|Year : 2013 | Volume
| Issue : 3 | Page : 148-154
Community knowledge and attitude to pulmonary tuberculosis in rural Edo state, Nigeria
Ekaete Alice Tobin1, Paul-West Okojie2, Essy Clementina Isah2
1 Institute of Lassa Fever Research and Control, Irrua Specialist Teaching Hospital, Irrua, Edo State, Nigeria
2 Department of Community Health, University of Benin Teaching Hospital, Benin-City, Edo State, Nigeria
|Date of Web Publication||5-Sep-2013|
Ekaete Alice Tobin
Institute of Lassa Fever Research and Control, ISTH, Irrua, Edo State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: A high level of community awareness and positive perception toward pulmonary TB (PTB) and its management is crucial for the success of any control strategy. This study was carried out to assess the knowledge, attitudes, and practice as regard to TB and its treatment.
Materials and Methods: A descriptive cross sectional study involving 193 persons was carried out in a rural community in Ward 5 of Etsako-West local government area of Edo state, selected through a multi-stage sampling process.
Results: About 86% of respondents had heard of PTB, with a greater proportion being females (55.7%). Mean knowledge score (16.26±5.8) showed that a greater proportion (55.1%) had poor knowledge (range 0-35), with males having better (though not significant) knowledge than females (mean score 17.28±5.9 and 16.94±5.0, respectively, P=0.68). Although attitude toward TB did not influence caring for sick relatives or friends, it impeded social interactions and marriage prospects with infected persons within the community.
Conclusion: Knowledge and attitude toward PTB was generally poor in this rural community. Efforts should be intensified by health authorities in the local government to raise awareness and knowledge of the disease, so as to improve social perception and early recognition of infection.
| Abstract in French|| |
Contexte: Un niveau élevé de sensibilisation communautaire et de la perception positive vers la tuberculose pulmonaire (PTB) et sa gestion est crucial pour la réussite de toute stratégie de contrôle. Cette étude a été réalisée afin d'évaluer les connaissances, les attitudes et pratiques en matière de tuberculose et de son traitement.
Méthodes et matériaux: Une étude descriptive de sectionnelle croisée impliquant 193 personnes a été réalisée dans une communauté rurale dans la zone d'administration locale de Ward 5 de Etsako-ouest de l'état d'Edo, sélectionné par un processus à plusieurs étapes d'échantillonnage.
Résultats: Environ 86 % des personnes interrogées avaient déjà entendu parler du PTB, avec une plus grande proportion étant les femmes (55,7 %). Connaissances score moyen (16.26±5.8) a montré qu'une plus grande proportion (55,1 %) avait mauvaise connaissance (gamme 0 à 35), les mâles ayant mieux connaissance (bien que non significative) que les femelles (signifie marquer 17.28±5.9 et 16.94±5.0, respectivement, P= 0,68). Bien que l'attitude de TB n'influence pas prendre soin de parents malades ou des amis, il entravé des interactions sociales et les perspectives de mariage avec des personnes infectées au sein de la communauté.
Conclusion: Connaissances et l'attitude envers la PTB a été généralement pauvres dans cette communauté rurale. Des efforts devraient être intensifiés par les autorités sanitaires du gouvernement local pour sensibiliser et connaissance de la maladie, afin d'améliorer la perception sociale et la reconnaissance précoce de l'infection.
Mots-clés: Attitude, communauté, connaissances, rural, stigmatisation, de la tuberculose
Keywords: Attitude, community, knowledge, rural, stigma, tuberculosis
|How to cite this article:|
Tobin EA, Okojie PW, Isah EC. Community knowledge and attitude to pulmonary tuberculosis in rural Edo state, Nigeria. Ann Afr Med 2013;12:148-54
| Introduction|| |
Pulmonary tuberculosis (PTB) is one of the major diseases responsible for the public health and economic crisis in low income countries. , The global incidence rate of TB per capita is growing by approximately 1.1% per year.  Of the 1.7 billion people estimated to be infected with TB, 1.3 billion live in developing countries.  Globally, the disease kills approximately 5000 people daily, with 98% of deaths occurring in developing world, affecting mostly young adults in their most productive years.  Among the 15 countries with the highest estimated TB incidence rates, 13 are in Africa which accounts for 31% of the global total, more so as countries in the sub-Saharan region are experiencing a great burden of human immunodeficiency virus (HIV) infection increasing the risk of TB infection in these African countries. 
