Long delays in leprosy diagnosis aggregate negative consequences for individuals and families and increase the risk for the spread of the disease. To shorten delays, health-seeking processes have to be understood and documented. For this purpose, in 2015 the International Nepal Fellowship launched a 3-year research project entitled "A medicalanthropological study of delays in diagnosis and treatment of leprosy in Western Nepal". Methods: During 12 consecutive months in-depth interviews were completed with 81 inpatients on anti-leprosy treatment with a focus upon health-seeking efforts prior to the leprosy diagnosis. Results: Most of the respondents recalled a long, frustrating, and expensive healthseeking process. The mean delay within the cohort was found to be 29•8 months. The various sectors of the health system were involved, not necessarily in order, but intermingled and overlapping. Conclusions: Leprosy will only be eradicated when delays are shortened. In regard to voluntary presentations this will only be accomplished as patterns of health seeking are understood and taken into account for interventions. As this study shows, increased leprosy diagnostic skills within the public health services will not suffice but have to go together with leprosy capacity building within the private health services. Moreover, such efforts have to run parallel to context-specific leprosy awareness-raising programmes within society at large.

Prolonged delays between first symptoms and diagnosis easily result in more impairment in newly detected leprosy patients, and aggregate negative consequences for individuals and their families. In cases of infectious leprosy, longer delays increase the risk for the spread of the disease. Limited studies have been carried out to explore the causes for delays in Nepal. This is a community level qualitative study conducted in Dang district. The information was obtained through in-depth interviews with 8 leprosy affected persons, 8 contacts, 8 community members and 5 service providers in Dang district. Skin patches were regarded as a simple skin disease, in particular of paucibacillary patients who had a limited number of skin lesions and no nerve damage. A local medical shop was the first choice for medicine to treat skin conditions. Delays in diagnosis of leprosy occurred at many stages from the development of the symptoms to consultation of health care services. The use of traditional medicine, a belief in self-cure and visit to traditional healers, and misdiagnosis (a disease other than leprosy by the health worker) and inadequate knowledge about the disease and its early symptoms were the main factors that influenced the delayed diagnosis. Delays accumulated as the result of series of help-seeking actions that reflected local socio-cultural beliefs and practices. Misdiagnoses could be reduced if adequate information on leprosy is given to community people and health service providers. Specific interventions are needed to promote knowledge and a good attitude among contacts and community members. To reduce patient delay, public health promotion is needed to increase the awareness of leprosy, and the health service delay should be reduced by improving diagnostic skills in public and private sectors. Addressing both components of delays will decrease the time to diagnosis and ultimately the extent of transmission of the disease and reduce the risk of nerve function impairments.

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In late 2009, Nepal reached the leprosy elimination goal. However, the expected gradual decline in registered prevalence did not take place. In early 2015, the International Nepal Fellowship (INF) launched a three-year research project on leprosy delays in the western part of the country. The main focus of the present article is on health-seeking processes as reported by patients diagnosed in INF outpatient skin clinics (the Outpatient cohort) and by patients diagnosed in a massive, governmentled, one-off, case detection operation (the Follow-up cohort). The former represents voluntary presentations and passive case detection, the latter, active case finding in the field. Methods: A mixed qualitative and quantitative approach with in-depth patient interview data enhanced by consultations with key informants and on the spot observations, plus structured data from clinic records and interviews. Results and Conclusions: The mean delay of the Outpatient cohort was found to be 28.1 months, and 23.2 months for the Follow-up cohort. While the causes of delay are complex, the long delays foremost reflect a lack of ability of individuals and families to recognize the seriousness of early leprosy symptoms compounded by health service professionals' failure to diagnose the condition. Without early case detection and treatment, Nepal will not free itself of leprosy. A broad-scale dissemination of public education and awareness of leprosy is essential and so is an upgrading of leprosy skills among private and public health service professionals. In addition, in some contexts a double approach of self-referrals and active screening is likely to be necessary.

In focus is the emic perspective on cause/s of tuberculosis. The ethnographic data is from two major studies in one and the same community in the Hill district of Pyuthan, in the Mid-Western Development Region. The findings show a pooling of old and new influences with a dazzling plurality of thoughts and ideas within a framework of great uncertainty. Moreover, changes in perceptions over the last decade and an half are quite marginal. For health workers to function efficiently the perceived causes of patients and their communities need to be understood and taken into account.