Knowledge of tuberculosis and associated health-seeking behaviour among rural Vietnamese adults with a cough for at least three weeks

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1 ORIGINAL ARTICLE Knowledge of tuberculosis and associated health-seeking behaviour among rural Vietnamese adults with a cough for at least three weeks Nguyen Phuong Hoa 1,3, Anna E K Thorson 3,4, Nguyen Hoang Long 2,3 and Vinod K Diwan 3,4 1 National Institute of Tuberculosis and Respiratory Diseases, Hanoi, Vietnam, 2 Ministry of Health, Hanoi, Vietnam, 3 Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden, 4 Nordic School of Public Health, Gothenburg, Sweden Scand J Public Health 2003; 31(Suppl. 62): Aims: Good general lay knowledge of tuberculosis (TB), its cause and treatment is considered important for both prompt healthcare seeking and adherence to treatment. The main aim of this study was to describe the knowledge of TB among men and women with a cough for more than three weeks and to see how their health seeking related to TB knowledge. Methods: A population-based survey was carried out within a demographic surveillance site in Vietnam. The study population included 35,832 adults aged 15 years or over. Cough cases were identified at household level and structured interviews were carried out with all cases of cough in person. Results: A total of 559 people (1.6%) reported coughing with a duration of three weeks or longer (259 men and 300 women). A large proportion of individuals with a cough for more than three weeks had limited knowledge of the causes, transmission modes, symptoms, and curability of TB. Men had a significantly higher knowledge score than women (3.04 vs 2.55). Better knowledge was significantly related to seeking healthcare and seeking hospital care. More men than women did not take any health care action at all. Discussion: Health education for TB thus seems to be useful, but efforts must be made to ensure that both men and women in different socioeconomic contexts can access the information. Key words: cough, gender, health seeking, knowledge, population-based, tuberculosis, Vietnam. Nguyen Phuong Hoa, National Institute of Tuberculosis and Respiratory Diseases, Hanoi, Vietnam. hoatuber@ yahoo.com INTRODUCTION Tuberculosis (TB) is one of the greatest public health problems in the world. It accounts for about 2.5% of the global burden of disease and 26% of preventable deaths. About 95% of all TB cases and 99% of deaths due to TB occur in low-income countries (1). There are an estimated 8.4 million new TB cases every year (2). In most low-income countries, about two-thirds of the reported TB cases are among men, with only onethird among women (3). The reasons for this gender difference in case reporting are unclear. There are two hypotheses to explain such a difference: either a real difference in incidence, or under-diagnosis and underreporting of TB in females (4 6). Vietnam ranks thirteenth among the world s nations in terms of numbers of TB cases (2). Gender-specific notification rates in Vietnam show similar ratios to This paper has been independently peer-reviewed according to the usual SJPH practice and accepted as an original article. # Taylor & Francis ISSN those globally, with a total of 88,879 TB cases detected in 1999, with a male to female ratio of 2:1 (7). Vietnam is one of only a few countries with a high TB burden that have reached the WHO targets on case finding and treatment success (2). High political commitment in Vietnam is translated into high priority on TB control. Major obstacles to sustain effective TB control in Vietnam include the increasingly active but poorly regulated private health sector (8), the growing threat from HIV/AIDS (9) and the emergence of multi-drug resistant TB (7). Vietnam has developed a vast infrastructure of health facilities, achieving a good density of service provision at all levels, including hospitals and health centres (10). Since 1986 an economic reform movement from planned to market-oriented economy, Doi Moi, has been implemented in Vietnam. Major healthcare reforms have included the introduction of hospital user fees and legalisation of private healthcare practices. The large amount of out-of-pocket expenditure on healthcare shows that families pay significant user costs even DOI: /

