These findings indicate that patients’ education, BCG vaccination status and first consultation with qualified persons were significant predictors for delay initiation of proper TB treatment. Educated patients who primarily sought care from health care personnel were more likely to have an acceptable delay in starting proper TB treatment in comparison to uneducated patients. Moreover, qualified personnel had longer delays before initiation of TB management. A lower proportion of women were diagnosed with TB at the facility, and they had a higher rate of considerable delay before initiating treatment. For this study, being educated reduces the odds of considerable delay in getting proper treatment of TB. In fact, despite proper diagnosis or guidance during the first consultation, uneducated patients may suffer a considerable delay in the initiation of proper TB treatment. Reasons include time wasted to seek a second or even third opinion due to psychological factors of denial among the patients diagnosed with this stigmatized disease [26,27,28].
Whereas, in terms of a considerable delay made before initiation of proper TB treatment after the first consultation with qualified personnel, it could be explained that some of the private practitioners with less awareness about TB may not want to acknowledge failure in diagnosing; therefore, they do not refer patients to UHC. This may justify the longer delay made in this sample who first sought care from private practitioners, and similar findings are evident also in another study in Bangladesh  and elsewhere . This is often observed, as private practitioners repeatedly prescribe different diagnosis procedures and treatments for cough before referring the patients to UHC, or did not refer patients at all. In this case, the patients sought treatment from other places causing a further delay in the initiation of proper TB treatment (Fig. 1).
The tendency for patients to seek care from private practitioners in this rural setting, was much lower than that observed in another study that covered populations from all over Bangladesh in which 43.8% first sought care from the private practitioners before reporting to public health facilities . Two other studies in Indonesia and India have shown that 27.3 and 48.7% respectively visited private facilities [30, 31].
A study in rural Tanzania  observed a somewhat lesser health system delay in the initiation of treatment (57 days) than our study, while the average delay was 151 days in Afghanistan  and 16 days in China .
Furthermore, the knowledge and awareness of TB in this study population was higher (76.1%) than in the neighboring country of India, where 56% of the people knew about TB and only 20% knew about the cause and mode of TB transmission . Most of our study population did not receive BCG vaccine during their childhood, which indicates that vaccination coverage in this area has increased [20, 21].
Our study found that less women sought treatment than men, though the gender distribution in the catchment was the same, which is in concordance with the national prevalence of TB in Bangladesh (male and female ratio more than 3:1,  1.45:0.48  and findings from other middle and low-income countries . The reasoning for less female attendance may be attributed to the social stigma associated with TB [25, 28]. Women prefer to visit traditional healers and seek alternative medicine rather than mainstream medical health professionals . Even though fewer women consult with qualified health care providers, clinicians are not able to aggressively investigate for the diagnosis of TB [20, 37, 38]. As a result, further evaluation of the low rates of female hospital attendance and TB among women is needed.
It is likely that access to health care was limited due to poor socio-economic conditions of this study population. This might have made the patients choose non-qualified practitioners, especially pharmacists, due to easy access and low-price of drugs. This finding is similar to a WHO report on the National Tuberculosis Control Programme of Bangladesh .
This paper suggests that all medical service providers, both qualified and non-qualified, should be integrated into the National Tuberculosis Control Programme (NTP). This integration could improve the proper referral system, increase awareness and reduce the stigma surrounding TB. It may also help to increase the utilization of free and complete treatment facilities for TB provided by the government.
In order to achieve the Sustainable Development Goals (SDGs), TB needs to be further highlighted in the National Health Policy of Bangladesh and incorporated into various public health programmes to increase knowledge, awareness, reduce gender differences and stigma in the National Tuberculosis Programme (NTP).
The limitations of this study were that we excluded all the patients who were less than 15 years, as well as extra-pulmonary TB patients, because it was very difficult to diagnose this age group due to nonspecific clinical symptoms. We also did not enroll those patients who did not visit the Upazila Health Complex, but sought treatment from private health care providers. The study was carried out in a single health facility; therefore, the findings are not representative of the whole of rural Bangladesh. The study delay data relied on patients recall and was thus prone to recall bias. This is a cross-sectional study, and thus no causal inferences could be made. Because of the above-mentioned limitations, the results may not be extrapolated to depict the TB situation in Bangladesh.