Beyond Access: Social Inequalities, Power Relations, and Healthcare Navigation among Urban Tuberculosis Patients in Thailand

Beyond Access: Social Inequalities, Power Relations, and Healthcare Navigation among Urban Tuberculosis Patients in Thailand | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Beyond Access: Social Inequalities, Power Relations, and Healthcare Navigation among Urban Tuberculosis Patients in Thailand Shinnawat Saengungsumalee, Patreeya Kitcharoen, Suyanee Pongthananikorn, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7207938/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract This study explores barriers to healthcare access among urban tuberculosis patients, focusing on social structures, economic factors, and cultural beliefs. Using qualitative methods, in-depth interviews with 12 patients in Bangkok (31 October 2024– 31 January 2025) revealed that universal healthcare reduces financial burdens, but challenges remain, including transportation, hidden costs, and treatment discontinuity. Family and workplace support enhance treatment success, while religious beliefs aid mental health. Health literacy and confidence in care impact self-management. Recommendations include addressing hidden costs, improving follow-up systems, and enhancing health literacy to better support patient needs. Health sciences/Health care Humanities/Health humanities Humanities/Medical humanities Social science/Social policy Healthcare access Tuberculosis Social structure Health Inequality Socioeconomic Barriers Urban Health Figures Figure 1 1. Introduction Healthcare access for urban tuberculosis patients remains a significant challenge in public health systems, particularly in urban societies with complex social, cultural, and economic dimensions. Barriers to healthcare access are not limited to physical factors but also include social and cultural constraints that affect patients’ decisions to seek treatment. Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis , which spreads through the respiratory system via droplets released during coughing, sneezing, or speaking by infected individuals (World Health Organization [WHO], 2023). While the disease primarily affects the lungs, it can also spread to other organs, including the lymph nodes, pleura, reproductive and urinary systems, bones and joints, meninges, and the abdomen. Key symptoms include a chronic cough lasting more than two weeks, potentially accompanied by sputum or blood, as well as systemic symptoms such as weight loss, loss of appetite, evening fever, night sweats, and fatigue. The 2023 Global Tuberculosis Report by the World Health Organization (WHO, 2023) indicates that in 2022, there were 10.6 million new tuberculosis cases worldwide, with Southeast Asia having the highest proportion at 46%, followed by Africa at 23%, and the Western Pacific at 18%. These statistics indicate an increasing trend compared to 2021 and 2020, which contradicts the WHO’s goal of reducing the incidence by 50% by 2025. In Thailand’s context, the Bureau of Tuberculosis, Department of Disease Control ( 2021 ) reported that in fiscal year 2021, there were 35,951 new and relapse tuberculosis cases (including Thai nationals, non-Thai nationals, and prison inmates), representing a rate of 54.0 per 100,000 population. Compared to fiscal year 2018, which had 85,029 registered patients, the treatment coverage rate was 80%, reflecting persistent gaps in service access. Mongkhonsuebsakul ( 2022 ) analyzed factors affecting healthcare access across three main dimensions: social status (encompassing gender, language, ethnicity, origin, and culture), social capital (referring to social relationships and networks supporting access to services), and human capital (including education and occupation levels that influence the ability to access and utilize healthcare services). This aligns with the findings of Sitthikant and Chongudommarn (2020), who found that behavioral and attitudinal factors, such as patients’ tolerance of illness symptoms and hesitation to seek services without severe symptoms, feelings of inferiority, and lack of confidence in seeking healthcare services, affect decision-making among vulnerable groups, particularly low-income individuals, those living in remote areas, and laborers. Delays in seeking treatment have severe impacts on both patients and communities. Meintjes et al. ( 2008 ) and El-Sony et al. ( 2002 ) demonstrated that allowing suspicious symptoms to persist without seeking medical examination increases mortality risk and leads to more excellent community transmission. This corresponds with Lienhardt et al.’s ( 2001 ) findings that delays in diagnosis and treatment are crucial factors affecting tuberculosis outbreak control in communities. Therefore, this research aims to study the influence of social structures on tuberculosis treatment access and understand the role of cultural beliefs in tuberculosis treatment processes. The study seeks to help understand the impact of social structures, cultural beliefs, and economic factors on tuberculosis patients’ access to treatment. It employs qualitative research methods to gain deep insights into the influence of social structures on tuberculosis treatment access and the impact of social structures, cultural beliefs, and economic factors on tuberculosis patients’ access to treatment. This study analyzes a structural and relational framework for healthcare access developed to understand the complexity of healthcare access among urban tuberculosis patients. It integrates three key theoretical concepts: political economy, social capital, and power relations. This multi-level analysis reveals interactions between socioeconomic structures, relationship networks, and power dynamics that determine opportunities and limitations in treatment access (Fig. 1 ). Marx’s political economy concept helps explain how production relations and social stratification affect healthcare system inequalities. Meanwhile, the social capital concept aids in understanding the role of social networks at three levels: bonding capital at the family level, bridging capital at the community and workplace level, and linking capital with the healthcare system. Foucault’s concepts of power and discourse help analyze power relations embedded in the healthcare system, both in terms of medical knowledge utilization, surveillance control, and patient negotiation. This framework demonstrates that any single factor does not determine treatment access but results from complex interactions between socioeconomic structures, relationship networks, and power dynamics in the healthcare system. Understanding these interactions will lead to policy development and practices that more effectively respond to patient needs. 2. Methodology This study employs phenomenological qualitative research methods to gain a deep understanding of urban tuberculosis patients’ experiences in accessing treatment. Data was collected between 31 October 2024 and 31 January 2025 at a tuberculosis clinic in a hospital in Bangkok. 2.1 Participants Selection The study used purposive sampling, establishing selection criteria that reflect diverse experiences, including age, gender, socioeconomic status, treatment duration, and type of tuberculosis. Additionally, snowball sampling was used to reach patients with specific experiences, such as those who had interrupted treatment or faced unique challenges in accessing services. Data collection continued until theoretical saturation was reached, resulting in 12 key informants. 2.2 Data Collection The study employed multiple data collection methods to obtain comprehensive and in-depth information, including 1) In-depth interviews using semi-structured questions developed from literature review and theoretical frameworks. Each interview lasted 60–90 minutes, conducted in private clinic areas, with audio recording upon participant consent; 2) Participant observation, where researchers spent 3–4 hours per day, three days per week in the tuberculosis clinic, observing interactions between patients and service systems, physical environment, and social dynamics in the clinic. Observations covered different periods to capture various situations; 3) Field notes, where researchers recorded observation details, thoughts, and preliminary interpretations after each data collection session. These notes included researcher reflexive notes about roles and potential biases affecting data collection and interpretation. 2.3 Data Analysis Data analysis employed thematic analysis combined with interpretive analysis, following these steps: 1) Verbatim transcription and multiple readings of data to achieve familiarity; 2) Data coding conducted at three levels, including open coding to identify key concepts in the data, theoretical coding linking data with theoretical frameworks, and selective coding to develop main themes; 3) Constant comparison between data from different informant groups and between data and theoretical frameworks; and 4) Negative case analysis to test and refine data interpretation. Using ATLAS. Ti Version 25.0.1 (32922), researchers analyzed in-depth interview results from key informants to identify approaches and recommendations. 2.4 Data Trustworthiness Researchers employed several steps to verify data trustworthiness. For internal validity, researchers engaged in prolonged engagement with key informants and maintained persistent observation throughout interviews. Researchers conducted triangulation of data, examining interview data on topics such as occupation, social status, education, household income, medical expenses, healthcare service utilization, ability to pay for medical care, beliefs, attitudes, and decision-making in tuberculosis treatment, verifying consistency across different key informants. After transcription, researchers engaged in group reflexivity discussions, conducted member checking by returning data to informants for accuracy verification, and consulted with experts (peer debriefing). 2.5 Ethical consolidation This study was reviewed and approved by the Human Research Ethics Committee, Faculty of Pharmacy, Siam University, Thailand (COA.013-2567), on 31 October 2024, in accordance with the ethical principles of the Declaration of Helsinki (2013 revision). All participants were fully informed about the objectives, procedures, potential risks, and benefits of the study. They were assured of the confidentiality of their information and informed that participation was entirely voluntary. Written informed consent to participate was obtained from all participants before data collection. 3. Results The tuberculosis clinic under study is in a large hospital in central Bangkok, surrounded by high-rise buildings and shopping centers. However, most patients travel from densely populated suburban communities with limited infrastructure. Every morning from 5 AM, patients gradually arrive to wait in designated areas, some accompanied by family members, others alone. The diversity of patients reflects that tuberculosis is not limited to low-income groups but affects all social classes. 3.1 General Characteristics of Interviewees This study collected demographic data from 12 interviewees. Most participants were female (58.33%), with males comprising 41.67%. Regarding age distribution, the majority were in the 41–50 age group (41.67%), followed by 61–70 years (33.33%), while the 31–40, 51–60, and over 70 age groups represented 8.33%. There were no participants in the 10–30 age range. Regarding religion, most participants were Buddhist (83.33%) and Muslim (16.67%). In terms of healthcare coverage, most participants used Social Security benefits (50.00%), followed by the Universal Coverage Scheme (41.67%) and self-payment (8.33%). Concerning tuberculosis history, most participants were new cases (83.33%), with equal proportions (8.33%) having multiple episodes or drug-resistant tuberculosis. These demographic data demonstrate the sample’s diversity across age, religion, and healthcare coverage types, providing comprehensive perspectives on urban tuberculosis patients’ healthcare access experiences. The general characteristics of interviewees are presented in Table 1 . Table 1 General Characteristics of Interviewees Patient Information Numbers Percent (%) Gender Male 5 41.67 Female 7 58.33 Age group (Years) 18–30 0 0 31–40 1 8.33 41–50 5 41.67 51–60 1 8.33 61–70 4 33.33 >70 1 8.33 Religion Buddhist 10 83.33 Muslim 2 16.67 Healthcare Coverage Universal Coverage Scheme (Gold Card) 5 41.67 Social Security 6 50.00 Out-of-Pocket Payment 1 8.33 Tuberculosis History First-time TB 10 83.33 Recurrent TB 1 8.33 Drug-resistant TB 1 8.33 3.2 Healthcare Access This study revealed key factors affecting urban tuberculosis patients’ healthcare access, comprising four main aspects: 3.2.1 Healthcare Coverage Systems The Universal Coverage Scheme (UCS) and Social Security System are crucial in reducing financial barriers for tuberculosis patients, particularly among low-income groups. Most patients expressed satisfaction with healthcare coverage systems, as they significantly reduced financial burden, as illustrated by one participant: “So, I’ve been receiving regular treatment here. When Social Security expired, I could use the Universal Coverage card. Having the UCS card is good; otherwise, it would be costly without any coverage. I could barely manage on my own as it is.” (TB-02) This reflects the vital importance of universal health coverage in supporting continuous patient access to treatment. 3.2.2 Service Accessibility and Limitations Healthcare services for tuberculosis patients demonstrate flexibility and consideration for patient convenience, particularly for those who must work. As evidenced by one patient’s experience: “I can work while getting treatment. Treatment doesn’t require hospitalization. After seeing the doctor, I go home, wake up in the morning and return to work. I can function normally.” (TB-02) Furthermore, the appointment system shows flexibility, as indicated by another patient: “No matter how long the wait, I come. Even while working, I rush here afraid of being late. If I can’t make it early someday, I call to reschedule. I want to keep getting treatment consistently.” (TB-02) 3.2.3 Role of Family and Community Family support significantly impacts treatment continuity. Families play crucial roles in care and medication adherence supervision, as exemplified by one case: “My child takes care of me and wants me to take medicine every day.” (TB-05) This demonstrates family involvement in patient care. However, some patients must manage care independently, which may affect treatment regularity. Therefore, establishing social support systems is crucial, particularly for patients lacking family support: “No one helps me, even my children don’t care.” (TB-02) 3.2.4 Quality and Equity in Treatment Most patients expressed satisfaction with the quality of care received from medical personnel, with doctors and nurses providing appropriate guidance and care, as stated: “The doctor has done the best possible treatment.” (TB-03). “The nurses and doctors are good.” (TB-08) Many viewed treatments as fair and equitable, with all patients receiving standardized care regardless of healthcare coverage type. Medical personnel provided care with attention and non-discrimination, offering support and encouragement to patients: “It’s fair because everyone receives equal treatment.” (TB-12) 3.3 Barriers to Healthcare Access The study found that tuberculosis patients face multiple interconnected barriers to healthcare access, with these obstacles affecting each other across various dimensions: 3.3.1 Transportation Barriers Transportation emerges as a significant barrier affecting patients’ access to treatment, manifesting in two primary forms: 1) Transportation Difficulties Patients who must travel to the hospital independently face multiple challenges, including travel fatigue, safety risks, and traffic congestion, as illustrated by one participant: “Traveling alone is difficult, sometimes dangerous... traffic jams, getting back home, there’s so much traffic. It’s exhausting.” (TB-02) These difficulties may affect treatment regularity, particularly for patients with physical limitations or those traveling long distances. 2) Dependence on Others for Transportation Many patients must rely on family members or public transportation, which, while reducing difficulties, may create a burden for families, as expressed: “My child drives me here. Transportation isn’t difficult, just morning traffic.” (TB-05) Meanwhile, patients dependent on public transportation may face accessibility issues: “It’s difficult when coming here, hard to get transportation.” (TB-06) 3.3.2 Cost-Related Barriers The cost burden represents a significant barrier to treatment access, particularly for low-income patients. Expenses extend beyond medical costs to include hidden costs such as transportation, meals during hospital visits, and lost income from missing work, as illustrated: “We need money for personal expenses, transportation, food. No one helps... There was one year I didn’t come for treatment at all because I had no money and transportation was difficult.” (TB-02) This demonstrates how cost burdens can lead to treatment discontinuity. Interestingly, some patients view costs as secondary to treatment success: “Money isn’t the problem, as long as I get cured.” (TB-12) This reflects that patients prioritize treatment outcomes over associated costs. 