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Indian Journal of Community Medicine

Awareness Regarding Tuburculosis in a Rural Population of Delhi

Author(s): R. Malhotra, D.K. Taneja, V.K. Dhingra*, S. Rajpal*, M. Mehra

Vol. 27, No. 2 (2002-04 - 2002-06)

Deptt. of Community Medicine, Maulana Azad Medical College, New Delhi *New Delhi Tuberculosis Centre, New Delhi

Abstract:

Research question: How aware are the rural people in Delhi about tuberculosis?

Objectives: 1. To assess the knowledge about symptoms, mode of transmission, causation, prevention and treatment relating to tuberculosis in a rural population of Delhi. 2. To study relationship of level of awareness with age, sex and educational status.

Study design: Cross-sectional.

Setting: Rural field practice area, village Barwala, Delhi.

Participants: Head of the family or an adult member from every third household constituting a total of 213 individuals.

Study variables: Awareness about tuberculosis, age, sex, educational status.

Statistical analysis: Proportions.

Results: 213 individuals were interviewed. Cough with sputum (73.7%) was the most common symptom known, 95.3% were aware that tuberculosis could spread to others with 65% being aware of air as a route, 48.4% knew an infectious agent is the cause of tuberculosis. Females and those without schooling were significantly less aware of various aspects of tuberculosis. Majority (73.7%) stated government health facilities as place of choice for treatment. Misconceptions like separate utensils and food for the patient and consumption of tortoise meat for treatment were observed. Doctors and health care workers were cited by majority (50.2%) as the source of information.

Keywords : Tuberculosis, Knowledge, Awareness

Introduction:

Tuberculosis is a major public heath problem in India, coupled with rising member of cases of AIDS, in whom the most common opportunistic infection is tuberculosis1, it has gained even greater importance. The Revised National Tuberculosis Control Programme (RNTCP) depends on the passive reporting of the chest symptomatics to the health institutions2. Therefore, it is important that the basic knowledge about the disease and the availability of treatment is clear among the individuals in the community. Equally important is to assess the practices of the people to find out unhealthy practices, if any. The present study was undertaken with the objective of assessing the knowledge and practices regarding tuberculosis in a rural population of Delhi.

Material and Methods:

Study area:

The study was conducted in village Barwala, Delhi having a population of approximately 4550 constituting 640 households. The village houses the Rural Field Practice Centre for the department of Community Medicine, Maulana Azad Medical College which provides preventive, promotive and curative services to the population residing in the village and the adjoining areas. It also houses a microscopy centre, which is under the administrative control of Chest and Tuberculosis Clinic at Narela, Delhi.

Study period: The study was carried out from July to November 2001.

Participants: All households in the village formed the universe of the study. For obtaining the study sample, systematic random sampling was carried out. After random selection of the first household, every third household was included in the study. The head of the household or in his/her absence any other adult member of the family, was interviewed by the investigator. In case the selected house was found locked on three successive weekly visits, the adjacent household was interviewed. On an average, each interview lasted for about 15-20 minutes.

Study Instrument: A 2-page structured questionnaire was prepared. The questionnaire contained questions on socio-demographic variables such as age, sex, religion, caste, type of family, literacy status, occupation, per capita income, knowledge about symptoms, transmission, aetiology, investigations, treatment and prevention of tuberculosis; choice of treatment facilities in case of chest symptoms and source of the information provided. Individuals with an educational status of primary school and above were considered under the category of "schooling present". A pretest was conducted and the questionnaire was finalized. Statistical Analysis: The data was analyzed using MS Excel 2000 and Chi-square test was applied.

Results: Socio-demographic profile:

A total of 213 individuals with a mean age of 43.02 years (Range: 20-90 years) were interviewed, out of which 102(47.9%) were males and 111(52.1%) were females. Nearly all (99.1%) were Hindus with a majority being Jats (46%). Majority were from nuclear families (53.6%). One-fourth of the individuals were illiterate. Housewives constituted 47.9% of respondents followed by government/private service employees (21.5%) and owner cultivators. Majority of the females were housewives (91.9%) and males were predominantly in government/private service (43.1%) or were owner cultivators (27.5%). The mean per capita income per month was Rs. 911.42 (range: Rs. 187.50-5833.33).

Awareness of symptoms:

Table I: Relationship of knowledge of symptoms with age (%).

