Knowledge, Attitude and Practice about Tuberculosis in India A Midline Survey, 2013
International Union Against Tuberculosis and Lung Disease, South-East Asia Region, New Delhi
Contributors Principal Investigators: Dr. Nevin C Wilson, Dr. Sarabjit S Chadha Co-investigators: Dr. Karuna D Sagili, Dr. Srinath Satyanarayana, Dr. Geetanjali Sharma, Mr. Subrat Mohanty, Ms. Surabhi Joshi, Dr. Prasad BM, Dr. Ajay MV Kumar, Dr. Ramya Ananthakrishnan, Dr. Nalini Krishnan Report compiled and written by: Dr. Karuna D Sagili
© International Union Against Tuberculosis and Lung Diseases All rights reserved.
Design, layout and printing by: New Concept Information Systems Pvt. Ltd. Email:
[email protected]
Contents Acknowledgements
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Executive Summary ix-xiv CHAPTER 1 Background 1-10 CHAPTER 2 Results: General Population
11-27
Summary Results
28-29
CHAPTER 3 Results: TB Patients
30-47
Summary Results
48-49
CHAPTER 4 Results: Health Service Providers
50-58
Summary Results
59-60
CHAPTER 5 Results: Opinion Leaders
61-71
Summary Results
72-73
CHAPTER 6 Results: NGO/CBO Representatives
74-83
Summary Results
84-85
CHAPTER 7 Comparison of KAP About TB among Target Groups in Baseline and Midline Surveys
86-90
Summary Results
91-92
ANNEXURES
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List of Tables TABLE 1.1: Number of respondents from general population and TB diseased persons by urban-rural residence
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TABLE 1.2: Number of respondents interviewed (General Population, TB Diseased, Health Service Providers NGO representatives and Opinion Leaders) stratified by zones 8 TABLE 1.3: Number of Respondents (GP, TB Diseased, Health Service Providers, Opinion Leaders & NGOs) interviewed stratified by state
8
TABLE 2.1: Socio-demographic characteristics of respondents from the general population interviewed during midline KAP survey, 2013
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TABLE 2.2: Household characteristics of respondents from the general population interviewed during midline KAP survey, 2013
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TABLE 2.3: Household assets owned by respondents from the general population interviewed during midline KAP survey, 2013
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TABLE 2.4: Characteristics of respondents among general population who heard of TB interviewed during midline KAP survey, 2013
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TABLE 2.5: Awareness about symptoms of TB among the respondents from general population who heard of TB interviewed during midline KAP survey, 2013
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TABLE 2.6: Awareness about mode of TB transmission among the respondents from general population who heard of TB interviewed during midline KAP survey, 2013 17 TABLE 2.7: Opinion of respondents from general population who heard of TB on “people who are prone to TB in the community” interviewed during midline KAP survey, 2013 18 TABLE 2.8: Awareness about mode of TB diagnosis among respondents from general population who heard of TB interviewed during midline KAP survey, 2013
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TABLE 2.9: Knowledge about seriousness of TB disease and its curability among respondents from general population who heard of TB interviewed during midline KAP survey, 2013 19 TABLE 2.10: Awareness about the best treatment for TB and the duration of TB treatment among respondents from general population who heard of TB interviewed during midline KAP survey, 2013
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TABLE 2.11: Proportion of respondents who heard of the term ‘DOTS’ and free treatment for TB among the general population interviewed during midline KAP survey, 2013
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TABLE 2.12: Perception of self-susceptibility to develop TB disease among the general population interviewed during midline KAP survey, 2013
21
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List of Tables
TABLE 2.13: Attitudes towards TB disease, who are prone to TB and how TB patients are treated in their communities among respondents from general population interviewed during midline KAP survey, 2013
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TABLE 2.14: Attitudes towards TB patients and their families from general population interviewed during midline KAP survey, 2013
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TABLE 2.15: Possible practices towards TB patients by respondents from general population interviewed during midline KAP survey, 2013 24 TABLE 2.16: Existing and preferred source of TB related information of the respondents among the general population interviewed during midline KAP survey, 2013
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TABLE 2.17: Respondents reply to ‘visit’ by any individual to provide information regarding TB and the information shared by those who visited
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TABLE 2.18: Summary of key indicators of knowledge about TB among respondents who heard of TB from general population interviewed during midline KAP survey, 2013 27 TABLE 3.1: Distribution of TB patients identified from the household line-listing process during midline KAP survey, 2013
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TABLE 3.2: Socio-demographic characteristics of the TB patients identified and interviewed in the midline KAP survey, 2013
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TABLE 3.3: Household characteristics of the TB patients identified and interviewed in the midline KAP survey, 2013
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TABLE 3.4: Household assets of the TB patients identified and interviewed in the midline KAP survey, 2013
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TABLE 3.5: Awareness about causes of TB among TB patients interviewed during midline KAP survey, 2013
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TABLE 3.6: Symptoms experienced by TB patients prior to diagnosis of TB among TB patients interviewed during midline KAP survey, 2013
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TABLE 3.7: Duration of cough and fever before diagnosis of TB among TB patients interviewed during midline KAP survey, 2013
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TABLE 3.8: Health seeking behaviour of TB patients prior to diagnosis of TB among TB patients interviewed during midline KAP survey, 2013
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TABLE 3.9: Place of diagnosis, number of providers visited and duration of symptoms before diagnosis of TB among TB patients interviewed during midline KAP survey, 2013 38 TABLE 3.10: Treatment initiation, place of treatment and awareness on treatment duration among TB patients interviewed during midline KAP survey, 2013
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TABLE 3.11: General health seeking behaviour of TB patients interviewed during midline KAP survey, 2013
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TABLE 3.12: Tobacco use among TB patients interviewed during the midline KAP survey, 2013 41 TABLE 3.13: Experiences of stigma and discrimination among TB patients interviewed during the midline KAP survey, 2013
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TABLE 3.14: Existing and preferred source of TB related information among TB patients interviewed during midline KAP survey, 2013
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TABLE 3.15: Summary of key indicators of knowledge about TB among TB patients interviewed during midline KAP survey, 2013
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TABLE 4.1: General characteristics of health service providers interviewed during the midline KAP survey, 2013
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TABLE 4.2: Knowledge about TB symptoms, type of TB patients treating and awareness on MDR TB among health service providers who treat TB patients
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TABLE 4.3: TB diagnosis and treatment approach of health service providers interviewed during the midline KAP survey, 2013
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TABLE 4.4: Challenges faced, precautions taken and advices given to TB patients by health service providers interviewed during the midline KAP survey, 2013 55 TABLE 4.5: Perception about DOTS and awareness on RNTCP schemes among the health service providers interviewed during midline KAP survey, 2013
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TABLE 4.6: Predominant source of TB related information among the health service providers interviewed during midline KAP survey, 2013
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TABLE 4.7: Summary of key knowledge and practice indicators of health service providers in treating TB
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TABLE 5.1: General profile of opinion leaders interviewed during midline KAP survey, 2013 61 TABLE 5.2: Knowledge about TB, symptoms, mode of transmission and diagnosis of TB among opinion leaders interviewed during midline KAP survey, 2013
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TABLE 5.3: Knowledge on treatment of TB opinion leaders interviewed during midline KAP survey, 2013
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TABLE 5.4: Role played by opinion leaders in their communities to address TB
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TABLE 5.5: Seriousness about TB disease, awareness about those prone to TB among opinion leaders and behaviour of community towards TB patients
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TABLE 5.6: Attitudes of towards TB and TB patients among opinion leaders interviewed during midline KAP survey, 2013
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TABLE 5.7: Health seeking behaviour among opinion leaders interviewed during midline KAP survey, 2013
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List of Tables
TABLE 5.8: Potential practices towards TB patients among opinion leaders interviewed during midline KAP survey, 2013
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TABLE 5.9: Sources of general and TB related information among opinion leaders interviewed during midline KAP survey, 2013
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TABLE 5.10: Summary of key indicators of knowledge about TB among opinion leaders interviewed during midline KAP survey, 2013
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TABLE 6.1: General profile of NGO/CBO representatives interviewed during midline KAP survey, 2013
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TABLE 6.2: Knowledge about TB, symptoms, mode of transmission and diagnosis of TB among NGO/CBO representatives who heard of TB
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TABLE 6.3: NGO/CBO representatives knowledge about treatment of TB among those who heard of TB
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TABLE 6.4: Role played by NGO/CBO representatives in their communities to address TB
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TABLE 6.5: Attitudes towards TB disease and TB patients among NGO/CBO representatives who heard of TB interviewed in the midline KAP survey, 2013
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TABLE 6.6: Attitudes towards TB patients and their families among NGO/CBO representatives interviewed in the midline KAP survey, 2013
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TABLE 6.7: General health seeking behaviour among NGO/CBO representatives interviewed during midline KAP survey, 2013
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TABLE 6.8: Potential practices towards TB patients by NGO/CBO representatives among those interviewed in midline KAP survey, 2013
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TABLE 6.9: Source of general and TB related information among NGO/CBO representatives interviewed in midline KAP survey, 2013 (All are multiple response questions) 81 TABLE 6.10: Summary of key indicators of knowledge about TB among NGO/CBO representatives interviewed in midline KAP survey, 2013
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TABLE 7.1: Key indicators of knowledge about TB among general population in the midline KAP survey compared with baseline KAP survey
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TABLE 7.2: Key indicators of knowledge about TB among TB patients in the midline KAP survey compared with baseline KAP survey across the 30 districts from 15 states in India
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TABLE 7.3: Key indicators of knowledge about TB among opinion leaders in the midline KAP survey compared with baseline KAP survey across the 30 districts from 15 states in India
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TABLE 7.4: Key indicators of knowledge about TB among NGO functionaries in the midline KAP survey compared with baseline KAP survey conducted across the 30 districts from 15 states in India
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Acknowledgements The Midline KAP survey was conducted as a follow up to the Baseline KAP survey conducted in 2010-11 under Project Axshya supported by the Global Fund. We thank Global Fund for their support. We thank Central TB Division, Ministry of Health and Family Welfare, Government of India and the State and District TB officers from the 15 states where the survey was conducted (Andhra Pradesh, Bihar, Chhattisgarh, Haryana, Karnataka, Kerala, Maharashtra, Mizoram, Orrisa, Punjab, Rajasthan, Tamil Nadu, Uttar Pradesh, West Bengal, Madhya Pradesh) for their support in conducting this survey. We are extremely thankful to Dr. Nevin C Wilson, former Regional Director of The Union SouthEast Asia Office for his guidance and scientific inputs to the survey. We appreciate the efforts of GfK MODE’s research team, especially Dr. R.B. Gupta and Dr. Piyusha Majumdar and their field teams for completing the study successfully within the stipulated time period. We thank all our study participants who participated voluntarily and gave their valuable time by sharing their knowledge, views and opinions to help us understand the knowledge and service gaps in TB control. We thank Dr. Anil G Jacob and Dr. Badri Thapa for their contribution in data analysis ; Mr. Kishore Kumar V and Mr. Babu E.R for supervision of the survey activities; Mr. Deepak Tamang for assisting in data verification and Ms Renu for administrative support. We thank the Project Management Unit, the finance team, the administration team and the State Technical Consultants from the Union’s South East Asia Office for their support in completing this survey. We also acknowledge Project Axshya’s Sub-recipient partners for their support to this survey completion. We thank New Concept for designing and printing this document.
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Executive Summary Background Every year, thousands of people die of diseases that are completely curable. Tuberculosis (TB) is one among them. TB is an infectious bacterial disease that spreads through the air and most commonly affects the lungs. Once infected, a person has about a 10% lifetime risk of developing tuberculosis. The most common symptom of a person with pulmonary TB is a cough of two weeks or more. In 2012, the World Health Organisation (WHO) estimated that 8.6 million people across the world developed TB and around 1.3 million of them died from TB (WHO 2013). India contributes one fourth (26%) of the total global incidence of tuberculosis. The Revised National TB Control Programme (RNTCP) initiated in 1997 covered the entire country by March 2006. Aligned with the WHO-recommended Stop TB strategy, the RNTCP provides free diagnostic and treatment facilities for TB across the country. Every year nearly 1.5 million TB patients are put on treatment under DOTS. The programme has been successful in significantly reducing the prevalence and mortality due to TB in line with the Millennium Development Goals (MDGs). Despite the enormous success of the programme, the incidence of TB continues to be high and there are nearly a million cases annually who do not or are unable to access TB services under RNTCP. In order to enhance the reach and access to TB services, Project Axshya (meaning TB free) was launched in 2010. Supported by the Global Fund, Axshya is being implemented in 374 districts across 23 states in the country focussing on marginalised and vulnerable populations through increased civil society engagement. Axshya is being implemented by International Union Against Tuberculosis and Lung Disease (The Union) in 300 districts across 21 states and by World Vision India in 74 districts across five states. Project activities focus on advocacy, communication and social mobilization (ACSM) along with strengthening systems for enhancing access to diagnostic and treatment services. ACSM as a strategy for TB control has been viewed with concern by TB experts due to limitations in assessing the impact. In order to substantiate the progress of Axshya in achieving its objectives a series of Knowledge, Attitude and Practices (KAP) surveys have been planned at different time points under the project. The baseline KAP survey was conducted in 2010-11 http://axshyatheunion.org/images/documents/kap-survey.pdf). The midline survey was conducted between November 2012 and April 2013. An endline survey is scheduled in the last year of the project. The information generated through these surveys is representative of the various demographic and social characteristics of population living in these districts, keeping in view the relationship between these characteristics to tuberculosis control, and the impact of activities under Axshya.
Objectives of the Midline KAP Survey Midline KAP survey aimed to gather information and assess change in the knowledge, attitude and practices towards TB amongst the key constituent groups observed in baseline KAP survey. In particular, this survey sought to;
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
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Gather midline information on TB related knowledge among general population, TB patients, opinion leaders, health service providers and NGO/CBO workers. Explore attitudes and experiences of stigma and discrimination related to TB among general public and persons/relatives affected by the disease with particular reference to gender. Understand the individual, social and environmental factors including provider and patient related delay that could contribute to low TB case detection and poor completion of TB treatment. Know gender specific health seeking behaviour in different target groups when they experience TB related symptoms and the places where health care is sought and time taken to seek care. Relationship between TB health care providers and the persons affected with TB and the role of opinion leaders (community influencers) and NGOs/CBOs in TB control efforts. Identify media habits/preferences of the target groups, their sources of information on TB and exposure to mass media channels.
Methodology A cross-sectional community-based survey was conducted in 30 districts where baseline KAP survey was conducted in 2011. The methodology followed was also identical to that used in baseline KAP survey implementation. In brief, the 30 districts were selected by a stratified cluster sampling technique out of the 374 project districts. Districts were initially stratified into the 4 RNTCP zones (north, south, east and west) of the country. The number of districts in each zone was selected in proportion to the distribution of the 374 districts in the respective zones of the country and the required number of districts in each zone was selected by population proportionate to size sampling. From each of these districts, the population was divided into urban and rural primary sampling units (PSUs) of approximately 250 households (the average approximate population in each household is 4 and the approximate size of the primary sampling unit is 1000 population), based on the data available from the country’s 2001 census. Ten PSUs were selected randomly in each district from the urban and rural PSUs in proportion to the districts’ estimated urban and rural population. The study was conducted by The Union, South-East Asia Regional Office with assistance from field investigators of the social research organization GfK MODE. The trained field investigators conducted a household line listing in the identified primary sampling units during the months of November 2012 to April, 2013. After this line listing process, the respondents from the General Population, TB patients, the locally available health service providers, opinion leaders and representatives of NGOs were identified and interviewed by a semi-structured questionnaire designed to provide information on knowledge, attitude and practices of these respondents with respect to tuberculosis.
Results The Results of the Survey in the Target Groups is Summarised below
General population: A sample of 4804 respondents was selected from general population which included 1123 from North, 1279 from East, 1280 from West and 1122 from South zone states. The proportion of male to female was equal (~50% each). About 88% of the respondents had heard of TB, 81% had knowledge that a cough of over 2 weeks could be TB, 71% knew that TB is caused by germs/bacteria and transmits through air. Only 66% knew that TB can be diagnosed by sputum test. 83% of the respondents had knowledge that TB is curable, however only 48% knew that
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Executive Summary
correct duration of the treatment (6-8 months). Only 26% had heard of DOTS and 23% knew that TB treatment is available free under DOTS. Less than half (41%) of the general population said that TB patients are accepted and supported in their communities. Only one tenth felt that female TB patients face problem in their marriages. Nearly half of the respondents (48%) believed that TB patients are a threat to the community. 74% mentioned that they will not share meals with a TB patient and 79% said that will not marry their sons/daughters to an individual who they knew had TB. TB patients: A total of 496 TB patients were identified and interviewed for the survey purposes. Of these, 111 were from North, 179 from East, 100 from West and 106 from South zone states. 369 were from rural and 127 were from urban settings. Nearly 60% were males, 34% were illiterate and 52% had family income less than Rs. 4000 per month and 15% less than Rs. 2000 per month. Less than half (44%) were aware that TB is caused due to germs/bacteria. 71% had heard of free diagnosis and treatment for TB and of these 96% were diagnosed in government facilities. 45% of the respondents had visited 2 or more providers prior to their diagnosis. 81% were diagnosed with TB within one month of onset of symptoms, however only 47% were initiated on treatment within one week of diagnosis. About 59% were taking treatment free of cost under DOTS. Although 76% knew that they have to take the treatment regularly, only 55% knew that correct duration of the treatment as 6-8 months. 35% of the TB patients were using some form of tobacco when interviewed. Most of the TB patients (95%) had shared their disease status with their families/households and almost everyone experienced supportive behaviour from their families. However, only 60% of them informed their disease status to their friends of which 24% experienced discrimination by their friends. Of those who were married, 15% experienced discriminatory behaviour from their partners. Only 17% shared their disease status with their employers of which 34% had to change their work after sharing their status. Health service providers: A total of 523 locally available health service providers in the primary sampling units were identified and interviewed for the survey purposes. Nearly three-fourths of them (73%) did not have any formal qualification. Only 26% were qualified either in allopathy, alternative medicine, nursing or pharmacy. Just over half (53%) knew that a cough of over 2 weeks as a key symptom of TB and 80% would refer the patient to a government facility for sputum test. On diagnosis of TB, 45% of the providers refer the patient to government health centre for free treatment under DOTS, 12% start treatment on their own and the remaining refer to other sources like private clinics etc. Of those who start treatment on their own, 71% follow allopathy system of medicine. 76% of the providers knew the correct duration of treatment as 6-8 months. Overall 75% of the HSPs felt that DOTS was the best treatment for TB. Only one third (29%) of the HSPs had heard of multi-drug resistant TB and of them 76% knew that MDR was diagnosed by culture and drug susceptibility testing. The predominant source of TB related information for the HSPs was CME/Training programs (38%) followed by peers/colleagues (34%). Opinion leaders: A total of 611 opinion leaders (Village Pradhan, Sarpanch/Panch/Ward members, religious leaders, teachers or health functionaries like Auxiliary Nursing Midwife and Anganwadi Worker) were interviewed. There was almost equal representation of male and female leaders (52% male and 48% female) and most of them were literate (68% secondary education and above). 94% of them had heard of TB and 90% knew that cough of over two weeks or more is the predominant symptom of TB, 78% knew that TB is transmitted through air when the diseased person coughs or sneezes and almost 72% knew that sputum has to be tested for the diagnosis of tuberculosis.
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
More than 90% of the opinion leaders knew that TB is curable, that allopathic medicines are the predominant mode of treatment of tuberculosis and 53 % knew that the duration of TB treatment is for 6-8 months. 88% of the opinion leaders informed that the Government hospitals are the places for TB diagnosis and treatment. Two thirds (60%) of the opinion leaders had heard of DOTS and were able to associate it with tuberculosis. Less than one fifth of the respondents (17%) had taken any initiative to address TB control in their localities and the most common form of initiative was by organising camps and rallies for TB awareness. A majority of the opinion leaders (77%) strongly agreed that female TB patients face problem in their marriages. About 40% agree that daily wage labourers suffering from TB should not be allowed to work. Three-fourths of them (73%) said that they will not share meals with TB patients and would not marry their sons/daughters to someone they knew had TB anytime in the past. NGO/CBO representatives: A total of 93 NGOs/CBO representatives were identified in the primary sampling units. More than three fourths (78%) of the respondents knew that TB is a major public health problem in our country and 94% of them knew that TB is completely curable. Nearly 90% of them were aware that cough of more than 2 weeks was the key symptom for TB and that TB spreads through air when a TB diseased person coughs or sneezes and nearly all persons mentioned that allopathic system of treatment is the best method to treat tuberculosis. 84% of them had heard of DOTS and 90% knew that diagnosis and TB treatment is provided free of cost at all government health facilities. Only 32% knew that the treatment has to be taken for 6-8 months duration. Only 14% of them were aware of the RNTCP schemes, of which 70% were willing to collaborate with RNTCP. Nearly three-fourth (70%) of the respondents felt that female TB patients face problems in their marriages. Over 80% will not share meals with a TB patient and will not marry their sons/daughters to individuals who they know had TB.