3.3.3 Healthcare System Barriers The study revealed systemic limitations that obstruct access and treatment continuity for tuberculosis patients. These limitations affect both treatment efficiency and patients’ quality of life. 1) Treatment Follow-up Discontinuity The lack of an efficient follow-up system can cause patient confusion about treatment plans: “The doctors at the previous hospital didn’t follow up. How would patients know if they’re cured or need to come back?” (TB-11) This discontinuity creates multiple impacts. First, inefficient follow-up systems confuse self-care requirements and appointment schedules. Second, ineffective communication between medical personnel and patients may lead to a misunderstanding about the importance of continuous follow-up or awareness of treatment progress. Third, the lack of systematic follow-up may miss opportunities to identify and address problems arising during treatment, such as medication side effects or drug resistance. 2) Extended Waiting Times Another significant barrier in the healthcare system is the long waiting time for services, as reflected by patients: “It affects us, makes patients reluctant to come to the hospital.” (TB-06) In terms of treatment, long waiting times can cause frustration and discouragement, potentially leading to non-compliance. Some patients may decide to miss appointments or discontinue treatment due to the inability to tolerate extended waiting periods. Regarding work and daily life, long waiting times during each visit impact daily schedule management, particularly for patients who work or have other responsibilities. 3.3.4 Time Management Barriers Time management presents a significant challenge, especially for patients with other responsibilities such as family care and work: “I also take care of my grandchild. Sometimes I don’t want to travel frequently, it’s difficult going alone.” (TB-02) The need to balance various responsibilities may affect treatment regularity. 3.4 Economic Factors The study reveals that economic factors significantly impact tuberculosis patients’ treatment outcomes. These factors affect healthcare access, treatment continuity, and quality of life for patients and their families. 3.4.1 Limited Income and Expenditure The imbalance between income and expenditure emerges as a fundamental problem significantly impacting tuberculosis patients’ treatment. As one participant explained: “Monthly income barely covers expenses. We’re living hand to mouth.” (TB-02) This reflects the financial management difficulties patients face. Tuberculosis illness not only reduces income due to work absences for treatment but also increases expenses through treatment and transportation costs. This situation creates substantial financial pressure for patients. The illness directly impacts patients’ work capacity and income, as illustrated by one participant: “If we take a full day off, we have to pay someone three to four hundred baht to cover, that money is lost.” (TB-02) This impact is particularly severe for daily wage workers or self-employed individuals, as their income depends on daily work. Taking time off for treatment directly translates to lost income. In some cases, patients must bear additional expenses from hiring replacements. Beyond managing personal expenses, many patients carry the burden of caring for family members: “My grandchild is starting to drink milk, and I’m raising them. Their mother left them here, coming back in the evening to check on them.” (TB-02) This situation forces patients to allocate limited resources for their treatment and family care in terms of expenses and time. The decision-making process between using money for treatment versus family expenses represents an ongoing challenge for patients. 3.4.2 Transportation Costs Transportation costs reflect healthcare access inequalities, with data showing significant cost variations: “Round trip costs 120 baht” (TB-06) to “Round trip costs 500–600 baht plus” (TB-08) This disparity demonstrates that patients living in remote areas bear significantly higher cost burdens, which may influence treatment-seeking decisions. Patients attempt to manage transportation costs through various strategies, as evidenced by the following: “If it’s a non-air-conditioned bus, it’s 8 baht, but air-conditioned is 15 baht” (TB-04) Choosing economical public transportation represents one strategy patients use to reduce costs, though this often comes at the expense of comfort and increased travel time. Transportation choice thus becomes a balance between cost, time, and comfort. 3.4.3 Social Security System Support The Social Security System plays a crucial role in supporting patients’ healthcare access: “Having Social Security makes treatment more accessible” (TB-01) Social Security helps reduce medical expenses, increasing patients’ confidence in seeking treatment. Additionally, the insurance system provides patients access to standardized healthcare facilities and necessary medications and medical supplies. However, the Social Security System has certain limitations, as reflected: “Sometimes it doesn’t cover all treatments. Sometimes I want a health check-up but don’t dare tell the doctor” (TB-01) These limitations extend beyond benefit coverage, including communication barriers between patients and medical personnel, lack of confidence in inquiring about their rights, and concerns about potential expenses beyond covered benefits. 3.4.4 Income Compensation and Workplace Support Workplace support emerges as a crucial factor enabling patients to maintain continuous treatment: “Work allows sick leave with a medical certificate” (TB-01), and “They pay wages for that day, but require a medical certificate” (TB-09) Clear policies regarding sick and paid medical leave help reduce patients’ financial security concerns. Additionally, flexible work scheduling and colleague support are important in helping patients appropriately manage between work and treatment. However, the disparity between formal and informal sector workers is a crucial issue affecting treatment access. Formal sector workers typically receive legal protection and clear benefits, while informal sector workers often lack social protection and must bear risks independently. This inequality affects both treatment continuity and patient quality of life. 3.5 Cultural Factors Cultural factors significantly support treatment and healthcare management among urban tuberculosis patients, particularly in building resilience and psychological healing. The study reveals that religious and cultural beliefs are intricately connected to patients’ treatment experiences across multiple dimensions. 3.5.1 Religious Beliefs and Psychological Therapy Religious beliefs serve a crucial role in supporting the mental health of tuberculosis patients. The study finds that many patients use religion as a psychological anchor and source of strength in their battle against illness, as illustrated by one participant: “Normally, I pray before bed every day, praying to be cured and stay with my children for a long time.” (TB-03) Religious practices form daily routines that help generate hope and mental tranquility for patients. Religious teachings also contribute to patients’ psychological healing, as one patient stated: “The Buddha’s teachings are all true.... I believe in the teachings and use them for mental healing.” (TB-11) Applying religious principles helps patients develop frameworks for understanding and accepting their illness. Furthermore, religious beliefs help patients manage stress and anxiety better, as evidenced by the following: “Religion is already good, makes people less stressed, because when I first got it, I was completely shocked.” (TB-07) Having spiritual support helps mitigate the psychological impact of diagnosis and coping with long-term treatment. 3.5.2 Religious Interpretation and Treatment The relationship between religious beliefs and modern medical treatment presents interesting dynamics. Many patients view both aspects as complementary rather than contradictory, as illustrated: “Islam makes allowances for this, as it’s disease treatment.” (TB-04) This reflects how religious principles support healthcare and do not obstruct medical treatment. However, perspectives on religion’s role in treatment vary. Some patients express disbelief in prayer or wishes: “It’s impossible, it’s fantasy. If you talk about making wishes, I don’t believe in that.” (TB-09) This reflects how some patients clearly distinguish between religious beliefs and medical treatment. 3.5.3 Role of Cultural Beliefs in Daily Life Religious practices in daily life form part of patients’ illness management mechanisms, as evidenced: “I always pray to Buddha anyway, I pray to the Buddha at home every day.” (TB-05) These practices reflect the integration of religious beliefs into daily healthcare routines. The study also found that religious practices help reduce obsession with illness: “We don’t obsess; we feel more comfortable physically and mentally. When we come to see the doctor, we feel better physically and mentally.” (TB-02) Having religious activities helps patients maintain focus beyond their illness, promoting psychological well-being. Meanwhile, some patients do not connect religion with healthcare, simply stating: “I don’t pray to Buddha.” (TB-10) This reflects the diversity and significance attributed to religion’s role in treatment. Therefore, studying cultural factors in tuberculosis patients demonstrates the diversity of religious beliefs and practices. Religion plays a crucial role in supporting mental health and illness management for many patients, while others choose to separate religious beliefs from treatment. Understanding this diversity is important for developing patient care systems that respond to different spiritual needs. 3.6 Social Factors The study reveals that social factors are crucial in supporting successful tuberculosis treatment, particularly within the complex social context of urban environments. The analysis demonstrates the importance of social networks at multiple levels, from family to workplace to healthcare systems. 3.6.1 Family and Community Support Family emerges as the most crucial source of support for tuberculosis patients. The study finds that having an understanding and supportive family directly impacts treatment success. Families play vital roles in multiple aspects of care and support. First, families help manage daily treatment routines, as illustrated by one participant’s experience: “They make decisions for me to come here, to stay. They tell me today and tomorrow I’ll go see the doctor, they remind me to take medicine, to eat so I can take medicine...” (TB-02) Family assistance with food and medication management provides essential support that helps patients maintain treatment continuity. Beyond physical support, families are crucial in providing emotional support and encouragement. The emotional impact is evident in one patient’s poignant statement: “Mom... Mom said to go get treatment at the hospital until cured (eyes welling with tears).” (TB-12) This demonstrates the power of family concern in influencing patients’ decisions to seek treatment. 3.6.2 Workplace Relations and Interactions The workplace environment significantly affects patients’ ability to manage treatment alongside work responsibilities. The study finds that acceptance and understanding from colleagues are crucial factors in helping patients effectively balance work and treatment. One patient’s narrative clearly illustrates this: “They say, ‘Auntie, if you’re sick, get treatment, you’ll get better.’” They talk well and don’t discriminate. I can work while getting treatment. Treatment doesn’t require hospitalization. After seeing the doctor, I go home, wake up in the morning and return to work. I can function normally. Colleagues understand and say treatment will cure it.” (TB-02) Such support reduces stigma and helps build motivation and encouragement for continuous treatment. The moral support from colleagues, as expressed in: “Colleagues and neighbors encourage” (TB-12) Demonstrates that social support in the workplace is crucial in creating an environment conducive to treatment. 3.6.3 Relationships with Medical Personnel The quality of relationships between patients and medical personnel significantly impacts treatment success. The study finds that attentive and understanding care from medical personnel directly affects patients’ trust and cooperation in treatment, as evidenced by statements such as: “The doctors here take good care of us, so we don’t dare change hospitals, afraid of finding doctors who care less” (TB-08), and “The doctor doesn’t abandon patients, the doctor is excellent, loves patients, no harsh treatment...” (TB-02) These reflections demonstrate that caring and good interpersonal relationships with medical personnel create positive impressions and play a crucial role in maintaining treatment continuity. The analysis of social factors demonstrates that successful tuberculosis treatment depends on medical treatment and social support systems encompassing family, workplace, and healthcare systems. Creating an environment conducive to treatment, free from stigma, and with appropriate emotional support are crucial factors in successfully helping patients complete their prescribed treatment course. As Waitzkin (2021) emphasizes, improving healthcare access requires consideration of the political, economic, and social dimensions of the healthcare system. 3.7 Psychological Factors The study of psychological factors in tuberculosis patients reveals the crucial role of mental states in treatment success. Analysis shows that both internal motivation and confidence in treatment processes significantly contribute to patients’ ability to combat the disease effectively. 3.7.1 Personal Commitment and Motivation Internal motivation emerges as a powerful force enabling patients to face the challenges of tuberculosis treatment. The study finds that patients express their determination to fight the disease in various forms, as evidenced by statements showing firm resolve: “If I can recover, I will fight on” (TB-02) and “I’m confident I must recover” (TB-12) These statements reflect positive attitudes and self-efficacy beliefs in their ability to overcome the disease. Interestingly, patients’ motivation often links to their responsibilities toward themselves and their families, as illustrated by the statement: “We work, so we must come for treatment. If we don’t come for treatment, we won’t have the strength to fight anything” (TB-02) This demonstrates patients’ recognition that treatment importance extends beyond personal health to affect their ability to fulfill various life roles and responsibilities. This awareness becomes a crucial driving force motivating patients to maintain continuous treatment. 3.7.2 Confidence in Treatment Processes Confidence in treatment processes emerges as another crucial factor affecting treatment success. The study finds that patients who trust in their doctors’ capabilities and the effectiveness of prescribed medications tend to develop more positive attitudes toward treatment, as evidenced by the statement: “Not stressed or worried, symptoms will improve if I complete the medicine course, that’s what the doctor said (patient feels confident)” (TB-01) This confidence helps reduce anxiety and builds hope for treatment. Moreover, effective communication and encouragement from doctors play crucial roles in building patient confidence, as illustrated by the statements: “Confident (very confident voice) that I must recover because the doctor gave medicine and I’ve improved a lot, don’t feel tired anymore, so I’m confident I must recover. Very confident” (TB-03) and “The doctor gives good advice, gives us encouragement to fight on” (TB-02) These reflect how psychological support from medical personnel significantly affects patients’ confidence and morale. The analysis reveals an interconnected relationship between personal motivation and confidence in treatment processes. Internal motivation helps patients adhere to treatment plans, while confidence in treatment reinforces motivation. Positive treatment results increase confidence in treatment processes, reinforcing motivation to continue treatment. Medical personnel support is crucial in strengthening patient motivation and confidence. 3.8 Health Literacy Factors The study of health literacy among tuberculosis patients reveals complex relationships between knowledge and understanding of the disease and healthcare behaviors. It identifies key issues affecting treatment efficiency and infection prevention. 3.8.1 Knowledge and Understanding About Tuberculosis Patients’ knowledge and understanding of tuberculosis varies significantly and meaningfully. The study finds that most patients have limited knowledge about disease causes and infection mechanisms, which may affect prevention and treatment. Limitations in understanding disease causes surface in most patients expressing uncertainty about infection sources, as illustrated by one narrative: “I don’t know either. I only knew when the doctor said it was tuberculosis. No one in the family has it. I don’t smoke or drink alcohol. Strange how I got it, don’t know” (TB-02) This uncertainty reflects gaps in communicating knowledge about tuberculosis infection in communities. Misconceptions about disease causes emerge as another finding. The study reveals that many patients hold incorrect beliefs about tuberculosis causes, often linking it to environmental factors, particularly dust exposure, as evidenced by statements: “Think it’s from underground construction, lots of dust” (TB-01) and “When we encounter dust we cough, when encountering lots of dust we start coughing, have a runny nose, we think that dust might cause us to get it too” (TB-09) These misconceptions may lead to incorrect preventive behaviors and inaccurate risk assessment. However, some patients demonstrate good disease knowledge, particularly those with healthcare-related experience, as illustrated: “I used to be in prison, worked as a nurse assistant, so I know what tuberculosis is” (TB-12) This reflects how experience and access to accurate information affect disease understanding. 