Symptoms* Age group
  20-29 (n=45) 30-39 (n=55) 40-49 (n=39) 50-59 (n=33) 60-69 (n=24) >70 (n=17) Total (n=213) % p value
Cough with sputum 75.8 80.1 74.5 69.7 62.6 70.6 157 (73.7) <0.05
Fever 31.2 34.6 41.1 33.3 25.0 41.2 73 (34.3)
Hemoptysis 22.3 34.6 23.1 30.3 33.4 47.0 64 (30.0)
Chest pain 2.2 3.6 2.6 6.1 20.9 5.9 12 (5.6)
Not aware 20.1 16.4 18.0 18.2 20.9 17.6 39 (18.3)
Weakness+breathlessness 22.3 32.8 51.4 42.4 58.4 58.8 86 (40.4)

*Responses are not mutually exclusive.

Table II: Relationship of knowledge of symptoms with sex.

Symptoms Sex p value
Males (n=102) % Females (n=111) %
Cough with sputum 80 (78.4) 77 (69.4) <0.05
Fever 34 (33.3) 39 (35.1)
Hemoptysis 44 (43.1) 20 (18.0)
Chest pain 6 (5.9) 6 (5.9)
Not aware 12 (11.8) 27 (24.3)
Weakness+breathlessness 44 (43.14) 42 (37.8)

Figures in parentheses indicate percentages.

Table III: Relationship of knowledge of symptoms with literacy status (%).

Symptoms Literacy status
Illiterate (n=53) Just literate (n=7) Primary (n=33) Middle (n=27) High (n=51) Sr.Sec. (n=30) Graduate (n=9) P.G. (n=3) p value
Cough with sputum 56.7 28.6 66.7 96.5 78.4 86.8 89.0 100.0 <0.05
Fever 26.5 28.6 33.3 40.8 35.3 36.7 44.5 66.7
Hemoptysis 24.6 14.3 24.2 40.8 33.3 33.4 33.4 33.3
Chest pain 9.5 0.0 3.0 3.7 7.8 0.0 11.1 0.0
Not aware 30.2 57.2 27.3 0.0 9.8 13.4 11.1 0.0
Weakness+breathlessness 47.3 0.0 39.4 37.1 41.2 23.4 77.8 100.0

All the 213 individuals had heard about tuberculosis. Cough with sputum (73.7%) was the most common symptom known, followed by weakness and breathlessness (40.4%), fever (34.3%), haemoptysis (30.0%) and chest pain (5.6%). None was aware of all the chest symptoms. As much as 18.3% of the individuals were not aware about any symptoms of tuberculosis. Males and those with schooling were significantly more aware about symptoms of tuberculosis. Individuals above 60 years of age were significantly more aware of chest pain. (Table I-III)

Mode of transmission:

Table IV: Relationship of knowledge of mode of spread with age (%).

Mode of spread* Age group
20-29
(n=41)
30-39
(n=52)
40-49
(n=38)
50-59
(n=33)
60-69
(n=23)
>70
(n=16)
Total
(n=203)
% p value
Casual physical contact 2.2 1.8 5.1 6.1 12.5 0.0 9 (4.4) <0.05
Air 53.5 52.8 77.1 63.6 66.7 70.6 132 (65.0)
Not aware 11.2 9.1 5.1 15.2 0.0 5.9 18 (8.9)
Food+utensils 51.3 63.7 48.8 45.5 62.6 41.2 114 (56.2) >0.05
Others 0.0 1.8 0.0 0.0 0.0 5.9 2 (1.0)

*Responses are not mutually exclusive.

Table V: Relationship of knowledge of mode of spread with sex.

Mode of spread Sex p value
Males (n=96) % Females (n=107) %
Casual physical contact 4 (4.2) 5 (4.7) <0.05
Air 74 (77.1) 58 (54.2)
Not aware 2 (2.1) 16 (15.0)
Food+utensils 51 (53.13) 63 (58.9) >0.05
Others 2 (2.1) 0 (0.0)  

Figures in parentheses are percentages.

Table VI: Relationship of knowledge of mode of spread with literacy status (%).

Mode of spread Literacy status
Illiterate
(n=52)
Just literate
(n=7)
Primary
(n=31)
Middle
(n=25)
High
(n=49)
Sr.Sec.
(n=27)
Graduate
(n=9)
P.G.
(n=3)
p value
Casual physical contact 7.6 0.0 6.1 11.1 0.0 0.0 0.0 0.0  
Air 49.1 57.2 57.6 59.4 70.6 70.1 89.0 66.7 <0.05
Not aware 15.1 0.0 18.2 7.4 2.0 3.3 0.0 0.0  
Food+utensils 54.8 57.2 45.5 51.9 54.9 50.1 77.8 66.7 <0.05
Others 0.0 0.0 0.0 3.7 0.0 0.0 0.0 33.3  

are that tuberculosis could be transmitted from one person to another but only 65% respondents cited transmission via air. Significantly higher proportion of individuals with age more than 40, males and those with schooling were aware of this correct mode of transmission. Utensils and food as a route of spread were cited by 56.2%, with no significant difference in the awareness of this incorrect route with age, sex and schooling of the study subjects. (Table IV-VI)

Aetiology:

Table VII: Relationship of knowledge of cause with age (%).