Comparison of Knowledge about TB among Respondents in Baseline and Midline Surveys
General Population: The total sample number in baseline survey was 4562 and in midline survey the comparable number was 4804 from the same 30 districts under Project Axshya. The proportion of respondents who had heard of TB was 84% in baseline which increased to 88% in midline. The proportion of respondents who knew cough of >2 weeks could be TB was 62% in baseline which increased to 72% in midline. The proportion of respondents who knew that TB is caused by bacteria and is transmitted through air was 50% in baseline which increased to 63% in midline. The proportion of those who knew TB is curable did not change (73% in baseline & midline). The proportion of those who knew that the correct duration of treatment is 6-8 months increased from 38% in baseline to 43% in midline. Overall, the proportion of respondents who had correct knowledge about TB i.e. heard of TB, and know that cough of >2 weeks as key symptom of TB; know that TB is curable and had heard of DOTS increased from 18% in baseline to 32% in midline survey. This change is statistically significant (p2 weeks could be TB increased from 78% in baseline to 88% in midline. The proportion of those who knew TB is curable did not change (92% in baseline & 91% in midline). The proportion of respondents who knew that sputum test is used for TB diagnosis had decreased from 80% in baseline to 69% in midline and also those who knew the correct duration of treatment as 6-8 months decreased from 62% in baseline to 53% in midline. The proportions of respondents who had heard of DOTS decreased from 68% in baseline to 60% in midline, and the proportion of opinion leaders who took any initiatives in TB control decreased from 22% in baseline to 17% in midline. NGO/CBO representatives: A total of 51 NGO representatives were interviewed in baseline survey and 93 representatives were interviewed in midline survey. There was a decrease in the proportions of respondents who knew cough of >2 weeks as a key symptom from 92% in baseline to 88% in midline survey. When compared with baseline findings, there was a significant increase in proportion of representatives who knew that treatment of TB is through allopathic medicines (51% in baseline to 85% in midline). However, there was an equal decrease in proportions who knew the correct duration of TB treatment as 6-8 months (80% in baseline to 31% in midline).
Limitations of the Survey
While we believe that the findings are valid, there are some limitations to the study. First, these data are not nationally representative but representative of the 374 Axshya intervention districts. These districts were selected for the project interventions by RNTCP based on their relatively poor programme performance. Second, the study identified respondents based on a door-to-door household survey and some of the respondents were identified based on self-reporting (e.g. TB patients, opinion leaders, heads of the NGO representatives). Third, only 10% of respondents of all stakeholder categories were re-visited to cross check the accuracy of the information gathered by the field investigators and was found to be accurate in more than 95% of the cases. Fourth, we were not able to interview nearly 10% of the TB patients identified in this survey due to certain operational and ethical reasons (like unwillingness to providing consent) despite repeated attempts by the field staff.
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Key Recommendations l
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Priority should be given to make the general population aware of correct knowledge on TB through various ACSM programs. General health awareness programs could be used as a platform for TB awareness. The most-accessible and most used media sources should be used to disseminate information on TB. Detailed survey analysis on media use could throw light on individual preferences. Stigma and discrimination towards TB patients among general population is still prevalent and needs to be addressed contextually. Qualitative studies on the reasons of existing stigma and discrimination could help in finding ways to create stigma free societies for TB patients. It is essential that all TB patients know about the cause and mode of transmission of TB, duration of treatment, need for regular medication and availability of free diagnosis/treatment. Most of these facts are key to treatment success and infection control. Immediate interventions to reduce delay in diagnosis and treatment initiation are a must. Awareness among TB patients on tobacco use and its harmful effects on their treatment outcomes needs to be enhanced with support systems for cessation in place. Opinion leaders are a very strategic group to involve and made responsible to create TB free villages and wards. They resource need to be equipped adequately and engaged in TB care and control. Local NGOs and non-registered groups should be encouraged to participate in TB care and control with improved strategies as most of them felt that though they want to be part of the programme, they are discouraged due to technical and financial delays at the end of government.
Conclusion In conclusion, this community-based survey provides the current levels of knowledge about TB and attitude and practice of various stakeholders in the context of TB. It also assesses the changes in the knowledge levels from the baseline survey conducted in 2011. Various indicators show good progress in the work, while at the same time other indicators also show gaps and opportunities to strengthen the TB control programme. The recommendations highlight the immediate measures to improve India’s TB control programme. Further detailed analysis of the survey findings could contribute significantly in improving strategies and in designing interventions to control TB in India.
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CHAPTER
1 Background
The Global Burden of Disease TB is an airborne infectious disease caused by Mycobacterium tuberculosis and is one of the leading causes of morbidity and mortality worldwide. As per the WHO Global TB control report 2013, about 8.6 million TB cases were estimated to have occurred across the globe in 2012, of which 1.3 million have resulted in death. In 2012, ~ 1.5 million TB cases were notified by the national programme in India. This included 1.18 million new cases and 0.28 million retreatment cases. However, it is estimated that globally about 3 million TB cases are missed in 2012, of these about 30% are estimated to be from India1. Among the new cases 2.2% and among the retreatment cases 15% were multi-drug resistant (MDRTB); with 64,000 MDR-TB cases among the notified TB cases. It is estimated that 1.1 million (13%) out of 8.6 million TB patients were co-infected with HIV and 75% of these were from African region.
The TB Control Strategy World Health Organisation and its partners across the world are implementing a six point Stop TB Strategy which builds on the successes of DOTS while also explicitly addressing the key challenges facing TB. Its goal is to reduce the global burden of tuberculosis by 2015 by ensuring all TB patients, including for example, those co-infected with HIV and those with drug-resistant TB, benefit from universal access to high quality diagnosis and patient-centered treatment. The strategy also supports the development of new and effective tools to prevent, detect and treat TB. The Stop TB Strategy underpins the Stop TB Partnership’s Global Plan to Stop TB 2006-2015.2 The Stop TB strategy has 6 key components: l Pursue high-quality DOTS expansion and enhancement l Address TB/HIV, MDR-TB and other challenges l Contribute to health system strengthening l Engage all care providers l Empower people with TB, and communities l Enable and promote research All high TB burden countries across the world recognise and have endorsed the importance of completely implementing all components of the strategy for reducing the burden of TB.
TB Control in India India is one of the most populous countries with high TB burden and high HIV burden. Combined with other risk factors for TB including malnutrition due to poverty, migration, large slum dwellings, tobacco smoking and alcohol abuse pose a huge threat to TB control in India.
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Global TB Report, WHO 2013 Stop TB Partnership and World Health Organization, Geneva (2006) Global Plan to Stop TB 2006–2015
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
In 2012, RNTCP notified over 1.4 million TB cases. The treatment success rate for smear positive TB was 88% in new cases and 75% in retreatment cases. Over 16,000 MDR cases were diagnosed of which about 14000 were started on treatment3. The Revised National TB Control Programme (RNTCP), based on the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy, was launched by the Government of India in 1997, and expanded across the country in a phased manner. Full nationwide coverage was achieved in March 2006. The goal of RNTCP is to decrease mortality and morbidity due to TB and cut transmission of infection until TB ceases to be a major public health problem in India. Initially the objectives of the programme were to achieve and maintain a cure rate of at least 85% among New Sputum Positive (NSP) patients and to achieve and maintain case detection of at least 70% of the estimated NSP cases in the community.
Project Axshya “Axshya” is a project co-ordinated by two civil society representative organisations, namely International Union Against Tuberculosis and Lung Disease (The Union) South-East Asia Regional Office located in Delhi and World Vision India (WVI). The project is supported through a the Global Fund grant for the period 2010-15. The overarching objectives of Axshya is to support the RNTCP to expand its reach, visibility and effectiveness, engaging community-based providers to improve TB services, especially for women and children, marginalized, vulnerable and TB-HIV co-infected populations. This is being done in 374 districts (300 districts by The Union and 74 districts by WVI) across 23 states of India. For more details please visit www.axshya-theunion.org/.
The expected outcomes of the Project Axshya Greater community involvement through increased awareness and mobilisation
Enhanced involvement of all health care providers
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Increased case notification Decrease in loss to follow up rate l Improved treatment success rates l Universal access to quality TB services l
Increased access to TB control services especially by vulnerable and marginalised populations
Increased political commitment and increased allocation of resources for TB control
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Global TB Report, WHO 2013
2
Chapter 1 Background
Knowledge, Attitude and Practices (KAP) Survey The Knowledge, Attitudes and Practice survey is a tool to measure changes in knowledge, attitudes and practices in response to a specific intervention. It is also considered as statistically representative of a specific population regarding the information known, believed or practiced concerning a particular subject. The socio-cultural and economic aspects of a given community play a significant role in the implementation and success of a specific public health initiative, to this end KAP surveys are ideal and widely practiced. KAP studies provide information about the existing public health work in a given area at an implementation level, the success or gaps of the current intervention, they help in identifying the knowledge gaps, cultural beliefs or behavioural patterns that may facilitate or create barriers for the proposed public health initiative. In the context of TB control, these surveys could also help in setting priorities, establish baseline levels and measure the changes due to intervention4. Hence, baseline, midline and end line KAP surveys have been incorporated as a part of Axshya to assess the changes in the knowledge, attitude and practices towards TB in the project districts. The baseline KAP survey was conducted in a sample of 30 Project Axshya districts during January – March 2011. The study established the baseline levels of knowledge, attitudes and practices among general population, TB patients, opinion leaders, health care providers and NGOs and CBOs5. During and after the baseline survey, Project Axshya was implementing activities including high level advocacy at national and state level, along with the sensitisation and training programmes at district and community levels. The midline survey was planned to measure changes in the knowledge, attitude and practices concerning TB in the target groups. The findings may help in identifying potential gaps that need to be addressed to fulfill the goals of Project Axshya. The midline survey was planned during the period October – December 2012. However due to logistical and operational delay, the field work was completed in April 2013.
Objectives of Midline KAP Survey The main aim of the midline KAP survey is to assess levels of knowledge, attitude and practices towards TB among the target groups and measure any changes in comparison to baseline KAP survey, specifically; l
TB related knowledge among general population, TB patients, opinion leaders, health service providers and NGO/CBO workers. l Attitudes and experiences of stigma and discrimination related to TB among general public and persons/relatives affected by the disease. l The attitudes of respondents from different target groups towards TB patient with particular reference to gender. l The individual, social and environmental factors including provider and patient related delay that could contribute to low TB case detection and poor completion of TB treatment.
4 5
http://www.stoptb.org/assets/documents/resources/publications/acsm/ACSM_KAP%20GUIDE.pdf http://www.axshya-theunion.org/Documents/KAP.pdf
3
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
l
l l l l
Health seeking behaviour of women and men from the general population, especially vulnerable groups such as people living in hard to reach areas, backward communities and those from tribal areas when they experience TB related symptoms and describe the places of health care sought and time taken to seek care. The relationship between TB health care providers and those affected with TB, the role of opinion leaders (community influencers) and NGOs/CBOs in RNTCP. Media habits or preferences of the target groups, their sources of information on TB and exposure to mass media platforms. The preferred or trusted communication channels of the target groups for receiving messages related to TB. The knowledge, attitudes and practices of the general public and TB patients towards tobacco use/control.
Methodology Study Design
The Midline KAP survey is a cross-sectional survey among the target groups in 30 districts of Project Axshya. In order to maintain comparability with the baseline survey, the methodology adopted was similar to that of baseline survey but for a few additions in the objectives and questionnaires. The survey instrument/tool is a semi-quantitative questionnaire specifically designed for each target group. The instrument was translated into eight local languages and pilot tested before being administered to the target groups.
Sample Size
The sample size was calculated for estimating the change in the proportion of the general population with appropriate knowledge on critical aspects of TB (the primary objective of the survey). During the baseline survey the proportion of population who had correct knowledge about TB i.e. heard of TB, knew that cough of over 2 weeks is a symptom of TB, knew that TB is completely curable with 6-8 months of treatment and heard of DOTS was 12%. Since the baseline KAP survey, Project Axshya has been conducting various interventions like sensitization meetings of panchayati raj members, self-help groups, gaon kalyan samitis (Village Health and Sanitation Committees), local NGOs and developing advocacy tools for TB awareness. Therefore, we expect an improvement in knowledge, attitudes and practices. We hypothesised that the proportion of population who had heard of TB, knew that cough of over 2 weeks is a symptom of TB, knew that TB is completely curable with 6-8 months of treatment and heard of DOTS will be at least 25%, which is double the proportion we found in the baseline survey. As described in the methodology used in the baseline survey and if ~4500 persons from the general population are studied, then we will have more than 80% power to assess if the change is 2% or more at the aggregate level. At the district level by studying 160 persons per district we will have an 80% power to assess if the change is more than 1.6 times that of the baseline. For the other group of respondents, all eligible persons identified in the primary sampling unit were interviewed. A three stage stratified random sampling method was used to select target respondents for the study.
4
Chapter 1 Background
Stage 1: Selection of Districts
Thirty districts out of the 374 districts of Project Axshya were selected for the survey. These 30 districts have representation from the districts covered by the two PRs (Principal Recipients of Global Fund) The Union and World Vision. Since the Union is implementing the project in 300 districts and World Vision in 74 districts, 24 out of 30 districts were those covered by the Union and 6 by World Vision. The list of all 30 districts is provided in Annexure 1. The districts were selected by a stratified cluster sampling technique. Districts were initially stratified into the 4 RNTCP zones (north, south, east and west) of the country. The number of districts in each zone was selected in proportion to the distribution of the 374 districts in the respective zones of the country and the required number of districts in each zone was selected by population proportionate to size sampling.
Stage 2: Selection of PSUs
In each district, 10 primary sampling units which were villages for rural areas and wards for urban areas were selected by Population Proportional to size sampling procedure (PPS). The urban: rural ratio of the primary sampling units in each district was maintained in proportion to the district’s actual urban – rural population ratio. For selection of PSU, the 2001 census list served as a sampling frame (as 2011 Census data was not yet available during the study design period). The list of villages and wards were separately drawn from each district. The villages and wards were arranged in the ascending order based on their population size. The required number of PSUs from each district was selected using circular systematic sampling procedure.
Stage 3: Selection of Households
In every primary sampling unit, a house listing operation was carried out. The listing provided the necessary sampling frame for identification of respondents from the general population and for selecting self-reported TB diseased persons from each primary sampling unit. The household listing process involved assigning numbers to each residential structure, recording address and location of these structures, and listing the numbers of individuals in the households, identification of the head of the household and self-reported TB diseased persons. In order to obtain the awareness about tuberculosis among general population, 16 individuals aged 18 years and above interviewed from each PSU. These 16 persons were selected by systematic random sampling method from the list of persons identified in the house listing process; the male to female ratio selected for the interview was 1:1. All self-reported TB patients identified in each primary sampling unit were approched and those who gave consent were interviewed. All health service providers, NGOs/CBOs representative and two opinion leaders working in the primary sampling units were line listed and interviewed. While interviewing the respondents of the general population and the TB patients, they were asked to identify the health service providers that they usually visit and opinion leaders that they usually seek advice for health/medical care related matters. All such medical providers if located within the PSU were interviewed. The NGOs working in the area of the PSU were identified based on interviews of the village/ward representatives, and then the local heads or representatives of these identified organisations were interviewed as per the availability during the survey.
5
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Geographical distribution of 30 districts where baseline and midline KAP surveys have been conducted
Axshya
Survey Instruments
The main instrument used for collection of data in this survey was a set of separate semi-structured questionnaires for General Population, TB diseased, Health Service Providers, Opinion Leaders and NGOs. The questionnaire was developed in English and then translated in 9 local regional languages (Hindi, Bengali, Marathi, Telugu, Kannada, Tamil, Malayalam, Oriya, and Assamese). The final translated questionnaire was pilot-tested with the target groups, mainly for language checks and partly to ascertain that most issues were accurately covered. The English versions of the questionnaires are enclosed in annexures. Operational Definition of Target Groups l General Population: The respondents were persons identified from the general population who are the usual members of the household. Information on age, sex, marital and education status was collected. Efforts were made to get information on the Standard of Living Index. l TB Patients: The respondents in this group were TB patients identified from the household listing (both undergoing treatment and who have taken treatment in last 1year). The demographic and socio-economic statuses of these people were obtained.
6
Chapter 1 Background
l
Health Service Providers: Any practicing medical practitioners (unqualified providers, qualified doctors, nurses, ANM’s PHC workers, AYUSH providers, ASHA workers) in the Government and Private (including NGO or Corporate sector) in the community were considered as health care providers. l Opinion Leaders: The respondents in this group were opinion leaders like religious leader, teachers, ward member or panchayat member of a community. l NGO/CBO Representatives: NGO or CBO representatives working in health and non–health sector. Inclusion criteria: l Any individual whose age is ≥18 years l Any individual who is identified as a TB patient by self reporting/line listing/reported by the head of the household Exclusion criteria: l Any individual who is not willing to give consent to participate in the study l Those individuals who are selected in the household listing process but unavailable for the interviews in spite of appointments on two consecutive days Key areas discussed in the questionnaires were: Awareness on TB Signs and symptoms of TB Knowledge, Attitude & Practice related to TB
Treatment of TB Tobacco use Source of awareness Attitude towards TB patients Existing health facility
Health care facilities provided to people suffering from TB
Infrastructure available Diagnostic preferences Attitude of health worker towards TB patients
Stigma and discrimination towards TB patients
Stigma in workplace Stigma in health care settings Stigma in family/friends/immediate community Link with existing HIV/AIDS stigma
Health seeking behaviour of people affected with TB
Type of service provider; Government, private, NGO Reason for choosing it Services provided in health facilities Age and sex
Socio-cultural and demographic factors
Caste and religion Education and occupation Standard of living index Mode of entertainment; radio, television, films
Media habits and preferences
Source of Information for disease related knowledge Programme help in changing the attitude of people Share the knowledge with other person
7
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Data Collection
Fieldwork was carried out in all the 15 states (Uttar Pradesh, Punjab, Haryana, Rajasthan, West Bengal, Orissa, Bihar, Mizoram, Karnataka, Tamil Nadu, Kerala, Andhra Pradesh, Maharashtra, Chhattisgarh and Madhya Pradesh) simultaneously from November 2012 and completed in April 2013. The total numbers of respondents in each stakeholder group stratified by zone and state is given in Tables 1.1, 1.2 and 1.3. TABLE 1.1: Number of respondents from general population and TB diseased persons by urban-rural residence Sample Coverage
Rural
%
Urban
%
Total
Number of General Population Interviewed
3360
70
1444
30
4804
Number of TB Diseased Persons Interviewed
369
74
127
26
496
The total number of respondents covered during the survey was 6527. Zone wise number of respondents interviewed from each category is provided in the Table 1.2 TABLE 1.2: Number of respondents interviewed (General Population, TB Diseased, Health Service Providers NGO representatives and Opinion Leaders) stratified by zones Sample coverage
North
East
West
South
Total
General Population
1123
1279
1280
1122
4804
TB Diseased Person
111
186
93
106
496
Health Service Providers
111
134
78
200
523
Opinion Leaders
135
180
163
133
611
2
25
5
61
93
NGOs
TABLE 1.3: Number of Respondents (GP, TB Diseased, Health Service Providers, Opinion Leaders & NGOs) interviewed stratified by state State
GP
TB Diseased
Health Service Providers
Opinion Leaders
NGOs
Uttar Pradesh
643
50
54
75
2
Punjab
160
8
12
22
-
Haryana
320
53
45
38
-
Rajasthan
160
4
17
21
-
West Bengal
160
24
20
26
3
Orissa
319
22
31
45
8
Bihar
640
105
61
85
9
Mizoram
160
28
22
24
5
Karnataka
160
12
20
22
1
Tamil Nadu
483
27
58
52
17
Kerala
319
57
104
40
43
Andhra Pradesh
160
10
18
19
-
Maharashtra
160
12
10
20
4
Chhattisgarh
160
7
10
18
-
Madhya Pradesh
800
77
41
104
1
Total
4804
496
523
611
93
8
Chapter 1 Background
Recruitment, Training and Fieldwork GfK-MODE, conducted 2 Training of Trainers (TOT) workshops; one in north zone and one in south zone. The purpose of the workshops was to ensure uniformity in data collection procedure in different states. The Union’s technical team also attended the workshop to give its technical inputs to the trainers. Field Executives received training in the workshop. They subsequently trained the field staff (Investigators and supervisors) in each state according to the standard procedures discussed in the TOT. Training consisted of classroom training, demonstration and practice interviews, as well as field practice. Field staff in each state was trained over a period of three days. The fieldwork in each state was carried out by a number of interviewing teams, each team consisting of four investigators and one supervisor. One such team was deployed in each state. Prior to the main field work at each primary sampling unit, household listing was carried out by a team of two listers in order to list all persons and TB diseased persons in each PSU. Experienced and qualified interviewers were hired from our panel of investigators, taking into consideration their education background and experience in health-related surveys. The field supervisor was responsible for the overall management of the field team. In addition, the field supervisor conducted spot-checks to verify the accuracy of key information, particularly with respect to the eligibility of respondents. In each state monitoring and supervision was performed by the field executive of Gfk MODE and The Union’s staff. From time to time, The Union’s technical staff visited the field sites to monitor the data collection operation.