3.8.2 Self-Care Behaviors Despite limitations in knowledge and understanding, the study finds that most patients demonstrate appropriate self-care behaviors, particularly regarding medication adherence and infection prevention practices. Regarding medication management, patients demonstrate awareness of the importance of consistent medication intake, reflected in strict time management. As evidenced by the following statements: “Must take it regularly without missing any day, even when hospitalized I still have to take it” (TB-08) and “Will remember that every day must take medicine at what time, must take it at that time every day, don’t miss medication” (TB-04) This understanding of medication continuity’s importance forms a crucial foundation for treatment success. However, treatment challenges still emerge in some cases, such as drug resistance, as illustrated: “I’ve been taking medicine consistently, but don’t know why there’s drug resistance, there are many complications” (TB-02) This reflects the need for additional education about medication use and side effect management. Regarding infection prevention, patients demonstrate social responsibility through appropriate infection-prevention behaviors, as evidenced by their management of living spaces and personal items: “Sleep in separate rooms from the spouse, buy ready-made food in foam containers, separate everything because afraid of transmission” (TB-01) and “I separate bowls, plates, and dishes” (TB-04) Furthermore, patients show caution during the initial infection period: “Separated for the first two weeks, didn’t meet anyone at all for about a month” (TB-05) This reflects the understanding of the importance of preventing infection transmission during the disease’s early stages. 4. Discussion The discussion of findings regarding healthcare access among tuberculosis patients in urban areas, examined through the lens of Karl Marx’s political economy theory, reveals complex relationships between economic structures, social class, and healthcare accessibility. This analysis provides profound insights across multiple dimensions. Beginning with the analysis of production relations and social class, the findings reflect that patients’ economic status directly impacts their ability to access treatment, particularly among informal workers and low-income populations. This aligns with Marx’s conceptualization of class oppression within capitalist systems (Harvey, 2018 ). This is evident in patient narratives such as “Monthly income barely covers expenses. We’re living hand to mouth” and “If we take a full day off, we have to pay someone three to four hundred baht to cover, that money is lost” These accounts reflect the economic struggles that affect healthcare access. The fact that patients must choose between seeking treatment and working for income demonstrates the contradiction between health necessities and survival within the capitalist system. Subsequently, when examining the disparities between formal and informal workers in accessing health welfare, the findings reflect inequalities in the healthcare system that are interconnected with employment structures. Benach et al. ( 2014 ) analyzed how precarious employment directly impacts healthcare access, with informal workers often facing limitations in accessing welfare benefits and sick leave. This corresponds with study findings indicating that patients who are informal workers experience difficulties managing work and treatment simultaneously. This disparity is evident in the contrasting experiences between patients with social insurance, who stated “Work allows sick leave with a medical certificate” and informal workers, who must bear both financial burdens and income loss. Furthermore, patients’ encounters with hidden treatment costs, including transportation expenses, food costs, and income lost due to work absence, reflect the concept of surplus extraction within capitalist systems (Waitzkin, 2021), whereby workers must bear the burden of their own healthcare costs despite the existence of universal health coverage systems. The variation in transportation costs identified in this study, ranging from “Round trip costs 120 bah t” to “ Round trip costs 500–600 baht plus , ” demonstrates disparities in healthcare access linked to geographical location and affordability. More significantly, Marmot et al. (2012) presented empirical evidence demonstrating that health inequalities result from social and economic determinants, which corresponds with study findings indicating that patients of different socioeconomic backgrounds possess varying capacities to access healthcare services. This is particularly evident in terms of transportation affordability, income loss from work absence, and access to social welfare benefits. The study revealed that low-income patients face difficult decisions between healthcare expenditures and essential living costs, as evidenced by the statement “... There was one year I didn’t come for treatment at all because I had no money and transportation was difficult” . Concurrently, the employment-linked health insurance system reflects the concept of economic monopolization that Marx analyzed, whereby capitalist systems utilize welfare as a mechanism for labor control (Navarro, 2020). Those outside the formal employment system frequently face limitations in accessing health welfare benefits. The study revealed that patients with social insurance exhibited greater confidence in seeking treatment, as expressed in the statement “Having Social Security makes treatment more accessible.” However, simultaneously, limitations within the social insurance system were identified, such as “Sometimes it doesn’t cover all treatments. Sometimes I want a health check-up but don’t dare tell the doctor,” reflecting power relations within the healthcare system. Another compelling issue is how power relations in healthcare systems are manifested through service organizations that may not align with patient needs, particularly in terms of prolonged waiting times and discontinuous treatment follow-up. This is evident in statements such as “It affects [patients], making them reluctant to come to the hospital” and “If the doctor at the original hospital doesn’t follow up, how would patients know if they’re cured or need to return?” These reflect that healthcare systems are designed with greater consideration for resource management efficiency than patient needs responsiveness. Furthermore, the division of labor within healthcare systems reflects complex power structures. Patients are often constrained to passive recipient roles, required to follow medical personnel’s instructions without power in treatment decision-making. Marmot et al. (2012) examined how power relations within health systems influence treatment quality and health outcomes. The study found that some patients exhibited uncertainty in communicating with medical personnel due to perceived limited bargaining power. Regarding its impact, tuberculosis disease affects not only health but also work capacity and the sustainability of livelihoods. Benach et al. ( 2014 ) demonstrated how precarious employment conditions impact both physical and mental health of workers. The study revealed that patients bear multifaceted burdens, including family care, earning livelihoods, and self-treatment, reflecting how illness in capitalist systems creates compounded burdens for patients. Another critical dimension is the existing social welfare system, which, despite reducing healthcare treatment costs, remains unable to address the structural problems that constitute the root causes of healthcare access inequality. As Navarro (2020) analyzed, welfare systems in capitalist societies often serve as mere palliative measures that fail to address the deeply embedded inequalities within economic and social structures. Ultimately, the relationship between illness and poverty reflects the cycle of oppression within capitalist systems. Harvey ( 2018 ) analyzed how illness in capitalist systems frequently leads to loss of work capacity and income, resulting in deteriorating economic conditions and making healthcare access increasingly difficult. The study found that many patients face this cycle, as reflected in the statement “We need money for personal expenses, transportation, food. No one helps...,” demonstrating the economic vulnerability exacerbated by illness. Analysis from a Marxian political economy perspective demonstrates that addressing healthcare access problems requires consideration of both structural factors and power relations in society, not merely healthcare system improvements, but also the creation of equality within economic and social systems. Understanding the interconnections between illness, poverty, and access to healthcare will lead to more holistic and sustainable policy formulation. The analysis of healthcare access for tuberculosis patients in urban areas, conducted through the social capital framework, reveals the crucial role of social networks and relationships in affecting patients’ treatment experiences. Putnam (2000) explained that social capital comprises networks, norms, and trust that facilitate cooperation for mutual benefit. When applying this conceptual framework to study findings, social capital is shown to have multidimensional roles in supporting patient treatment. Family emerges as the most significant source of social capital, providing support in caregiving, financial assistance, and daily life management. Lin (2017) demonstrated that strong family relationships enhance access to resources necessary for treatment. This is reflected in patient narratives such “My child takes care of me and wants me to take medicine every day.” and “My child drives me here. Transportation isn’t difficult, just morning traffic.” Family support encompasses not only physical assistance but also encouragement and psychological stability, which are essential for long-term treatment. Beyond family, broader social networks, or what Szreter and Woolcock ( 2004 ) termed "bridging social capital," play crucial roles in creating environments conducive to treatment. Colleagues and neighbors who demonstrate understanding and acceptance help reduce social stigma and increase patient confidence, as reflected in the statement “They say, ‘Auntie, if you’re sick, get treatment, you’ll get better.’” This acceptance and understanding from the surrounding society significantly contribute to treatment continuity. The relationship between patients and healthcare systems demonstrates the importance of "linking social capital." Kawachi et al. ( 2008 ) explained that trust between patients and healthcare providers constitutes a critical factor in achieving positive health outcomes. Patients with good relationships with medical personnel often exhibit greater confidence and treatment continuity, as expressed in the statement “The doctors here take good care of us, so we don’t dare change hospitals, afraid of finding doctors who care less.” However, this study also reveals the vulnerability of patients with limited social capital. Bourdieu ( 1986 ) warned that unequal distribution of social capital can lead to the reproduction of social inequality. Patients lacking family support (“No one helps me, even my children don’t care.”) often face greater challenges in accessing treatment, similar to informal workers who typically possess more limited social capital and fewer options for managing work and treatment balance. These findings underscore the need for developing public policies that not only focus on healthcare system development but also prioritize strengthening and supporting social capital, particularly for vulnerable groups with limited social capital. Developing robust social support systems will help reduce inequality and enhance the effectiveness of long-term tuberculosis patient care. The analysis of healthcare access experiences among tuberculosis patients in urban areas, through the lens of Michel Foucault's concepts of power and discourse, reveals complex power relations within health systems, particularly about knowledge, power, and medical control. Foucault (1975/1995) proposed that power does not merely operate through top-down coercion but permeates social relationships at all levels. When applied to analyze this study's findings, power relations are evident in doctor-patient relationships. Lupton (2012) analyzed how modern medical discourse creates unequal power relations between medical experts and patients, reflected in patient statements such as “Sometimes I want a health check-up but don’t dare tell the doctor,.” Demonstrating a lack of bargaining power and uncertainty in expressing personal needs. The surveillance system constitutes another crucial mechanism that Armstrong ( 1995 ) analyzed as a tool used by modern medicine to control health behaviors. The study found that patients are monitored through appointment systems, medication compliance tracking, and reporting requirements, as reflected in the statement “No matter how long the wait, I come. Even while working, I rush here afraid of being late. If I can’t make it early someday, I call to reschedule. I want to keep getting treatment consistently.” This demonstrates how patients are controlled and supervised through treatment monitoring systems. The use of medical knowledge as a tool to legitimize the exercise of power is an issue that Rabinow (1991) analyzed in his interpretation of Foucault's concepts, highlighting the relationship between knowledge and power. This study found that patients often accept medical decisions without question, viewing doctors as superior knowledge holders, reflected in statements such as “The doctor has done the best possible treatment.” and “The doctors here take good care of us, so we don’t dare change hospitals.” This demonstrates acceptance of medical authority through acknowledgment of the expert's knowledge and expertise. Rabinow and Rose (2006) analyzed the management of space and time as tools of medical power. The study found that health systems determine patients' use of space and time through appointment systems, waiting periods, and service prioritization, where patients have limited bargaining power. This is reflected in the narrative “It affects us, makes patients reluctant to come to the hospital.” demonstrating that time management in health systems constitutes a form of power exercise affecting patient decisions. However, the study also identified forms of patient resistance and power negotiation. Pickett and Wilkinson (2015) analyzed that resistance to power in health systems often appears in subtle forms. Patients in this study demonstrated power negotiation through choosing service times, requesting appointment postponements, or even deciding to temporarily discontinue treatment, as expressed in “... There was one year I didn’t come for treatment at all…” This suggests that patients are not merely passive recipients of medical power, but rather engage in various forms of negotiation and resistance. Clarke et al. (2010) analyzed the modern emphasis on individual responsibility for health through medical processes and technology. The study found that patients are expected to take responsibility for their treatment, including medication compliance, appointment attendance, and following instructions, as reflected in statements such as “Will remember that every day must take medicine at what time, must take it at that time every day, don’t miss medication” This demonstrates how patients internalize the discourse of health responsibility as part of their identity as “good patients.” Analysis through Foucault's framework reveals that healthcare access is not merely about service provision or reducing physical barriers, but involves complex power relations within health systems. Understanding these dimensions will lead to the development of health service systems that recognize power relations and create spaces for greater patient participation in treatment decision-making. When compared with other relevant studies, findings regarding health insurance systems reveal that universal health coverage and social security systems play crucial roles in reducing financial barriers to healthcare. This aligns with McManus and Health Systems Research Institute's (2012) study, which demonstrated that Thailand's universal health coverage project serves as a significant mechanism for reducing inequality and increasing healthcare access among low-income populations. However, in-depth analysis reveals coverage gaps in health insurance systems, particularly regarding hidden costs not included in benefit packages, which may lead to long-term inequality. This issue reflects the necessity for developing policies that encompass additional indirect costs. Regarding service accessibility, the study found that transportation barriers remain significant challenges for tuberculosis patients in urban areas, both in terms of costs and difficulties in using public transportation systems. These findings correspond with Mishra et al.'s (2021) research in the Indian context, which identified transportation barriers as crucial factors affecting treatment continuity, particularly among vulnerable populations. A comparison between these two contexts reveals that transportation-related service access problems constitute shared challenges in developing countries, despite varying levels of health system development. Analysis of family roles in treatment support revealed that family involvement is important in both physical caregiving and psychological support dimensions. This corresponds with Harvey's (2021) study, which found that family support affects patients' self-care behaviors and mental health. This finding highlights the importance of developing support approaches that encompass both patients and their families, including the establishment of social support systems for patients who lack family support. Regarding patient-health system relationships, the study found that confidence in treatment systems and medical personnel correlates positively with continuous treatment. This aligns with Bandura's (1977) self-efficacy theory, which explains that confidence in system and provider capabilities constitutes a crucial factor affecting health care behaviors. This finding indicates the importance of developing service quality and communication between providers and recipients. In the economic dimension, although health insurance systems help reduce primary cost burdens, the study found that patients still face financial burdens from hidden costs and income loss. This corresponds with Russell's (2004) study, which found that the economic impacts of tuberculosis treatment are more complex and comprehensive than direct medical costs. This finding reflects the necessity for developing policies that encompass broader economic impacts. 