2 60 NP Hoa et al. to use subsidized public facilities. Expenditures on fees and drugs average US$2 visit to a commune health centre, despite the fact that there are no official fees, and about US$5 for a hospital outpatient visit (11). Some evidence indicates that economic reforms have affected the public healthcare system, making it less accessible and less affordable, particularly for the poor (11). In Vietnam, as recommended by the WHO, case detection is based on passive case finding using sputum smear microscopy. The patients should themselves seek an adequate health facility. However, factors such as the stigma attached to TB (12, 13), perceptions of TB as a dirty and incurable disease (14) and popular misconceptions are likely to have negative effects on the health-seeking behaviour of undiagnosed TB patients. Considerable delays in healthcare seeking and TB diagnosis have been reported (15). TB control could improve significantly if more consideration were given to knowledge and attitudes towards TB and related healthcare seeking among the population (16 18). The main aim of this study was to describe the knowledge of TB among men and women with a cough for more than three weeks and how that knowledge affected their health-seeking behaviour. METHODS The study was conducted within a longitudinal population-based demographic surveillance site called FilaBavi, in Bavi District, in a northern rural area of Vietnam. The population of Bavi District in 2000 was 242,780. The public healthcare system in this district included a district hospital with 150 beds, three intercommunal polyclinics and 32 commune health centres. In addition, there were more than one hundred private practitioners and some private pharmacies and drug outlets in the district. However, most of them practised illegally, without licences. The sample size for FilaBavi included 67 randomly selected clusters comprising 11,547 households with 49,893 inhabitants, about one-fifth of the total district s population (19). A population-based cross-sectional survey was carried out during April June All people aged 15 years or older in all 67 clusters of the FilaBavi were included in the study. During the survey, all households were visited by specially trained interviewers. Potential cough cases were identified by a screening question. The definition of a cough case was an individual who had had a cough for three or more weeks at the point of interview. Female interviewers asked the household representative (most often the senior female head of the family) whether anyone in the family had a prolonged cough, and, if so, the individual was interviewed in person using a structured questionnaire. A structured questionnaire was developed and administered for all identified cough cases to collect socioeconomic and demographic variables (age, gender, marital status, education, health insurance, means of transportation, smoking, etc.), symptoms other than cough, healthcare-seeking behaviour from the onset of the cough symptoms, and knowledge of TB. To classify education, skills in reading and writing were first elicited. If literate, then the level of schooling was used to classify education; otherwise the individual was categorized as illiterate. The knowledge questions were based on the medical perspective on TB promoted by the National Tuberculosis Control Programme (NTP). The cough cases were asked about the causes of TB, whether TB was contagious, the mode of TB transmission, whether TB was curable and symptoms suggestive of TB. The questions asked were open-ended and several alternatives were allowed in the responses. Answers were categorized into correct (if matching the medically correct answer) or else incorrect and then in turn sorted into categories inspired by the qualitative studies by Long et al. in 1996 in Vietnam (13). One point was given for each of the correct answers. If several alternatives were given and at least one was defined as correct, one point was given. The interviewees were also asked how and from which sources they had received information about TB. The questionnaire was pre-tested in the field to ensure that all questions were clear and understandable. No person refused to take part in the interview study. A local authority classification was used to define socioeconomic status. This classification is based on the amount of rice produced per capita. Healthcare actions and providers were classified as: (a) selftreatment, (b) private practitioners, (c) pharmacies, (d) traditional healers, (e) communal health centres (CHCs), (f) hospitals, and (g) others. Qualified health providers were defined as those operating within the government healthcare system. Less qualified providers were defined as those less regulated by the government, whose quality of care has proved to be low (20, 21). To minimize recall bias, the interviewers used calendars or individual events. A medical record crosscheck was done in cases who had used healthcare at CHCs or hospitals. One medical doctor supervised the data collection, including rechecking all questionnaires submitted by field supervisors. Some 15% of all cases were randomly selected to be re-interviewed by the study supervisor or by one of the investigators within a week of the original interview. Data were processed and analysed using Epi-Info 6.04 and SPSS version Means and proportions