Ethics Ethics approval was obtained from the Union’s Ethics Advisory Group. This is an approved activity under the Global Fund supported Project Axshya being implemented in collaboration with Central TB Division, Ministry of Health and Family Welfare, Government of India. The protocol was also submitted to the REACH Independent Ethics Committee, Chennai, Tamil Nadu. Prior to conducting the survey, permission was obtained from the community heads/representatives of the PSUs in each district. All the participants were informed about the study and were invited to participate in the study after written informed consent was obtained.
Data Processing The collected data was double entered and validated using CSPro v3.1. All completed questionnaires were sent to the analysis office of the GfK MODE for editing and data processing (including office editing, coding, data entry, and machine editing). Although field supervisors examined every completed questionnaire in the field, the questionnaires were re-edited by office editors. The office editors checked all skip sequences, response codes that were circled, and information recorded in filter questions. The data were entered directly from the pre-coded questionnaires, usually starting within one week of the receipt of the first set of completed questionnaires. Data entry and editing operations were usually completed a few days after the end of fieldwork in each state. Data was double entered by two different data entry operators and validated. The errors were corrected using the hard copy of the questionnaire and final datasets were generated for each of the target group.
9
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
After GfK submitted the validated data, the Union technical team cross-checked the data randomly and appropriate steps were taken in case of any erroneous data entered. The validated data was then exported to EpiData and used for analysis. The raw data was cleaned and analysed using EpiData Analysis software. Each target group was analysed for the respondent’s knowledge about TB, attitude and practices towards TB affected individuals. Changes in KAP were measured within target groups from baseline to midline survey and analysed for the key indicators.
10
CHAPTER
2 Results: General Population
A total of 65,209 households were line-listed from 300 primary sampling units covering 3,14,913 general population of which 4804 individuals were interviewed. Number of respondents zone wise – north zone (7 districts) N=1123; east zone (8 districts) N=1279, west zone (8 districts) N=1280 and south zone (7 districts) N=1122. Of those interviewed, 3360 were from rural settings and 639 were from tribal districts.
Demographic Profile Table 2.1 describes the socio-demographic characteristics of respondents from the general population. As with other recent demographic data regarding India’s population profile, the bulk of the respondents fall in the middle age group, with 54% of the individuals between the age of 26 and 45 years. In the south, the bulk of respondents are aged over 46 years. The majority of the respondents are married (87%). Being as close to representational ratios for gender, the sexes are equally divided (50-50). Similarly, about 42% of the respondents at the all-India level have had at least Primary or Secondary education with the exception of northern (38%) and eastern (34%) regions. One third (31%) of the respondents are either illiterate or have no formal education with majority of them from east zone (43%). TABLE 2.1: Socio-demographic characteristics of respondents from the general population interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
SEX Male
565
(50)
638
(50)
638
(50)
567
(51)
2408
(50)
Female
558
(50)
641
(50)
642
(50)
555
(49)
2396
(50)
18-25yrs
233
(21)
242
(19)
252
(20)
158
(14)
885
(18)
26-35yrs
323
(29)
374
(29)
433
(34)
300
(27)
1430
(30)
36-45yrs
244
(22)
292
(23)
311
(24)
308
(27)
1155
(24)
46+
323
(29)
371
(29)
284
(22)
356
(32)
1334
(28)
Illiterate
346
(31)
418
(33)
265
(21)
81
(7)
1110
(23)
Literate but no formal education
70
(6)
123
(10)
97
(8)
116
(10)
406
(8)
Less than primary
74
(7)
106
(8)
137
(11)
166
(15)
483
(10)
AGE
EDUCATION
Primary
194
(17)
250
(20)
295
(23)
253
(23)
992
(21)
Secondary
240
(21)
185
(14)
304
(24)
301
(27)
1030
(21)
Senior secondary
129
(11)
105
(8)
113
(9)
98
(9)
445
(9)
Graduation and above
70
(6)
90
(7)
68
(5)
83
(7)
311
(6)
Not recorded
0
(0)
2
(0)
1
(0)
24
(2)
27
(1)
Contd...
11
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
North
%
East
%
West
%
South
%
Total
%
MARITAL STATUS Married
928
(83)
1128
(88)
1107
(86)
1000
(89)
4163
(87)
Unmarried
134
(12)
91
(7)
144
(11)
98
(9)
467
(10)
Divorced
3
(0)
5
(0)
3
(0)
1
(0)
12
(0)
Widowed
56
(5)
53
(4)
24
(2)
23
(2)
156
(3)
Separated
2
(0)
2
(0)
2
(0)
0
(0)
6
(0)
145
(13)
307
(24)
335
(26)
346
(31)
1133
(24)
OCCUPATION Wage labour Skilled labour
34
(3)
39
(3)
62
(5)
81
(7)
216
(4)
Self employed
34
(3)
28
(2)
68
(5)
65
(6)
195
(4)
Service (govt. and private)
43
(4)
100
(8)
65
(5)
62
(6)
270
(6)
Business
66
(6)
93
(7)
82
(6)
70
(6)
311
(6)
Agriculture/ cultivator
262
(23)
197
(15)
173
(14)
111
(10)
743
(15)
Unemployed
32
(3)
40
(3)
29
(2)
45
(4)
146
(3)
Housewife
409
(36)
408
(32)
377
(29)
276
(25)
1470
(31)
Student
77
(7)
47
(4)
72
(6)
37
(3)
233
(5) (2)
Other
21
(2)
20
(2)
17
(1)
29
(3)
87
Total
1123
(100)
1279
(100)
1280
(100)
1122
(100)
4804
By occupation, the single largest category of respondents is in the category of housewives. This is possibly because of their obvious presence at home when the survey data investigators visited homes. Logically correlated with this observation is the category with fewest respondents which included workers, skilled labor, the self-employed and those in the service professions, all below 10% of all respondents. Strikingly, over one-third (39%) of all respondents are wage-laborers and cultivators. This is true across the east, south and west regions. In the north, the bulk of respondents work in the agricultural sector. Table 2.2 describes the household characteristics of respondents from the general population. Interestingly, close to half of respondents in the north and the south zones live in pucca houses (North: 59%; South: 46%) whereas this is below 40% in the east and west. Similarly, in the south, the bulk of the respondents own their own homes (74% in the south, compared with 55% in the east). On the whole, 45% of the respondents have access to safe drinking water (user defined) through private tap/private hand pump. There is an interesting variation between regions with respect to access to safe drinking water: 38% of those in the north have access to drinking water through a private tap; this is lower in the south – 35%. The east is very low on this parameter (only 9% of those in the east have access to safe drinking water through private taps). The bulk source of fuel is biomass – in the north, wood and dung cakes account for 89% of the fuels used for cooking, as compared to 55% for the south. It is encouraging, however, to note that access to LPG and natural gas fuels is increasing – at least one in four houses all over India have access to LPG/Natural gas, with the south accounting for over 50% of this parameter. Read together, this portends well for indoor air pollution trends – if there is increasing penetration or at least access to cleaner fuels, TB control may become more effective in the years to come.
12
Chapter 2 Results: General Population
TABLE 2.2: Household characteristics of respondents from the general population interviewed during midline KAP survey, 2013 North TYPE OF HOUSE Pucca Semi-pucca Kutcha Total
%
East
%
West
%
South
%
Total
%
657 302
(59) (27)
454 371
(35) (29)
414 477
(32) (37)
520 477
(46) (43)
2045 1627
(43) (34)
164 1123
(15) (100)
454 1279
(35) (100)
389 1280
(30) (100)
125 1122
(11) (100)
1132 4804
(24)
703 420 1123
(63) (37) (100)
699 580 1279
(55) (45) (100)
780 500 1280
(61) (39) (100)
831 291 1122
(74) (26) (100)
3013 1791 4804
(63) (37)
(38) (31) (9) (14) (4) (2) (2) (0) (100)
120 453 243 207 91 15 78 72 1279
(9) (35) (19) (16) (7) (1) (6) (6) (100)
290 91 369 378 32 6 113 1 1280
(23) (7) (29) (30) (3) (0) (9) (0) (100)
395 31 494 42 17 0 141 2 1122
(35) (3) (44) (4) (2) (0) (13) (0) (100)
1235 921 1212 783 184 43 350 76 4804
(26) (19) (25) (16) (4) (1) (7) (2)
HOUSE OWNERSHIP Yes No Total
SOURCE OF DRINKING WATER Private Tap Private Hand Pump Public Tap Public Hand Pump Tubewell Supply Tanker Well/River/Pond Others Total
430 346 106 156 44 22 18 1 1123
TYPE OF FUEL USED FOR COOKING Wood Dung cakes LPG/natural gas Straw/shrubs/grass Agricultural crop waste Electricity Coal/lignite Kerosene Charcoal Bio-gas
729 272 247 16 79
(65) (24) (22) (1) (7)
688 396 351 254 108
(54) (31) (27) (20) (8)
837 16 372 4 6
(65) (1) (29) (0) (0)
593 21 568 0 2
(53) (2) (51) (0) (0)
2847 705 1538 274 195
(59) (15) (32) (6) (4)
8 2 11 1 11
(1) (0) (1) (0) (1)
12 7 21 6 3
(1) (1) (2) (0) (0)
48 3 11 1 21
(4) (0) (1) (0) (2)
9 1 69 5 72
(1) (0) (6) (0) (6)
77 13 112 13 107
(2) (0) (2) (0) (2)
Household Assets owned by Respondents from the General Population Overall, this data suggests that liberalisation policies have indeed percolated to the level of the general population. For one, overall access to electricity is quite high at all India level, more than 80% of the respondents have access to power (Table 2.3). Similarly, very high penetration of mobile phones all over India (82% average in India) portends well for directly accessing patients. Coupled with decreasing of prices of high-feature phones, this may indicate better, more direct pathways to communicate with individuals all over the country irrespective of socio economic status. Coupled with this, fewer households have Black and White TVs, so the bulk of people have colour TVs. National tendencies tend to be confirmed in terms of distribution of income: 47% of respondents in the east live on less than Rs 4000 per month while more than 66% of respondents in the south live on at least Rs 4000 per month or more. Over half of the respondents have mattresses and pressure cookers; while 40% of those in the north own their own sewing machines.
13
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TABLE 2.3: Household assets owned by respondents from the general population interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
HOUSEHOLD ASSETS* Electricity
884
(79)
932
(73)
1199
(94)
1109
(99)
4124
(86)
Mattress
956
(85)
632
(49)
887
(69)
819
(73)
3294
(69)
Pressure cooker
705
(63)
610
(48)
727
(57)
698
(62)
2740
(57)
Chair
818
(73)
902
(71)
962
(75)
1076
(96)
3758
(78)
A cot or bed
1109
(99)
875
(68)
1142
(89)
821
(73)
3947
(82)
A table
681
(61)
645
(50)
655
(51)
901
(80)
2882
(60)
Fan
811
(72)
586
(46)
993
(78)
1049
(93)
3439
(72)
Radio
199
(18)
164
(13)
241
(19)
206
(18)
810
(17)
A black & white television
105
(9)
80
(6)
117
(9)
55
(5)
357
(7)
A colour television
743
(66)
588
(46)
982
(77)
1062
(95)
3375
(70)
A sewing machine
444
(40)
212
(17)
346
(27)
207
(18)
1209
(25)
A mobile telephone
1009
(90)
933
(73)
1090
(85)
920
(82)
3952
(82)
Land line
42
(4)
50
(4)
53
(4)
159
(14)
304
(6)
A computer/laptop
36
(3)
107
(8)
78
(6)
100
(9)
321
(7)
A refrigerator
311
(28)
249
(19)
260
(20)
367
(33)
1187
(25)
A watch or clock
922
(82)
914
(71)
1167
(91)
1035
(92)
4038
(84)
A bicycle
817
(73)
790
(62)
791
(62)
646
(58)
3044
(63)
A motorcycle or scooter
399
(36)
276
(22)
439
(34)
553
(49)
1667
(35)
An animal drawn cart
86
(8)
33
(3)
172
(13)
23
(2)
314
(7)
A car
44
(4)
47
(4)
23
(2)
59
(5)
173
(4)
Water pump
329
(29)
135
(11)
175
(14)
229
(20)
868
(18)
A thresher
34
(3)
12
(1)
8
(1)
2
(0)
56
(1)
A tractor
62
(6)
11
(1)
37
(3)
5
(0)
115
(2)
STANDARD OF LIVING INDEX (SLI) Low SLI
199
(18)
600
(47)
288
(23)
92
(8)
1179
(25)
Medium SLI
390
(35)
327
(26)
508
(40)
450
(40)
1675
(35)
High SLI
534
(48)
352
(28)
484
(38)
580
(52)
1950
(40)
Less than Rs. 2000
141
(13)
187
(15)
233
(18)
125
(11)
686
(14)
Rs 2001 - 4000
430
(38)
414
(32)
400
(31)
235
(21)
1479
(31)
Rs 4001 - 8000
330
(29)
350
(27)
281
(22)
357
(32)
1318
(27)
Rs 8001 - 10000
104
(9)
146
(11)
152
(12)
242
(22)
644
(13)
Rs 10000+
89
(8)
129
(10)
105
(8)
137
(12)
460
(10)
Can't say
29
(3)
53
(4)
109
(9)
26
(2)
217
(5)
1123
(100)
1279
(100)
1280
(100)
1122
(100)
4804
HOUSEHOLD INCOME
Total
*Multiple response question
14
Chapter 2 Results: General Population
The standard of living index (SLI) is calculated according to National Family Health Survey (NFHS) method. Less than half (42%) of the population fall in high SLI with south zone having the highest and east zone having lowest proportions of people in this group. It is also important to note that east zone has highest proportion of people in low SLI (46%). The findings are consistent with overall economic trends in India; however there is still a large group of people who are in low SLI group whom may need hand holding for their progress.
Knowledge about TB The respondent’s knowledge about TB was elicited by asking questions starting with whether they heard about TB, awareness on symptoms, diagnosis, treatment and cure of TB. The following paragraphs summarise the knowledge of respondents on these aspects.
Heard of TB Most respondents (88%) admitted to have heard of TB either spontaneously or on probing (Table 2.4). The bulk of those who have heard of TB are not significantly differentiated by their origin in either rural (87%) or urban (90%) areas. TABLE 2.4: Characteristics of respondents among general population who heard of TB interviewed during midline KAP survey, 2013 HEARD OF TB Type of settlement Rural Urban SEX Male Female
No 445 148
% (13) (10)
Yes 2915 1296
% (87) (90)
Total 3360 1444
% (100) (100)
265 328
(11) (14)
2143 2068
(89) (86)
2408 2396
(100) (100)
AGE GROUP 18 to 24 years
57
(8)
629
(92)
686
(100)
25 to 34 years
138
(11)
1134
(89)
1272
(100)
35 to 44 Years
170
(14)
1068
(86)
1238
(100)
45 to 54 Years
117
(14)
748
(86)
865
(100)
55+ years
111
(15)
632
(85)
743
(100)
1
(4)
26
(96)
27
(100)
Illiterate
221
(20)
889
(80)
1110
(100)
Literate but no formal education
68
(17)
338
(83)
406
(100)
Less than primary
70
(14)
413
(86)
483
(100)
Primary
109
(11)
883
(89)
992
(100)
Secondary
89
(9)
941
(91)
1030
(100)
Senior Secondary
26
(6)
419
(94)
445
(100)
Graduation and above
9
(3)
302
(97)
311
(100)
133
(12)
990
(88)
1123
(100)
EDUCATION Missing
ZONES North East
97
(8)
1182
(92)
1279
(100)
West
150
(12)
1130
(88)
1280
(100)
South
213
(19)
909
(81)
1122
(100)
Total
593
(12)
4211
(88)
4804
15
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Over 80% of those surveyed have indeed heard of TB, so this implies that the working population is quite aware of TB. 9% of those with secondary education and 6% of those with senior secondary education were not aware about TB, while responses of about 9% were missing. Awareness about TB is high, with at least 80% of the surveyed population knowing about it independent of region.
Awareness about Symptoms of TB among those who Heard of TB Currently, a key criterion for screening TB is “Cough of 2 weeks or more with or without other symptoms”. On average, most of the general population was aware of “cough of 2 weeks” as a TB symptom (83%) (Table 2.5). This was followed by “coughing up blood” (55%). Respondents from east zone are less aware of “cough of 2 weeks” as a TB symptom (68%). About 11% and 9% of the respondents from east and south zone respectively did not know about any symptoms of TB. Less than 30% of the respondents were less aware that chest pain, weight loss, night sweat, and loss of appetite are also TB symptoms. 19% of the respondents who did not know “cough of 2 weeks” as TB symptom would not seek diagnosis and treatment services until and unless they are made aware of TB symptoms. If the general population is aware of the TB symptoms they can advise their peers, family members having these symptoms to go to a local health centre for TB diagnosis. TABLE 2.5: Awareness about symptoms of TB among the respondents from general population who heard of TB interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
SYMPTOMS OF TB A cough of 2 weeks
849
(86)
803
(68)
1018
(90)
751
(83)
3421
(81)
Coughing up blood
589
(59)
729
(62)
610
(54)
383
(42)
2311
(55)
Fever
338
(34)
367
(31)
408
(36)
401
(44)
1514
(36)
Pain in the chest
245
(25)
290
(25)
313
(28)
290
(32)
1138
(27)
Weight loss
211
(21)
210
(18)
253
(22)
401
(44)
1075
(26)
Night sweat
32
(3)
51
(4)
54
(5)
185
(20)
322
(8)
Loss of appetite
185
(19)
156
(13)
144
(13)
194
(21)
679
(16)
Don't know
31
(3)
134
(11)
38
(3)
79
(9)
282
(7)
Total Respondents
990
1182
1130
909
4211
Awareness about Mode of Transmission of TB among those who Heard of TB The level of awareness on the mode of transmission among the general population is crucial to prevent TB transmission to family members and the community. 71% of the respondents were aware of the mode of TB transmission through air. This awareness was more than 65% across all zones (Table 2.6). More than 40% of the respondents in north, east and west zones thought that sharing food with a person with TB can transmit TB. One fifth also responded that TB is transmitted through sharing bed or clothes used by TB patients. This misconception would contribute to increase the stigma and discrimination towards TB patients. 14% of the respondents did not know the mode of transmission of TB at all.
16
Chapter 2 Results: General Population
TABLE 2.6: Awareness about mode of TB transmission among the respondents from general population who heard of TB interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
MODE OF TB TRANSMISSION Through the air when the infected person coughs or sneezes
742
(75)
778
(66)
845
(75)
608
(67)
2973
(71)
Through sharing food with a person with TB
461
(47)
490
(41)
460
(41)
157
(17)
1568
(37)
By sharing bed/clothes with a person with TB
290
(29)
147
(12)
327
(29)
111
(12)
875
(21)
Through handshake with a person with TB
80
(8)
134
(11)
87
(8)
93
(10)
394
(9)
Don't know/Not aware
88
(9)
239
(20)
119
(11)
134
(15)
580
(14)
Total Respondents
990
1182
1130
909
4211
Inadequate knowledge or false belief and misconceptions about the mode of transmission may increase social stigma and discrimination of TB patients. This can be reduced by spreading knowledge about the mode of transmission of TB. Adequate knowledge on transmission will also help the general population to practice TB infection control and put in place prevention practices in houses where there are TB patients. There is a possibility that higher levels of awareness on the mode of transmission will eventually decrease TB transmission to the family members and the community.
Knowledge on the People who are more Prone to TB On average, 50% of respondents gave an opinion that smokers and people ‘exposed to cough and cold for long time’ are prone to TB (Table 2.7). 69% of the respondents from south zone knew the association between smoking and TB. There remain almost one third of the respondents in the south zone who can be made aware that smokers are prone to TB which will also help indirectly to control tobacco use. Only 24% of the respondents gave the opinion that alcoholics are also prone to TB which is same across all zones. There is an acute need to increase the knowledge among the general population that alcoholics are prone to developing TB and also affect the treatment outcomes negatively. The respondents from all zones seemed to have lesser awareness that malnutrition, children, women and HIV positives are more prone to TB. The dual epidemics of HIV and TB are ruining the efforts made by HIV and TB control programmes as TB is one of the common opportunistic infections among HIV positives. This knowledge seemed very less (≤5%) among the general population across all zones. One tenth of the general population also did not know who actually is prone to TB. The general population needs to be aware of the risk factors for TB or else the risk factors like, HIV infection; smoking and alcohol intake will not adversely affect the efforts of RNTCP in reducing TB prevalence, incidence and mortality.