5. Limitations and Future Research Directions While our phenomenological approach provides valuable insights into patient experiences, future research might benefit from mixed methods approaches that could quantify identified barriers and their impacts. Comparative studies across different urban contexts might also help distinguish between universal and context-specific challenges in urban healthcare access. Future research should prioritize studying interactions between macro-level health policies and micro-level patient experiences, as Navarro (2020) suggests. Additional research on how universal health coverage policies can adapt to address specific challenges in the urban context would be particularly valuable. 6. Policy Applications Our findings directly affect urban health policy development, particularly in middle-income countries. As Marmot et al. (2012) suggest, addressing health inequalities requires comprehensive approaches that consider social determinants of health. Our study supports this view and proposes specific policy measures: Development of Support Systems for Indirect Costs. The study reveals the need for comprehensive support systems that address indirect healthcare costs. While crucial, universal healthcare coverage does not fully address the financial burden patients face. Policy interventions should consider developing mechanisms to support transportation costs, compensate for lost income, and address other hidden expenses, particularly for informal sector workers who lack formal social protection systems. Integration of Social Support Networks. Recognizing the vital role of family and community support, policies should aim to formally integrate these social support networks into healthcare delivery systems. This could include developing family education programs, establishing support groups, and creating mechanisms for family involvement in treatment planning and monitoring. Cultural Sensitivity in Healthcare Delivery. The study demonstrates the importance of culturally sensitive healthcare delivery approaches. Policy frameworks should incorporate cultural competency training for healthcare providers, recognize the role of religious and cultural beliefs in treatment processes, and develop communication strategies that respect local cultural norms and practices. Systemic Improvements in Healthcare Delivery. Policy interventions should address systemic barriers identified in the study, including: Implementing more efficient appointment and follow-up systems. Developing strategies to reduce waiting times. Creating flexible service hours that accommodate working patients. Establishing better coordination between different levels of healthcare services. Enhanced Health Literacy Programs. Policies should focus on developing context-appropriate health literacy programs considering local cultural beliefs and practices while promoting an accurate understanding of disease prevention and treatment. 7. Conclusions This study demonstrates that healthcare access in urban settings involves complex interactions among structural conditions, social relationships, and power dynamics that extend far beyond the provision of universal health coverage. The research reveals how socioeconomic structures perpetuate healthcare access barriers through transportation costs, hidden expenses, and lost income opportunities that disproportionately affect vulnerable populations, particularly informal sector workers, while social support networks, especially family relationships, remain crucial to treatment success despite evolving urban contexts that require healthcare systems to adapt and integrate traditional and modern support forms. Power dynamics within healthcare settings manifest through patients developing unique strategies for navigating medical systems, with cultural and religious beliefs continuing to play important roles in treatment experiences, suggesting the need for culturally sensitive approaches that respect patient agency while ensuring treatment effectiveness. For middle-income countries experiencing rapid urbanization, these findings emphasize that while universal health coverage provides an essential foundation, achieving genuine health equity requires comprehensive interventions addressing both direct and indirect barriers, supporting evolving social capital networks, recognizing culturally specific forms of patient agency, and developing healthcare systems capable of addressing traditional and emerging urban challenges through attention to the political, economic, and social dimensions of healthcare access. Declarations Ethics declarations Competing interests The authors declare no competing interests. Ethical approval This study was reviewed and approved by the Human Research Ethics Committee, Faculty of Pharmacy, Siam University, Thailand (COA.013-2567), in accordance with the ethical principles of the Declaration of Helsinki (2013 revision). Informed consent All participants were fully informed about the objectives, procedures, potential risks, and benefits of the study. They were assured of the confidentiality of their information and informed that participation was entirely voluntary. Written informed consent to participate was obtained from all participants between 31 October 2024 and 31 January 2025, prior to data collection. Data availability The qualitative interview data generated and analyzed during this study are not publicly available due to confidentiality concerns but are available from the corresponding author upon reasonable request. Funding No funding. References Armstrong D (1995) The rise of surveillance medicine. Sociol Health Illn 17(3):393–404. https://doi.org/10.1111/1467-9566.ep10933329 Bandura A (1977) Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev 84(2):191–215. https://doi.org/10.1037/0033-295X.84.2.191 Benach J, Vives A, Amable M, Vanroelen C, Tarafa G, Muntaner C (2014) Precarious employment: Understanding an emerging social determinant of health. Annu Rev Public Health 35:229–253. https://doi.org/10.1146/annurev-publhealth-032013-182500 Bourdieu P (1986) The forms of capital. In: Richardson J (ed) Handbook of theory and research for the sociology of education. Greenwood, pp 241–258 Bureau of Tuberculosis, Department of Disease Control (2021) Tuberculosis situation and surveillance report in Thailand, fiscal year 2021. Ministry of Public Health, Thailand. [Original in Thai] Chinkhaokham D, Wongsawang N, Sritawan K (2021) Perception of real condition and expectation towards health care services for the older people in Tambon Don Tako, Ratchaburi Province. J Prachomklao Coll Nurs Phetchaburi Province 4(1):170–182. https://doi.org/10.37708/pcnpj.v4i1.246095 El-Sony A, Enarson D, Khamis A, Baraka O, Bjune G (2002) Relation of grading of sputum smears with clinical features of tuberculosis patients in routine practice in Sudan. Int J Tuberculosis Lung Disease 6(2):91–97 Foucault M (1995) Discipline and punish: The birth of the prison (A. Sheridan, Trans.). Vintage Books. (Original work published 1975) Harvey D (2018) Marx, capital, and the madness of economic reason. Oxford University Press Kawachi I, Subramanian SV, Kim D (2008) Social capital and health. Springer Lienhardt C, Rowley J, Manneh K, Lahai G, Needham D, Milligan P, McAdam KP (2001) Factors affecting time delay to treatment in a tuberculosis control programme in a sub-Saharan African country: The experience of The Gambia. Int J Tuberculosis Lung Disease 5(3):233–239 Meintjes G, Schoeman H, Morroni C, Wilson D, Maartens G (2008) Patient and provider delay in tuberculosis suspects from communities with a high HIV prevalence in South Africa: A cross-sectional study. BMC Infect Dis 8(72):1–8. https://doi.org/10.1186/1471-2334-8-72 Mongkhonsuebsakul W (2022) Thailand’s access to healthcare services: The reflection and inequality of vulnerable group. SAU J Social Sci Humanit 6(1):55–69. https://doi.org/10.14456/saujssh.2022.4 Russell S (2004) The economic burden of illness for households in developing countries: A review of studies focusing on tuberculosis. Am J Trop Med Hyg 71(2):147–155. https://doi.org/10.4269/ajtmh.2004.71.147 Szreter S, Woolcock M (2004) Health by association? Social capital, social theory, and the political economy of public health. Int J Epidemiol 33(4):650–667. https://doi.org/10.1093/ije/dyh013 World Health Organization (2023) Global tuberculosis report 2023. WHO Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 31 Mar, 2026 Reviews received at journal 22 Mar, 2026 Reviews received at journal 17 Mar, 2026 Reviewers agreed at journal 17 Mar, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers agreed at journal 09 Jan, 2026 Reviews received at journal 03 Oct, 2025 Reviewers agreed at journal 25 Sep, 2025 Reviewers invited by journal 25 Sep, 2025 Editor assigned by journal 25 Sep, 2025 Editor invited by journal 25 Sep, 2025 Submission checks completed at journal 08 Sep, 2025 First submitted to journal 08 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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08:04:31","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":109703,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7207938/v1/5234ffcf28a00fd699ddce16.html"},{"id":93016258,"identity":"dcecc8c4-b01a-4418-895c-5b0075e4e0a6","added_by":"auto","created_at":"2025-10-08 08:04:31","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":430503,"visible":true,"origin":"","legend":"\u003cp\u003eStructural-Relational Framework of Healthcare Access: A Multi-level Integration of Political Economy, Social Networks, and Power Dynamics in Urban TB Care\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7207938/v1/1742087ebccb39c05eb1bebd.jpeg"},{"id":93019001,"identity":"5fb509e3-55e6-41a5-8e65-a3d65aa5fe2d","added_by":"auto","created_at":"2025-10-08 08:28:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1584658,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7207938/v1/e1b53895-6adc-41e4-9b13-7f5f25480e34.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond Access: Social Inequalities, Power Relations, and Healthcare Navigation among Urban Tuberculosis Patients in Thailand","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eHealthcare access for urban tuberculosis patients remains a significant challenge in public health systems, particularly in urban societies with complex social, cultural, and economic dimensions. Barriers to healthcare access are not limited to physical factors but also include social and cultural constraints that affect patients\u0026rsquo; decisions to seek treatment.\u003c/p\u003e\u003cp\u003eTuberculosis is an infectious disease caused by \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e, which spreads through the respiratory system via droplets released during coughing, sneezing, or speaking by infected individuals (World Health Organization [WHO], 2023). While the disease primarily affects the lungs, it can also spread to other organs, including the lymph nodes, pleura, reproductive and urinary systems, bones and joints, meninges, and the abdomen. Key symptoms include a chronic cough lasting more than two weeks, potentially accompanied by sputum or blood, as well as systemic symptoms such as weight loss, loss of appetite, evening fever, night sweats, and fatigue.\u003c/p\u003e\u003cp\u003eThe 2023 Global Tuberculosis Report by the World Health Organization (WHO, 2023) indicates that in 2022, there were 10.6\u0026nbsp;million new tuberculosis cases worldwide, with Southeast Asia having the highest proportion at 46%, followed by Africa at 23%, and the Western Pacific at 18%. These statistics indicate an increasing trend compared to 2021 and 2020, which contradicts the WHO\u0026rsquo;s goal of reducing the incidence by 50% by 2025.\u003c/p\u003e\u003cp\u003eIn Thailand\u0026rsquo;s context, the Bureau of Tuberculosis, Department of Disease Control (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) reported that in fiscal year 2021, there were 35,951 new and relapse tuberculosis cases (including Thai nationals, non-Thai nationals, and prison inmates), representing a rate of 54.0 per 100,000 population. Compared to fiscal year 2018, which had 85,029 registered patients, the treatment coverage rate was 80%, reflecting persistent gaps in service access.\u003c/p\u003e\u003cp\u003eMongkhonsuebsakul (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) analyzed factors affecting healthcare access across three main dimensions: social status (encompassing gender, language, ethnicity, origin, and culture), social capital (referring to social relationships and networks supporting access to services), and human capital (including education and occupation levels that influence the ability to access and utilize healthcare services). This aligns with the findings of Sitthikant and Chongudommarn (2020), who found that behavioral and attitudinal factors, such as patients\u0026rsquo; tolerance of illness symptoms and hesitation to seek services without severe symptoms, feelings of inferiority, and lack of confidence in seeking healthcare services, affect decision-making among vulnerable groups, particularly low-income individuals, those living in remote areas, and laborers.\u003c/p\u003e\u003cp\u003eDelays in seeking treatment have severe impacts on both patients and communities. Meintjes et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) and El-Sony et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2002\u003c/span\u003e) demonstrated that allowing suspicious symptoms to persist without seeking medical examination increases mortality risk and leads to more excellent community transmission. This corresponds with Lienhardt et al.\u0026rsquo;s (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2001\u003c/span\u003e) findings that delays in diagnosis and treatment are crucial factors affecting tuberculosis outbreak control in communities.\u003c/p\u003e\u003cp\u003eTherefore, this research aims to study the influence of social structures on tuberculosis treatment access and understand the role of cultural beliefs in tuberculosis treatment processes. The study seeks to help understand the impact of social structures, cultural beliefs, and economic factors on tuberculosis patients\u0026rsquo; access to treatment. It employs qualitative research methods to gain deep insights into the influence of social structures on tuberculosis treatment access and the impact of social structures, cultural beliefs, and economic factors on tuberculosis patients\u0026rsquo; access to treatment.\u003c/p\u003e\u003cp\u003eThis study analyzes a structural and relational framework for healthcare access developed to understand the complexity of healthcare access among urban tuberculosis patients. It integrates three key theoretical concepts: political economy, social capital, and power relations. This multi-level analysis reveals interactions between socioeconomic structures, relationship networks, and power dynamics that determine opportunities and limitations in treatment access (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eMarx\u0026rsquo;s political economy concept helps explain how production relations and social stratification affect healthcare system inequalities. Meanwhile, the social capital concept aids in understanding the role of social networks at three levels: bonding capital at the family level, bridging capital at the community and workplace level, and linking capital with the healthcare system. Foucault\u0026rsquo;s concepts of power and discourse help analyze power relations embedded in the healthcare system, both in terms of medical knowledge utilization, surveillance control, and patient negotiation.\u003c/p\u003e\u003cp\u003eThis framework demonstrates that any single factor does not determine treatment access but results from complex interactions between socioeconomic structures, relationship networks, and power dynamics in the healthcare system. Understanding these interactions will lead to policy development and practices that more effectively respond to patient needs.\u003c/p\u003e"},{"header":"2. Methodology","content":"\u003cp\u003eThis study employs phenomenological qualitative research methods to gain a deep understanding of urban tuberculosis patients\u0026rsquo; experiences in accessing treatment. Data was collected between 31 October 2024 and 31 January 2025 at a tuberculosis clinic in a hospital in Bangkok.