as age [13, 16, 19, 32], educational attainment [12, 18, 20] and employment [13, 21] and history of smoking . It can be implied that health care seeking goes beyond sociodemographic elements and that other factors may have a more powerful influence over a decision to seek health care.
Accesibility variables namely 1) distance to DOTS facility (p=0.553) and, 2) travel time to DOTS facility (p=0.083) have also no significant relationship to the patients’ HCSP. Patients living near or far from the TB DOTS facility may have equal risk of delaying their HCSP, a finding that is different to some published studies [16, 23, 24, 25]
Cognition specific variables such as 1) knowledge on TB symptoms (p=0.686); 2) knowledge of someone with TB (p=0.507), and; 3) Awareness of available TB services (p=0.309) were also not significantly associated with HCSP. Although several literatures identified knowledge of TB symptoms [18, 21, 26] and awareness of available TB services [5, 27, 28] as fundamental variables with a huge impact on how patients seek health care, it is not the case in Cebu City. It is alarming however to note that only 2 tuberculosis-related symptoms were known by the respondents. 39% of them also declared not being aware of available free public TB services prior to their first contact with the TB DOTS facility. Public dissemination of correct TB information and the availability of TB DOTS services might either be too low or that the efficiency of information penetration to these intended population was poor. Paradoxically, TB DOTS facilities were reported to be located less than 1 kilometer and less than 30 minutes from the patients’ residence, an advantage that could have been used to intensify health education and information dissemination.
Prior health recourses variables such as 1) type of prior health recourse mostly utilized (p=0.059), 2) type of first prior health recourse (p=0.231), 3) number of prior health recourses made (p=0.321), 4) type of first health facility visited (p=0.326), and 5) ownership of first health facility visited (p=0.685) have no significant relationship to a patients’ HCSP. Therefore, prompt and delayed health care seeking may be observed in patients regardless of whether they made prior recourses on their symptoms, negating the findings of previous studies [6, 8, 15, 16, 18, 23]. Although variables under prior health recourses did not seem to influence HCSP, the huge proportion of patients patronizing non-medical health options is alarming. The high utilization rates for non-medical choices may suggest that there could be 1) poor information dissemination on the available medical services; 2) presence of deeply-founded cultural & traditional beliefs, 3) poor awareness on the effect of non-medically suggested alternatives, and; 4) presence of economic barriers that hinder patients from accessing appropriate scientific treatment. Multiple health recourses were also made prior to contact with the TB DOTS facility, placing an impact to the total length of health seeking and diagnostic delays, as revealed in many studies [8, 11, 21, 29]. Most of the first health recourse made is still self-medication, implying a widely-accepted culture of self-medication among Cebuanos, a relatively easy access to pharmaceutical drugs or a pervasive poor knowledge on ill-effects of self-medication. Self-medication for TB-related symptoms is highly correlated with patient delay [6, 15, 18]. Inappropriate and unprescribed use of antibacterial medications especially those that are used for treatment of tuberculosis also predisposes patients to develop drug-resistant tuberculosis .In terms of medical recourses, 31% of the respondents opted to visit a private medical clinic with general practitioner as attending physician at least once prior to reaching a TB DOTS facility. Most Filipinos still associate the private sector with better quality of services . Comparing the respondents’ first choice of facilities, 46% of the patients went first to government-recognized health facilities compared to 35% who went first to stand-alone clinics. The results were different from a study in Ethiopia , which noted that most of presumptive TB cases opted to go to clinics that lack diagnostic facilities than health centers and other health facilities. Patients may have more trust on established health facilities as their first choice versus stand-alone clinics probably due to the comprehensiveness of their medical services or because of the facility’s capacity to accept government-subsidized health insurance, e.g. PhilHealth. In terms of ownership of health facility, 44% of the patients went first to a public health facility/clinic in contrast to the 38% who accessed a private health facility/clinic first. The high preference to public health services as first choice may indicate a high trust towards public health service or it might be plain economics knowing that public health services in the Philippines are almost, if not at all, free-of-charge. The health cost usually drives Filipinos to ultimately prefer public services over their private counterparts, even though they view the latter as better .
79% of the respondents declared family as their primary influencer to health seeking. Kin-based opinions still account a huge weight in a Filipino patient’s decision making, similar to a study in Uganda . However, social influence (p=0.645) has no bearing on health care seeking delays.
Marital status, that is, presence of a marital or cohabitating partner (p=0.033) is the only sociodemographic variable that showed a significant relationship with the patient’s HCSP. Cross tabulation was done showing that more respondents without partners tend to delay seeking care (55%). Consequently, respondents who were married and/or currently cohabitating during the time of contact with a TB DOTS facility tend to seek earlier medical care (63%). It may be deduced that patients who had partners during their contact with the TB DOTS facility were likely to engage in prompt health seeking behaviors than those who do not, negating earlier studies [32,33]. The respondents’ partners probably provided an additional push, be it in the form of physical, psychological or emotional support, for them to seek consultation and treatment.