17
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TABLE 2.7: Opinion of respondents from general population who heard of TB on “people who are prone to TB in the community” interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
WHO ARE PRONE TO TB? Smokers
455
(46)
513
(43)
480
(42)
623
(69)
2071
(49)
Those living in unhygienic condition
417
(42)
466
(39)
404
(36)
235
(26)
1522
(36)
Alcoholics
195
(20)
255
(22)
256
(23)
290
(32)
996
(24)
Exposed to cough and cold for long time
668
(67)
349
(30)
664
(59)
298
(33)
1979
(47)
Poor people
142
(14)
106
(9)
139
(12)
41
(5)
428
(10)
Malnourished
146
(15)
258
(22)
251
(22)
102
(11)
757
(18)
Children
38
(4)
24
(2)
106
(9)
84
(9)
252
(6)
Women
52
(5)
15
(1)
86
(8)
97
(11)
250
(6)
HIV positive persons
48
(5)
63
(5)
37
(3)
59
(6)
207
(5)
Don't know
46
(5)
216
(18)
61
(5)
112
(12)
435
(10)
Total Respondents
990
1182
1130
909
4211
Awareness about Mode of Diagnosis of TB among those who Heard of TB On an average, 66% and 54% of the respondents knew that TB is diagnosed by ‘sputum smear test’ and ‘X-ray’ respectively (Table 2.8). Strikingly, 52% of the respondents also responded to ‘blood test’ for diagnosis of TB which confirms that blood tests are widely used for diagnosing TB. This may imply that the serological tests (although this was not specifically asked) which have been banned by RNTCP are still being prescribed. The level of awareness among the general population seemed relatively lower on the appropriate diagnostic tool for TB. One tenth of the general population also do not know how TB is diagnosed. Very few respondents (5%) thought that TB could be diagnosed by a skin test and most of these (65%) were from the south zone. TABLE 2.8: Awareness about mode of TB diagnosis among respondents from general population who heard of TB interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
DIAGNOSIS OF TB Sputum smear test
609
(62)
769
(65)
825
(73)
561
(62)
2764
(66)
X-Ray
685
(69)
498
(42)
611
(54)
487
(54)
2281
(54)
Skin test
15
(2)
36
(3)
24
(2)
134
(15)
209
(5)
Blood test
498
(50)
664
(56)
579
(51)
458
(50)
2199
(52)
Other
20
(2)
13
(1)
18
(2)
8
(1)
59
(1)
Don't know
76
(8)
210
(18)
126
(11)
150
(17)
562
(13)
Total Respondents
990
1182
1130
18
909
4211
Chapter 2 Results: General Population
Sputum smear test is widely used for diagnosis of TB across 13,000 DMCs across the country for diagnosis of TB and there is still a significant proportion of the general population (34%) who need to be made aware on this. 52% of the respondents are not aware that ‘Blood test’ is not a reliable test for TB diagnosis. Increasing public awareness on correct test for diagnosis of TB will help respondents to ask for ‘sputum smear test’.
Knowledge on Seriousness of TB Disease and its Curability The majority of those who heard of TB consider TB a serious disease (70%) and curable (83%), with lowest proportions in the south (Table 2.9). This also means that 30% of them do not consider TB as a serious disease. And 17% of them do not know TB is completely curable. Individuals with lack of knowledge on seriousness of the disease and its curability may not take the symptoms such as a cough of over 2 weeks seriously thus delaying medical care and those who do not know about the curability may restrict themselves from accessing treatment. They may fear stigma and discrimination and consider their condition as not treatable. Although we cannot rule out that even people who know the seriousness and curability of TB may still delay seeking medical care due to reasons of fear of stigma and discrimination. TABLE 2.9: Knowledge about seriousness of TB disease and its curability among respondents from general population who heard of TB interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
884
(89)
872
(74)
836
(74)
337
(37)
2929
(70)
Yes, completely
876
(88)
986
(83)
974
(86)
669
(74)
3505
(83)
Yes, partially
95
(10)
119
(10)
117
(10)
119
(13)
450
(11)
No
6
(1)
21
(2)
10
(1)
14
(2)
51
(1)
Don't know
13
(1)
56
(5)
29
(3)
107
(12)
205
(5)
Total
990
(100)
1182
(100)
1130
(100)
909
(100)
4211
IS TB A SERIOUS DISEASE ? Yes, serious life threatening disease CAN TB BE CURED ?
Awareness about the Best Treatment for TB among those who Heard of TB 74% of respondents know that TB treatment is through allopathic drugs (DOTS or TB drugs or other allopathic drugs) with highest in north zone (80%) and lowest in south zone (69%) (Table 2.10). Though south has greater literacy and better functioning health programmes, this observation is quite an anomaly. When asked specifically about ‘DOTS’ only 44% knew DOTS as treatment for TB. About 11% of general population consider alternative medicines like ayurveda or homeopathy or others as the best treatment and nearly one fifth of the population (16%) did not know what the best treatment is. Knowledge on TB treatment seems reasonably good with a lot of space to improve. Zonal variations suggest contextualisation of knowledge dissemination programmes to reach different groups of people in each zone.
19
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TABLE 2.10: Awareness about the best treatment for TB and the duration of TB treatment among respondents from general population who heard of TB interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
TREATMENT OF TB Allopathic medicines
306
(31)
461
(39)
155
(14)
351
(39)
1273
(30)
DOTS
481
(49)
407
(34)
679
(60)
270
(30)
1837
(44)
Herbal remedies
5
(1)
7
(1)
21
(2)
71
(8)
104
(2)
Home remedies
10
(1)
6
(1)
14
(1)
53
(6)
83
(2)
Ayurvedic
67
(7)
26
(2)
17
(2)
7
(1)
117
(3)
Homeopathy
12
(1)
24
(2)
25
(2)
9
(1)
70
(2)
Other
13
(1)
16
(1)
26
(2)
12
(1)
67
(2)
Don't know
96
(10)
235
(20)
193
(17)
136
(15)
660
(16)
DURATION OF TB TREATMENT 4 weeks or less
16
(2)
23
(2)
24
(2)
34
(4)
97
(2)
1-5 months
78
(8)
108
(9)
77
(7)
95
(10)
358
(9)
6-8 months
444
(45)
525
(44)
654
(58)
405
(45)
2028
(48)
More than 8 months
223
(23)
189
(16)
216
(19)
149
(16)
777
(18)
Don’t Know
229
(23)
337
(29)
159
(14)
226
(25)
951
(23)
Total
990
(100)
1182
(100)
1130
(100)
909
(100)
4211
Less than half (48%) of the general population who heard of TB know the correct duration of TB treatment (6-8 months) and one fifth of the populations said they do not know the treatment duration. In TB treatment duration is considerably long and faces the challenge of adherence. Non-adherence to treatment is the key reason for drug resistance in TB patients. Hence the findings are quite alarming that not even half the population know about the correct duration of treatment. This gap needs to be plugged in to ensure treatment adherence.
Heard of ‘DOTS’ and Free Treatment for TB among those who Heard of TB Only 23% of those who had heard of TB had heard of DOTS with least in south zone (12%) (Table 2.11). Of this, 88% know that it is free treatment for TB. ‘DOTS’ is the treatment strategy for TB in India, however majority of general population in India were not aware of DOTS. This lack of awareness on ‘DOTS’ must be urgently considered
Knowledge about Self-susceptibility to develop TB Disease among the General Population Though 31% of the general population believe that they can get TB, 46% of them believe that they cannot get TB (Table 2.12). When asked for reasons for their belief, a majority said that they are strong and healthy and generally do not fall sick easily. The fact that anyone can get TB and that it depends on the individual’s health should be actively disseminated across all age groups. It is also noticeable that more than one tenth (11%) did not know whether they can get TB or not.
20
Chapter 2 Results: General Population
TABLE 2.11: Proportion of respondents who heard of the term ‘DOTS’ and free treatment for TB among the general population interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
HEARD OF DOTS Yes
222
(20)
320
(25)
413
(32)
139
(12)
1094
(23)
No
770
(69)
867
(68)
720
(56)
819
(73)
3176
(66)
Don't know
131
(12)
92
(7)
147
(11)
164
(15)
534
(11)
HEARD OF FREE TREATMENT Yes
201
(91)
272
(85)
368
(89)
120
(86)
961
(88)
No
11
(5)
27
(8)
27
(7)
6
(4)
71
(6)
Don't know
10
(5)
21
(7)
18
(4)
13
(9)
62
(6)
Total
222
(100)
320
(100)
413
(100)
139
(100)
1094
TABLE 2.12: Perception of self-susceptibility to develop TB disease among the general population interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
CAN YOU GET TB ? Yes
420
(37)
553
(43)
428
(33)
110
(10)
1511
(31)
No
473
(42)
446
(35)
565
(44)
740
(66)
2224
(46)
Don’t know/Can’t Say
99
(9)
188
(15)
140
(11)
108
(10)
535
(11)
Other
131
(12)
92
(7)
147
(11)
164
(15)
534
(11)
Total
1123
(100)
1279
(100)
1280
(100)
1122
(100)
4804
Attitudes or Perceptions about TB Disease and TB Patients The attitudes/perceptions of the general population with regard to TB and TB patients were gathered by asking for agreement or disagreement on a particular statement or their response to a multiple choice question. The responses are quantitative and not qualitative hence the reasons for the response are not known. Various statements were presented to the survey respondents to elicit their overall attitudes towards TB or TB patients. On the whole, most indicators suggest healthy attitudes towards TB patients and their families.
Acceptance in the Communities Nearly half (46%) feel that in their communities, people are friendly with TB patients but generally avoid them (Table 2.13). A quarter (25%) say that people in their communities mostly reject TB patients. From these two findings, there seems a significant level of apathy towards TB patients in the community. However, 41% of the respondents also said that in their communities mostly people help and support TB patients. Regarding the female TB patient’s situation, there is a considerable progress in care taking and non-discrimination by husband or in-laws. Only about one tenth of people feel that female TB patients face problems in marriage.
21
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
These findings suggest that acceptance is more at family level than at community level. This also suggests that specific interventions to increase acceptance at community level needs to be implemented. And community should be involved in planning and designing these specific interventions. TABLE 2.13: Attitudes towards TB disease, who are prone to TB and how TB patients are treated in their communities among respondents from general population interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
874
(68)
838
(65)
350
(31)
2948
(61)
DO YOU CONSIDER TB AS A SERIOUS DISEASE? TB is a serious disease
886
(79)
WHO DO YOU THINK ARE MORE PRONE TO GET TB? Those living in unhygienic condition
417
(37)
467
(37)
404
(32)
247
(22)
1535
(32)
Poor people
142
(13)
106
(8)
139
(11)
43
(4)
430
(9)
Malnourished
147
(13)
258
(20)
251
(20)
121
(11)
777
(16)
Children
38
(3)
24
(2)
106
(8)
85
(8)
253
(5)
Women
52
(5)
15
(1)
86
(7)
99
(9)
252
(5)
Family members of TB person
432
(38)
179
(14)
444
(35)
262
(23)
1317
(27)
Exposed to cough and cold for long time
668
(59)
349
(27)
665
(52)
309
(28)
1991
(41)
HIV +ve
48
(4)
63
(5)
37
(3)
60
(5)
208
(4)
Smokers
455
(41)
514
(40)
480
(38)
652
(58)
2101
(44)
Alcoholics
195
(17)
255
(20)
257
(20)
309
(28)
1016
(21)
IN YOUR COMMUNITY HOW ARE TB PATIENTS TREATED Most people reject him/ her
219
(20)
227
(18)
359
(28)
405
(36)
1210
(25)
Most people are friendly but generally avoid them
672
(60)
373
(29)
683
(53)
488
(43)
2216
(46)
Community mostly helps and support him/her
523
(47)
575
(45)
466
(36)
412
(37)
1976
(41)
Husbands/in-laws do not accompany female patients to hospital/ DOTS centres
15
(1)
51
(4)
44
(3)
163
(15)
273
(6)
Female accompany their spouse to hospitals suffering from TB to hospital/DOTS centres
59
(5)
119
(9)
75
(6)
209
(19)
462
(10)
Females suffering from TB face problem in marriage
147
(13)
161
(13)
95
(7)
182
(16)
585
(12)
No change in the reaction
71
(6)
304
(24)
102
(8)
52
(5)
529
(11)
53
(5)
180
(14)
125
(10)
75
(7)
433
(9)
Don't know Total Respondents
1123
1279
1280
22
1122
4804
Chapter 2 Results: General Population
Fear and Threat Feelings A particularly disturbing fact across India is indicated with response to the statement, “TB patients are a threat to the community” – high proportions of the respondents in the north (64%), 41% of those in the east, and 50% of those in the west “somewhat agreed” or “strongly” agreed with this statement (Table 2.14). Even in the south, 35% of respondents agreed. Feelings of threat are usually developed by subconscious fear, though people may not agree to it up front. The fear of infection in general public may affect TB patients in the communities adversely in the form of apathy, stigma and discrimination. TABLE 2.14: Attitudes towards TB patients and their families from general population interviewed during midline KAP survey, 2013* North
%
East
%
West
%
South
%
Total
%
A FAMILY WITH TB PATIENT SHOULD NOT BE ALLOWED TO PARTICIPATE IN ANY SOCIAL FUNCTION Strongly agree
138
(12)
186
(15)
102
(8)
122
(11)
548
(11)
Somewhat agree
186
(17)
188
(15)
197
(15)
173
(15)
744
(15)
Disagree
755
(67)
826
(65)
945
(74)
810
(72)
3336
(69)
MARRIED FEMALE TB PATIENT SHOULD BE SENT OFF TO HER PARENTS HOUSE Strongly agree
93
(8)
67
(5)
54
(4)
70
(6)
284
(6)
Somewhat agree
135
(12)
122
(10)
178
(14)
172
(15)
607
(13)
Disagree
866
(77)
1031
(81)
1033
(81)
864
(77)
3794
(79)
CHILDREN WITH TB SHOULD NOT BE ALLOWED TO GO TO SCHOOL Strongly agree
173
(15)
153
(12)
134
(10)
117
(10)
577
(12)
Somewhat agree
217
(19)
233
(18)
398
(31)
170
(15)
1018
(21)
Disagree
693
(62)
797
(62)
708
(55)
820
(73)
3018
(63)
CHILDREN OF PARENTS SUFFERING FROM TB SHOULD NOT BE ALLOWED TO GO TO SCHOOL Strongly agree
96
(9)
102
(8)
79
(6)
94
(8)
371
(8)
Somewhat agree
186
(17)
190
(15)
252
(20)
183
(16)
811
(17)
Disagree
802
(71)
879
(69)
906
(71)
825
(74)
3412
(71)
TB PATIENTS ARE THREAT TO COMMUNITY Strongly agree
425
(38)
215
(17)
268
(21)
176
(16)
1084
(23)
Somewhat agree
296
(26)
309
(24)
366
(29)
215
(19)
1186
(25)
Disagree
334
(30)
647
(51)
585
(46)
689
(61)
2255
(47)
TB PATIENTS SHOULD BE LEFT ISOLATED Strongly agree
149
(13)
86
(7)
71
(6)
92
(8)
398
(8)
Somewhat agree
263
(23)
252
(20)
266
(21)
195
(17)
976
(20)
Disagree
658
(59)
848
(66)
901
(70)
811
(72)
3218
(67)
DAILY WAGE LABOURER, SUFFERING FROM TB SHOULD NOT BE ALLOWED TO WORK Strongly agree
216
(19)
165
(13)
182
(14)
160
(14)
723
(15)
Somewhat agree
291
(26)
245
(19)
365
(29)
172
(15)
1073
(22)
Disagree
552
(49)
761
(59)
678
(53)
772
(69)
2763
(58)
Total
1123
(100)
1279
(100) 1280
(100) 1122
(100)
4804
*Percentages do not add upto 100, as missing or not recorded values are not included in the table
23
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
About one third of the respondents agree that TB patient’s children or children with TB should not be allowed to attend school, TB patients should be isolated and daily wage labourers should not be allowed to work. These attitudes yield negative and depressing feelings in individuals with TB and send a wrong message to those who observe these things happening in practice. These attitudes also perpetuate and sustain stigma and discrimination towards TB patients in the communities. The root cause of these attitudes needs to be identified and eliminated permanently if we want to see a TB free India.
Practices related to/towards TB or TB Patients Discriminatory Practices towards TB Patients
A majority of the general population (76%) responded that they would not share a meal with TB patients (Table 2.15). Most of them will take a female member in the family with TB like symptoms to the hospital (92%). Majority of the general population (79%) would not get their sons or daughters married to person who they knew had TB. There is no gender difference in this response. However, if a family member is known to have TB they will not isolate him or her nor will they send their daughter-in- law affected by TB to her parent’s house. Stigma and discrimination towards TB patients persists amongst members of the general population. The practice of sharing a meal is considered hospitable in India. It affirms and builds the relationship between the individuals who practice it. However, if one knows that the other person has TB, it is TABLE 2.15: Possible practices towards TB patients by respondents from general population interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
SHARE A MEAL WITH PERSON YOU KNOW HAD TB Yes
128
(11)
255
(20)
121
(9)
215
(19)
719
(15)
No
976
(87)
945
(74)
1136
(89)
606
(54)
3663
(76)
IF YOU SUSPECT ONE OF THE FEMALE MEMBER OF YOUR FAMILY IS SUFFERING FROM TB, WOULD YOU TAKE HER TO HOSPITAL Yes
1034
(92)
1180
(92)
1218
(95)
987
(88)
4419
(92)
No
77
(7)
57
(4)
54
(4)
86
(8)
274
(6)
MARRY YOUR DAUGHTER TO A BOY KNOWING HE HAD TB Yes
53
(5)
191
(15)
60
(5)
153
(14)
457
(10)
No
1047
(93)
942
(74)
1165
(91)
640
(57)
3794
(79)
ISOLATE YOUR FAMILY MEMBER HAVING TB IN THE HOUSE Yes
394
(35)
209
(16)
406
(32)
156
(14)
1165
(24)
No
676
(60)
1007
(79)
845
(66)
676
(60)
3204
(67)
MARRY YOUR SON TO A GIRL WHO YOU KNOW HAD TB Yes
60
(5)
191
(15)
64
(5)
153
(14)
468
(10)
No
1028
(92)
938
(73)
1158
(90)
654
(58)
3778
(79)
SEND YOUR DAUGHTER IN LAW TO PARENTS HOUSE IF SHE HAD TB IN ORDER TO PROTECT OTHER FAMILY MEMBERS FROM TB Yes
149
(13)
88
(7)
149
(12)
360
(32)
746
(16)
No
931
(83)
1114
(87)
1107
(86)
597
(53)
3749
(78)
Total
1123
(100)
1279
(100)
1280
(100)
1122
(100)
4804
Percentages do not add upto 100, as missing or not recorded values are not included in the table 24
Chapter 2 Results: General Population
quite possible that they will not share a meal with that person. This has been the case for many years now. It is a discriminatory practice which is not being addressed in any way. Similarly, the practice of not marrying one’s children with a person who had TB is discriminatory These practices force TB patients to keep their status a secret, lest they be discriminated, rejected or not-valued due to their health condition. This practice can be prevented if only people knew that TB is completely curable and is not transmitted sexually or genetically. These findings also show the current dissemination of correct knowledge about TB is insufficient. Immediate measures need to be taken to break the prevailing myths about TB, its transmission and curability.
