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Table of Contents
Year : 2021  |  Volume : 20  |  Issue : 3  |  Page : 184-192  

Tuberculosis stigma: Assessing tuberculosis knowledge, attitude and preventive practices in surulere, Lagos, Nigeria

1 Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idiaraba, Lagos, Nigeria
2 Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
3 Department of Medicine, College of Medicine, University of Lagos, Idiaraba, Lagos, Nigeria

Date of Submission12-May-2020
Date of Acceptance25-Dec-2020
Date of Web Publication17-Sep-2021

Correspondence Address:
Oluchi Joan Kanma-Okafor
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idiaraba, Lagos
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aam.aam_40_20

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Context: Tuberculosis (TB), though preventable and curable, remains a global health problem, ranked one of the top causes of death worldwide, despite the World Health Organization's strategies. This may be due to the stigma surrounding the disease. Aim: This study assesses TB stigma in light of knowledge, attitudes, and preventive practices among individuals in an urban community. Settings and Design: This was a descriptive, cross-sectional study among 317 residents of Surulere, Lagos, Nigeria, selected by multi-stage sampling. Subjects and Methods: Data were collected using a pretested, semi-structured, interviewer-administered questionnaire and analyzed using Epi InfoTM version 2018 (Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA). Statistical Analysis Used: Descriptive variables were summarized as frequencies, and the Chi-square test was used to test the associations. The level of significance was predetermined at P s804;0.05. Results: Most participants were between the age group of 21 and 40 years. Approximately 9 out of every 10 respondents (91.8%) were aware of TB. Overall, only 2.4% of respondents had good knowledge of TB, more than half (59.1%) had positive attitudes toward TB, about one-third (37.1%) had good preventive practices and 22.7% of respondents expressed TB stigma, 63.6% would show no compassion or desire to help people with TB while 64.3% would rather people with TB were never employed. However, good knowledge translated into less stigma (P <0.001). Conclusions: Most participants were aware of TB, although knowledge, attitude, and practice levels were poor. Knowledge was found to reduce TB stigma, reinforcing the need for improved community literacy regrading TB. This has the potential to influence health-seeking behavior and promote better TB prevention, detection, and treatment outcomes.

   Abstract in French 

Contexte: La tuberculose (TB), bien qu'évitable et curable, reste un problème de santé mondial, classé parmi les causes de décès dans le monde, malgré les stratégies de l'Organisation mondiale de la santé. Cela peut être dû à la stigmatisation entourant la maladie. Objectif: Cette étude évalue la stigmatisation de la tuberculose à la lumière des connaissances, des attitudes et des pratiques préventives chez les individus d'une communauté urbaine. Paramètres et conception: il s'agissait d'une étude transversale descriptive menée auprès de 317 résidents de Surulere, Lagos, Nigéria, sélectionnés par échantillonnage. Sujets et méthodes: Les données ont été collectées à l'aide d'un questionnaire pré-testé, semi-structuré et administré par un intervieweur et analysées en utilisant Epi Info 7.1. Analyse statistique utilisée: les variables descriptives ont été résumées sous forme de fréquences, et le test du chi carré a été utilisé pour tester le les associations. Le niveau de signification était prédéterminé à P ≤ 0,05. Résultats: La plupart des participants étaient âgés de 21 à 40 ans. Environ 9 répondants sur 10 (91,8%) étaient au courant de la tuberculose. Dans l'ensemble, seulement 2,4% des répondants avaient une bonne connaissance de la tuberculose, plus de la moitié (59,1%) avaient des attitudes positives à l'égard de la tuberculose, environ un tiers (37,1%) avaient de bonnes pratiques préventives et 22,7% des répondants ont exprimé la tuberculose stigmatisation, 63,6% ne montreraient ni compassion ni désir d'aider les personnes atteintes de tuberculose, tandis que 64,3% préféreraient que les personnes atteintes de tuberculose ne soient jamais employées. Cependant, une bonne connaissance se traduit par moins de stigmatisation (P <0,001). Conclusions: la plupart des participants étaient au courant de la tuberculose, bien que l'attitude et les niveaux de pratique étaient médiocres. On a constaté que les connaissances réduisaient la stigmatisation de la tuberculose, renforçant la nécessité d'améliorer l'alphabétisation communautaire reclassement de la tuberculose. Cela a le potentiel d'influencer les comportements de recherche de santé et de promouvoir une meilleure prévention, détection et traitement de la tuberculose.