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Participants Selection\u003c/h2\u003e\u003cp\u003eThe study used purposive sampling, establishing selection criteria that reflect diverse experiences, including age, gender, socioeconomic status, treatment duration, and type of tuberculosis. Additionally, snowball sampling was used to reach patients with specific experiences, such as those who had interrupted treatment or faced unique challenges in accessing services. Data collection continued until theoretical saturation was reached, resulting in 12 key informants.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Data Collection\u003c/h2\u003e\u003cp\u003eThe study employed multiple data collection methods to obtain comprehensive and in-depth information, including 1) In-depth interviews using semi-structured questions developed from literature review and theoretical frameworks. Each interview lasted 60\u0026ndash;90 minutes, conducted in private clinic areas, with audio recording upon participant consent; 2) Participant observation, where researchers spent 3\u0026ndash;4 hours per day, three days per week in the tuberculosis clinic, observing interactions between patients and service systems, physical environment, and social dynamics in the clinic. Observations covered different periods to capture various situations; 3) Field notes, where researchers recorded observation details, thoughts, and preliminary interpretations after each data collection session. These notes included researcher reflexive notes about roles and potential biases affecting data collection and interpretation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data Analysis\u003c/h2\u003e\u003cp\u003eData analysis employed thematic analysis combined with interpretive analysis, following these steps: 1) Verbatim transcription and multiple readings of data to achieve familiarity; 2) Data coding conducted at three levels, including open coding to identify key concepts in the data, theoretical coding linking data with theoretical frameworks, and selective coding to develop main themes; 3) Constant comparison between data from different informant groups and between data and theoretical frameworks; and 4) Negative case analysis to test and refine data interpretation. Using ATLAS. Ti Version 25.0.1 (32922), researchers analyzed in-depth interview results from key informants to identify approaches and recommendations.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Data Trustworthiness\u003c/h2\u003e\u003cp\u003eResearchers employed several steps to verify data trustworthiness. For internal validity, researchers engaged in prolonged engagement with key informants and maintained persistent observation throughout interviews. Researchers conducted triangulation of data, examining interview data on topics such as occupation, social status, education, household income, medical expenses, healthcare service utilization, ability to pay for medical care, beliefs, attitudes, and decision-making in tuberculosis treatment, verifying consistency across different key informants. After transcription, researchers engaged in group reflexivity discussions, conducted member checking by returning data to informants for accuracy verification, and consulted with experts (peer debriefing).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Ethical consolidation\u003c/h2\u003e\u003cp\u003e This study was reviewed and approved by the Human Research Ethics Committee, Faculty of Pharmacy, Siam University, Thailand (COA.013-2567), on 31 October 2024, in accordance with the ethical principles of the Declaration of Helsinki (2013 revision). All participants were fully informed about the objectives, procedures, potential risks, and benefits of the study. They were assured of the confidentiality of their information and informed that participation was entirely voluntary. Written informed consent to participate was obtained from all participants before data collection.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe tuberculosis clinic under study is in a large hospital in central Bangkok, surrounded by high-rise buildings and shopping centers. However, most patients travel from densely populated suburban communities with limited infrastructure. Every morning from 5 AM, patients gradually arrive to wait in designated areas, some accompanied by family members, others alone. The diversity of patients reflects that tuberculosis is not limited to low-income groups but affects all social classes.\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.1 General Characteristics of Interviewees\u003c/h2\u003e\u003cp\u003eThis study collected demographic data from 12 interviewees. Most participants were female (58.33%), with males comprising 41.67%. Regarding age distribution, the majority were in the 41\u0026ndash;50 age group (41.67%), followed by 61\u0026ndash;70 years (33.33%), while the 31\u0026ndash;40, 51\u0026ndash;60, and over 70 age groups represented 8.33%. There were no participants in the 10\u0026ndash;30 age range.\u003c/p\u003e\u003cp\u003eRegarding religion, most participants were Buddhist (83.33%) and Muslim (16.67%). In terms of healthcare coverage, most participants used Social Security benefits (50.00%), followed by the Universal Coverage Scheme (41.67%) and self-payment (8.33%).\u003c/p\u003e\u003cp\u003eConcerning tuberculosis history, most participants were new cases (83.33%), with equal proportions (8.33%) having multiple episodes or drug-resistant tuberculosis.\u003c/p\u003e\u003cp\u003eThese demographic data demonstrate the sample\u0026rsquo;s diversity across age, religion, and healthcare coverage types, providing comprehensive perspectives on urban tuberculosis patients\u0026rsquo; healthcare access experiences. The general characteristics of interviewees are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGeneral Characteristics of Interviewees\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatient Information\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumbers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercent (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge group (Years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e31\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e41\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e51\u0026ndash;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e61\u0026ndash;70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;70\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReligion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBuddhist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMuslim\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealthcare Coverage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUniversal Coverage Scheme (Gold Card)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Security\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOut-of-Pocket Payment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTuberculosis History\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e First-time TB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecurrent TB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrug-resistant TB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Healthcare Access\u003c/h2\u003e\u003cp\u003eThis study revealed key factors affecting urban tuberculosis patients\u0026rsquo; healthcare access, comprising four main aspects:\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1 Healthcare Coverage Systems\u003c/h2\u003e\u003cp\u003eThe Universal Coverage Scheme (UCS) and Social Security System are crucial in reducing financial barriers for tuberculosis patients, particularly among low-income groups. Most patients expressed satisfaction with healthcare coverage systems, as they significantly reduced financial burden, as illustrated by one participant:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, I\u0026rsquo;ve been receiving regular treatment here. When Social Security expired, I could use the Universal Coverage card. Having the UCS card is good; otherwise, it would be costly without any coverage. I could barely manage on my own as it is.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThis reflects the vital importance of universal health coverage in supporting continuous patient access to treatment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2 Service Accessibility and Limitations\u003c/h2\u003e\u003cp\u003eHealthcare services for tuberculosis patients demonstrate flexibility and consideration for patient convenience, particularly for those who must work. As evidenced by one patient\u0026rsquo;s experience:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I can work while getting treatment. Treatment doesn\u0026rsquo;t require hospitalization. After seeing the doctor, I go home, wake up in the morning and return to work. I can function normally.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eFurthermore, the appointment system shows flexibility, as indicated by another patient:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;No matter how long the wait, I come. Even while working, I rush here afraid of being late. If I can\u0026rsquo;t make it early someday, I call to reschedule. I want to keep getting treatment consistently.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e3.2.3 Role of Family and Community\u003c/h2\u003e\u003cp\u003eFamily support significantly impacts treatment continuity. Families play crucial roles in care and medication adherence supervision, as exemplified by one case:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My child takes care of me and wants me to take medicine every day.\u0026rdquo;\u003c/em\u003e (TB-05)\u003c/p\u003e\u003cp\u003eThis demonstrates family involvement in patient care.\u003c/p\u003e\u003cp\u003eHowever, some patients must manage care independently, which may affect treatment regularity. Therefore, establishing social support systems is crucial, particularly for patients lacking family support:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;No one helps me, even my children don\u0026rsquo;t care.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003e3.2.4 Quality and Equity in Treatment\u003c/h2\u003e\u003cp\u003eMost patients expressed satisfaction with the quality of care received from medical personnel, with doctors and nurses providing appropriate guidance and care, as stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The doctor has done the best possible treatment.\u0026rdquo;\u003c/em\u003e (TB-03). \u003cem\u003e\u0026ldquo;The nurses and doctors are good.\u0026rdquo;\u003c/em\u003e (TB-08)\u003c/p\u003e\u003cp\u003eMany viewed treatments as fair and equitable, with all patients receiving standardized care regardless of healthcare coverage type. Medical personnel provided care with attention and non-discrimination, offering support and encouragement to patients:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s fair because everyone receives equal treatment.\u0026rdquo;\u003c/em\u003e (TB-12)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Barriers to Healthcare Access\u003c/h2\u003e\u003cp\u003eThe study found that tuberculosis patients face multiple interconnected barriers to healthcare access, with these obstacles affecting each other across various dimensions:\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e3.3.1 Transportation Barriers\u003c/h2\u003e\u003cp\u003eTransportation emerges as a significant barrier affecting patients\u0026rsquo; access to treatment, manifesting in two primary forms:\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003e1) Transportation Difficulties\u003c/h3\u003e\n\u003cp\u003ePatients who must travel to the hospital independently face multiple challenges, including travel fatigue, safety risks, and traffic congestion, as illustrated by one participant:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Traveling alone is difficult, sometimes dangerous... traffic jams, getting back home, there\u0026rsquo;s so much traffic. It\u0026rsquo;s exhausting.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThese difficulties may affect treatment regularity, particularly for patients with physical limitations or those traveling long distances.\u003c/p\u003e\n\u003ch3\u003e2) Dependence on Others for Transportation\u003c/h3\u003e\n\u003cp\u003eMany patients must rely on family members or public transportation, which, while reducing difficulties, may create a burden for families, as expressed:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My child drives me here. Transportation isn\u0026rsquo;t difficult, just morning traffic.\u0026rdquo;\u003c/em\u003e (TB-05)\u003c/p\u003e\u003cp\u003eMeanwhile, patients dependent on public transportation may face accessibility issues:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s difficult when coming here, hard to get transportation.\u0026rdquo;\u003c/em\u003e (TB-06)\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\u003cdiv class=\"Heading\"\u003e3.3.2 Cost-Related Barriers\u003c/div\u003e\u003cp\u003eThe cost burden represents a significant barrier to treatment access, particularly for low-income patients. Expenses extend beyond medical costs to include hidden costs such as transportation, meals during hospital visits, and lost income from missing work, as illustrated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We need money for personal expenses, transportation, food. No one helps... There was one year I didn\u0026rsquo;t come for treatment at all because I had no money and transportation was difficult.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThis demonstrates how cost burdens can lead to treatment discontinuity. Interestingly, some patients view costs as secondary to treatment success:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Money isn\u0026rsquo;t the problem, as long as I get cured.\u0026rdquo;\u003c/em\u003e (TB-12)\u003c/p\u003e\u003cp\u003eThis reflects that patients prioritize treatment outcomes over associated costs.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\u003cdiv class=\"Heading\"\u003e3.3.3 Healthcare System Barriers\u003c/div\u003e\u003cp\u003eThe study revealed systemic limitations that obstruct access and treatment continuity for tuberculosis patients. These limitations affect both treatment efficiency and patients\u0026rsquo; quality of life.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e1) Treatment Follow-up Discontinuity\u003c/h3\u003e\n\u003cp\u003eThe lack of an efficient follow-up system can cause patient confusion about treatment plans:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The doctors at the previous hospital didn\u0026rsquo;t follow up. How would patients know if they\u0026rsquo;re cured or need to come back?\u0026rdquo;\u003c/em\u003e (TB-11)\u003c/p\u003e\u003cp\u003eThis discontinuity creates multiple impacts. First, inefficient follow-up systems confuse self-care requirements and appointment schedules. Second, ineffective communication between medical personnel and patients may lead to a misunderstanding about the importance of continuous follow-up or awareness of treatment progress. Third, the lack of systematic follow-up may miss opportunities to identify and address problems arising during treatment, such as medication side effects or drug resistance.\u003c/p\u003e\n\u003ch3\u003e2) Extended Waiting Times\u003c/h3\u003e\n\u003cp\u003eAnother significant barrier in the healthcare system is the long waiting time for services, as reflected by patients:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It affects us, makes patients reluctant to come to the hospital.\u0026rdquo;\u003c/em\u003e (TB-06)\u003c/p\u003e\u003cp\u003eIn terms of treatment, long waiting times can cause frustration and discouragement, potentially leading to non-compliance. Some patients may decide to miss appointments or discontinue treatment due to the inability to tolerate extended waiting periods. Regarding work and daily life, long waiting times during each visit impact daily schedule management, particularly for patients who work or have other responsibilities.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003cdiv class=\"Heading\"\u003e3.3.4 Time Management Barriers\u003c/div\u003e\u003cp\u003eTime management presents a significant challenge, especially for patients with other responsibilities such as family care and work:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I also take care of my grandchild. Sometimes I don\u0026rsquo;t want to travel frequently, it\u0026rsquo;s difficult going alone.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThe need to balance various responsibilities may affect treatment regularity.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Economic Factors\u003c/h2\u003e\u003cp\u003eThe study reveals that economic factors significantly impact tuberculosis patients\u0026rsquo; treatment outcomes. These factors affect healthcare access, treatment continuity, and quality of life for patients and their families.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003e3.4.1 Limited Income and Expenditure\u003c/h2\u003e\u003cp\u003eThe imbalance between income and expenditure emerges as a fundamental problem significantly impacting tuberculosis patients\u0026rsquo; treatment. As one participant explained:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Monthly income barely covers expenses. We\u0026rsquo;re living hand to mouth.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThis reflects the financial management difficulties patients face. Tuberculosis illness not only reduces income due to work absences for treatment but also increases expenses through treatment and transportation costs. This situation creates substantial financial pressure for patients.