3 Knowledge of TB and associated health-seeking behaviour 61 were calculated as appropriate. Chi-squared tests and 95% confidence intervals for means or proportions were used to describe differences between groups. Non-parametric methods were used for some comparisons. Logistic regression analyses were performed to study associations between background variables and healthcare action or hospital treatment. The following variables were included as independent variables: gender, age, education, economic status, cough duration, number of symptoms, health insurance, means of transportation, and TB knowledge score. Ethical permission for the study was obtained from the Ministry of Health, local authorities of the Bavi District, Vietnam, and Karolinska Institutet, Sweden. The Research Ethics Committee at Umeå University has given ethical approval for the FilaBavi household surveillance system, including data collection on vital statistics (reference number ). RESULTS Prevalence of cough and background data A screening question was put to a total of 11,547 households (covering 35,832 people aged 15 or over; Table I. Socioeconomic and demographic characteristics of 300 women and 259 men in Vietnam with a cough for more than three weeks Characteristics Women n (%) Men n (%) Occupation: Farmer 199 (66.3) 147 (56.7) Student & Government staff 21 (7.0) 45 (17.4) Other 80 (26.7) 67(25.9) Education: Illiterate 45 (15.0) 10 (3.9) Primary and secondary school 232 (77.3) 214 (82.6) High school 17 (5.7) 23 (8.9) University or higher 6 (2.0) 12 (4.6) Economic classification: Very poor 26 (8.7) 25 (9.7) Poor 55 (18.3) 51 (19.7) Average 159 (53.0) 134 (51.7) Upper average 57 (19.0) 46 (17.8) Rich 3 (1.0) 3 (1.1) Religion: Non-religious 282 (94) 244 (94.2) Buddhists and others 18 (6) 15 (5.8) Marital status: Married 166 (55.3) 210 (81.1) Single 37 (12.3) 31 (12.0) Separated, divorced, widowed 97 (32.4) 18 (6.9) Number of persons in household: (31.7) 66 (25.5) (39.0) 125 (48.3) 6 or more 88 (29.3) 68 (26.2) 16,737 men and 19,095 women). Among those, 559 people (1.6%) reported a cough with duration of three weeks or longer (prolonged cough) at the point of interview (259 men and 300 women). The prolonged cough prevalence was similar among men and women in the age groups years, but significantly higher among men compared with women in the older age groups (54 years or over). The illiteracy rate was significantly higher among women (15%) than men (4%) (pv0.001). More men (22%) than women (13%) reported having health insurance (pv0.01). More men than women reported being smokers (48% compared with 12%, pv0.001) (Table I). Knowledge and sources of information about TB Among the 559 people who reported a prolonged cough, 41% of the women and 57% of the men thought that TB was caused by hard work and 31% of the women and 36% of the men that it was hereditary (Table II). Only 22% of the people reported that bacteria caused TB. Significantly more men than women gave the answer of a bacterial cause (pv0.05); 86% of the men and 79% of the women (pv0.05) reported that TB is contagious. Knowledge about the mode of TB transmission (droplet spread) was lower among women (63%) than among men (73%), pv0.05. Significantly more men than women thought that TB was curable if correct treatment were given (73% of men vs 59% of women, pv0.001). The mean knowledge score was 2.78 (95% CI ). Men had a significantly higher score than women (3.04 and 2.55 respectively, pv0.001). A higher knowledge score was significantly associated with higher education, age less than 65 years, being married, being government staff, and being a student (Table III). Commonly reported sources of information included television and radio (54% of men, 46% of women, pv0.001), friends and relatives (50% of men and 49% of women). People who reported television and radio as sources of information had higher knowledge scores compared with those who reported receiving information from friends or relatives (mean score: 3.39 vs 2.05 respectively, pv0.001). Health-seeking behaviour More women (94.6%) than men (78.8%) reported that they took healthcare action for their symptom of cough (pv0.001). The most common reason for not taking action was that the disease symptoms were not considered serious (42%). The general healthcareseeking pattern was quite similar among men and women with a preference for private health providers. However, significantly more women than men chose self-medication or a visit to the pharmacy as their first