Cause* Age group
20-29 (n=45) 30-39 (n=55) 40-49 (n=39) 50-59 (n=33) 60-69 (n=24) >70 (n=17) Total (n=213) % p value
Infective organism 37.9 45.5 59.1 54.5 50.0 47.0 103 (48.4) <0.05
Heredity 2.2 1.8 7.7 6.1 4.2 11.8 10 (4.7)  
Curse 0.0 0.0 0.0 3.0 0.0 0.0 1 (0.5)  
Not aware 46.8 34.6 25.7 30.3 37.5 5.9 70 (32.9)  
Smoking+alcohol+diet 11.2 5.5 7.7 6.1 12.5 23.5 20 (9.4)  
Others 2.2 12.7 2.6 9.1 0.0 17.6 15 (7.1)  

*Responses are not mutually exclusive.

Table VIII: Relationship of knowledge of cause with sex.

Cause Sex
Males (n=102) Females (n=111) p value
Infective organism 60 (58.8) 43 (28.7) <0.05
Heredity 4 (3.9) 6 (5.4)  
Curse 0 (0.0) 1 (0.9)  
Not aware 21 (20.6) 49 (44.2)  
Smoking+alcohol+diet 13 (12.8) 7 (6.3)  
Others 10 (9.8) 5 (4.5)  

Figures in parentheses are percentages.*

Table IX: Relationship of knowledge of cause with literacy status (%).

Cause Literacy status
Illiterate
(n=53)
Just literate
(n=7)
Primary
(n=33)
Middle
(n=27)
High
(n=51)
Sr.Sec.
(n=27)
Graduate
(n=30)
P.G.
(n=3)
p value
Infective organism 26.5 14.3 48.5 51.9 62.7 53.4 77.8 100.0 <0.05
Heredity 9.5 0.0 9.1 0.0   3.3 0.0 0.0  
Curse 1.9 0.0 0.0 22.3 0.0 0.0 0.0 0.0  
Not aware 45.4 71.5 36.4 29.7 23.5 26.7 11.1 0.0  
Smoking+alcohol+diet 13.2 0.0 9.1 11.1 9.8 3.3 11.1 0.0  
Others 5.7 14.3 0.0 11.1 7.8 13.4 0.0 0.0  

Only 48.4% individuals knew the correct aetiology of tuberculosis i.e. an infective organism. This was observed to be significantly greater among males and those with schooling, being maximum in graduates and postgraduates. The other causes cited by the individuals included smoking and alcohol consumption along with a poor diet (9.4%), heredity (4.7%), curse (0.5%) and others (7.1%) like motijhara, occurs from within, pollution and mental anxiety. (Table VII-IX)

Investigations and treatment:

Majority (55.4%) were not aware of the investigations carried out to diagnose tuberculosis. Only 30.5% stated sputum examination, 25.4% stated X-ray, 24.4% blood examination and 7.1% stated other investigations like urine or stool examination as the investigations to be done in a suspected patient of tuberculosis. Some respondents cited more than one investigation.

A large number (94.4%) believed that tuberculosis is curable. Government health facilities (allopathic) were stated to be the place of choice for diagnosis and treatment of tuberculosis by 73.7%, whereas, 13.1% had faith in private practitioners and 12.7% had no pre decided choice. Only 0.5% gave Ayurveda as their treatment of choice.

A strange practice of consumption of tortoise meat was observed to be prevalent in the study population with 3.3% individuals admitting to have eaten it themselves or given it to a relative, on being diagnosed as a tuberculosis patient and 11.7% of having heard about the practice.

Awareness about the microscopy centre in the village was present among 55.9% of the individuals and 15% were unaware of any facility for treatment of tuberculosis. The fact that anti-tubercular drugs are available free of cost at government health facilities was known to 72.8%, whereas, 1.4% stated that the treatment was not free and 25.8% were not aware of the status. The duration of treatment (6-9 months) was correctly known to only 31.5%.

Almost all individuals responded that both the patient and the family members could be adversely affected if the patient did not take the anti-tubercular drugs regularly, as per the schedule.

Knowledge regarding prevention:

Majority (97.7%) of the subjects stated that some precautions should be taken if a family member is diagnosed as a patient of tuberculosis. Separate utensils and food for the patient was the most common precaution (79.3%) observed. Other precautions included covering the mouth while coughing (46.6%), proper sputum disposal (38.9%), separate room and washing of clothes (28.4%), good diet and a clean environment (26%) and avoid contact with children (8.7%). Many respondents stated more than one precaution. Only two (0.9%) individuals were of the opinion that the patient should not be allowed to stay in the house and three (1.4%) stated that no precautions were to be taken. BCG vaccine was known only to 9.8% of the individuals inspite of coverage of 93% of infants in the village.