Nigeria ranks fourth among the 22 countries with the highest TB burden in the world, with a prevalence rate of 616 per 100,000 (compared with a global prevalence of 217 per 100,000), incidence rate of 311 per 100,000 annually and 150,000 deaths every year. ,,,, The global targets and indicators for TB control have been developed with the framework of the Millennium Development Goals (MDGs), Stop TB partnership, and World Health Organization (WHO). These were developed to halt and reverse TB incidence by 2015, to reduce by half the prevalence and death rates by 2015, while by 2050, to totally eliminate TB as a public health problem with one case per one million population insinuated.  In order to achieve this goal the WHO launched the Directly Observed Treatment Strategy short course (DOTS) and Stop TB program, of which one of the important strategies is the education and empowerment of communities. Nigeria commenced the implementation of DOTS in 1993.  The goal of DOTS is to detect 70% of all sputum-smear-positive TB cases and to cure 80% of them through passive detection and directly observed treatment.  Despite the fact that DOTS has recorded significant improvement in detection, treatment and control of TB in Nigeria, neither the set target for the detection rate nor the cure rate has been achieved nationwide, as several challenges detract its effective implementation so much so that many TB cases are still undetected (presently case detection rate stands at 27%). ,, Detecting infectious TB cases is critical in TB control, so early detection of infectious TB cases reduces the pool of infectious individuals in the community and therefore limits transmission. DOTS relies on patients presenting themselves to TB clinics for evaluation of their symptoms. This approach assumes that patients and their families are knowledgeable of TB symptoms and that structural and cultural barriers to TB services are nonexistent. Unfortunately, that is not always the situation.  One major setback to the success of TB control in the country is the poor knowledge and stigma attached to the disease particularly in rural areas of the country. ,,, Achieving the country goals of the Stop TB strategy requires active community enlightenment in these rural communities by way of creating awareness on the etiology, symptomatology, management, preventive measures, and information of availability of services for TB. It is also essential to remove the fear and stigma associated with TB, a common feature in the rural communities, so that people can come forward for seeking care. , Correct knowledge and positive perception of the community toward TB and its management is a prerequisite to early treatment seeking. , The study therefore aimed to assess the level of knowledge of PTB and perceptions of the disease among residents in a rural community in Edo state.
| Materials and Methods|| |
A descriptive cross sectional study was conducted in 2010 in Edo state, Nigeria. Edo state lies in the South-south geopolitical zone of the country, in the tropical rain forest region. Through a multi-stage sampling process, a representative community was selected from among local government areas. This community, with a total population of 3500 persons, is a typical farming community, with social amenities including a market, government-owned secondary and primary school, and a primary health care center. Study population comprised households in the community. A minimum sample size of 176 was calculated using the appropriate formula for a descriptive study,  with prevalence taken as 86.8% representing proportion of respondents knowledgeable about PTB from a previous study carried out in Ethiopia  and a nonresponse rate of 10%. A preliminary survey was done to establish the number of houses and average number of households per house. Based on the findings, every third house was selected starting from the chief's house. In each selected house, the household head or in his absence an eligible adult was invited to participate. Where there was more than one household in a house, random sampling was used to select one. A structured pre-tested questionnaire adapted from that used in a study carried out among Afar pastoralists in northeast Ethiopia  served as the tool for data collection. The questionnaire sought information on socio-demographic characteristics, knowledge and attitude toward TB.
Overall knowledge about TB was assessed using the following points: (a) mention of bacteria/germ as a cause of TB, (b) mention of correct sign/symptoms of TB (persistent cough for 3 or more weeks, sputum with blood, chest pain, weight loss, loss of appetite, fever, and night sweat), (c) ability to recognize TB as a transmissible disease, (d) ability to enumerate correct mode of transmission of TB (cough/sputum from infected persons), (e) knowledge that TB is treatable, (f) knowledge that effective treatment for TB is modern drug, (7) knowledge that TB is preventable, and (g) ability to enumerate correct preventive methods of TB (not spitting everywhere, using separate room, early treatment, BCG vaccination). A score of one (1) was given to correct responses and zero (0) for incorrect/do not know responses. Only respondents who had ever had of PTB were asked knowledge questions. Responses were added together for each respondent to generate a knowledge score ranging from minimum of 0 to maximum of 35. The composite score was dichotomized using mean as a cut-off value so that values above the mean were categorized as high overall knowledge of PTB, and those below the mean as low knowledge of PTB. In scoring attitude of respondents toward persons with PTB, a score of 1 was assigned to a response (agree or disagree) that represented a good attitude for the question, and a score of 0 for poor attitude. Composite score for attitude ranged from 0 to 5, and for each respondent, was dichotomized using the mean score as cut-off, with values above the mean representing good attitude, and those below poor attitude.