Media Practices among the Respondents Existing and Preferred Source of TB Related Information
With regard to the efficacy of various sources of TB-related information: Health camps do not seem to be really effective, especially in the western region (only 6% of respondents prefer TB-related information while 59% of those in the west do rely on hospitals and doctors) (Table 2.16). But if combined as a source of information with hospitals and doctors and local health workers, the medical profession as a whole can be harnessed as a well-trusted source of TBrelated information. Television (TV) is a widely preferred source of information on an all-India basis (61%, with high reliance on TV in the south (81%) and the west (69%). Except for respondents TABLE 2.16: Existing and preferred source of TB related information of the respondents among the general population interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
EXISTING SOURCE OF TB RELATED INFORMATION* Television
545
(49)
497
(39)
841
(66)
814
(73)
2697
(56)
Hospital/Doctor
568
(51)
309
(24)
687
(54)
491
(44)
2055
(43)
Friends/Relatives
462
(41)
569
(44)
439
(34)
210
(19)
1680
(35)
Health & related workers
253
(23)
244
(19)
383
(30)
239
(21)
1119
(23)
Newspaper/Magazine
269
(24)
255
(20)
303
(24)
353
(31)
1180
(25)
Hoardings/Posters etc
100
(9)
204
(16)
113
(9)
133
(12)
550
(11)
Radio
135
(12)
112
(9)
153
(12)
184
(16)
584
(12)
PREFERRED SOURCE OF TB RELATED INFORMATION* Hospital/Doctors
827
(74)
514
(40)
752
(59)
472
(42)
2565
(53)
Television
611
(54)
540
(42)
877
(69)
914
(81)
2942
(61)
Newspaper/Magazine
228
(20)
245
(19)
321
(25)
382
(34)
1176
(24)
Hoardings/Posters etc
99
(9)
146
(11)
164
(13)
170
(15)
579
(12)
Local health workers
237
(21)
433
(34)
396
(31)
234
(21)
1300
(27)
Health camps
139
(12)
176
(14)
80
(6)
333
(30)
728
(15)
Friends & relatives
373
(33)
504
(39)
345
(27)
186
(17)
1408
(29)
Teachers
92
(8)
46
(4)
26
(2)
44
(4)
208
(4)
1123
(100)
1279
(100)
1280
(100)
1122
(100)
4804
Total
25
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
in the south (only 17% prefer TB-related information from friends and relatives); word-of-mouth sources of information are respected. It is curious that there is a fairly low level of preference vis a vis hospitals and doctors as source of TB related information in the south and the east (42% and 40%), respectively, compared with higher preference for doctors and hospitals in the north (74%) and west (59%) (Table 2.13). Only 7% of the respondents said that some one visited their locality or community to talk about TB. Of these individuals, only 293 knew who had visited (Table 2.17). 83% of these mentioned a health worker visiting. Mostly the information provided includes prevention, cure and treatment of TB. Areas like myths or misconceptions around TB are not addressed generally. TABLE 2.17: Respondents reply to ‘visit’ by any individual to provide information regarding TB and the information shared by those who visited North
%
East
%
West
%
South
%
Total
%
56
(5)
316
(6)
DID ANYBODY VISIT YOUR LOCALITY TO DISCUSS TB RELATED INFORMATION? Yes
31
(3)
58
(5)
171
(13)
No
1035
(92)
1167
(91)
1076
(84)
889
(79)
4167
(87)
57
(5)
54
(4)
33
(3)
177
(16)
321
(7)
Don't know Total
1123
(100) 1279
(100) 1280
(100) 1122
(100)
4804
IF YES, WHO VISITED? AWW/ASHA/HW/ANM
21
(75)
41
(85)
156
(96)
28
(52)
246
(84)
Government doctor
3
(11)
4
(8)
4
(2)
25
(46)
36
(12) (4)
Private doctor
4
(14)
3
(6)
3
(2)
1
(2)
11
Total
28
(100)
48
(100)
163
(100)
54
(100)
293
TYPE OF INFORMATION PROVIDED Symptoms of TB
2
(6)
5
(9)
4
(2)
3
(6)
14
(4)
Prevention from TB
8
(26)
8
(14)
30
(18)
21
(40)
67
(21)
Cure for TB
5
(16)
13
(22)
54
(32)
12
(23)
84
(27)
DOTS
7
(23)
6
(10)
10
(6)
3
(6)
26
(8)
Place of treatment
4
(13)
26
(45)
54
(32)
14
(26)
98
(31)
Information on prevailing myths about TB patients
5
(16)
0
(0)
18
(11)
0
(0)
23
(7)
Total
31
(100)
58
(100)
170
(100)
53
(100)
312
Summary of Key Indicators of Knowledge about TB Low DOTS awareness (26%) at the all-India level suggests that greater efforts could be coupled with sharing information publicly that it is already free (only 23% of respondents know). This would increase the reach and the effectiveness of this clearly important national programme. There is very high awareness in the west about the fact that DOTS treatment is free (33%) as compared to the south, where only 5% know the same. There is generally high awareness at all-India level that a cough of over 2 weeks is a key symptom of TB (81%). There is a significant lack in the awareness on the treatment duration which also needs special advocacy measures.
26
Chapter 2 Results: General Population
TABLE 2.18: Summary of key indicators of knowledge about TB among respondents who heard of TB from general population interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
Heard of TB
990
(88)
1182
(92)
1130
(88)
909
(81)
4211
(88)
Know that cough of over 2 weeks is a key symptom for TB
849
(86)
803
(68)
1018
(90)
751
(83)
3421
(81)
Know that TB is caused by bacteria/germ transmits through air
742
(75)
778
(66)
845
(75)
608
(67)
2973
(71)
Know that TB can be diagnosed by sputum test
609
(62)
769
(65)
825
(73)
561
(62)
2764
(66)
Know that TB is curable
876
(88)
986
(83)
974
(86)
669
(74)
3505
(83)
Know that the duration of TB treatment is 6-8 months
444
(45)
525
(44)
654
(58)
405
(45)
2028
(48)
Heard of DOTS
222
(22)
320
(27)
413
(37)
132
(15)
1087
(26)
Know that TB treatment is free under DOTS
201
(20)
272
(23)
368
(33)
116
(13)
957
(23)
Total Respondents
990
1182
1130
27
909
4211
Summary Results: General Population Demographic Profile
• 54% in the age group between 26-45 years • One third (31%) of the respondents are either illiterate or
• 65,209 households line listed, 3,14,913 population covered
have no formal education
& 4,804 interviewed
• Over one-third (39%) of all respondents are wage-labourers
• Respondents from rural areas 3,360; from tribal areas 639
and cultivators
74
South West East
58
62
62 65
67
73
75
75 66
68
80
60
Heard of DOTS
Know that the duration of TB treatment is 6-8 months
Know that TB is curable
Know that TB can be diagnosed by sputum test
Know that TB is caused by bacteria/germ transmits through air
Heard of TB
0
Know that cough of over 2 weeks is a key symptom for TB 86
23 13
20
Know that TB treatment is free under DOTS 20
15
22
23
27
40
33
37
45
North 45 44
Percentage
88 83 86
90 83 81
81
100
88 92 88
Knowledge about TB
Key knowledge indicators • • • • •
88% of the respondents heard of TB 81% of the respondents knew “cough of over 2 weeks” as key symptom for TB 71% of the respondents knew that mode of TB transmission is through air Only about half (48%) knew the correct duration of TB treatment (6-8 months) Only 23% of the respondents heard of DOTS
Attitudes towards TB disease and TB patients 100
Percentage
80
79 68
65
61
60 40
31
20 0
North
East
West
South
Consider TB as a serious disease
Total
Attitudes of respondents towards TB disease • 70% consider TB a serious disease • 83% consider TB curable • 17% of them do not know that TB is completely curable • 31% perceive that they can get TB
South
Knowledge about the people who are prone to TB
58
West
52
East
59
North
60
• About 50% opined that smokers and people ‘exposed to cough and cold for long time’ are prone to TB • Only 24% gave the opinion that alcoholics are also prone to TB • Less than 10% were aware that malnourished, children, women and HIV positives are more prone to TB
38 35
37 37
28
27 23 Malnourished
17 3
5
4 5
8
Poor people
3
4 People living in unhygienic conditions
Women & Children
Family members of TB person
Exposed to cough and cold for long time
HIV +ve
Alcholics
South
36 37 29
36
24
28
36
West
47 45
43
48
East
North
53
60
19
10 5
7
8 5
6
7
6
5
1
4 3
9
12
14
13 13
15
16
24
20 18
Percentage
Smokers
60
0
14
15 17 11
13
11
8
12
20 20
20 20
22 13
24
28
32
Percentage
36
41 40 38
48
0
Most people Most people Community Husbands/inFemale Females No change Don't know reject him/her are friendly mostly helps laws do not accompany suffering from in the reaction but generally and support accompany their spouce TB face avoid them him/her female patients to hospitals problem in to hospital/ suffering from marriage DOTS centres TB to hospital /DOTS centres
Opinion on how TB patients are treated in the community • Nearly half (46%) feel that people are friendly with TB patients but generally avoid them • A quarter of them (25%) say that people in their communities mostly reject TB patients • 41% said that in their communities mostly people help and support TB patients • Only about one tenth of people feel that female TB patients face problems in marriage
Practices of respondents towards TB patients
88
95
92
100
92
Practices towards TB patients & TB Disease
North
East
West
South
Share a meal Taking female TB Marry your daughter Isolate your family with person you suspect of the to a boy knowing member having TB know had TB family to the hospital he had TB in the house
12 7
5
5
13
14
15
14
16
5
5
0
14
15
19 9
11
20
32
35
40
32
60
20
Percentage
80
Marry your son to a girl who you know had TB
Send your daughter in law to parent's house if she had TB in order to protect other family members from TB
• A large majority (76%) said that they would not share a meal with TB patients • Most of them will take a female member in the family suffering from TB like symptoms to the hospital (92%) • 79% would not get their sons or daughters married to a person who they knew had TB
Conclusion • Low DOTS awareness (23%) at the all-India level suggests that greater efforts could be coupled with sharing information publicly that it is already free • There is generally high awareness across the country that a cough of over 2 weeks is a key symptom of TB (81%) • There is a significant lack in the awareness on the treatment duration which needs special advocacy measures.
CHAPTER
3 Results: TB Patients
A total of 631 TB patients were identified during the household listing process. However, 135 (21%) could not be interviewed due to non-availability of patients during the time of home visits and/or unwillingness to participate in the survey. Hence, total study population is 496.
Demographic Profile The data here presents a clear and explicitly survey-specific picture of the average TB patients identified and interviewed for the KAP survey. The distribution of TB patients across the states surveyed is equivalent to India’s rural: urban ratio (3:1), this was taken to be representative of the country. The distribution is also limited by the population proportionate random sampling of number of districts from different zones and states.
Geography The state with highest number of TB patients in our survey is Bihar (N=105) followed by Madhya Pradesh (N=77) and Kerala (N=57) (Table 3.1). Based on the type of their settlements, TB appears to be an overwhelmingly rural disease. The two states where this is the exception is Mizoram (75% urban) and Maharashtra (100% urban). In four states (Haryana, Chhattisgarh, Andhra Pradesh and Bihar) over 90% of TB patients are in rural areas.
Gender and Age Most TB patients are male (61%). 40% of the TB patients are between 26 and 45, while 43% of the patients are aged above 43. In the south zone 57% are above 46 years. Together, this accounts for TABLE 3.1: Distribution of TB patients identified from the household line-listing process during midline KAP survey, 2013 Rural
%
Urban
%
Total
%
Andhra Pradesh
10
(3)
0
(0)
10
(2)
Bihar
96
(26)
9
(7)
105
(21)
Chhattisgarh
7
(2)
0
(0)
7
(1)
Haryana
53
(14)
0
(0)
53
(11)
Karnataka
11
(3)
1
(1)
12
(2)
Kerala
43
(12)
14
(11)
57
(11)
Maharashtra
0
(0)
12
(9)
12
(2)
Mizoram
7
(2)
21
(17)
28
(6)
Orissa
13
(4)
9
(7)
22
(4)
Punjab
6
(2)
2
(2)
8
(2)
Rajasthan
3
(1)
1
(1)
4
(1)
Tamil Nadu
18
(5)
9
(7)
27
(5)
Uttar Pradesh
38
(10)
12
(9)
50
(10)
West Bengal
16
(4)
8
(6)
24
(5)
Madhya Pradesh
48
(13)
29
(23)
77
(16)
Total
369
(100)
127
(100)
496
30
Chapter 3 Results: TB Patients
nearly 83% of the working population –which clearly portends poorly at the aggregate, all-India level (Table 3.2). TABLE 3.2: Socio-demographic characteristics of the TB patients identified and interviewed in the midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
SEX Male
69
(62)
102
(57)
65
(65)
66
(62)
302
(61)
Female
42
(38)
77
(43)
35
(35)
40
(38)
194
(39)
AGE GROUP* 18-25 yrs
15
(14)
24
(13)
17
(17)
5
(5)
61
(12)
26-35yrs
24
(22)
40
(22)
18
(18)
15
(14)
97
(20)
36-45yrs
24
(22)
32
(18)
19
(19)
24
(23)
99
(20)
46+
45
(41)
69
(39)
40
(40)
60
(57)
214
(43)
Illiterate
43
(39)
80
(45)
29
(29)
15
(14)
167
(34)
Literate but no formal education
14
(13)
7
(4)
17
(17)
14
(13)
52
(10)
Less than primary
11
(10)
23
(13)
16
(16)
15
(14)
65
(13)
Primary
20
(18)
43
(24)
10
(10)
24
(23)
97
(20)
Secondary
15
(14)
18
(10)
18
(18)
29
(27)
80
(16)
Senior secondary
5
(5)
6
(3)
8
(8)
3
(3)
22
(4)
Graduation and above
3
(3)
1
(1)
2
(2)
2
(2)
8
(2)
Married
87
(78)
123
(69)
79
(79)
91
(86)
380
(77)
Unmarried
15
(14)
34
(19)
11
(11)
7
(7)
67
(14)
Widowed
9
(8)
18
(10)
8
(8)
6
(6)
41
(8)
Not applicable
0
(0)
4
(2)
2
(2)
2
(2)
8
(2)
Wage labour
22
(20)
42
(23)
25
(25)
32
(30)
121
(24)
Skilled labour
4
(4)
2
(1)
4
(4)
12
(11)
22
(4)
Self employed
7
(6)
2
(1)
9
(9)
3
(3)
21
(4)
Service (govt. and private)
1
(1)
7
(4)
1
(1)
5
(5)
14
(3)
Business
4
(4)
3
(2)
1
(1)
6
(6)
14
(3)
Agriculture/Cultivator
25
(23)
20
(11)
20
(20)
5
(5)
70
(14)
Unemployed
13
(12)
24
(13)
14
(14)
14
(13)
65
(13)
Housewife
30
(27)
55
(31)
19
(19)
24
(23)
128
(26)
Student
4
(4)
15
(8)
7
(7)
3
(3)
29
(6) (2)
EDUCATION*
MARITAL STATUS**
OCCUPATION
Other
1
(1)
6
(3)
0
(0)
1
(1)
8
Total
111
(100)
179
(100)
100
(100)
106
(100)
496
* Percentages do not add up to 100 as other groups like missing/not recorded are not included in the table ** Percentages exceed 100, due to rounding up to zero decimals
31
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Education and Marital Status In terms of educational profile, the low socio-economic status is clear: 44% of the identified TB patients are illiterate or have no formal education, nearly 55% had some schooling (primary, secondary or senior-secondary education). The majority of them are married (77%) In this survey, 26% of the identified TB patients are housewives. This may be attributed to indoor air pollution (smoke from firewood or other harmful cooking fuels and second-hand smoking) especially in rural settings. Infection control measures need to be strengthened within the families and members should be encouraged to be proactive health seekers.
Occupation In terms of economic or sectoral origin, more than half of the TB patients are either daily wage labourers or agriculture workers (51%). There are significant zonal variations in occupation. For example, the proportion of daily wage laborers is highest in the south (30%) whereas agriculture workers or cultivators are the least in the south zone. South zone also has a larger number of TB patients who are skilled workers. This distribution is more homogenous in other zones. It is noticeable that around 13% of TB patients are unemployed which is almost uniform across the zones. Whether this is due to their disease condition or other factors is not clear. If it is due to their disease condition, then the question arises whether it is due to poor health that they left their work or they were removed by the employer. However this is beyond the scope of this survey.
Household Characteristics Housing
As with other studies, this survey accentuates the clearly low socio-economic profile of the average TB patient in India. Beginning with the positive, it is heartening to note that most TB patients live in at least semi-pucca (37%) or pucca houses (33%) – accounting for at least 70% of TB patients in decent to good housing conditions (Table 3.3) However in the east and west zone, majority of them live in kutcha houses (44% and 42% respectively).
Drinking Water
A high degree of spatial variation regarding access to drinking water is observed. In the north, 47% of the TB patients identified have their own private taps; in the east, TB patients access water through tube wells (22%) and/or private pumps (34%), in the south, public taps (44%) supplement private taps (41%) while in the western region, public sources of water dominate: public hand pumps (32%) and public taps (27%).
Cooking Fuel
With regard to cooking fuel, unfortunately, it is quite clear that most TB patients do not have access to clean sources of fuel. Overall biomass sources dominate all sources of fuel supply: wood (69%) followed by dung cakes (20%). However, it is encouraging to note that LPG and natural gas are accessed by at least 25% of the TB patients. Almost none of the TB patients (1% only in the south, and 0% in the north and the east) accessed electricity for cooking. These figures clearly correlate biomass fuel sources and primitive combustion technologies with an increased risk of TB. Therefore, clean cooking fuel for TB patients must be actively advocated.
32
Chapter 3 Results: TB Patients
TABLE 3.3: Household characteristics of the TB patients identified and interviewed in the midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
TYPE OF HOUSE Pucca
47
(42)
40
(22)
27
(27)
51
(48)
165
(33)
Semi-pucca
48
(43)
60
(34)
31
(31)
45
(42)
184
(37) (29)
Kutcha
16
(14)
78
(44)
42
(42)
9
(8)
145
Total
111
(100)
179
(100)
100
(100)
106
(100)
496
SOURCE OF DRINKING WATER Private tap
52
(47)
6
(3)
17
(17)
43
(41)
118
(24)
Private hand pump
23
(21)
61
(34)
11
(11)
1
(1)
96
(19)
Public tap
10
(9)
30
(17)
27
(27)
47
(44)
114
(23)
Public hand pump
22
(20)
28
(16)
32
(32)
1
(1)
83
(17)
Tube well
4
(4)
40
(22)
2
(2)
1
(1)
47
(9)
Supply tanker
0
(0)
2
(1)
0
(0)
0
(0)
2
(0)
Well/River/Pond
0
(0)
4
(2)
9
(9)
12
(11)
25
(5)
Other
0
(0)
6
(3)
0
(0)
0
(0)
6
(1)
Total
111
(100)
179
(100)
100
(100)
106
(100)
496
TYPE OF COOKING FUEL Electricity
0
(0)
0
(0)
3
(3)
1
(1)
4
(1)
Wood
76
(68)
124
(69)
67
(67)
75
(71)
342
(69)
Coal/Lignite
1
(1)
2
(1)
1
(1)
3
(3)
7
(1)
Kerosene
0
(0)
1
(1)
2
(2)
1
(1)
4
(1)
LPG/Natural gas
13
(12)
31
(17)
23
(23)
55
(52)
122
(25)
Charcoal
0
(0)
1
(1)
0
(0)
1
(1)
2
(0)
Bio-gas
1
(1)
0
(0)
1
(1)
1
(1)
3
(1)
Dung cakes
28
(25)
69
(39)
2
(2)
0
(0)
99
(20)
Agricultural crop waste
9
(8)
22
(12)
0
(0)
0
(0)
31
(6)
Straw/Shrubs/ Grass
3
(3)
48
(27)
0
(0)
0
(0)
51
(10)
Total Respondents
111
179
100
Household Assets
106
496
The data on household assets owned by TB patients suggests improved conditions of basic living: 81% of the patients had access to electricity, possessed their own basic furniture: mattresses (63%), chairs (74%) cot or bed (82%) and a fan (62%) (Table 3.4). Mobile ownership is high (73%) with south zone having the lowest percentage of mobile phone ownership (58%) – an interesting anomaly considering other overall indicators of economic development. However, the south dominates in terms of TB patients having access to motorised means of transport (46% of patients owned either a motorbike or scooter) while in the north and the west, most owned a bicycle (55% and 64%, respectively).