\u003c/p\u003e\u003cp\u003eThe illness directly impacts patients\u0026rsquo; work capacity and income, as illustrated by one participant:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If we take a full day off, we have to pay someone three to four hundred baht to cover, that money is lost.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThis impact is particularly severe for daily wage workers or self-employed individuals, as their income depends on daily work. Taking time off for treatment directly translates to lost income. In some cases, patients must bear additional expenses from hiring replacements.\u003c/p\u003e\u003cp\u003eBeyond managing personal expenses, many patients carry the burden of caring for family members:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My grandchild is starting to drink milk, and I\u0026rsquo;m raising them. Their mother left them here, coming back in the evening to check on them.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThis situation forces patients to allocate limited resources for their treatment and family care in terms of expenses and time. The decision-making process between using money for treatment versus family expenses represents an ongoing challenge for patients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003e3.4.2 Transportation Costs\u003c/h2\u003e\u003cp\u003eTransportation costs reflect healthcare access inequalities, with data showing significant cost variations:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Round trip costs 120 baht\u0026rdquo;\u003c/em\u003e (TB-06) to \u003cem\u003e\u0026ldquo;Round trip costs 500\u0026ndash;600 baht plus\u0026rdquo;\u003c/em\u003e (TB-08)\u003c/p\u003e\u003cp\u003eThis disparity demonstrates that patients living in remote areas bear significantly higher cost burdens, which may influence treatment-seeking decisions.\u003c/p\u003e\u003cp\u003ePatients attempt to manage transportation costs through various strategies, as evidenced by the following:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If it\u0026rsquo;s a non-air-conditioned bus, it\u0026rsquo;s 8 baht, but air-conditioned is 15 baht\u0026rdquo;\u003c/em\u003e (TB-04)\u003c/p\u003e\u003cp\u003eChoosing economical public transportation represents one strategy patients use to reduce costs, though this often comes at the expense of comfort and increased travel time. Transportation choice thus becomes a balance between cost, time, and comfort.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003e3.4.3 Social Security System Support\u003c/h2\u003e\u003cp\u003eThe Social Security System plays a crucial role in supporting patients\u0026rsquo; healthcare access:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Having Social Security makes treatment more accessible\u0026rdquo;\u003c/em\u003e (TB-01)\u003c/p\u003e\u003cp\u003eSocial Security helps reduce medical expenses, increasing patients\u0026rsquo; confidence in seeking treatment. Additionally, the insurance system provides patients access to standardized healthcare facilities and necessary medications and medical supplies.\u003c/p\u003e\u003cp\u003eHowever, the Social Security System has certain limitations, as reflected:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes it doesn\u0026rsquo;t cover all treatments. Sometimes I want a health check-up but don\u0026rsquo;t dare tell the doctor\u0026rdquo;\u003c/em\u003e (TB-01)\u003c/p\u003e\u003cp\u003eThese limitations extend beyond benefit coverage, including communication barriers between patients and medical personnel, lack of confidence in inquiring about their rights, and concerns about potential expenses beyond covered benefits.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section3\"\u003e\u003ch2\u003e3.4.4 Income Compensation and Workplace Support\u003c/h2\u003e\u003cp\u003eWorkplace support emerges as a crucial factor enabling patients to maintain continuous treatment:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Work allows sick leave with a medical certificate\u0026rdquo;\u003c/em\u003e (TB-01), and \u003cem\u003e\u0026ldquo;They pay wages for that day, but require a medical certificate\u0026rdquo;\u003c/em\u003e (TB-09)\u003c/p\u003e\u003cp\u003eClear policies regarding sick and paid medical leave help reduce patients\u0026rsquo; financial security concerns. Additionally, flexible work scheduling and colleague support are important in helping patients appropriately manage between work and treatment.\u003c/p\u003e\u003cp\u003eHowever, the disparity between formal and informal sector workers is a crucial issue affecting treatment access. Formal sector workers typically receive legal protection and clear benefits, while informal sector workers often lack social protection and must bear risks independently. This inequality affects both treatment continuity and patient quality of life.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Cultural Factors\u003c/h2\u003e\u003cp\u003eCultural factors significantly support treatment and healthcare management among urban tuberculosis patients, particularly in building resilience and psychological healing. The study reveals that religious and cultural beliefs are intricately connected to patients\u0026rsquo; treatment experiences across multiple dimensions.\u003c/p\u003e\u003cdiv id=\"Sec30\" class=\"Section3\"\u003e\u003ch2\u003e3.5.1 Religious Beliefs and Psychological Therapy\u003c/h2\u003e\u003cp\u003eReligious beliefs serve a crucial role in supporting the mental health of tuberculosis patients. The study finds that many patients use religion as a psychological anchor and source of strength in their battle against illness, as illustrated by one participant:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Normally, I pray before bed every day, praying to be cured and stay with my children for a long time.\u0026rdquo;\u003c/em\u003e (TB-03)\u003c/p\u003e\u003cp\u003eReligious practices form daily routines that help generate hope and mental tranquility for patients. Religious teachings also contribute to patients\u0026rsquo; psychological healing, as one patient stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The Buddha\u0026rsquo;s teachings are all true.... I believe in the teachings and use them for mental healing.\u0026rdquo;\u003c/em\u003e (TB-11)\u003c/p\u003e\u003cp\u003eApplying religious principles helps patients develop frameworks for understanding and accepting their illness.\u003c/p\u003e\u003cp\u003eFurthermore, religious beliefs help patients manage stress and anxiety better, as evidenced by the following:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Religion is already good, makes people less stressed, because when I first got it, I was completely shocked.\u0026rdquo;\u003c/em\u003e (TB-07)\u003c/p\u003e\u003cp\u003eHaving spiritual support helps mitigate the psychological impact of diagnosis and coping with long-term treatment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec31\" class=\"Section3\"\u003e\u003ch2\u003e3.5.2 Religious Interpretation and Treatment\u003c/h2\u003e\u003cp\u003eThe relationship between religious beliefs and modern medical treatment presents interesting dynamics. Many patients view both aspects as complementary rather than contradictory, as illustrated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Islam makes allowances for this, as it\u0026rsquo;s disease treatment.\u0026rdquo;\u003c/em\u003e (TB-04)\u003c/p\u003e\u003cp\u003eThis reflects how religious principles support healthcare and do not obstruct medical treatment.\u003c/p\u003e\u003cp\u003eHowever, perspectives on religion\u0026rsquo;s role in treatment vary. Some patients express disbelief in prayer or wishes:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s impossible, it\u0026rsquo;s fantasy. If you talk about making wishes, I don\u0026rsquo;t believe in that.\u0026rdquo;\u003c/em\u003e (TB-09)\u003c/p\u003e\u003cp\u003eThis reflects how some patients clearly distinguish between religious beliefs and medical treatment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section3\"\u003e\u003ch2\u003e3.5.3 Role of Cultural Beliefs in Daily Life\u003c/h2\u003e\u003cp\u003eReligious practices in daily life form part of patients\u0026rsquo; illness management mechanisms, as evidenced:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I always pray to Buddha anyway, I pray to the Buddha at home every day.\u0026rdquo;\u003c/em\u003e (TB-05)\u003c/p\u003e\u003cp\u003eThese practices reflect the integration of religious beliefs into daily healthcare routines.\u003c/p\u003e\u003cp\u003eThe study also found that religious practices help reduce obsession with illness:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We don\u0026rsquo;t obsess; we feel more comfortable physically and mentally. When we come to see the doctor, we feel better physically and mentally.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eHaving religious activities helps patients maintain focus beyond their illness, promoting psychological well-being. Meanwhile, some patients do not connect religion with healthcare, simply stating:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t pray to Buddha.\u0026rdquo;\u003c/em\u003e (TB-10)\u003c/p\u003e\u003cp\u003eThis reflects the diversity and significance attributed to religion\u0026rsquo;s role in treatment. Therefore, studying cultural factors in tuberculosis patients demonstrates the diversity of religious beliefs and practices. Religion plays a crucial role in supporting mental health and illness management for many patients, while others choose to separate religious beliefs from treatment. Understanding this diversity is important for developing patient care systems that respond to different spiritual needs.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec33\" class=\"Section2\"\u003e\u003ch2\u003e3.6 Social Factors\u003c/h2\u003e\u003cp\u003eThe study reveals that social factors are crucial in supporting successful tuberculosis treatment, particularly within the complex social context of urban environments. The analysis demonstrates the importance of social networks at multiple levels, from family to workplace to healthcare systems.\u003c/p\u003e\u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\u003ch2\u003e3.6.1 Family and Community Support\u003c/h2\u003e\u003cp\u003eFamily emerges as the most crucial source of support for tuberculosis patients. The study finds that having an understanding and supportive family directly impacts treatment success. Families play vital roles in multiple aspects of care and support.\u003c/p\u003e\u003cp\u003eFirst, families help manage daily treatment routines, as illustrated by one participant\u0026rsquo;s experience:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They make decisions for me to come here, to stay. They tell me today and tomorrow I\u0026rsquo;ll go see the doctor, they remind me to take medicine, to eat so I can take medicine...\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eFamily assistance with food and medication management provides essential support that helps patients maintain treatment continuity.\u003c/p\u003e\u003cp\u003eBeyond physical support, families are crucial in providing emotional support and encouragement. The emotional impact is evident in one patient\u0026rsquo;s poignant statement:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Mom... Mom said to go get treatment at the hospital until cured (eyes welling with tears).\u0026rdquo;\u003c/em\u003e (TB-12)\u003c/p\u003e\u003cp\u003eThis demonstrates the power of family concern in influencing patients\u0026rsquo; decisions to seek treatment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec35\" class=\"Section3\"\u003e\u003ch2\u003e3.6.2 Workplace Relations and Interactions\u003c/h2\u003e\u003cp\u003eThe workplace environment significantly affects patients\u0026rsquo; ability to manage treatment alongside work responsibilities. The study finds that acceptance and understanding from colleagues are crucial factors in helping patients effectively balance work and treatment. One patient\u0026rsquo;s narrative clearly illustrates this:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They say, \u0026lsquo;Auntie, if you\u0026rsquo;re sick, get treatment, you\u0026rsquo;ll get better.\u0026rsquo;\u0026rdquo; They talk well and don\u0026rsquo;t discriminate. I can work while getting treatment. Treatment doesn\u0026rsquo;t require hospitalization. After seeing the doctor, I go home, wake up in the morning and return to work. I can function normally. Colleagues understand and say treatment will cure it.\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eSuch support reduces stigma and helps build motivation and encouragement for continuous treatment. The moral support from colleagues, as expressed in:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Colleagues and neighbors encourage\u0026rdquo;\u003c/em\u003e (TB-12)\u003c/p\u003e\u003cp\u003eDemonstrates that social support in the workplace is crucial in creating an environment conducive to treatment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec36\" class=\"Section3\"\u003e\u003ch2\u003e3.6.3 Relationships with Medical Personnel\u003c/h2\u003e\u003cp\u003eThe quality of relationships between patients and medical personnel significantly impacts treatment success. The study finds that attentive and understanding care from medical personnel directly affects patients\u0026rsquo; trust and cooperation in treatment, as evidenced by statements such as:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The doctors here take good care of us, so we don\u0026rsquo;t dare change hospitals, afraid of finding doctors who care less\u0026rdquo;\u003c/em\u003e (TB-08), and \u003cem\u003e\u0026ldquo;The doctor doesn\u0026rsquo;t abandon patients, the doctor is excellent, loves patients, no harsh treatment...\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThese reflections demonstrate that caring and good interpersonal relationships with medical personnel create positive impressions and play a crucial role in maintaining treatment continuity.\u003c/p\u003e\u003cp\u003eThe analysis of social factors demonstrates that successful tuberculosis treatment depends on medical treatment and social support systems encompassing family, workplace, and healthcare systems. Creating an environment conducive to treatment, free from stigma, and with appropriate emotional support are crucial factors in successfully helping patients complete their prescribed treatment course. As Waitzkin (2021) emphasizes, improving healthcare access requires consideration of the political, economic, and social dimensions of the healthcare system.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e\u003ch2\u003e3.7 Psychological Factors\u003c/h2\u003e\u003cp\u003eThe study of psychological factors in tuberculosis patients reveals the crucial role of mental states in treatment success. Analysis shows that both internal motivation and confidence in treatment processes significantly contribute to patients\u0026rsquo; ability to combat the disease effectively.\u003c/p\u003e\u003cdiv id=\"Sec38\" class=\"Section3\"\u003e\u003ch2\u003e3.7.1 Personal Commitment and Motivation\u003c/h2\u003e\u003cp\u003eInternal motivation emerges as a powerful force enabling patients to face the challenges of tuberculosis treatment. The study finds that patients express their determination to fight the disease in various forms, as evidenced by statements showing firm resolve:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If I can recover, I will fight on\u0026rdquo;\u003c/em\u003e (TB-02) and \u003cem\u003e\u0026ldquo;I\u0026rsquo;m confident I must recover\u0026rdquo;\u003c/em\u003e (TB-12)\u003c/p\u003e\u003cp\u003eThese statements reflect positive attitudes and self-efficacy beliefs in their ability to overcome the disease. Interestingly, patients\u0026rsquo; motivation often links to their responsibilities toward themselves and their families, as illustrated by the statement:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We work, so we must come for treatment. If we don\u0026rsquo;t come for treatment, we won\u0026rsquo;t have the strength to fight anything\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThis demonstrates patients\u0026rsquo; recognition that treatment importance extends beyond personal health to affect their ability to fulfill various life roles and responsibilities. This awareness becomes a crucial driving force motivating patients to maintain continuous treatment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec39\" class=\"Section3\"\u003e\u003ch2\u003e3.7.2 Confidence in Treatment Processes\u003c/h2\u003e\u003cp\u003eConfidence in treatment processes emerges as another crucial factor affecting treatment success. The study finds that patients who trust in their doctors\u0026rsquo; capabilities and the effectiveness of prescribed medications tend to develop more positive attitudes toward treatment, as evidenced by the statement:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Not stressed or worried, symptoms will improve if I complete the medicine course, that\u0026rsquo;s what the doctor said (patient feels confident)\u0026rdquo;\u003c/em\u003e (TB-01)\u003c/p\u003e\u003cp\u003eThis confidence helps reduce anxiety and builds hope for treatment. Moreover, effective communication and encouragement from doctors play crucial roles in building patient confidence, as illustrated by the statements:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Confident (very confident voice) that I must recover because the doctor gave medicine and I\u0026rsquo;ve improved a lot, don\u0026rsquo;t feel tired anymore, so I\u0026rsquo;m confident I must recover. Very confident\u0026rdquo;\u003c/em\u003e (TB-03) and \u003cem\u003e\u0026ldquo;The doctor gives good advice, gives us encouragement to fight on\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThese reflect how psychological support from medical personnel significantly affects patients\u0026rsquo; confidence and morale.