Four symptom-related variables showed a significant relationship to the patient’s HCSP, namely, the 1) number of symptoms experienced (p= 0.000); 2) first symptom experienced (p=0.016); 3) perceived dangerousness of all the symptoms experienced (p=0.009), and; 4) perceived dangerousness of first symptoms experienced (p=0.001). Analysis shows that as the number of symptoms increases, the likelihood that the patient delays seeking health care also increases. Therefore, the number of symptoms has a deterring and delaying power over HCSP. Some patients wait for the appearance of more symptoms before they are convinced to have themselves checked. Waiting for the appearance of many symptoms causes further delays in the diagnosis and treatment. Another perspective that might be considered in this analysis is to look at the HCSP as the variable that affects the appearance of the number of symptoms. As the patient, regardless of the reason, delays diagnosis and treatment, the number of symptoms he experiences also increases. This corroborates with the findings of many studies that delaying diagnosis and treatment may pose additional symptomatic burden to the patients, accelerate risk towards developing a more advanced disease [4, 34] and increase the possibilities of complications and mortality [5,34].
Another finding showed that most of the respondents who had 1) unexplained fever (100%), 2) shortness of breath (83%), 3) chest/ back pain (83%) and pulmonary tuberculosis-consistent chest X-Ray (75%) as their first symptom were classified as prompt health seekers. Most of the respondents who had fatigue/ malaise (100%) as the first symptom, on the other hand, were classified as delayed health seekers. The type of symptom first experienced by the patient might influence his HCSP. Shortness of breath, chest/ back pain and pulmonary tuberculosis-consistent chest X-Ray are respiratory specific symptoms while unexplained fever and fatigue or malaise are general symptoms. The results somehow affirm the results of previous studies that presence of less specific symptoms are associated with longer delays (13; 35].
The increased perception in the dangerousness of all the symptoms experienced (p=0.007) also increases the likelihood of delay as did the increase in the perceived dangerousness of the first symptom (p=0.001). This implies that increased perception of dangerousness is a deterrent to prompt health care seeking, a finding that runs in contrast to other studies . Some patients equate the perception of danger in the symptoms they experience with intense fear of having a severe disease, a possibility of prolonged hospitalization or risk of incurring additional financial expenses. These discouraged them from accessing appropriate health care, as evidenced by an anecdotal statement made by one patient: “Mahadlok ko sa akong sintomas pero mas mahadlok ko mupakonsulta kay basin og nay makit-an nga grabe nga sakit. Makagasto pa unya ug dako ang akong pamilya”. (Translation: “I’m afraid of my symptoms but I am more afraid of seeking consultation because I might find out that I have a complicated illness. My family might spend a huge amount of money because of this.”)
Intrapersonal variables 1) perceived social stigma (p=0.035) and 2) perceived social support (p=0.002) were also significantly associated with the respondents’ HCSP. Perceived social stigma (r-value of 0.188) has a weakly positive correlation with HCSP. Because the data gathering instrument used measures the respondents’ level of internalized stigma, it is surmised that higher internalized internal stigma translates to longer HCSP. The finding suggests that high perception of social stigma among TB patients prevents them from seeking timely medical care. The findings further verify results of many studies (8, 12, 21]. Health seeking is hampered by the presence of social stigma because it can inflict damage to the person’s social status, social relationships and even income source .
Analysis of the data also revealed that perceived social support (r-value=-0.278) has a weakly negative correlation with HCSP, implying that an increase in the level of the patient’s perceived social support decreased the tendency to delay HCSP. Patients with high levels of social support are highly likely to engage in prompt health care seeking behaviors . As reflected in Table 1, perceived social support in Cebu is high implying that patients’ circles such as partners, family, friends and the community might have been explicitly supportive making it tangible to the patient. In the Philippine society, the Filipino virtue ethics is richly “relationship-oriented” which is established on the two basic foundations of the country’s culture, “loob” which is interpreted as “relational will” and “kapwa” which is better understood as “together with the person” , which may have a relative impact on the patients’ perceived assessment of social support. The high perception of social support may also explain the relatively low perception of stigma among the respondents.
Extending to multivariate analysis using discriminant analysis, only five (5) independent variable (marital status, number of symptoms experienced, perceived dangerousness of all the symptoms experienced, perceived social stigma and perceived social support) came out as the predictors of HCSP. The results further strengthen the concept that a supportive, non-stigmatizing and accepting social environment, is fundamental to promoting positive health seeking behaviors among presumptive of TB patients. The presence of a physically tangible source of support such as a spouse or a partner further reinforces this health promoting social environment. This confirms the findings in literatures where explicit social support from social relationships and social networks serve as a potent starting point and driver for a causal flow of positive health outcomes . The relationship between the number of symptoms and HCSP implies that patients do wait for the appearance of more symptoms before making contact with TB DOTS facilities. A higher perception of danger over the symptom experienced also derails further action which may be associated with intrapersonal and psychological impacts of apprehension or fear to health care seeking