33
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TABLE 3.4: Household assets of the TB patients identified and interviewed in the midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
HOUSEHOLD ASSETS* Electricity
87
(78)
124
(69)
87
(87)
105
(99)
403
(81)
Mattress
87
(78)
81
(45)
67
(67)
77
(73)
312
(63)
Pressure cooker
62
(56)
70
(39)
51
(51)
61
(58)
244
(49)
Chair
72
(65)
121
(68)
74
(74)
99
(93)
366
(74)
A cot or bed
111
(100)
133
(74)
84
(84)
81
(76)
409
(82)
A table
58
(52)
81
(45)
48
(48)
76
(72)
263
(53)
Fan
75
(68)
70
(39)
66
(66)
98
(92)
309
(62)
Radio
12
(11)
17
(9)
20
(20)
19
(18)
68
(14)
A black & white television
11
(10)
19
(11)
7
(7)
2
(2)
39
(8)
A colour television
58
(52)
56
(31)
62
(62)
99
(93)
275
(55)
A sewing machine
34
(31)
26
(15)
21
(21)
12
(11)
93
(19)
A mobile telephone
89
(80)
129
(72)
84
(84)
62
(58)
364
(73)
Land line
0
(0)
5
(3)
2
(2)
11
(10)
18
(4)
A computer/laptop
0
(0)
9
(5)
4
(4)
6
(6)
19
(4)
A refrigerator
13
(12)
26
(15)
17
(17)
23
(22)
79
(16)
A watch or clock
90
(81)
118
(66)
89
(89)
99
(93)
396
(80)
A bicycle
69
(62)
97
(54)
64
(64)
45
(42)
275
(55)
A motorcycle or scooter
25
(23)
17
(9)
23
(23)
49
(46)
114
(23)
An animal drawn cart
6
(5)
13
(7)
10
(10)
1
(1)
30
(6)
A car
1
(1)
13
(7)
0
(0)
4
(4)
18
(4)
Water pump
18
(16)
22
(12)
9
(9)
8
(8)
57
(11)
A thresher
2
(2)
2
(1)
1
(1)
0
(0)
5
(1)
A tractor
5
(5)
0
(0)
4
(4)
0
(0)
9
(2)
STANDARD OF LIVING INDEX (SLI) Low SLI
28
(25)
99
(55)
28
(28)
12
(11)
167
(34)
Medium SLI
44
(40)
45
(25)
46
(46)
52
(49)
187
(38)
High SLI
39
(35)
35
(20)
26
(26)
42
(40)
142
(28)
Less than Rs. 2000
15
(14)
23
(13)
23
(23)
14
(13)
75
(15)
Rs 2001 - 4000
48
(43)
72
(40)
39
(39)
24
(23)
183
(37)
Rs 4001 - 8000
34
(31)
47
(26)
20
(20)
19
(18)
120
(24)
Rs 8001 - 10000
6
(5)
10
(6)
5
(5)
27
(26)
48
(10)
Rs 10000+
1
(1)
12
(7)
3
(3)
18
(17)
34
(7)
Can't say
7
(6)
15
(8)
10
(10)
2
(2)
34
(7)
HOUSEHOLD INCOME
* Multiple response question
34
Chapter 3 Results: TB Patients
Standard of Living Index
The national data for the standard of living index (SLI) suggests an equal distribution across low, medium and high standard of living with about a third in each segment with majority in medium SLI. However, the majority of patients from the east zone are from low SLI (55%). 52% of all TB patients live on lesser than Rs 4000 a month. Interestingly 26% of patients from the south live on an income between Rs 8000- 10,000 per month, which is highest amongst all zones.
Knowledge about TB Awareness about what Causes TB
Less than half of the TB patients knew the cause of TB across sexes and all age groups while a noticeable proportion of patients irrespective of literacy did not know the cause of TB (Table 3.5). Greater proportion of TB patients in high income group knew the cause of TB (40%). The level TABLE 3.5: Awareness about causes of TB among TB patients interviewed during midline KAP survey, 2013 Micro organism/ germs
%
Other cause
%
Don’t know
%
Not recorded
%
Total
%
SEX Male
141
(47)
24
(8)
130
(43)
7
(2)
302
(100)
Female
78
(40)
16
(8)
98
(51)
2
(1)
194
(100)
AGE GROUP 25-54 Years
124
(45)
24
(9)
120
(44)
5
(2)
273
(100)
55+ Years
72
(46)
11
(7)
70
(45)
3
(2)
156
(100)
Illiterate
57
(34)
11
(7)
97
(58)
2
(1)
167
(100)
Literate
159
(49)
28
(9)
130
(40)
7
(2)
324
(100)
LITERACY
MONTHLY HOUSEHOLD INCOME < 4000 Rs
97
(37)
25
(10)
131
(50)
7
(3)
260
(100)
>= 4000 Rs
107
(53)
13
(6)
80
(40)
2
(1)
202
(100)
Don't know
15
(44)
2
(6)
17
(50)
0
(0)
34
(100)
Tribal
37
(44)
13
(15)
32
(38)
3
(4)
85
(100)
Non-Tribal
182
(44)
27
(7)
196
(48)
6
(1)
411
(100)
DISTRICT TYPE
TYPE OF SETTLEMENT Rural
157
(43)
36
(10)
170
(46)
6
(2)
369
(100)
Urban
62
(49)
4
(3)
58
(46)
3
(2)
127
(100)
North
32
(29)
20
(18)
56
(50)
3
(3)
111
(100)
East
68
(38)
10
(6)
98
(55)
3
(2)
179
(100)
West
45
(45)
7
(7)
47
(47)
1
(1)
100
(100)
South
74
(70)
3
(3)
27
(25)
2
(2)
106
(100)
Total
219
(44)
40
(8)
228
(46)
9
(2)
496
ZONES
35
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
of awareness of cause of TB among the tribal and non-tribal TB patient was not different and awareness in urban TB patients was higher than the rural. The TB patients from the south zone are more literate than the other zones which might have influenced on the higher knowledge for the ‘cause of TB’.
Symptoms Experienced by TB Patients Prior to Diagnosis of TB
On an average, the majority of TB patients experienced cough as a symptom of TB (81%) and this is similar across all zones followed by fever (59%) (Table 3.6). The RNTCP strategy of case finding by screening patients with ‘cough for 2 weeks or more with or without others symptoms’ seems ideal as per the evidence seen in this survey. TABLE 3.6: Symptoms experienced by TB patients prior to diagnosis of TB among TB patients interviewed during midline KAP survey, 2013 North New TB patients
95
%
East
%
West
%
South
%
Total
%
(86)
135
(75)
82
(82)
83
(78)
395
(80)
MAJOR SYMPTOMS EXPERIENCED Cough
94
(85)
127
(71)
86
(86)
95
(90)
402
(81)
Fever
68
(61)
115
(64)
52
(52)
58
(55)
293
(59)
Chest pain
42
(38)
68
(38)
41
(41)
52
(49)
203
(41)
Blood in sputum
34
(31)
93
(52)
44
(44)
8
(8)
179
(36)
Weight loss
16
(14)
50
(28)
34
(34)
18
(17)
118
(24)
Total Respondents
111
179
100
106
496
Most of the TB patients had cough of more than 3 weeks (21%) in comparison with 2 weeks (9%) (Table 3.7). However, a noticeable proportion of patients had cough of 1 week (15%). Using the current strategy of identifying TB suspect will lose or delay the diagnosis in 15% of the TB cases. TABLE 3.7: Duration of cough and fever before diagnosis of TB among TB patients interviewed during midline KAP survey, 2013 Cough Duration
%
Fever Duration
%
DURATION IN WEEKS 1 week
90
18
75
15
2 weeks
47
9
34
7
3 weeks
102
21
57
11
4-6 weeks
42
8
27
5
7-10 weeks
7
1
11
2
11-20 weeks
10
2
2
0
Absence of corresponding symptom
198
40
290
58
Total
496
100
496
100
Health Seeking Behaviour of TB Patients Prior to Diagnosis
Overall, 73% of those who experience TB like symptoms seek health care between 1-30 days for their symptoms. Almost 11% of the patients who had TB symptoms for less than a week sought medical care (Table 3.8). Most of the TB patients (62%) with symptoms actively sought health
36
Chapter 3 Results: TB Patients
care after 1 week to 1 month. Noticeably higher proportion of the patients (85%) from the south zone seek early healthcare in comparison to other zones. Almost 26% of those with TB symptoms seek healthcare within 1-3 months. This is high risk behaviour and could play a key role in TB transmission. The health seeking behaviour in TB patients from north, east and west is less which correlates with the lower overall levels of education in these zones. Almost 53% of TB patients visit qualified practitioners and a higher proportion of patients visit Government practitioners or health providers (35%) as compared to private practitioners. TB patients from north and east zones mostly consulted qualified private doctors while TB patients from west and south seek healthcare from Government dispensaries. Almost 25% of the TB patients seek health care from unqualified providers. The level of awareness on the duration of TB symptoms and treatment services should be enhanced especially in the north, east and west zones so that they seek health care early from qualified health care providers in the Government sector. TABLE 3.8: Health seeking behaviour of TB patients prior to diagnosis of TB among TB patients interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
FIRST VISIT TO HEALTH SERVICE PROVIDER AFTER ONSET OF SYMPTOM* Less than a week
16
(14)
21
(12)
9
(9)
10
(9)
56
(11)
After a week to 14 days
46
(41)
50
(28)
30
(30)
54
(51)
180
(36)
15 days to a month
28
(25)
45
(25)
30
(30)
27
(25)
130
(26)
After a month to less than 2 months
11
(10)
27
(15)
14
(14)
7
(7)
59
(12)
2-3 Months
3
(3)
12
(7)
3
(3)
0
(0)
18
(4)
More than 3 months
2
(2)
13
(7)
9
(9)
2
(2)
26
(5)
Not visited/Don't remember
5
(5)
11
(6)
5
(5)
6
(6)
27
(5)
AFTER SYMPTOMS - WHOM DID YOU CONSULT ?* Qualified private doctor/ clinic
44
(40)
61
(34)
14
(14)
13
(12)
132
(27)
Govt dispensary/health centre
38
(34)
30
(17)
30
(30)
29
(27)
127
(26)
Unqualified healer in locality (quack)
15
(14)
20
(11)
19
(19)
0
(0)
54
(11)
Local health care provider
8
(7)
19
(11)
7
(7)
12
(11)
46
(9)
Chemist
16
(14)
24
(13)
1
(1)
5
(5)
46
(9)
Faith healer
3
(3)
6
(3)
1
(1)
13
(12)
23
(5)
111
(100)
179
(100)
100
(100)
106
(100)
496
Total
*Percentages do not add upto 100 as missing or not recorded values are not included in the table
37
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Place of Diagnosis, Number of Providers Visited and Duration of Symptoms before Diagnosis
A total of 71% of the respondents have heard of free diagnosis and treatment with highest proportions in west (83%) and lowest in east (59%). Of those who had heard of free diagnosis and treatment, 96% went to government facility for diagnosis (Table 3.9). From this it is very clear that knowledge plays a key role in taking health related decisions. 81% visit one or two providers before they are diagnosed with TB, with south being the highest (92%). 81% get diagnosed within one month of onset of symptoms with south again the highest (94%) and east being the least (70%). 28% in east get diagnosed after one month. This needs immediate attention. The delay in diagnosis has direct implication on continued transmission. TABLE 3.9: Place of diagnosis, number of providers visited and duration of symptoms before diagnosis of TB among TB patients interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
HEARD OF FREE DIAGNOSIS AND TREATMENT Yes
80
(72)
106
(59)
83
(83)
82
(77)
351
(71)
Govt health facility
75
(68)
100
(56)
81
(81)
81
(76)
337
(68)
Pvt health facility
0
(0)
5
(3)
5
(5)
2
(2)
12
(2)
Non-govt health facility
1
(1)
2
(1)
0
(0)
0
(0)
3
(1)
DOTS centre
0
(0)
2
(1)
1
(1)
0
(0)
3
(1)
PLACE OF DIAGNOSIS*
NUMBER OF PROVIDERS VISITED** 1 provider
47
(42)
86
(48)
59
(59)
85
(80)
277
(56)
2 providers
37
(33)
49
(27)
24
(24)
13
(12)
123
(25)
3 providers
22
(20)
39
(22)
13
(13)
5
(5)
79
(16)
5 providers
0
(0)
2
(1)
1
(1)
0
(0)
3
(1)
>5 providers
5
(5)
3
(2)
3
(3)
3
(3)
14
(3)
DURATION BETWEEN ONSET OF SYMPTOMS TO DIAGNOSIS** 1 month
13
(12)
51
(28)
17
(17)
6
(6)
87
(18)
Can't say
4
(4)
3
(2)
1
(1)
0
(0)
8
(2)
WAS THIS THE FIRST TIME YOU WERE DIAGNOSED WITH TB New
95
(86)
135
(75)
82
(82)
83
(78)
395
(80)
Previously treated
16
(14)
44
(25)
18
(18)
23
(22)
101
(20)
Total
111
(100)
179
(100)
100
(100)
106
(100)
496
*Percentages do not add to 100 as others, missing or not recorded values are not included in the table **Total percentages exceeds 100 due to rounding up to zero decimals
38
Chapter 3 Results: TB Patients
Treatment Initiation, Place of Treatment and Awareness on Treatment Duration
47% of the TB patients were started on treatment within one week and 43% were initiated on treatment more than a week after diagnosis (Table 3.10). Interestingly, east zone had highest proportion of people who were put on treatment within one week (52%) and least in the west (32%). This is an area that cannot be neglected. The reasons for the delay in initiation of treatment need to be ascertained and appropriate measures need to be taken to address it. Zone wise data reveals that in west 57% are initiated on treatment after one week, of this strikingly 32% are initiated on treatment at 3 weeks or later. In other zones this is 12-13%. The delay in treatment initiation suggests sustained transmission. TABLE 3.10: Treatment initiation, place of treatment and awareness on treatment duration among TB patients interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
TREATMENT INITIATION 1-3 days
43
(39)
77
(43)
19
(19)
27
(25)
166
(33)
4 days-1 week
11
(10)
17
(9)
13
(13)
26
(25)
67
(14)
>1-2 weeks
9
(8)
33
(18)
11
(11)
20
(19)
73
(15)
>2-3 weeks
18
(16)
14
(8)
14
(14)
10
(9)
56
(11)
>3 weeks
13
(12)
23
(13)
32
(32)
14
(13)
82
(17)
Can't say
0
(0)
1
(1)
0
(0)
0
(0)
1
(0)
Not recorded
17
(15)
14
(8)
11
(11)
9
(8)
51
(10)
Total
111
(100)
179
(100)
100
(100)
106
(100)
496
PLACE OF TREATMENT* AND REGULARITY Govt health centres, free of cost under DOTS
48
(43)
70
(39)
58
(58)
77
(73)
253
(51)
Govt health centres, with payment for medicines
11
(10)
5
(3)
11
(11)
7
(7)
34
(7)
Non-govt health centres, free of cost
1
(1)
0
(0)
1
(1)
3
(3)
5
(1)
Non-govt health centres, with payment for medicines
15
(14)
33
(18)
8
(8)
3
(3)
59
(12)
Self purchase
18
(16)
39
(22)
9
(9)
3
(3)
69
(14)
Aware that treatment has to be taken regularly
78
(70)
116
(65)
86
(86)
98
(92)
378
(76)
Less than 2 weeks
2
(2)
0
(0)
0
(0)
2
(2)
4
(1)
2-4 weeks
1
(1)
2
(1)
0
(0)
0
(0)
3
(1)
1-3 months
2
(2)
11
(6)
4
(4)
1
(1)
18
(4)
4-5 months
1
(1)
8
(4)
4
(4)
5
(5)
18
(4)
6-8 months
62
(56)
87
(49)
59
(59)
67
(63)
275
(55)
More than 8 months
29
(26)
55
(31)
26
(26)
26
(25)
136
(27)
Don't know
13
(12)
14
(8)
7
(7)
1
(1)
35
(7)
Total
219
(44)
40
(8)
228
(46)
9
(2)
496
DURATION OF TREATMENT
* Multiple response question
39
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Overall, only 59% are taking treatment under DOTS (free of cost), with the highest proportions from the south zone (76%) and least from east (39%). The maximum number of patients who pay for their medicines comes from east zone (43%) closely followed by north (40%) and west (29%). The east zone also shows the lowest proportions that were aware of TB treatment regularity and the correct duration of the treatment. These observations correlate with the providers they seek and their place of treatment, requiring special attention in east zone. Inspite of a strong TB control programme offering free TB diagnosis and treatment services with country-wide coverage, one third of TB patients (34%) are buying their own TB medicines, with inadequate treatment follow up, irrational regimens and high risk of drug-resistance. This is a major gap in which needs a systematic regulation of TB services outside the programme. Only 76% knew that TB treatment should be taken regularly and only 55% knew that the treatment duration as 6-8 months. Obviously, there appears to be a serious lack of communication of treatmentrelated information to the patient. There must be specific efforts to inform the patient about his/ her treatment details by the providers. The general health seeking behaviour suggests that 39% seek health care from the private sector (Table 3.11). This correlates with the observation that 34% take TB treatment outside DOTS programme. The major reason for seeking private health care is the distance from a government centre followed by long waiting hours. The private clinics/hospitals are usually close-by to the home i.e. easy access; this is clearly a very important factor especially during sickness. The long distance also means taking leave from work, which translates to loss of wages for daily wage workers who constitute the second largest group of patients in the study. General health seeking TABLE 3.11: General health seeking behaviour of TB patients interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
HEALTH SEEKING BEHAVIOUR* Govt hospital (including PHC, CHC)
41
(37)
80
(45)
63
(63)
85
(80)
269
(54)
Private clinic/ Private hospital
65
(59)
74
(41)
36
(36)
20
(19)
195
(39)
Ayurvedic health service providers
0
(0)
0
(0)
0
(0)
1
(1)
1
(0)
Traditional healer/ Quacks
1
(1)
6
(3)
0
(0)
0
(0)
7
(1)
REASON FOR NOT GOING TO GOVERNMENT CENTRES** Lack of diagnostic facility
9
(8)
14
(8)
6
(6)
1
(1)
30
(6)
Unfriendly behaviour of govt staff
3
(3)
9
(5)
2
(2)
9
(8)
23
(5)
Facility is far from home
40
(36)
41
(23)
9
(9)
7
(7)
97
(20)
Long waiting hours
18
(16)
28
(16)
12
(12)
6
(6)
64
(13)
Unavailability of doctors
9
(8)
18
(10)
8
(8)
8
(8)
43
(9)
Pvt clinics offer better services
11
(10)
20
(11)
7
(7)
3
(3)
41
(8)
* Percentages do not add upto 100 as ‘others’ not included in the table ** Multiple response by those who opted other than govt hospitals
40
Chapter 3 Results: TB Patients
behaviour of TB patients shows specific patterns which need to be understood and integrated into policy in the context of TB care.
Tobacco Use among TB Patients
All the respondents were asked whether they use tobacco in any form of which 175 respondents (35%) responded affirmatively. Further to this, among those respondents who use tobacco, 24% smoke, 36% use smokeless tobacco and 5% are dual users. Noticeably 35% did not respond to this question (Table 3.12). 49% of the tobacco users have been using tobacco for more than 10 years. A majority of the smokers use beedi and among those using smokeless tobacco, 55% chew tobacco. The median age of initiation for tobacco use is 20 years. Though there was a fair knowledge about TB and tobacco linkage, and 73% were advised to quit using tobacco during their visits to the hospital however they continue to use tobacco even till the time the survey was conducted. Over and above their own use, 32% are further exposed to second hand smoke. The co-morbidity of TB and tobacco has been well established. However, the efforts to help TB patients quit using tobacco are still poor. Awareness among the health service providers to advise TB patients about quitting tobacco by explaining the harmful effects and the dangers especially during the treatment should be an absolute must. At the same time, the required support systems like cessation centres accessible to the patients either in their communities or in the hospitals must be established. TABLE 3.12: Tobacco use among TB patients interviewed during the midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
DO YOU CURRENTLY USE TOBACCO? Missing
0
(0)
0
(0)
0
(0)
1
(1)
1
(0)
Yes, using Tobacco
34
(31)
74
(40)
38
(41)
29
(27)
175
(35)
No, not using Tobacco
75
(68)
105
(56)
53
(57)
74
(70)
307
(62)
Not applicable
2
(2)
7
(4)
2
(2)
2
(2)
13
(3)
111
(100)
186
(100)
93
(100)
106
(100)
496
Total
IF YES, TYPE OF TOBACCO CURRENTLY USE No response
9
(26)
26
(35)
16
(42)
11
(38)
62
(35)
Smoke
16
(47)
16
(22)
8
(21)
2
(7)
42
(24)
Smokeless
9
(26)
28
(38)
11
(29)
15
(52)
63
(36)
Both
0
(0)
4
(5)
3
(8)
1
(3)
8
(5)
Total
34
(100)
74
(100)
38
(100)
29
(100)
175
IF YES, FOR HOW LONG HAVE YOU BEEN USING TOBACCO No response
6
(18)
8
(11)
3
(8)
16
(55)
33
(19)
less than 1 year
0
(0)
1
(1)
7
(18)
1
(3)
9
(5)
1-3 Years
12
(35)
6
(8)
6
(16)
0
(0)
24
(14)
4-10 Years
3
(9)
11
(15)
6
(16)
3
(10)
23
(13)
>10 Years
13
(38)
48
(65)
16
(42)
9
(31)
86
(49)
Total
34
(100)
74
(100)
38
(100)
29
(100)
175
Contd...