Data were entered into SPSS version 15 (SPSS Inc, Chicago IL 60606-6412) for analysis. Descriptive data were represented as tables, and charts, continuous data as mean and standard deviations. Chi-square test, Odds ratio (OR) and F test were used to examine statistical associations between variables with level of significance set as P<0.05. Approval was obtained from the community's traditional head before the start of the study. Information was provided to the potential participants on the purpose and scope of the study. They were assured that their responses would be confidential, would not be handled with personal identifiers and would not affect them in any manner. Consent was then sought and voluntarily obtained from the eventual participants. The interviews were conducted by trained interviewers.
| Result|| |
One hundred and ninety-three persons participated in the study. Socio-demographic characteristics are shown in [Table 1]. Mean age of respondents was 39+16.6 years. Mean duration of stay in the community was 29.3+18.9 years. One hundred and sixty-seven subjects (86.5%) had heard of PTB, 74 (44.3%) being males, and 93 (55.7%) being females; with the largest proportion of respondents, 92 (55.1%) having their main source of information as the health worker [Figure 1]. Regarding the cause of TB, only 64 (38.3%) of respondents knew the cause to be bacteria, of which 22 (34.4%) were males and 42 (65.6%) were females. Cold (39.5%), food shortage (16.8%), smoking (68.9%), alcohol (46.1%), and dust (41.3%) were incorrectly mentioned as causes of PTB as well. [Table 2] and [Table 3] show that 143 (85.6%) respondents knew prolonged cough, 143 (85.6%), blood stained sputum 112 (67.1%), weight loss 110 (65.9%) to be symptoms of PTB, and less commonly chest pain (47.3%), fever (41.3%), and night sweat (32.3%).
Cough and sneeze from someone infected with the disease was correctly mentioned as mode of transmission by a greater proportion of respondents, 129 (77.2%). Fewer respondents knew hereditary (29.3%), sharing drinking utensils (28.7%), body contact (39.5%), drinking raw milk (26.3%) were not methods of transmission of PTB. Eight-seven (52.1%) respondents were unsure of whether a pregnant woman can transmit PTB to her unborn child [Table 4].
One hundred and twenty-five (74.9%) respondents knew that PTB transmission is preventable, out of which 116 (69.5%) of respondents mentioned the avoidance of coughing or sneezing on persons, 94 (56.3%) mentioned infected persons should avoid spitting on floors, 90 (53.9%) sleeping in separate rooms, and 113 (67.7%) early treatment. Seventy-nine (47.3%) knew BCG vaccination as a means of prevention of infection. One hundred and eight (64.9%) respondents incorrectly mentioned PTB transmission can be prevented by not sharing drinking utensils with infected persons.
One hundred and forty-seven (88.0%) respondents knew that PTB can be treated, out of which a greater proportion, 101 (68.7%) knew correctly that only modern medicine is effective; 2 (1.2%) thought it is untreatable, while 18 (10.8%) did not know [Figure 2].
One hundred and thirty-two (89.8%) and 110 (74.8%) of 147 respondents, respectively knew that PTB can be cured if an infected person took his treatment regularly, and that treatment takes months to complete. Mean score for knowledge was 16.26±5.8, median was 17.00, with 92 (55.1%) scoring below the mean, and 75 (44.9%) scoring above the mean. Males had a higher mean score (17.28±5.9) compared with females (16.94±5.0), however, the difference was not significant (t=0.41, P=0.68).
There was no association between sex (P=0.25), age (P=0.17), religion (P=0.62), and marital status (P=0.30) with knowledge of PTB, however, educational level (P=0.013, OR=2.80, 95% confidence interval [CI]=1.71, 4.60) was significantly associated with knowledge such that the higher the educational level the better the knowledge of PTB. There was a significant difference between mean scores across the different strata of educational level (F test=11.96, P=0.00) [Table 5].
|Table 5: Educational level of respondents as a predictor of knowledge of PTB (n=167)|
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There was a weakly negative, though insignificant (P=-0.061) correlation between duration of stay in the community and knowledge score.