Keywords: Tuberculosis, stigma, knowledge, attitude, preventive practices, Lagos, Nigeria
Mots-clés: Tuberculose, stigmatisation, connaissances, attitude, pratiques préventives, Lagos, Nigéria

How to cite this article:
Junaid SA, Kanma-Okafor OJ, Olufunlayo TF, Odugbemi BA, Ozoh OB. Tuberculosis stigma: Assessing tuberculosis knowledge, attitude and preventive practices in surulere, Lagos, Nigeria. Ann Afr Med 2021;20:184-92

How to cite this URL:
Junaid SA, Kanma-Okafor OJ, Olufunlayo TF, Odugbemi BA, Ozoh OB. Tuberculosis stigma: Assessing tuberculosis knowledge, attitude and preventive practices in surulere, Lagos, Nigeria. Ann Afr Med [serial online] 2021 [cited 2023 Oct 2];20:184-92. Available from:

   Introduction Top

Tuberculosis (TB) is an infectious disease, which is an important cause of morbidity and mortality worldwide.[1] TB is preventable and curable yet it remains a global health problem,[2] ranking above HIV/AIDS as the leading cause of death from a single infectious agent.[3] TB is also one of the major diseases that cause enormous economic crisis in low-income countries.[4] It flourishes wherever there is poverty, overcrowding, and chronic debilitating illnesses. Although TB occurs in every part of the world, in 2018, thirty high TB burden countries accounted for 87% of new TB cases and eight countries out of these accounted for two thirds of all new cases, with Nigeria having the sixth highest number of new cases.[2] As a result of the high morbidity and mortality of TB, three important global public health strategies (i.e., Directly Observed Treatment Short-course [DOTS], stop TB, and end TB) by the World Health Organization (WHO) were developed to improve the TB scenario worldwide.[2],[5] At the heart of these programs is the DOTS, WHO's time-honored approach to treatment combined with patient supervision and support.[6] The DOTS strategy depends on the self-presentation of patients to the health centers. These strategies have had a relevant epidemiological impact by reducing the number of deaths and new TB infections,[7] aiming to eliminate TB as a public health problem by the year 2050.[8]

Central to the success of these control programs are the individuals to whom they apply. People do not know enough or perceive positively about TB. This lack of knowledge about the cause, mode of transmission, and symptoms, as well as appropriate treatment of TB within communities, does not only affect the health-seeking behavior of patients but also contributes to poor adherence to TB treatment and/or long delays in the diagnosis. This poses a formidable challenge to controlling the disease.[9] Previous studies have shown that TB stigma may be more expressed where knowledge, attitude, and preventive practice are suboptimal.[10],[11] The success of TB control in case-finding depends on patient motivation, and the stigma against people with TB affects this strategy because people do not self-present due to the fact that they do not want to be identified with TB. In addition, perceived stigma can prevent people from getting tested, from using care services and from changing their behavior to avoid the spread of TB.[11] As the general public becomes more aware of the relationship between TB and HIV/AIDS, people with TB are now at risk of further stigmatization, which would further deteriorate the care-seeking behavior of those who might think they have TB and their treatment adherence.[11] Stigma, which refers to being disgracefully marked, kills socially and literally; socially in the sense that it excludes people with TB from social life, by cutting off social networks, their ability to get a job, get a life partner, etc., and literally as it causes delay in seeking care which leads to exacerbation of disease. Furthermore, as a result of the social exclusion of people with TB, there is a reduction in their economic capital and an inability to cope with the cost of the illness.[12] The stigmatization of people with TB is one of the challenges against TB control that requires tailor-made interventions that address the knowledge, attitudes, and perceptions of the community.[13] This study aimed at assessing stigmatizing attitudes toward TB considering knowledge, attitude, and preventive practices. This will help quantify the burden of the problem and possibly direct interventions toward reducing stigma against TB.

   Subjects and Methods Top

This was a descriptive, cross-sectional study conducted in Surulere, Lagos, one of the 20 local government areas (LGAs) in Lagos State, Nigeria. Surulere is home to people of both the high and low social classes in Lagos. Surulere is also both a residential and a commercial area with a total land mass of 27.1 km2 and a total population, according to the 2006 census, of 502,865 people, with a projected population of 692,500 inhabitants in 2016.[14] Surulere is sub-divided into Surulere LGA and two local council development areas (LCDAs), Itire-Ikate and Coker-Aguda LCDAs. Each of these subdivisions is further divided into administrative wards.