Source of information:

Doctors and health care workers were stated to be the source of the information regarding various aspects of tuberculosis by 50.2% followed by mass media (33.8%), friend/relative who has/had tuberculosis (32.9%) and interaction with others in the community (34.7%).

Discussion:

In the present study, cough with sputum (73.7%), weakness and breathlessness (40.4%), fever (34.3%) and haemoptysis (30%) have been observed to be the symptoms of tuberculosis known to the people indicating a fairly good level of knowledge. Uplekar3 and Subramanian4 have reported that cough, haemoptysis and fever were known to 66%, 13%, 6% and 60%, 15%, 8% individuals respectively. Croft reported 44% individuals to be aware of cough as a symptom in Bangladesh5. The greater awareness of these symptoms in the present study is encouraging and may help to improve the passive case finding.

It was also encouraging to observe that 95.3% study subjects knew that tuberculosis could be transmitted from one person to another although the correct route i.e. air was cited by only 65% of these individuals. The wrong knowledge about utensils and food as routes of transmission needs to be addressed to remove any misconceptions about the disease so as to help in removing the stigma attached with the disease. This incorrect concept is also reflected as 79.3% individuals stated separate utensils and food precautions when a family member had tuberculosis.

The low awareness regarding correct knowledge about an infectious agent as the aetiology of tuberculosis observed among only 48.4%, coupled with the lack of knowledge or incorrect knowledge about the cause such as heredity, curse, motijhara, pollution, mental anxiety, observed in our study, might lead to harbouring of wrong beliefs and misconceptions about the cause of the disease which may affect the timely reporting of patients to the health institutions.

Females and individuals without `schooling' were observed to be the groups with a significantly lower level of knowledge about the symptoms, transmission and cause of the disease. Purohit6 also observed a poor level of knowledge about tuberculosis among illiterate population. These groups should be given health education about the disease and its control on a priority basis, so as to improve early reporting and regular treatment by the patients.

Although 73.7% individuals favoured treatment from government health facilities, but a small proportion (3.3%) had taken tortoise meat in the past as treatment for tuberculosis. Such wrong practices may hamper the timely and proper treatment of tuberculosis patients and spread misconceptions about the disease.

BCG as a vaccine against tuberculosis was known to 9.8% individuals only. Subramanian4 reported this to be 14%. However, the lack of knowledge did not reflect on the immunisation status of the children as 93% infants had received BCG vaccination.

In the present study, the sources of information on various aspects of tuberculosis i.e. health care workers, mass media, friends/relatives who have/had tuberculosis, other people in the community are similar to those reported by Subramanian4. All these sources can be utilized to improve the existing level of knowledge and bring about a positive change in the practices of people regarding tuberculosis.

Conclusions:

Although knowledge regarding symptoms, mode of transmission and causation was fairly good, however, females and those without schooling need to be educated on a priority basis. Misconceptions like food and utensils as mode of transmission and tortoise meat as treatment need to be removed.

Acknowledgement:

The authors acknowledge the kind co-operation of Dr. Y. Tripathi (Chief Medical Officer, Rural Field Practice Centre, MAMC), Dr. Yogesh Uppal and Dr. Deepti Pagare (Postgraduate students).

References:

  1. Combating HIV/AIDS in India 1999-2000. Government of India, Ministry of Health and Family Welfare, National AIDS Control Organization. Section 1: p6.
  2. Operational Guidelines for Tuberculosis Control. Revised National Tuberculosis Control Programme. Central TB Division, Directorate General of Health Services, Nirman Bhavan, New Delhi, India, May 1997; section 1: p1.
  3. Uplekar MW, Rangan S. Tackling TB - the search for solutions. The Foundation for Research in Community Health, Mumbai 1996.
  4. Subramanian T, Charles N, Balasubramanian R, Balambal R, Sundram V, Ganapathy S et al. Knowledge of tuberculosis in a south Indian rural Community, initially and after health education. Ind J Tub, 1999; 46: 251-4.
  5. Croft RP, Croft RA. Knowledge, attitudes and practice regarding leprosy and tuberculosis in Bangladesh. Lepr Rev 1999; 70: 34-42.
  6. Purohit SD, Gupta ML, Madan A, Gupta PR, Mathur BB, Sharma TN. Awareness about tuberculosis among general population: A pilot study. Ind J Tub 1988; 35: 183-7.
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