\u003c/p\u003e\u003cp\u003eThe analysis reveals an interconnected relationship between personal motivation and confidence in treatment processes. Internal motivation helps patients adhere to treatment plans, while confidence in treatment reinforces motivation. Positive treatment results increase confidence in treatment processes, reinforcing motivation to continue treatment. Medical personnel support is crucial in strengthening patient motivation and confidence.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec40\" class=\"Section2\"\u003e\u003ch2\u003e3.8 Health Literacy Factors\u003c/h2\u003e\u003cp\u003eThe study of health literacy among tuberculosis patients reveals complex relationships between knowledge and understanding of the disease and healthcare behaviors. It identifies key issues affecting treatment efficiency and infection prevention.\u003c/p\u003e\u003cdiv id=\"Sec41\" class=\"Section3\"\u003e\u003ch2\u003e3.8.1 Knowledge and Understanding About Tuberculosis\u003c/h2\u003e\u003cp\u003ePatients\u0026rsquo; knowledge and understanding of tuberculosis varies significantly and meaningfully. The study finds that most patients have limited knowledge about disease causes and infection mechanisms, which may affect prevention and treatment. Limitations in understanding disease causes surface in most patients expressing uncertainty about infection sources, as illustrated by one narrative:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know either. I only knew when the doctor said it was tuberculosis. No one in the family has it. I don\u0026rsquo;t smoke or drink alcohol. Strange how I got it, don\u0026rsquo;t know\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThis uncertainty reflects gaps in communicating knowledge about tuberculosis infection in communities. Misconceptions about disease causes emerge as another finding. The study reveals that many patients hold incorrect beliefs about tuberculosis causes, often linking it to environmental factors, particularly dust exposure, as evidenced by statements:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Think it\u0026rsquo;s from underground construction, lots of dust\u0026rdquo;\u003c/em\u003e (TB-01) and \u003cem\u003e\u0026ldquo;When we encounter dust we cough, when encountering lots of dust we start coughing, have a runny nose, we think that dust might cause us to get it too\u0026rdquo;\u003c/em\u003e (TB-09)\u003c/p\u003e\u003cp\u003eThese misconceptions may lead to incorrect preventive behaviors and inaccurate risk assessment. However, some patients demonstrate good disease knowledge, particularly those with healthcare-related experience, as illustrated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I used to be in prison, worked as a nurse assistant, so I know what tuberculosis is\u0026rdquo;\u003c/em\u003e (TB-12)\u003c/p\u003e\u003cp\u003eThis reflects how experience and access to accurate information affect disease understanding.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec42\" class=\"Section3\"\u003e\u003ch2\u003e3.8.2 Self-Care Behaviors\u003c/h2\u003e\u003cp\u003eDespite limitations in knowledge and understanding, the study finds that most patients demonstrate appropriate self-care behaviors, particularly regarding medication adherence and infection prevention practices.\u003c/p\u003e\u003cp\u003eRegarding medication management, patients demonstrate awareness of the importance of consistent medication intake, reflected in strict time management. As evidenced by the following statements:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Must take it regularly without missing any day, even when hospitalized I still have to take it\u0026rdquo;\u003c/em\u003e (TB-08) and \u003cem\u003e\u0026ldquo;Will remember that every day must take medicine at what time, must take it at that time every day, don\u0026rsquo;t miss medication\u0026rdquo;\u003c/em\u003e (TB-04)\u003c/p\u003e\u003cp\u003eThis understanding of medication continuity\u0026rsquo;s importance forms a crucial foundation for treatment success. However, treatment challenges still emerge in some cases, such as drug resistance, as illustrated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;ve been taking medicine consistently, but don\u0026rsquo;t know why there\u0026rsquo;s drug resistance, there are many complications\u0026rdquo;\u003c/em\u003e (TB-02)\u003c/p\u003e\u003cp\u003eThis reflects the need for additional education about medication use and side effect management.\u003c/p\u003e\u003cp\u003eRegarding infection prevention, patients demonstrate social responsibility through appropriate infection-prevention behaviors, as evidenced by their management of living spaces and personal items:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sleep in separate rooms from the spouse, buy ready-made food in foam containers, separate everything because afraid of transmission\u0026rdquo;\u003c/em\u003e (TB-01) and \u003cem\u003e\u0026ldquo;I separate bowls, plates, and dishes\u0026rdquo;\u003c/em\u003e (TB-04)\u003c/p\u003e\u003cp\u003eFurthermore, patients show caution during the initial infection period:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Separated for the first two weeks, didn\u0026rsquo;t meet anyone at all for about a month\u0026rdquo;\u003c/em\u003e (TB-05)\u003c/p\u003e\u003cp\u003eThis reflects the understanding of the importance of preventing infection transmission during the disease\u0026rsquo;s early stages.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe discussion of findings regarding healthcare access among tuberculosis patients in urban areas, examined through the lens of Karl Marx\u0026rsquo;s political economy theory, reveals complex relationships between economic structures, social class, and healthcare accessibility. This analysis provides profound insights across multiple dimensions.\u003c/p\u003e\u003cp\u003eBeginning with the analysis of production relations and social class, the findings reflect that patients\u0026rsquo; economic status directly impacts their ability to access treatment, particularly among informal workers and low-income populations. This aligns with Marx\u0026rsquo;s conceptualization of class oppression within capitalist systems (Harvey, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This is evident in patient narratives such as \u003cem\u003e\u0026ldquo;Monthly income barely covers expenses. We\u0026rsquo;re living hand to mouth\u0026rdquo; and \u0026ldquo;If we take a full day off, we have to pay someone three to four hundred baht to cover, that money is lost\u0026rdquo;\u003c/em\u003e These accounts reflect the economic struggles that affect healthcare access. The fact that patients must choose between seeking treatment and working for income demonstrates the contradiction between health necessities and survival within the capitalist system.\u003c/p\u003e\u003cp\u003eSubsequently, when examining the disparities between formal and informal workers in accessing health welfare, the findings reflect inequalities in the healthcare system that are interconnected with employment structures. Benach et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) analyzed how precarious employment directly impacts healthcare access, with informal workers often facing limitations in accessing welfare benefits and sick leave. This corresponds with study findings indicating that patients who are informal workers experience difficulties managing work and treatment simultaneously. This disparity is evident in the contrasting experiences between patients with social insurance, who stated \u003cem\u003e\u0026ldquo;Work allows sick leave with a medical certificate\u0026rdquo;\u003c/em\u003e and informal workers, who must bear both financial burdens and income loss.\u003c/p\u003e\u003cp\u003eFurthermore, patients\u0026rsquo; encounters with hidden treatment costs, including transportation expenses, food costs, and income lost due to work absence, reflect the concept of surplus extraction within capitalist systems (Waitzkin, 2021), whereby workers must bear the burden of their own healthcare costs despite the existence of universal health coverage systems. The variation in transportation costs identified in this study, ranging from \u003cem\u003e\u0026ldquo;Round trip costs 120 bah\u003c/em\u003et\u0026rdquo; to \u0026ldquo;\u003cem\u003eRound trip costs 500\u0026ndash;600 baht plus\u003c/em\u003e,\u003cem\u003e\u0026rdquo;\u003c/em\u003e demonstrates disparities in healthcare access linked to geographical location and affordability.\u003c/p\u003e\u003cp\u003eMore significantly, Marmot et al. (2012) presented empirical evidence demonstrating that health inequalities result from social and economic determinants, which corresponds with study findings indicating that patients of different socioeconomic backgrounds possess varying capacities to access healthcare services. This is particularly evident in terms of transportation affordability, income loss from work absence, and access to social welfare benefits. The study revealed that low-income patients face difficult decisions between healthcare expenditures and essential living costs, as evidenced by the statement \u003cem\u003e\u0026ldquo;... There was one year I didn\u0026rsquo;t come for treatment at all because I had no money and transportation was difficult\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eConcurrently, the employment-linked health insurance system reflects the concept of economic monopolization that Marx analyzed, whereby capitalist systems utilize welfare as a mechanism for labor control (Navarro, 2020). Those outside the formal employment system frequently face limitations in accessing health welfare benefits. The study revealed that patients with social insurance exhibited greater confidence in seeking treatment, as expressed in the statement \u003cem\u003e\u0026ldquo;Having Social Security makes treatment more accessible.\u0026rdquo;\u003c/em\u003e However, simultaneously, limitations within the social insurance system were identified, such as \u003cem\u003e\u0026ldquo;Sometimes it doesn\u0026rsquo;t cover all treatments. Sometimes I want a health check-up but don\u0026rsquo;t dare tell the doctor,\u0026rdquo;\u003c/em\u003e reflecting power relations within the healthcare system.\u003c/p\u003e\u003cp\u003eAnother compelling issue is how power relations in healthcare systems are manifested through service organizations that may not align with patient needs, particularly in terms of prolonged waiting times and discontinuous treatment follow-up. This is evident in statements such as \u0026ldquo;It affects [patients], making them reluctant to come to the hospital\u0026rdquo; and \u0026ldquo;If the doctor at the original hospital doesn\u0026rsquo;t follow up, how would patients know if they\u0026rsquo;re cured or need to return?\u0026rdquo; These reflect that healthcare systems are designed with greater consideration for resource management efficiency than patient needs responsiveness.\u003c/p\u003e\u003cp\u003eFurthermore, the division of labor within healthcare systems reflects complex power structures. Patients are often constrained to passive recipient roles, required to follow medical personnel\u0026rsquo;s instructions without power in treatment decision-making. Marmot et al. (2012) examined how power relations within health systems influence treatment quality and health outcomes. The study found that some patients exhibited uncertainty in communicating with medical personnel due to perceived limited bargaining power.\u003c/p\u003e\u003cp\u003eRegarding its impact, tuberculosis disease affects not only health but also work capacity and the sustainability of livelihoods. Benach et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) demonstrated how precarious employment conditions impact both physical and mental health of workers. The study revealed that patients bear multifaceted burdens, including family care, earning livelihoods, and self-treatment, reflecting how illness in capitalist systems creates compounded burdens for patients.\u003c/p\u003e\u003cp\u003eAnother critical dimension is the existing social welfare system, which, despite reducing healthcare treatment costs, remains unable to address the structural problems that constitute the root causes of healthcare access inequality. As Navarro (2020) analyzed, welfare systems in capitalist societies often serve as mere palliative measures that fail to address the deeply embedded inequalities within economic and social structures.\u003c/p\u003e\u003cp\u003eUltimately, the relationship between illness and poverty reflects the cycle of oppression within capitalist systems. Harvey (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) analyzed how illness in capitalist systems frequently leads to loss of work capacity and income, resulting in deteriorating economic conditions and making healthcare access increasingly difficult. The study found that many patients face this cycle, as reflected in the statement \u003cem\u003e\u0026ldquo;We need money for personal expenses, transportation, food. No one helps...,\u0026rdquo;\u003c/em\u003e demonstrating the economic vulnerability exacerbated by illness.\u003c/p\u003e\u003cp\u003eAnalysis from a Marxian political economy perspective demonstrates that addressing healthcare access problems requires consideration of both structural factors and power relations in society, not merely healthcare system improvements, but also the creation of equality within economic and social systems. Understanding the interconnections between illness, poverty, and access to healthcare will lead to more holistic and sustainable policy formulation.\u003c/p\u003e\u003cp\u003eThe analysis of healthcare access for tuberculosis patients in urban areas, conducted through the social capital framework, reveals the crucial role of social networks and relationships in affecting patients\u0026rsquo; treatment experiences. Putnam (2000) explained that social capital comprises networks, norms, and trust that facilitate cooperation for mutual benefit. When applying this conceptual framework to study findings, social capital is shown to have multidimensional roles in supporting patient treatment.\u003c/p\u003e\u003cp\u003eFamily emerges as the most significant source of social capital, providing support in caregiving, financial assistance, and daily life management. Lin (2017) demonstrated that strong family relationships enhance access to resources necessary for treatment. This is reflected in patient narratives such \u003cem\u003e\u0026ldquo;My child takes care of me and wants me to take medicine every day.\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;My child drives me here. Transportation isn\u0026rsquo;t difficult, just morning traffic.\u0026rdquo;\u003c/em\u003e Family support encompasses not only physical assistance but also encouragement and psychological stability, which are essential for long-term treatment.\u003c/p\u003e\u003cp\u003eBeyond family, broader social networks, or what Szreter and Woolcock (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) termed \"bridging social capital,\" play crucial roles in creating environments conducive to treatment. Colleagues and neighbors who demonstrate understanding and acceptance help reduce social stigma and increase patient confidence, as reflected in the statement \u0026ldquo;They say, \u0026lsquo;Auntie, if you\u0026rsquo;re sick, get treatment, you\u0026rsquo;ll get better.\u0026rsquo;\u0026rdquo; This acceptance and understanding from the surrounding society significantly contribute to treatment continuity.\u003c/p\u003e\u003cp\u003eThe relationship between patients and healthcare systems demonstrates the importance of \"linking social capital.\" Kawachi et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) explained that trust between patients and healthcare providers constitutes a critical factor in achieving positive health outcomes. Patients with good relationships with medical personnel often exhibit greater confidence and treatment continuity, as expressed in the statement \u0026ldquo;The doctors here take good care of us, so we don\u0026rsquo;t dare change hospitals, afraid of finding doctors who care less.\u0026rdquo;\u003c/p\u003e\u003cp\u003eHowever, this study also reveals the vulnerability of patients with limited social capital. Bourdieu (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1986\u003c/span\u003e) warned that unequal distribution of social capital can lead to the reproduction of social inequality. Patients lacking family support (\u0026ldquo;No one helps me, even my children don\u0026rsquo;t care.\u0026rdquo;) often face greater challenges in accessing treatment, similar to informal workers who typically possess more limited social capital and fewer options for managing work and treatment balance.\u003c/p\u003e\u003cp\u003eThese findings underscore the need for developing public policies that not only focus on healthcare system development but also prioritize strengthening and supporting social capital, particularly for vulnerable groups with limited social capital. Developing robust social support systems will help reduce inequality and enhance the effectiveness of long-term tuberculosis patient care.\u003c/p\u003e\u003cp\u003eThe analysis of healthcare access experiences among tuberculosis patients in urban areas, through the lens of Michel Foucault's concepts of power and discourse, reveals complex power relations within health systems, particularly about knowledge, power, and medical control.