Participant selection

Adult residents aged 18 years and above who had lived in Surulere for a minimum of 6 months were included in the study. Residents currently on the treatment for TB were excluded from the study. A multi-stage sampling method was used to select 317 study participants. In sampling stage 1, by the simple random sampling method (balloting), Itire-Ikate LCDA was selected out of the three decentralised subdivisions in Surulere. In the second stage, 3 of the administrative wards were selected out of 7 in Itire-Ikate LCDA by simple random sampling using balloting. Each ward is made up of an average of twenty streets. The third stage involved the selection of four streets from each selected ward by balloting. In all, 12 streets were selected. Each street had about 55 houses on the average; hence, in Stage 4 by systematic sampling, every second house was selected. From five of the streets, 27 houses were selected (135 houses in total), and from the remaining 7 streets, 26 houses were selected (182 houses in total), 317 houses in all. Each house had several households living in them. Stage 5 involved the selection of one household from each house by balloting. In Stage 6, one participant was selected by balloting from the eligible adults in the selected households to participate in the study.

Data collection

After obtaining consent from the head of each household, data were collected using a pre-tested, semi-structured, interviewer-administered questionnaire adapted from the WHO Advocacy, Communication and Social Mobilization for TB control Knowledge, Attitude, and Practice survey tool.[15] The questionnaire consisted of five sections designed to collect the information on the sociodemographic characteristics of respondents, their knowledge of TB, their attitude toward TB, their preventive practises and stigmatizing behavior toward persons with TB among residents of Surulere LGA of Lagos State. Scores were generated for knowledge, attitude, preventive practices, and stigmatizing behavior.

Data handling and analysis

The level of knowledge was assessed by scoring ten questions. The possible minimum and maximum scores for knowledge were 0 and 10, respectively. In scoring respondents' knowledge of TB, 1 point was awarded for every correct answer, and no point was awarded for an incorrect response or for not knowing the right answer. The total scores were converted to proportions. Using the mean score as a cutoff, any score ≤30% was regarded as poor knowledge and >31% was regarded as good knowledge.

In scoring respondents' attitude toward the disease, six attitude statements were scored according to a 5-point Likert scale, and each statement was graded with the highest score (5) for the most positive response ranging down to 1 for the least positive response. The possible total minimum and maximum scores for attitude were 5 and 30, respectively. The total scores were converted to proportions. “Positive attitude” was determined if the respondents scored 50% or more while scores <50% was considered “negative attitude”.

The preventive practices toward TB were assessed using 10 questions. The possible minimum and maximum scores for preventive practices were 0 and 10, respectively. “Good practice” was determined if the respondents indicated that they practiced 50% or more of the given options, while <50% was determined to be “poor practice”.

The presence of TB stigma was assessed using 14 questions, each question had a score of 1, and the highest score obtainable was 14. The scores were then converted to proportions. Stigma was determined as present if the respondents scored 50% or more while scores <50% were considered as indicating the absence of stigma.

Data were analyzed using Epi InfoTM version 2018 (Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA). The Chi-square test was used to determine the associations between the categorical variables (TB knowledge, attitude, preventive practices, and stigma). Associations were considered to be statistically significant when the two-tailed probability was <5% (P <0.05).

Ethical consideration

Ethical approval for the study was obtained from the Health Research and Ethics Committee (HREC) of the Lagos University Teaching Hospital (HREC No: ADM/DCST/HREC/APP/052). Permission was obtained from the local government authorities. Written informed consent was obtained from each study participant before the onset of the study. Confidentiality was maintained in terms of participant's identity and information provided. Participation was purely voluntary.

   Results Top

Most participants were within the age group 21–40 years, mean age 32.9 ± 12.6 years, mostly females (60.6%), with secondary school education as their highest attained level of education (50.8) [Table 1].
Table 1: Sociodemographic characteristics of respondents

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Almost all (91.8%) participants had heard of TB, less than a third (32.2%) had heard of TB from health workers. Less than half (39.2%) attributed TB to a germ, 48.0% rightly said that TB is airborne and slightly above half (52.4%) identified overcrowding as aiding the transmission of TB. Cigarette smoking was the most frequently identified risk for contracting TB (48.6%) The most commonly known symptom of TB was coughing up blood (48.0%). A large proportion of the respondents (86.8%) were certain that TB could be cured and 60.6% identified DOTS as the best approach to obtaining treatment for cure. Most participants (88.8%) knew TB to be preventable; through covering both mouth and nose when coughing (56.8%), by avoiding overcrowding (17.4%), or by not sharing plates/cutlery/cups (16.1%) [Table 2].
Table 2: Respondents' awareness and knowledge of tuberculosis