4 62 NP Hoa et al. Table II. Responses to questions on causes, communicable nature, modes of transmission, possibility of cure, and knowledge of TB symptoms among Vietnamese adults with a cough for more than three weeks Response to questions Women (n~300) n (%) Men (n~259) n (%) P b 1. Cause of TB Germ/bacillus a 55 (18.3) 67 (25.9) 0.03 Hard work 124 (41.3) 148 (57.1) Hereditary TB 92 (30.7) 93 (35.9) Other 19 (6.3) 35 (13.5) Do not know 115 (38.3) 66 (25.5) 2. Is TB transmissible? Yes a 238 (79.3) 222 (85.7) 0.04 No 12 (4.0) 9 (3.5) Do not know 50 (16.7) 28 (10.8) 3. Mode of transmission Infectious droplet spread a 150 (63.0) 163 (73.4) 0.04 Other (sharing eating, smoking) 56 (23.5) 47 (21.2) Do not know 32 (13.4) 12 (5.4) 4. Possible to cure TB? Yes a 177 (59.0) 190 (73.4) No 20 (6.7) 15 (5.8) Do not know 103 (34.3) 54 (20.8) 5. Knowledge of TB symptoms Yes a 145 (48.3) 145 (56.0) 0.08 No 154 (51.3) 114 (44.0) Notes: Correct answers according to the National Tuberculosis Programme health education guidelines; b p-values were calculated for the comparison of the proportions of men and women giving the correct answer. Table III. TB knowledge scores by gender, age group, level of education, occupation, and marital status among Vietnamese adults with a cough for more than three weeks Characteristics n Knowledge score Mean SD Gender: Male Female Age group: z Education: Illiterate Primary and secondary school High school or higher Occupation: Farmer Student, Government staff Other Marital status: Married Other (single, divorced, etc.) Notes: a p-values based on comparisons of two or several means using analysis of variance. p a healthcare action (33% vs 20%, pv0.02), and significantly more men (26%) than women (16%) sought care at a hospital at any point during their disease period (pv0.005). Factors that could influence healthcare seeking among men and women were also investigated. The mean duration of cough was significantly longer among men (21.1 weeks) than among women (16.2 weeks) (pv0.001). Sputum production was more common among men than among women (61% vs 50%, pv0.01). The mean numbers of symptoms other than cough were not significantly different between genders (3.1 among men and 3.0 among women). Knowledge score mean values did not differ significantly between those who took any healthcare action and those who did not (2.81 vs 2.55), but more people who knew TB symptoms than those who did not reported taking healthcare action (Table IV). However, in a logistic regression model taking healthcare action as the dependent variable and age, gender, education, economic status, cough duration, number of symptoms, means of transportation, and TB knowledge score as independent variables, being a woman (pv0.001) and having a higher knowledge score (pv0.05) were significantly associated with taking healthcare action.

5 Knowledge of TB and associated health-seeking behaviour 63 Table IV. Knowledge of TB among potential TB cases in Vietnam and subsequent healthcare actions Knowledge Healthcare action (n~559) Yes (%) p a Seeking hospital care (n~559) Yes (%) p a Score: 0 48 (88.9) 7 (13.0) (85.5) (15.7) (87.9) 85 (24.6) TB symptoms: Yes 265 (91.4) (27.7) No 223 (82.9) 37 (13.8) Cause of TB: Bacteria 116 (95.1) (27.2) 0.05 Others 372 (85.1) 84 (19.2) TB transmission: Yes 400 (87.0) (22.2) 0.13 No/unknown 88 (88.9) 15 (15.3) Mode of transmission: Droplet spread 268 (85.6) (22.3) 0.35 Others 20 (89.4) 47 (19.1) Curable disease: Yes 322 (87.7) (22.9) 0.12 No/unknown 166 (86.5) 33 (17.2) Notes: a p-values are based on chi-squared tests. Hospital care seeking was significantly related to mean knowledge score (Table IV). In the group who had visited a hospital, the mean knowledge score was 3.15 compared with 2.70 among those who did not visit a hospital (pv0.005). Individuals who did not know any symptoms suggestive of TB more commonly (80.0%) used less-qualified healthcare providers (such as self-medication, private practitioners, and pharmacies) for their first healthcare action than people who knew TB symptoms (68.3%) (pv0.01). In total, 30% among those who knew TB symptoms compared with 17% of those who did not visited a hospital. In a logistic regression model with visiting a hospital as the dependent variable, seeking hospital care was significantly associated with having a higher knowledge score, (pv0.05), longer cough duration (pv0.001), more disease symptoms (pv0.002), and having health insurance (pv0.001). Other variables (gender, age, economic status, means of transportation) were not significantly associated with going to hospital. DISCUSSION Most countries in the world nowadays apply passive case-finding approaches for TB detection, as recommended by the WHO. This means that individuals who suspect TB infection have to initiate the first patient-health provider contact. In this context, knowledge of causes, symptoms, modes of transmission, and curability of TB plays a critical role. Several studies have reported long delays in TB diagnosis, differences between men and women in TB diagnosis and health-seeking delays, and factors influencing these delays (12, 15, 17, 21). However, studies that have assessed health seeking in relation to knowledge are less common. We found that knowledge of causes, transmission routes, symptoms, and curability of TB was low: 82% of the women and 74% of the men did not know that TB is caused by bacteria. A large proportion reported that TB is caused by hard work or that it is a