41
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
North
%
East
%
West
%
South
%
Total
%
DO YOU KNOW THE ASSOCIATION BETWEEN SMOKING AND TB DISEASE No response
7
(21)
5
(7)
3
(8)
14
(48)
29
(17)
Yes
17
(50)
26
(35)
14
(37)
10
(34)
67
(38)
No
10
(29)
43
(58)
21
(55)
5
(17)
79
(45)
Total
34
(100)
74
(100)
38
(100)
29
(100)
175
DO YOU KNOW SMOKING INCREASES THE RISK OF DEVELOPING TB DISEASE No response
6
(18)
5
(7)
3
(8)
14
(48)
28
(16)
Yes
21
(62)
42
(57)
24
(63)
11
(38)
98
(56)
No
7
(21)
27
(36)
11
(29)
4
(14)
49
(28)
Total
34
(100)
74
(100)
38
(100)
29
(100)
175
ARE YOU AWARE THAT SMOKING DAMAGES THE DEFENCE MECHANISMS No response
5
(15)
5
(7)
4
(11)
14
(48)
28
(16)
Yes
22
(65)
39
(53)
24
(63)
12
(41)
97
(55)
No
7
(21)
30
(41)
10
(26)
3
(10)
50
(29)
Total
34
(100)
74
(100)
38
(100)
29
(100)
175
ARE YOU AWARE OF THE CONSEQUENCES IF YOU CONTINUE TO SMOKE DURING TREATMENT No response
5
(15)
4
(5)
4
(11)
14
(48)
27
(15)
Yes
19
(56)
31
(42)
23
(61)
11
(38)
84
(48)
No
10
(29)
39
(53)
11
(29)
4
(14)
64
(37)
Total
34
(100)
74
(100)
38
(100)
29
(100)
175
DURING YOUR VISIT TO A DOCTOR/HEALTH CARE PROVIDER WERE YOU ADVISED TO QUIT SMOKING/USING TOBACCO? No response
5
(15)
5
(7)
3
(8)
14
(48)
27
(15)
Yes
28
(82)
57
(77)
28
(74)
15
(52)
128
(73)
No
1
(3)
12
(16)
7
(18)
0
(0)
20
(11)
Total
34
(100)
74
(100)
38
(100)
29
(100)
175
ARE YOU EXPOSED TO SECOND-HAND SMOKE (PASSIVE SMOKING) No response
5
(15)
5
(7)
3
(8)
13
(45)
26
(15)
Yes
7
(21)
33
(45)
15
(39)
1
(3)
56
(32)
No
22
(65)
36
(49)
20
(53)
15
(52)
93
(53)
Total
34
(100)
74
(100)
38
(100)
29
(100)
175
DO YOU KNOW ITS HARMFUL EFFECTS ON YOU AS A TB PATIENT No response
19
(56)
24
(32)
14
(37)
23
(79)
80
(46)
Yes
10
(29)
32
(43)
20
(53)
4
(14)
66
(38)
No
5
(15)
18
(24)
4
(11)
2
(7)
29
(17)
Total
34
(100)
74
(100)
38
(100)
29
(100)
175
42
Chapter 3 Results: TB Patients
Experiences of Stigma and Discrimination
Most of the TB patients (95%) shared about their disease status with their families/households and almost everyone experienced supportive behaviour from their families (Table 3.13). However only 60% of them informed their disease status their friends of which 24% experienced discriminatory practices (like not shaking hands, not entering one’s house and not sharing meals) from their friends. Of those who were married, 15% experienced discriminatory behaviour from their partners. Nearly half (46%) believe that both male and female patients suffer equally in the communities, however when it comes to getting married, a female TB patients have less prospects when compared to male TB patients. Regarding to their work, only 17% shared their disease status with their employers of which 34% had to change their work after sharing their status. TABLE 3.13: Experiences of stigma and discrimination among TB patients interviewed during the midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
INFORMED ABOUT YOUR DISEASE STATUS TO YOUR HOUSEHOLD/FAMILY Missing
0
(0)
0
(0)
0
(0)
1
(1)
1
(0)
Yes
102
(92)
179
(96)
91
(98)
97
(92)
469
(95)
No
5
(5)
5
(3)
2
(2)
5
(5)
17
(3)
Do not want to answer
3
(3)
2
(1)
0
(0)
2
(2)
7
(1)
Not applicable
1
(1)
0
(0)
0
(0)
1
(1)
2
(0)
111
(100)
186
(100)
93
(100)
106
(100)
496
Total
IF YES THEN HOW DO YOU RATE THEIR REACTION? Missing
0
(0)
0
(0)
0
(0)
1
(1)
1
(0)
Supportive
94
(92)
174
(97)
88
(97)
97
(99)
453
(96)
Not supportive
3
(3)
4
(2)
1
(1)
0
(0)
8
(2)
Do not want to answer
5
(5)
1
(1)
2
(2)
0
(0)
8
(2)
102
(100)
179
(100)
91
(100)
98
(100)
470
Total
IF NO, WHY DID YOU NOT INFORM THEM? Missing
0
(0)
1
(20)
0
(0)
3
(60)
4
(24)
Fear
4
(80)
3
(60)
1
(50)
0
(0)
8
(47)
Discrimination
1
(20)
1
(20)
1
(50)
2
(33)
5
(29)
Total
5
(100)
5
(100)
2
(100)
5
(100)
17
HAVE YOU INFORMED YOUR DISEASE STATUS TO YOUR FRIENDS. Missing
0
(0)
0
(0)
0
(0)
2
(2)
2
(0)
Yes
57
(51)
136
(73)
70
(75)
35
(33)
298
(60)
No
50
(45)
44
(24)
23
(25)
67
(63)
184
(37)
Do not want to answer
4
(4)
6
(3)
0
(0)
2
(2)
12
(2)
111
(100)
186
(100)
93
(100)
106
(100)
496
Total
Contd...
43
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
North
%
East
%
West
%
South
%
Total
%
IF YES, DID YOU EXPERIENCE ANY DISCRIMINATION FROM YOUR FRIENDS Missing
0
(0)
0
(0)
0
(0)
1
(3)
1
(0)
Yes
18
(32)
27
(20)
13
(19)
14
(38)
72
(24)
No
38
(67)
108
(79)
57
(81)
20
(54)
223
(74)
Do not want to answer
1
(2)
1
(1)
0
(0)
2
(5)
4
(1)
Total
57
(100)
136
(100)
70
(100)
37
(100)
300
IF MARRIED, DID YOU SEE ANY DISCRIMINATORY CHANGE IN THE RELATIONSHIP WITH YOUR PARTNER? Missing
3
(3)
8
(6)
1
(1)
3
(3)
15
(4)
Yes
20
(23)
7
(5)
23
(30)
7
(8)
57
(15)
No
52
(60)
107
(82)
46
(61)
78
(86)
283
(74)
Do not want to answer
12
(14)
8
(6)
6
(8)
3
(3)
29
(8)
Total
87
(100)
130
(100)
76
(100)
91
(100)
384
IN YOUR COMMUNITY, DO YOU THINK THAT IF A BOY HAS TB, WILL HE GET MARRIED Missing
0
(0)
2
(1)
1
(1)
4
(4)
7
(1)
Yes
28
(25)
114
(61)
49
(53)
58
(55)
249
(50)
No
77
(69)
50
(27)
33
(35)
25
(24)
185
(37)
Do not want to answer
6
(5)
20
(11)
10
(11)
19
(18)
55
(11)
111
(100)
186
(100)
93
(100)
106
(100)
496
Total
IN YOUR COMMUNITY, DO YOU THINK THAT IF A GIRL HAS TB WILL SHE GET MARRIED? Missing
0
(0)
2
(1)
0
(0)
4
(4)
6
(1)
Yes
28
(25)
112
(60)
50
(54)
55
(52)
245
(49)
No
80
(72)
63
(34)
35
(38)
25
(24)
203
(41)
Do not want to answer
3
(3)
9
(5)
8
(9)
22
(21)
42
(8)
111
(100)
186
(100)
93
(100)
106
(100)
496
Total
IN YOUR COMMUNITY, WHO DO YOU THINK SUFFER MORE MALE OR FEMALE TB PATIENTS? Missing
0
(0)
0
(0)
0
(0)
2
(2)
2
(0)
Males
8
(7)
19
(10)
10
(11)
26
(25)
63
(13)
Females
21
(19)
25
(13)
7
(8)
12
(11)
65
(13)
Both suffer equally
48
(43)
70
(38)
55
(59)
56
(53)
229
(46)
Do not know
28
(25)
69
(37)
19
(20)
10
(9)
126
(25)
No one suffers
6
(5)
3
(2)
2
(2)
0
(0)
11
(2)
111
(100)
186
(100)
93
(100)
106
(100)
496
Total
Contd...
44
Chapter 3 Results: TB Patients
North
%
East
%
West
%
South
%
Total
%
IF THE PERSON IS EMPLOYED, DID YOU SHARE YOUR DISEASE STATUS WITH YOUR EMPLOYER? Missing
10
(9)
25
(13)
1
(1)
20
(19)
56
(11)
Yes
15
(14)
29
(16)
30
(32)
12
(11)
86
(17)
No
19
(17)
58
(31)
31
(33)
42
(40)
150
(30)
Do not want to answer
8
(7)
6
(3)
6
(6)
2
(2)
22
(4)
Not applicable
59
(53)
68
(37)
25
(27)
30
(28)
182
(37)
Total
111
(100)
186
(100)
93
(100)
106
(100)
496
DID YOU HAVE TO CHANGE YOUR EMPLOYMENT BECAUSE OF YOUR DISEASE STATUS? Missing
19
(17)
25
(13)
5
(5)
21
(20)
70
(14)
Yes
9
(8)
4
(2)
8
(9)
8
(8)
29
(6)
No
22
(20)
77
(41)
52
(56)
47
(44)
198
(40)
Do not want to answer
13
(12)
12
(6)
8
(9)
0
(0)
33
(7)
Not applicable
48
(43)
68
(37)
20
(22)
30
(28)
166
(33)
Total
111
(100)
186
(100)
93
(100)
106
(100)
496
Existing and Preferred Source of TB Related Information
Regarding the source of TB-related information most of the surveyed TB patients (59%) responded that hospital/doctor was their key source of TB related information, followed by television (48%) and friends/relatives (35%) (Table 3.14). Further, they prefer the same sources of information to receive any TB related information in future. These observations suggest that TB patients considered hospital/doctors as the most valued sources of the provision of TB related information, also suggesting that individual conversations are prioritised over mass media sources. It could also mean that all the TB related information the patients have at this time of survey could be contributed to health service providers. An important observation was that only 11% responded that radio is their existing source of TB related information and 12% said they would prefer receiving TB related information through the radio. This also correlates with the observation that only 14% of the study respondents possess a radio (Table 3.3). At present, many awareness programmes via radio are being implemented across the country. However these need to be revisited so that resources are allocated efficiently. The dissemination strategy for TB related information to TB patients needs to be contextualised and health workers need to be adequately trained to provide the right information to TB patients.
45
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TABLE 3.14: Existing and preferred source of TB related information among TB patients interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
SOURCE OF TB RELATED INFORMATION* EXISTING SOURCE Television
37
(33)
68
(38)
60
(60)
71
(67)
236
(48)
Hospital/doctor
91
(82)
97
(54)
49
(49)
55
(52)
292
(59)
Friends and relatives
38
(34)
78
(44)
37
(37)
20
(19)
173
(35)
Newspaper/ magazines/ hoardings/posters/ billboards/wall writing
34
(31)
26
(15)
27
(27)
53
(50)
140
(28)
Radio
5
(5)
12
(7)
16
(16)
20
(19)
53
(11)
Radio
7
(6)
17
(9)
11
(11)
25
(24)
60
(12)
Cinema
3
(3)
2
(1)
10
(10)
5
(5)
20
(4)
Newspaper/ magazine/hoardings
34
(31)
23
(13)
28
(28)
59
(56)
144
(29)
Television
44
(40)
72
(40)
66
(66)
74
(70)
256
(52)
Hospital/doctors
86
(77)
125
(70)
60
(60)
59
(56)
330
(67)
Friends and relatives
24
(22)
71
(40)
22
(22)
22
(21)
139
(28)
Total Respondents
111
PREFERRED SOURCE
179
100
106
496
* Multiple response questions
Summary There is a significant gap in the knowledge about TB among the TB patients in this study. There are variations across the different zones as well. Though 81% get diagnosed within one month, only 47% are initiated on treatment within one week. The larger health system gaps and the patient-provider related delays should be studied in detail and appropriate changes need to be implemented at the earliest. Apart from this, the lack of basic knowledge on cause of TB (germs/bacteria) among the TB patients reveals that even though they visit the doctors, health workers or DOT providers regularly, no one has time to explain to the TB patient about its causes, treatment duration, and transmission. It is a patient’s right to know his/her health condition and the reasons for the condition. Emphasis needs to be given on providing the correct information to every single TB patient.
46
Chapter 3 Results: TB Patients
TABLE 3.15: Summary of key indicators of knowledge about TB among TB patients interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
Total number of TB patients
111
22
179
36
100
20
106
21
496
(100)
TB patients who were male
69
(62)
102
(57)
65
(65)
66
(62)
302
(61)
TB patients who were illiterate
43
(39)
80
(45)
29
(29)
15
(14)
167
(34)
Patients with household income less than Rs. 2000
15
(14)
23
(13)
23
(23)
14
(13)
75
(15)
Aware that TB is caused by microorganisms
32
(29)
68
(38)
45
(45)
74
(70)
219
(44)
Heard of free diagnosis and treatment of TB
80
(72)
106
(59)
83
(83)
82
(77)
351
(71)
Aware of Govt health facility for free diagnosis and treatment
75
(68)
100
(56)
81
(81)
81
(76)
337
(68)
Visited Two or less providers for diagnosis of TB
84
(76)
135
(75)
83
(83)
98
(92)
400
(81)
Patients diagnosed within 1 month of the onset of symptoms
94
(85)
125
(70)
82
(82)
100
(94)
401
(81)
Patients initiated on treatment within 7 days of diagnosis
54
(49)
94
(53)
32
(32)
53
(50)
233
(47)
Receiving free treatment under DOTS
55
(50)
88
(49)
62
(62)
90
(85)
295
(59)
Aware that treatment has to be taken regularly
78
(70)
116
(65)
86
(86)
98
(92)
378
(76)
Aware that the duration of treatment is for 6-8 months
62
(56)
87
(49)
59
(59)
67
(63)
275
(55)
Total Respondents
111
179
100
47
106
496
Summary Results: TB Patients Demographic Profile • Around 44% were illiterate or have no formal education.
• Total interviewed 496, highest in Bihar State.
• More than half are either wage labourers or agriculture workers (51%).
• TB patients are predominantly male (61%). • 40% respondents in the age group 26-45 years and around 43% were above 43 years.
• 13% are unemployed equally across the four zones.
Knowledge about TB 100 90
83
80
Percentage
70
50
85
83 76
76 75
56
45
West
South
92 86 70 64
60
65
58 43
38
40
East
82 70
68 59
60
30
77
72
70
81
North
94
92
59
56
63
49
29
20 10 0
Patients Patients Aware that Aware that Heard of free Place of free Two or less diagnosed Initiated on treatment TB is caused diagnosis and diagnosis and providers for within treatment has to treatment of treatment diagnosis of TB by 1 month within 7 days be taken microorganisms Tuberculosis (Govt Health of the onset of diagnosis regularly facility) of symptoms
Aware that the duration of treatment is for 6-8 months
Knowledge of TB among TB patients • 71% heard of free diagnosis and treatment.
• Less than half (44%) knew the cause of TB as germs/ bacteria. This pattern is similar among both sexes and all age groups.
• 76% aware that treatment has to be taken regularly. • Only 55% of them knew correct duration of treatment as 6-8 months is quite low across all the zones.
• 73% of those who experience TB symptoms seek health care within one month of onset of symptoms.
Attitudes towards TB disease and TB patients 100
Disease status shared with friends North
80
Percentage
73 60
40
West
South
75
Experiences of stigma and discrimination • 95% of the TB patients shared their disease status with their families, out of which 96% experienced supportiveness of their families.
51 38 33
32 20 19
20
0
East
Informed disease status to friends
Experienced discriminatory behaviour from friends
• Only 60% shared their disease status with their friends, of which 24% experienced discrimination. • Only 17% shared with their employers and 6% had to change their jobs.
90
82
North
80
West
South
67
70
60
60 Percentage
East
54
50 40
49
52
50 44
38
33
37
34
31
27
30 19
20
5
10 0
Television
Hospital/Doctor
Friends and relatives
19
16
15 7
Newspaper/Magazines Hoardings/Posters Billboards
Radio
Media source for TB related information
Existing sources of related information
TB
• For 59% of TB patients hospital/doctor was the key source of TB related information followed by television (48%) • Friends/relatives don’t figure as one of the information sources for over 50% of the respondents across the zones. • Only 11% responded that radio is their existing source of TB related information.
Practices towards TB patients & TB Disease Type of facilities visited for TB diagnosis
DOTS Centre
0 1 1 0
Non-Govt Health facility
0 0 1 1
South
0
East
North
Diagnosis and treatment • 68% of the TB patients across the zones went to government health facilities for the diagnosis.
2 Pvt Health facility
West
• 81% were diagnosed within one month.
5
3
Number of providers visited 76
Govt Health facility
56
0
20
40
• Nearly half (45%) had visited more than one provider
81
68
60
80
100
• South zone has highest proportion of TB patients vising only one provider
Percentage
Treatment Initiation >5 providers
5 providers
2 0 0
• 47% were initiated on treatment within one week.
3 3
1 1
Tobacco use
West
• 35% of TB patients use tobacco in any form. • Of these, 24% smoke, 36% use smokeless and 5% are dual users.
North 13 20 12
2 providers
South
East 5
3 providers
Number of providers visited before diagnosing TB
5
22
24
• On an average, only 50% of those who use tobacco knew the association of TB and tobacco.
27 33
• 73% of all tobacco users are advised to quit using tobacco.
80 1 provider
42 0
20
48
40
59
60 Percentage
80
100
• 32% of all tobacco users are also exposed to second hand smoking.
Conclusion • Though 81% get diagnosed within one month, only 47% are initiated on treatment within one week. • There is a significant gap in the knowledge among the TB patients in this study. There are variations across the different zones as well. • The larger health system gaps and the patient-provider related delays should be studied in detail and appropriate changes need to be implemented at the earliest.
CHAPTER
4 Results: Health Service Providers
Health service providers in this survey included those available at the village/ward level whom the general population approaches for health care. There are very few formally qualified medical doctors at this level, most of them available were female health workers like ANM or anganwadi workers. When the investigators conducted the survey, in most of the primary health care centers doctors were not available. The locals shared that often there was no doctor available and that they sought the pharmacist’s or health worker’s help. For any emergencies the villagers are forced to either go to the district hospital or the nearest private nursing home.
Demographic Profile Table 4.1 describes the profile of Health service providers (HSPs) found at village or ward level and interviewed during the survey. Most of the service providers were mostly female (59%) and a larger proportion of them (70%) fall in the working age group of 26-45 years. Interestingly, half of the HSPs are either private practitioners (24%) or anganwadi workers (31%). Lesser than 15% of the providers appear to have been trained in the formal healthcare (allopathic) sector - government doctors (4%), nurses (7%) or PHC workers (4%). This is clearly reflected in the pattern of formal education that qualifies these health sector workers: nearly half have no formal qualifications (44%) or have “other” training (29%) – which appears to be a residual category and requires further research. After learning the profile of the health service providers, it is clear that at a given point of time in a village or ward, finding a medical qualified provider is quite a challenge. Considering the large population in India, using the available resources is most reasonable. Hence the available providers need to be trained in TB care and control as they could play a key role in Indian settings. Regional variation in the pattern of consultation and dispensing of health practice is pronounced: in the north, HSPs consult and dispense (50%) while this figure is much lower in the south (18%). Given that there is no non-allopathic cure for TB, this is a disturbing portrait, especially with the pronounced pattern of TB providers being in a position to both consult and dispense in the most populated parts of the country (73% of providers consult and dispense TB medicines in the west, 46% in the east) and the bulk of these providers being untrained in formal medicine.
HSPs Knowledge about TB Symptoms
Only about half of HSPs are aware of at least three of the key symptoms of TB: cough of 2 weeks (53%), pain in the chest (40% this is much less in the north and west zone where it is 9% and 12% respectively) and coughing up blood (41%) (Table 4.2). The inference here is a little disturbing: if there is such a wide degree of variation in knowledge about symptoms of TB amongst HSPs, then diagnosis itself will vary – and the risk of missing TB is correspondingly high.