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Regarding respondents' attitudes toward the disease about two thirds of the participants (65.6%) strongly agreed that anybody could contract TB, 75.3% strongly agreed that TB is a serious disease, over a third (38.1%) strongly disagreed that anyone with TB should be isolated, while 58.6% strongly agreed that TB is a highly contagious disease hence should be handled seriously to protect people [Table 3].
Table 3: Attitude of respondents toward tuberculosis (n=291)

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About a third (30%) of the participants had actively taken any of the specific measures thought to help prevent TB like deliberately avoiding people with cough and personal hygiene, 64.4% avoided being in overcrowded places with people that have cough. Only 16.1% had ever been screened for TB [Table 4].
Table 4: Preventive practices toward tuberculosis among respondents

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About two-thirds of the participants (63.6%) felt compassion and have a desire to help persons with TB while 35.4% would expect a change their relationship if a close friend had TB. About half of the respondents (47.1%) reported that they would feel uncomfortable being near people with TB, 64.3% were of the opinion that persons with TB should not be employed. Less than half of the respondents (47.1%) believed it would be difficult for a person with TB to find a life partner even after being cured, 66% were of the opinion that people with TB should keep their distance from others to avoid spreading the germs while 16.2% would hate to be seen going to a TB clinic [Table 5].
Table 5: Stigma toward tuberculosis

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Less than half (44.3%) of respondents had good knowledge of TB, over half (59.1%) of the respondents had good attitude toward TB, about 60% had poor preventive practices against TB, while 22.7% of the respondents showed stigmatizing attitudes [Figure 1].
Figure 1: Overall tuberculosis knowledge, attitude, preventive practices, and stigmatizing attitude

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There was a statistically significant association between knowledge and stigma among the respondents (P < 0.001); the better the level of knowledge the respondents had, the less likely they were to express stigma against people with TB. The respondents' attitude toward the disease was not significantly associated with the presence or absence of stigmatizing attitudes toward people with TB; good attitudes toward TB infection did not necessarily connote the absence of stigma toward people with TB (P = 0.459). There was no statistically significant association between TB prevention practices and TB stigma (P = 0.883); however, a greater proportion of those with stigmatizing attitudes poorly prevented TB [Table 6].
Table 6: Association between tuberculosis stigma and overall tuberculosis knowledge, attitude, and preventive practices

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   Discussion Top

Not many studies have examined TB stigma in Nigeria despite the impact of stigma on TB prevention and treatment outcomes. The Nigerian 2008 Demographic and Health Survey reported TB awareness rate of 74.7%.[16] Recent improvements in community outreach and awareness campaigns in Nigeria might have influenced the high level of awareness that was reported in this study, similar to recent reports in descriptive studies in Ethiopia (95.5%)[17] and in Imo State, South-Eastern Nigeria (97.3%)[18] but much higher than that reported in Edo State, South-South of Nigeria (86%).[19] In the Nigerian studies, the lower level of awareness in Edo might have been due to the educational level of the respondents, which was much lower in comparison to the levels reported in the Imo study and in the current study.

The respondents in this study had a low mean knowledge score despite the high level of awareness of the disease. Less than half of respondents had good knowledge of TB. Poor knowledge about the causative agents and transmission of TB is promoting the spread of myths, which are common in this part of Africa. It also has the potential of limiting preventive practices and promoting stigmatizing behaviour toward persons with TB. Higher levels of knowledge were reported in other studies in other low- and middle-income countries. For example, the level of knowledge reported in three studies in Lesotho,[20] Nigeria,[21] and in Saudi Arabia[22] was quite high, and this may have been due to the high percentage of educated participants in these studies.