\u003c/p\u003e\u003cp\u003eFoucault (1975/1995) proposed that power does not merely operate through top-down coercion but permeates social relationships at all levels. When applied to analyze this study's findings, power relations are evident in doctor-patient relationships. Lupton (2012) analyzed how modern medical discourse creates unequal power relations between medical experts and patients, reflected in patient statements such as \u003cem\u003e\u0026ldquo;Sometimes I want a health check-up but don\u0026rsquo;t dare tell the doctor,.\u0026rdquo;\u003c/em\u003e Demonstrating a lack of bargaining power and uncertainty in expressing personal needs.\u003c/p\u003e\u003cp\u003eThe surveillance system constitutes another crucial mechanism that Armstrong (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1995\u003c/span\u003e) analyzed as a tool used by modern medicine to control health behaviors. The study found that patients are monitored through appointment systems, medication compliance tracking, and reporting requirements, as reflected in the statement \u003cem\u003e\u0026ldquo;No matter how long the wait, I come. Even while working, I rush here afraid of being late. If I can\u0026rsquo;t make it early someday, I call to reschedule. I want to keep getting treatment consistently.\u0026rdquo;\u003c/em\u003e This demonstrates how patients are controlled and supervised through treatment monitoring systems.\u003c/p\u003e\u003cp\u003eThe use of medical knowledge as a tool to legitimize the exercise of power is an issue that Rabinow (1991) analyzed in his interpretation of Foucault's concepts, highlighting the relationship between knowledge and power. This study found that patients often accept medical decisions without question, viewing doctors as superior knowledge holders, reflected in statements such as \u003cem\u003e\u0026ldquo;The doctor has done the best possible treatment.\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;The doctors here take good care of us, so we don\u0026rsquo;t dare change hospitals.\u0026rdquo;\u003c/em\u003e This demonstrates acceptance of medical authority through acknowledgment of the expert's knowledge and expertise.\u003c/p\u003e\u003cp\u003eRabinow and Rose (2006) analyzed the management of space and time as tools of medical power. The study found that health systems determine patients' use of space and time through appointment systems, waiting periods, and service prioritization, where patients have limited bargaining power. This is reflected in the narrative \u003cem\u003e\u0026ldquo;It affects us, makes patients reluctant to come to the hospital.\u0026rdquo;\u003c/em\u003e demonstrating that time management in health systems constitutes a form of power exercise affecting patient decisions.\u003c/p\u003e\u003cp\u003eHowever, the study also identified forms of patient resistance and power negotiation. Pickett and Wilkinson (2015) analyzed that resistance to power in health systems often appears in subtle forms. Patients in this study demonstrated power negotiation through choosing service times, requesting appointment postponements, or even deciding to temporarily discontinue treatment, as expressed in \u003cem\u003e\u0026ldquo;... There was one year I didn\u0026rsquo;t come for treatment at all\u0026hellip;\u0026rdquo;\u003c/em\u003e This suggests that patients are not merely passive recipients of medical power, but rather engage in various forms of negotiation and resistance.\u003c/p\u003e\u003cp\u003eClarke et al. (2010) analyzed the modern emphasis on individual responsibility for health through medical processes and technology. The study found that patients are expected to take responsibility for their treatment, including medication compliance, appointment attendance, and following instructions, as reflected in statements such as \u003cem\u003e\u0026ldquo;Will remember that every day must take medicine at what time, must take it at that time every day, don\u0026rsquo;t miss medication\u0026rdquo;\u003c/em\u003e This demonstrates how patients internalize the discourse of health responsibility as part of their identity as \u0026ldquo;good patients.\u0026rdquo;\u003c/p\u003e\u003cp\u003eAnalysis through Foucault's framework reveals that healthcare access is not merely about service provision or reducing physical barriers, but involves complex power relations within health systems. Understanding these dimensions will lead to the development of health service systems that recognize power relations and create spaces for greater patient participation in treatment decision-making.\u003c/p\u003e\u003cp\u003eWhen compared with other relevant studies, findings regarding health insurance systems reveal that universal health coverage and social security systems play crucial roles in reducing financial barriers to healthcare. This aligns with McManus and Health Systems Research Institute's (2012) study, which demonstrated that Thailand's universal health coverage project serves as a significant mechanism for reducing inequality and increasing healthcare access among low-income populations. However, in-depth analysis reveals coverage gaps in health insurance systems, particularly regarding hidden costs not included in benefit packages, which may lead to long-term inequality. This issue reflects the necessity for developing policies that encompass additional indirect costs.\u003c/p\u003e\u003cp\u003eRegarding service accessibility, the study found that transportation barriers remain significant challenges for tuberculosis patients in urban areas, both in terms of costs and difficulties in using public transportation systems. These findings correspond with Mishra et al.'s (2021) research in the Indian context, which identified transportation barriers as crucial factors affecting treatment continuity, particularly among vulnerable populations. A comparison between these two contexts reveals that transportation-related service access problems constitute shared challenges in developing countries, despite varying levels of health system development.\u003c/p\u003e\u003cp\u003eAnalysis of family roles in treatment support revealed that family involvement is important in both physical caregiving and psychological support dimensions. This corresponds with Harvey's (2021) study, which found that family support affects patients' self-care behaviors and mental health. This finding highlights the importance of developing support approaches that encompass both patients and their families, including the establishment of social support systems for patients who lack family support.\u003c/p\u003e\u003cp\u003eRegarding patient-health system relationships, the study found that confidence in treatment systems and medical personnel correlates positively with continuous treatment. This aligns with Bandura's (1977) self-efficacy theory, which explains that confidence in system and provider capabilities constitutes a crucial factor affecting health care behaviors. This finding indicates the importance of developing service quality and communication between providers and recipients.\u003c/p\u003e\u003cp\u003eIn the economic dimension, although health insurance systems help reduce primary cost burdens, the study found that patients still face financial burdens from hidden costs and income loss. This corresponds with Russell's (2004) study, which found that the economic impacts of tuberculosis treatment are more complex and comprehensive than direct medical costs. This finding reflects the necessity for developing policies that encompass broader economic impacts.\u003c/p\u003e"},{"header":"5. Limitations and Future Research Directions","content":"\u003cp\u003eWhile our phenomenological approach provides valuable insights into patient experiences, future research might benefit from mixed methods approaches that could quantify identified barriers and their impacts. Comparative studies across different urban contexts might also help distinguish between universal and context-specific challenges in urban healthcare access.\u003c/p\u003e\u003cp\u003eFuture research should prioritize studying interactions between macro-level health policies and micro-level patient experiences, as Navarro (2020) suggests. Additional research on how universal health coverage policies can adapt to address specific challenges in the urban context would be particularly valuable.\u003c/p\u003e"},{"header":"6. Policy Applications","content":"\u003cp\u003eOur findings directly affect urban health policy development, particularly in middle-income countries. As Marmot et al. (2012) suggest, addressing health inequalities requires comprehensive approaches that consider social determinants of health. Our study supports this view and proposes specific policy measures:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDevelopment of Support Systems for Indirect Costs. The study reveals the need for comprehensive support systems that address indirect healthcare costs. While crucial, universal healthcare coverage does not fully address the financial burden patients face. Policy interventions should consider developing mechanisms to support transportation costs, compensate for lost income, and address other hidden expenses, particularly for informal sector workers who lack formal social protection systems.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIntegration of Social Support Networks. Recognizing the vital role of family and community support, policies should aim to formally integrate these social support networks into healthcare delivery systems. This could include developing family education programs, establishing support groups, and creating mechanisms for family involvement in treatment planning and monitoring.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCultural Sensitivity in Healthcare Delivery. The study demonstrates the importance of culturally sensitive healthcare delivery approaches. Policy frameworks should incorporate cultural competency training for healthcare providers, recognize the role of religious and cultural beliefs in treatment processes, and develop communication strategies that respect local cultural norms and practices.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eSystemic Improvements in Healthcare Delivery. Policy interventions should address systemic barriers identified in the study, including:\u003c/p\u003e\u003cp\u003e\u003col style=\"list-style-type:lower-alpha;\"\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eImplementing more efficient appointment and follow-up systems.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDeveloping strategies to reduce waiting times.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCreating flexible service hours that accommodate working patients.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eEstablishing better coordination between different levels of healthcare services.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eEnhanced Health Literacy Programs. Policies should focus on developing context-appropriate health literacy programs considering local cultural beliefs and practices while promoting an accurate understanding of disease prevention and treatment.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"7. Conclusions","content":"\u003cp\u003eThis study demonstrates that healthcare access in urban settings involves complex interactions among structural conditions, social relationships, and power dynamics that extend far beyond the provision of universal health coverage. The research reveals how socioeconomic structures perpetuate healthcare access barriers through transportation costs, hidden expenses, and lost income opportunities that disproportionately affect vulnerable populations, particularly informal sector workers, while social support networks, especially family relationships, remain crucial to treatment success despite evolving urban contexts that require healthcare systems to adapt and integrate traditional and modern support forms. Power dynamics within healthcare settings manifest through patients developing unique strategies for navigating medical systems, with cultural and religious beliefs continuing to play important roles in treatment experiences, suggesting the need for culturally sensitive approaches that respect patient agency while ensuring treatment effectiveness. For middle-income countries experiencing rapid urbanization, these findings emphasize that while universal health coverage provides an essential foundation, achieving genuine health equity requires comprehensive interventions addressing both direct and indirect barriers, supporting evolving social capital networks, recognizing culturally specific forms of patient agency, and developing healthcare systems capable of addressing traditional and emerging urban challenges through attention to the political, economic, and social dimensions of healthcare access.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Human Research Ethics Committee, Faculty of Pharmacy, Siam University, Thailand (COA.013-2567), in accordance with the ethical principles of the Declaration of Helsinki (2013\u0026nbsp;revision).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants were fully informed about the objectives, procedures, potential risks, and benefits of the study. They were assured of the confidentiality of their information and informed that participation was entirely voluntary. Written informed consent to participate was obtained from all participants between 31 October 2024 and 31 January 2025, prior to data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative interview data generated and analyzed during this study are not publicly available due to confidentiality concerns but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArmstrong D (1995) The rise of surveillance medicine. 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WHO\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"humanities-and-social-sciences-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"palcomms","sideBox":"Learn more about [Humanities \u0026 Social Sciences Communications](http://www.nature.com/palcomms/)","snPcode":"41599","submissionUrl":"https://submission.springernature.com/new-submission/41599/3","title":"Humanities and Social Sciences Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Healthcare access, Tuberculosis, Social structure, Health Inequality, Socioeconomic Barriers, Urban Health","lastPublishedDoi":"10.21203/rs.3.rs-7207938/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7207938/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study explores barriers to healthcare access among urban tuberculosis patients, focusing on social structures, economic factors, and cultural beliefs. Using qualitative methods, in-depth interviews with 12 patients in Bangkok (31 October 2024\u0026ndash; 31 January 2025) revealed that universal healthcare reduces financial burdens, but challenges remain, including transportation, hidden costs, and treatment discontinuity. Family and workplace support enhance treatment success, while religious beliefs aid mental health. Health literacy and confidence in care impact self-management. Recommendations include addressing hidden costs, improving follow-up systems, and enhancing health literacy to better support patient needs.\u003c/p\u003e","manuscriptTitle":"Beyond Access: Social Inequalities, Power Relations, and Healthcare Navigation among Urban Tuberculosis Patients in Thailand","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 08:04:26","doi":"10.21203/rs.3.rs-7207938/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-31T12:20:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-22T04:32:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-17T04:58:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147020747231134378264689033226226594102","date":"2026-03-17T04:14:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"117490234448507937177643918205347849154","date":"2026-03-14T01:08:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"17221521071470539093248280775864326624","date":"2026-01-10T00:38:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-04T03:30:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9683187872547143547441327381552454227","date":"2025-09-25T06:48:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-25T05:46:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-25T05:44:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-25T05:34:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-08T23:39:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Humanities and Social Sciences Communications","date":"2025-09-08T12:49:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"humanities-and-social-sciences-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"palcomms","sideBox":"Learn more about [Humanities \u0026 Social Sciences Communications](http://www.nature.com/palcomms/)","snPcode":"41599","submissionUrl":"https://submission.springernature.com/new-submission/41599/3","title":"Humanities and Social Sciences Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"84cb8208-d7b0-4316-bb33-15fb29d25445","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":55780718,"name":"Health sciences/Health care"},{"id":55780719,"name":"Humanities/Health humanities"},{"id":55780720,"name":"Humanities/Medical humanities"},{"id":55780721,"name":"Social science/Social policy"}],"tags":[],"updatedAt":"2026-05-21T14:53:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-08 08:04:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7207938","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7207938","identity":"rs-7207938","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}