Only 2 (1.2%) of 167 respondents had relatives who have ever been sick from PTB. A greater proportion, 114 (68.3%), of respondents did not see PTB as being a health problem in the community, while 14 (8.4%) agreed it was. Adults (15-70 years) were the age group most commonly perceived to be affected by PTB for 99 (59.2%) of respondents, while 23 (13.8%) mentioned children less than 5 years, 30 (18.0%) mentioned persons aged 5-15 years, and 15 (9.0%) mentioned persons above 70 years.
With regard to attitude toward persons with PTB, while a greater proportion where against the acceptance of persons receiving treatment for PTB in social gatherings and public places (44.3% and 44.9%, respectively), still a greater proportion were willing to take care of relatives with PTB (76.4%) and continue relationships with friends infected with the disease (50.9%) [Table 6].
|Table 6: Respondents' attitude towards persons infected with PTB (n=167)|
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Mean score for attitude was 1.94±1.2. Ninety-three (55.7%) of respondents had attitude scores below the mean, implying poor attitude, while 74 (44.3%) had attitude scores above the mean (good attitude). Attitude showed no association with age (P=0.62), sex (P=0.43), marital status (P=0.84), religion (P=0.35), or educational level (P=0.17).
| Discussion|| |
TB continues to present significant morbidity and mortality in low income countries in spite of effective and available treatment. Poor knowledge about the cause, mode of transmission, and symptoms, as well as appropriate treatment of TB not only affect the health-seeking behavior of patients, but also could affect control strategy, thereby sustaining the transmission of the disease within the community. 
The present study aims at gaining an insight into the level of awareness about various aspects of TB among the general population of a rural community in Edo state. The study showed that majority of people (86.5%) had heard of PTB. This high level of awareness has similarly been documented in the Nigeria demographic and health survey conducted in Nigeria in 2008,  however, findings from this study show that more women were aware of TB (88.6%) than in the national survey (71.0%). This might probably be as a result of a greater contact of women in the study area with the health facilities compared with men, and the fact that women are more likely to be the primary caregivers for infected persons. The study also showed that health workers were the main source of information on TB for the majority. This is different from what was found in earlier studies conducted in Benin City,  and Ibadan metropolis  that identified the media as most popular source of information ],[ . The greater involvement of health workers in the study area is encouraging as they are supposed to be the custodians of knowledge of disease. However, as much as they create the awareness of PTB, gaps in knowledge still exist, as only about one-third of respondents knew the cause of TB to be bacteria, and over 60% mentioned cigarette smoking as a causative agent. The poor knowledge of bacteria as a cause has also been demonstrated in other studies, ,, and needs to be addressed as misconceptions about the cause may affect treatment seeking behavior. The mention of smoking as a cause may not be unconnected to the higher incidence of respiratory disease among smokers, and their higher knowledge of cough as a symptom, a finding also reported in other studies. ,, The poorer knowledge of chest pain and fever as symptoms might be due to the downplaying of these symptoms in public enlightenment messages, and has similarly been reported in a previous study carried out in Ekiti state, Nigeria  and in Delhi, India. 
The lack of clarity about transmission of PTB from pregnant mother to child seen in this study was reported as well in a study conducted in Ethiopia,  and is a matter that demands urgent attention by health educators, as it could result in the stigmatization of pregnant women. The generally lower knowledge of PTB in this study is in contrast to what was obtained in Tanzania,  and South Africa.  The higher knowledge of PTB among men than women has also been documented in other studies, , and in this study may be as a result of the higher level of education in men than women, even as the study also showed that educational level influenced knowledge. Encouragingly, majority of the respondents were aware that PTB is treatable, that treatment takes months to complete and should be regular. This is important as compliance with treatment is one of the pivots of effective therapy. The poor attitude toward persons with PTB in this study has similarly been reported in an earlier study,  and signifies a stigmatization of the disease and those who suffer from it. Such stigmatization has been identified in studies carried out in South Africa and India. ,
| Conclusion|| |
Majority of respondents had heard of PTB, however, gaps existed in their knowledge of the etiology, mode of transmission, and manifestations of PTB with the educated generally having a better knowledge of PTB. Attitude toward PTB was poor and not related to socio-demographic characteristics of respondents. Health educators in the local government should intensify campaigns to sensitize the people to PTB, disseminating information to correct identified misconceptions and improve community perception of the disease. Other routes of information dissemination such as the media should be encouraged to play a more active role in enlightenment campaigns in order to enhance the success of control strategies and subsequent elimination of PTB.
| Acknowledgment|| |
The authors would like to thank the research assistants who participated in data collection.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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