About half (52.4%) of the respondents knew that overcrowding aids the transmission of the TB which is less than in an earlier study done in Metropolitan South Africa were 84.6% identified overcrowding as a risk factor for TB transmission.[23]

Contrary to a study in urban India where a persistent cough was the most common symptom known (48.4%),[24] in the current study, hemoptysis, being the most alarming symptom of TB, was the most commonly known symptom. The challenge with this is that persons who have a chronic cough without hemoptysis are less likely to seek help early and this is likely to lead to late presentation, increased transmission prior to treatment, and poor outcomes. This highlights a need for improved community education on the symptoms of TB that would encourage seeking health care early for TB, especially now that the diagnosis of TB using the rapid diagnostic test (GeneXpert) has been rolled out to most primary health centers in Nigeria at no financial cost to the public. According to the post-2015 global TB strategy, important ways to achieve the goal of 50% reduction in TB incidence rate by 2025 include community literacy on the important symptoms of TB to aid increased case finding and improving access to high-quality treatment and care.[25]

The majority of respondents in this study knew TB as being curable. This was surprisingly much higher than in a more recent survey in Nigeria (64,7%),[21] but lower than was found in an earlier study in Ethiopia (99%),[26] implying that despite improved health education efforts people do not know about TB. It might be because over half (53.9%) of the participants in the Ethiopian study heard of TB from health workers[26] compared to this study where less than a third heard about TB from health workers, rather, most of the participants received information from sources other than health workers, underscoring the importance of health workers in providing correct health information. Knowledge that TB is curable will promote confidence in the treatment and likely increase the number of persons accessing the treatment. It is also expected to reduce stigma as people who have been treated for TB can be integrated back into the society knowing that they are no longer contagious.

The attitude toward TB in our study was moderate, with over half of the participants strongly agreeing that anyone could have TB. This is similar to previous reports such as in a study done in Southern Iran[27] and may contribute to the moderate level of stigma in our study. Most respondents did not actively take measures to prevent TB with only a third adequately preventing TB. This is quite low compared to a study done in Free State, South Africa, where 72.9% had good TB control practices[28] and a study done in Zambia where 55.8% of the respondents were involved in the preventive practices toward TB,[29] but quite similar to a study done in India where a quarter of the respondents were not even engaged in any preventive measures against TB.[30] Knowledge about taking immunization (Bacillus calmette-guérin [BCG]) to prevent TB was abysmally low, lower than in a study done among factory communities in Bangladesh where only 11% knew about the preventive measures such as taking BCG vaccine.[31] BCG, being a childhood vaccine in developing countries, may not usually be associated with TB which is not typically a disease of children. Hence, BCG vaccination was adopted without knowing that it was for preventing TB. In another study in the slum communities in urban Lagos, about half of the respondents had good preventive practice even though their knowledge was poor.[21] Perhaps, it may be more beneficial if people know why some practices were encouraged to improve their compliance.

TB is associated with low social class, poverty, HIV, or being of disvalued behavior; hence, it is stigmatized. Above all, the perceived risk of transmission from TB-infected individuals to susceptible community members is the major cause of stigma.[32] Stigma and consequent discrimination have a double impact on TB control. First, concerns about being diagnosed with TB make it difficult for people with a cough of long duration who suspect they may have TB to seek care, because of the public nature of the TB diagnostic process. Second, it is more difficult for patients to continue with care, because their fears of being identified as being or having been infected with TB hinder their access to services on a daily basis,[32] even in low-incidence countries,[33] and this can lead to serious infection and increased transmission. Moreover, TB-related perceived stigma was found to be more when the patient was in the intensive phase of treatment.[34] About a fifth of the respondents expressed stigmatizing attitudes toward people with TB, mostly stating that they felt no compassion toward them, that they could not eat or drink with them, that people with TB should keep their distance from others and that no person with TB should be employed. Stigma toward people with TB could have harmful consequences (low self-esteem, insults, ridicule, discrimination, social exclusion, and isolation leading to a decreased quality of life and social status, nondisclosure, and/or difficulties with treatment compliance and adherence) as were identified among patients in a mixed-methods study in Lusaka, Zambia.[35]

Stigmatizing attitudes against people with TB was found to be significantly associated with poor TB knowledge. In a study carried out in Pakistan, poor knowledge, for example, about TB being a curable disease or of the mode of spread of TB, was associated with the presence of stigma.[36] Having better knowledge would allow people a clearer understanding of the disease and would prevent stigma.

   Conclusions Top

This study showed poor knowledge and poor preventive practices toward TB. Stigmatizing attitudes toward people with TB was particularly in terms of social isolation and in being denied employment. The local TB control program and other stakeholders need to improve community education through innovative methods to reduce stigma. This has the potential to influence health-seeking behavior and promote better TB prevention and treatment outcomes.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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