hereditary disease. Our findings indicate an association between knowledge levels and education, media access, and gender, and highlight the complexity of successful health communication. Promoting health education through radio and television may not be enough if the wish is to reach and influence potential TB cases. TB globally is most common among the socioeconomically disadvantaged, and if equal opportunities to education and media access are not forthcoming, health communication may fail despite good intentions. To understand traditionally held beliefs in causes and characteristics of TB is important for facilitating communication about the disease to the population. The NTP in Vietnam considers modern (biomedical) actual knowledge in the population important for TB control. A generally good knowledge level is wished for in order to minimize patients delay in receiving healthcare and to reduce TB-related stigma. The concept of knowledge has many aspects and the definition of what is right or wrong is not self-evident. People s expressed traditional beliefs may in some respects relate to correct perceptions of the disease. However, since the Vietnamese NTP has used health education and communication campaigns specifically to educate the population in medical knowledge of TB, we chose to study this aspect. Despite these campaigns knowledge levels were low. One reason for this could be that the NTP s message about TB is not contextualized in traditionally held beliefs. To be successful, any educational programme must begin with an understanding of the knowledge base of participants and relate traditional beliefs to modern medical knowledge. Traditional beliefs in the causes and transmission patterns of TB have been reported from many parts of the world (17, 22, 23). A qualitative study from Vietnam reported beliefs in four types of TB: hereditary TB congenital transmission, mental TB caused by too much thinking, physical TB caused by hard work, and lung TB caused by a germ (13). Our study reports similar findings. Hard work or

6 64 NP Hoa et al. inherited TB were both more often stated as causes of TB than bacteria. Healthcare seeking is a complex process, influenced by many external and internal factors. It seems that the level of medical knowledge is the common denominator steering health-seeking behaviour among potential TB cases in this community. We found knowledge to be associated with taking healthcare action as well as with the quality and type of provider sought. However, level of knowledge was also associated with education and gender. Women sought less qualified care than men, had a lower knowledge level, and less often reported having health insurance. An obvious limitation of the study is that the information depended on self-reported data from the respondents and the survey on health-seeking behaviour was based on recall history. To minimize bias, questionnaires were pre-tested to make sure that all questions were understandable. Cross-checked and repeated questions in the different sections of the questionnaire were used in order to check the internal consistency. Professional surveyors and supervisors were carefully trained. With the multiple-stage supervisory system in FilaBavi and direct interviewing of the cases, recall bias is considered to have been minimized. In conclusion, a large proportion of individuals with a cough for more than three weeks had limited knowledge of TB. Only 24% of the potential TB cases in this district had gone to hospital, which was related to lack of knowledge of TB. In general, women had a poorer knowledge of TB and sought healthcare from less qualified providers. The study results were derived from a Vietnamese rural population, but could be discussed also in relation to other populations with a similar gender structure and educational situation. It seems that medical knowledge of TB is positively related to health seeking. This area needs to be further explored and informative interventions within different societal levels need to be studied. ACKNOWLEDGEMENTS This study was conducted within the epidemiological field laboratory for Health Systems Research (Fila- Bavi) in Vietnam. The study was financially supported by Sida/SAREC, Stockholm. The authors are grateful for valuable advice and comments given by Prof. Peter Allebeck. REFERENCES 1. World Health Organization Progress in TB control in high-burden countries, WHO Report 2001, WHO/TB/01.4. Geneva: WHO. 2. World Health Organization Western Pacific Region Cases notified in 1999, WHO WPR Report WHO-WPR/TB/00.5. Manila: WHO-WPR, World Health Organization Global tuberculosis control: surveillance, planning, financing. Report 2002, WHO/CDS/TB/ Geneva: WHO. 4. Holmes CB, Hausler H, Nunn P. A review of sex differences in the epidemiology of tuberculosis. Int J Tuberc Lung Dis 1998; 2: Thorson A, Diwan VK. 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