50
Chapter 4 Results: Health Service Providers
TABLE 4.1: General characteristics of health service providers interviewed during the midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
CHARACTERISTICS Male
61
(55)
53
(40)
39
(50)
59
(30)
212
(41)
Female
50
(45)
81
(60)
39
(50)
141
(71)
311
(59)
12
(11)
8
(6)
6
(8)
9
(5)
35
(7)
AGE 18-25 years 26-35 years
33
(30)
43
(32)
29
(38)
67
(34)
172
(33)
36-45 years
33
(30)
47
(35)
29
(38)
85
(43)
194
(37)
46 + years
32
(29)
36
(27)
13
(17)
39
(20)
120
(23)
CATEGORY OF HEALTH SERVICE PROVIDER Private practitioner
45
(41)
32
(24)
31
(40)
16
(8)
124
(24)
Government doctor
2
(2)
7
(5)
7
(9)
6
(3)
22
(4)
Nurse
3
(3)
5
(4)
3
(4)
23
(12)
34
(7)
ANM
8
(7)
40
(30)
13
(17)
31
(16)
92
(18)
PHC worker
1
(1)
4
(3)
1
(1)
13
(7)
19
(4)
Anganwadi worker
37
(33)
29
(22)
20
(26)
75
(38)
161
(31)
Chemists/Druggist
15
(14)
17
(13)
3
(4)
36
(18)
71
(14)
MBBS
1
(1)
9
(7)
4
(5)
5
(3)
19
(4)
BAMS
5
(5)
0
(0)
8
(10)
8
(4)
21
(4)
EDUCATION
BHMS
2
(2)
2
(1)
4
(5)
2
(1)
10
(2)
BUMS
1
(1)
3
(2)
2
(3)
2
(1)
8
(2)
Degree/Diploma in nursing
3
(3)
13
(10)
8
(10)
23
(12)
47
(9)
B.Pharma/D. Pharma
3
(3)
3
(2)
2
(3)
20
(10)
28
(5)
Others
34
(31)
24
(18)
29
(37)
65
(33)
152
(29)
No formal qualification
60
(54)
80
(60)
19
(24)
71
(36)
230
(44)
Unknown
2
(2)
0
(0)
2
(3)
4
(2)
8
(2)
Consultation
22
(20)
37
(28)
9
(12)
51
(26)
119
(23)
Dispensing
26
(23)
27
(20)
8
(10)
37
(19)
98
(19)
Consulting and dispensing
55
(50)
61
(46)
57
(73)
35
(18)
208
(40)
Others
8
(7)
9
(7)
4
(5)
77
(39)
98
(19)
111
(100)
134
(100)
78
(100)
200
(100)
523
NATURE OF PRACTICE
Total
51
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
The majority of HSPs diagnosed pulmonary TB (90%). Sixty seven percent confirm pulmonary TB using sputum smear test. However, only about one third of the providers know about MDR-TB. The inferences suggested from this table are logically correlated with the fact that majority of HSPs are not formally trained. This clearly suggests that focused training or dissemination of precise and accurate knowledge about TB with HSPs would be a warranted investment with clear payoffs. TABLE 4.2: Knowledge about TB symptoms, type of TB patients treating and awareness on MDR TB among health service providers who treat TB patients North
%
East
%
West
%
South
%
Total
% (45) (55)
HSP’S WHO SEE/COME ACROSS TB PATIENTS IN THEIR TREATMENT No Yes
85 26
(77) (23)
58 76
(43) (57)
51 27
(65) (35)
41 159
(21) (80)
235 288
Total
111
(100)
134
(100)
78
(100)
200
(100)
523
Cough of over 2 weeks
24
(22)
74
(55)
25
(32)
155
(78)
278
(53)
Pain in the chest
10
(9)
50
(37)
12
(15)
138
(69)
210
(40)
Coughing up blood
15
(14)
54
(40)
15
(19)
128
(64)
212
(41)
Fever
11
(10)
36
(27)
10
(13)
96
(48)
153
(29)
Weight loss
13
(12)
37
(28)
15
(19)
112
(56)
177
(34)
8
(7)
33
(25)
7
(9)
64
(32)
112
(21)
SYMPTOMS OF TB*
Poor appetite Total
111
134
78
200
523
TYPE OF TB PATIENTS DIAGNOSED BY HSP* Pulmonary TB
20
(18)
74
(55)
20
(26)
150
(75)
264
(50)
Lymph TB
5
(5)
7
(5)
5
(6)
32
(16)
49
(9)
Spinal TB
3
(3)
2
(1)
3
(4)
36
(18)
44
(8)
Bone TB
4
(4)
5
(4)
7
(9)
43
(22)
59
(11)
Abdominal TB
9
(8)
5
(4)
8
(10)
38
(19)
60
(11)
Total
111
134
78
200
523
TESTS DO YOU USUALLY ADVICE FOR CONFIRMING PULMONARY TB Others
30
(27)
55
(41)
21
(27)
66
(33)
172
(33)
Sputum smear test
81
(73)
79
(59)
57
(73)
134
(67)
351
(67)
Total
111
(100)
134
(100)
78
(100)
200
(100)
523
AWARE OF MDR TB No Yes Total
92 19 111
(83) (17) (100)
97 37 134
(72) (28) (100)
58 20 78
(74) (26) (100)
123 77 200
(62) (39) (100)
370 153 523
(71) (29)
11
(58)
23
(62)
14
(70)
68
(88)
116
(76)
2 7 19
(11) (37)
5 4 37
(14) (11)
3 9 20
(15) (45)
17 5 77
(22) (6)
27 25 153
(18) (16)
DIAGNOSIS OF MDR TB Sputum Culture/Drug Susceptibility test Clinical examination Any other tests Total *Multiple response question
52
Chapter 4 Results: Health Service Providers
HSPs Knowledge on TB Diagnosis and Treatment
Reasonably high awareness levels about diagnostic facilities are observed: overall 80% of the HSPs refer TB symptomatics to government’s DMC facilities (Table 4.3). Very few problems are reportedly faced in terms of accessing sputum smear examinations for TB per se (about 13% did not face any problem for sputum examination). However, of those who did report some problems, the issues are concentrated around the non-availability of facilities (which is highest in the west, 60%) or the non-availability of staff (47% not available – highest in the south). TABLE 4.3: TB diagnosis and treatment approach of health service providers interviewed during the midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
REFER PLACE FOR SPUTUM TEST Nearest government facility including DMC
81
(73)
102
(76)
62
(79)
173
(87)
418
(80)
Private hospital/nursing home/local private labs
12
(11)
12
(9)
6
(8)
4
(2)
34
(7)
Private collection centres
3
(3)
0
(0)
0
(0)
0
(0)
3
(1)
Patients choose themselves
2
(2)
2
(1)
1
(1)
0
(0)
5
(1)
HSP conduct themselves
0
(0)
2
(1)
0
(0)
3
(2)
5
(1)
Total FACE ANY KIND OF PROBLEM FOR SPUTUM SMEAR EXAMINATION FOR TB Not recorded
0
(0)
0
(0)
0
(0)
5
(3)
5
(1)
Face any kind of problem for sputum smear examination for TB
11
(10)
9
(7)
5
(6)
36
(18)
61
(12)
No
27
(24)
41
(31)
28
(36)
76
(38)
172
(33)
Not applicable
73
(66)
84
(63)
45
(58)
83
(42)
285
(54)
Total
111
(100)
134
(100)
78
(100)
200
(100)
523
Non-availability of facility
4
(36)
4
(44)
3
(60)
23
(64)
34
(56)
Non-availability of staff
4
(36)
2
(22)
1
(20)
17
(47)
24
(39)
Patient is unable to pay for test
4
(36)
1
(11)
2
(40)
8
(22)
15
(25)
Poor quality result
1
(9)
0
(0)
0
(0)
0
(0)
1
(2)
Total
11
(100)
9
(100)
5
(100)
36
(100)
61
TYPE OF PROBLEMS FACED
Contd...
53
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
North
%
East
%
West
%
South
%
Total
%
POST DIAGNOSIS ACTIVITY Start treatment on my own
16
(14)
18
(13)
12
(15)
17
(9)
63
(12)
Refer patient to another doctor
20
(18)
31
(23)
14
(18)
55
(28)
120
(23)
Refer patient to private facility
8
(7)
5
(4)
4
(5)
5
(3)
22
(4)
Refer patient to government centre/DOTS provider/DOTS centre
48
(43)
54
(40)
33
(42)
102
(51)
237
(45)
Refer to NGO
0
(0)
1
(1)
0
(0)
2
(1)
3
(1)
Not applicable
14
(13)
24
(18)
15
(19)
10
(5)
63
(12)
Others
5
(5)
1
(1)
0
(0)
9
(5)
15
(3)
111
(100)
134
(100)
78
(100)
200
(100)
523
Total
SYSTEM OF MEDICINE FOLLOWED IF TREATING ON OWN Allopathic
12
(75)
14
(78)
11
(92)
8
(47)
45
(71)
Homeopathy
0
(0)
0
(0)
0
(0)
1
(6)
1
(2)
Ayurveda
0
(0)
0
(0)
0
(0)
1
(6)
1
(2)
Others
4
(25)
4
(22)
1
(8)
7
(41)
16
(25)
Total
16
(100)
18
(100)
12
(100)
17
(100)
63
TREATMENT DURATION FOR TB 1-2 weeks
1
(1)
1
(1)
0
(0)
0
(0)
2
(0)
2-4 weeks
3
(3)
1
(1)
2
(3)
5
(3)
11
(2)
1-5 months
5
(5)
9
(7)
0
(0)
4
(2)
18
(3)
6-8 months
80
(72)
86
(64)
62
(79)
170
(85)
398
(76)
More than 8 months
19
(17)
31
(23)
13
(17)
16
(8)
79
(15)
Not recorded
3
(3)
6
(4)
1
(1)
5
(3)
15
(3)
111
(100)
134
(100)
78
(100)
200
(100)
523
Total
What do HSPs actually do once TB is clearly diagnosed? Nearly half (45%) send the patients to a DOTS facility, which is the optimal course of action; 12% commence treatment on their own 23% refer to another doctor and 4% to a private facility. The health service providers (12%) who do initiate their patients on treatment on their own are aware that allopathy is the best treatment for TB whereas 25% seem to indicate “Other” – which may be deleterious for the patient, and risks development of MDR-TB. In terms of treatment duration, the majority of providers (76%) know that treatment length is between 6-8 months or more.
Challenges Faced by HSPs
On an average more than half of the HSPs responded that there were no difficulties in treating TB patients. Strikingly, HSPs from south zone responded (62%) that they have difficulties in the treating TB patients (Table 4.4). Although on average more than 80% of the TB people are not hesitant to come to HSPs and this is consistent across all zones. With the difficulty of treating patients in south zone, TB patients (15%) are also hesitant to visit the HSPs as responded by HSPs. TB drugs were not available for 19% of HSPs. This has a negative impact for the HSPs who are
54
Chapter 4 Results: Health Service Providers
TABLE 4.4: Challenges faced, precautions taken and advices given to TB patients by health service providers interviewed during the midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
DIFFICULTIES IN TREATING TB PATIENTS* People hesitate to come for treatment
27
(24)
40
(30)
29
(37)
125
(63)
221
(42)
Non-availabilty of antiTB drugs
23
(21)
32
(24)
13
(17)
30
(15)
98
(19)
No pathology or X-ray lab available in the vicinity
9
(8)
24
(18)
19
(24)
57
(29)
109
(21)
People do not reveal history of TB easily
11
(10)
22
(16)
18
(23)
112
(56)
163
(31)
Patients often do not complete treatment
0
(0)
10
(7)
0
(0)
10
(5)
20
(4)
Total
RISK OF TREATING TB PATIENTS Treating TB constitutes risk to others
25
(23)
37
(28)
16
(21)
35
(18)
113
(22)
No
50
(45)
76
(57)
43
(55)
132
(66)
301
(58)
Don't know/can't say
33
(30)
15
(11)
12
(15)
13
(7)
73
(14)
Not recorded
3
(3)
6
(4)
7
(9)
20
(10)
36
(7)
Total
PRECAUTION TO PROTECT SELF FROM TB* Maintain distance
54
(49)
44
(33)
37
(47)
140
(70)
275
(53)
Wear masks and gloves
30
(27)
24
(18)
36
(46)
88
(44)
178
(34)
Wash hands with soap
34
(31)
77
(57)
29
(37)
133
(67)
273
(52)
None
13
(12)
32
(24)
16
(21)
28
(14)
89
(17)
Total
ADVICE TO PATIENTS TO AVOID SPREADING TB* Cover mouth while coughing
98
(88)
123
(92)
72
(92)
182
(91)
475
(91)
Use separate utensils
60
(54)
36
(27)
42
(54)
147
(74)
285
(54)
Not to spit anywhere
78
(70)
83
(62)
56
(72)
164
(82)
381
(73)
Use separate towels/ clothes
39
(35)
48
(36)
25
(32)
144
(72)
256
(49)
Isolate the patient
16
(14)
21
(16)
13
(17)
97
(49)
147
(28)
Total Respondents
111
134
78
200
523
* Multiple response question
enthusiastic to treat the patients with the difficulties they have. Similarly, pathology and x-ray services were not available in 21% of the HSPs. The current study revealed that patients are not hesitant to visit the HSPs for the TB diagnosis, treatment and care, but if the diagnostics are not in place, the level of hesitancy might increase among the patients. This can also have direct
55
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
impact on the general population’s treatment seeking behaviour. On average, almost one third of the patients visiting the HSPs had no history of TB. However, more 50% patients visiting HSPs from south zone had a history of TB which is significantly higher than other zones which have less than 25% with history of TB. The study revealed that despite the difficulty in treating the TB patients there are very few patients who did not complete the treatment in all zones.
Provider Perceptions on DOTS
Half of the HSPs felt that DOTS is an excellent strategy for TB treatment with highest response from west zone (67%) (Table 4.5). DOTS is a strategy adopted by WHO and RNTCP for TB treatment but it seemed that other half of the HSPs are not aware that this is an excellent strategy for treatment of TB. A significant number of the HSPs interviewed had no formal qualification (44%) and this group of HSPs might not be aware of DOTS as an excellent strategy to treat TB patients. RNTCP has announced several schemes for HSPs to involve them in DOTS programme and all partners are putting their effort on it but it appears that 71% of the HSPs are not aware of these schemes. HSPs specially engaged in private sectors that are seeing almost 60% of TB patients can significantly increase TB case notification if they are involved in RNTCP through the existing schemes. On an average 76% of the HSPs responded that other patients still continue to visit HSPs who are also seeing TB patients. Despite of having the high level of stigma and discrimination towards TB patients among the general population, they are not hesitant to seek treatment and care services along with the TB patients from the HSPs. TABLE 4.5: Perception about DOTS and awareness on RNTCP schemes among the health service providers interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
OPINION ABOUT DOTS FOR TB TREATMENT Excellent
46
(41)
51
(38)
52
(67)
113
(57)
262
(50)
Good
24
(22)
48
(36)
15
(19)
44
(22)
131
(25)
Average
4
(4)
1
(1)
1
(1)
0
(0)
6
(1)
Bad
1
(1)
0
(0)
0
(0)
0
(0)
1
(0)
Not applicable
36
(32)
33
(25)
8
(10)
41
(21)
118
(23)
Not recorded
0
(0)
1
(1)
2
(3)
2
(1)
5
(1)
111
(100)
134
(100)
78
(100)
200
(100)
523
Total
AWARE ABOUT SCHEMES TO INVOLVE PRIVATE PRACTITIONERS IN DOTS PROGRAMME Yes
21
(19)
35
(26)
27
(35)
63
(32)
146
(28)
No
89
(80)
99
(74)
51
(65)
133
(67)
372
(71)
Not recorded
1
(1)
0
(0)
0
(0)
4
(2)
5
(1)
111
(100)
134
(100)
78
(100)
200
(100)
523
Total
OTHER PATIENTS AVOID VISITING Yes
3
(3)
5
(4)
7
(9)
9
(5)
24
(5)
No
76
(68)
106
(79)
49
(63)
166
(83)
397
(76)
Don't know/can't say
23
(21)
13
(10)
17
(22)
14
(7)
67
(13)
Not recorded
9
(8)
10
(7)
5
(6)
11
(6)
35
(7)
111
(100)
134
(100)
78
(100)
200
(100)
523
Total
56
Chapter 4 Results: Health Service Providers
TABLE 4.6: Predominant source of TB related information among the health service providers interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
SOURCE OF TB RELATED INFORMATION* Medical journal
30
(27)
38
(28)
24
(31)
74
(37)
166
(32)
Colleague
23
(21)
41
(31)
16
(21)
97
(49)
177
(34)
CME/trainings
10
(9)
55
(41)
26
(33)
109
(55)
200
(38)
Professional bodies
4
(4)
7
(5)
6
(8)
42
(21)
59
(11)
Total
111
134
78
200
523
* Multiple response question
The predominant source of information for HSPs regarding TB related information is Continuing Medical Education (CME) or other trainings followed by colleagues and the medical journals (Table 4.6). Professional bodies almost did not have any role for informing HSPs regarding TB. The programme should conduct more CME/trainings to inform HSPs regarding TB. Information on the RNTCP schemes can also be given in the same session.
Summary Health service providers at village or ward levels are initial point of contact for TB patients. Since most of the time, the primary health services are not functioning well, the patients are forced to seek health care from basic health care workers, unqualified (quacks), the local chemist or visit the nearest district hospital. Hence the role of this workforce in TB care and control becomes inevitable. Empowering this group of health workers with correct knowledge about TB, its transmission, diagnosis and treatment will contribute in better outcomes and TB control programme as such.
57
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TABLE 4.7: Summary of key knowledge and practice indicators of health service providers in treating TB North
%
East
%
West
%
South
%
Total
%
(22)
74
(55)
25
(32)
155
(78)
278
(53)
(73)
102
(76)
62
(79)
173
(87)
418
(80)
(43)
54
(40)
33
(42)
102
(51)
237
(45)
(71)
MAJOR SYMPTOM OF TB Cough of over 2 weeks
24
REFER PLACE FOR SPUTUM TEST Nearest government facility including DMC
81
REFER PLACE FOR TREATMENT Refer patient to government centre/DOTS provider/DOTS centre
48
SYSTEM OF MEDICINE FOLLOWED IF TREATING ON OWN (N = 63) Allopathic
12
(75)
14
(78)
11
(92)
8
(47)
45
Total
16
(100)
18
(100)
12
(100)
17
(100)
63
No
92
(83)
97
(72)
58
(74)
123
(62)
370
(71)
Yes
19
(17)
37
(28)
20
(26)
77
(39)
153
(29)
No
8
(42)
14
(38)
6
(30)
9
(12)
37
(24)
Sputum culture/drug susceptibility test
11
(58)
23
(62)
14
(70)
68
(88)
116
(76)
Total
19
(100)
37
(100)
20
(100)
77
(100)
153
(72)
86
(64)
62
(79)
170
(85)
398
(76)
AWARE OF MDR TB
DIAGNOSIS OF MDR TB
TREATMENT DURATION FOR TB 6-8 Months
80
AWARE ABOUT SCHEMES TO INVOLVE PRIVATE PRACTITIONERS IN DOTS PROGRAMME Yes
21
(19)
35
(26)
27
(35)
63
(32)
146
(28)
CME/trainings
10
(9)
55
(41)
26
(33)
109
(55)
200
(38)
Total
111
(100)
134
(100)
78
(100)
200
(100)
523
SOURCE OF INFORMATION
58
Summary Results: Health Service Providers (HSPs) Demographic Profile
• Most of the health service providers are female (59%) and a larger proportion of them (70%) fall in the working age group of 26-45 years
• Health service providers (HSPs) included private practitioner (24%), government doctors (4%),
• Less than 15% of the providers have been trained in the formal healthcare (allopathic)
nurses (7%), Auxiliary Nurse Midwife (18%), PHC workers
• Nearly half have no formal qualifications (44%) or have ‘other’ training (29%) – which requires further research
(4%), anganwadi workers (31%), chemist/drugist (14%)
Knowledge about TB 100 87
90 78
80
79
73 76
North
92
88 79
75 78
70
Percentage
70 60
58
55
51
50
43
40 30 20
East
62
West
South
85
72 64
47
40 42
39
32
35
28 26
22
32
26 19
17
10 0
Refer place Aware of Refer place major for sputum for treatment symptom of test (Nearest (Government TB (Cough of government center/DOTS centre) over 2 weeks) facilityinc luding DMC)
Medicine system fol lowed if treating on own (Allopathic)
Diagnosis of MDR TB (Sputum culture/Drug susceptibility test)
Aware of MDR TB
Treatment Aware about duration schemes to (6–8 mont) involve private for TB practitioners in DOTS programme
Knowledge about TB among HSPs • 53% knew cough over 2 weeks as key symptom of TB • Only about one-third of the providers knew about MDR-TB • 80% refer to the government’s DMC facilities for sputum test • Nearly half (45%) send the patients to a government centre/DOTS facility for treatment • 76% knew the correct duration of treatment 6-8 months
Attitudes towards TB disease and TB patients
32%
26%
41%
North
East 1% 4%
Opinion about DOTS for TB treatment 37%
0% 1%
• Half of the HSPs (50%) responded that DOTS is an
36%
excellent strategy for TB
Average
• Only 28% knew about the
22%
treatment Excellent
Good
Average
Bad
Not applicabel
Excellent
Good
Bad
Not applicabel
schemes to involve private 0% 1%
West
practitioners in DOTS
13%
19%
21%
South
67%
22%
Excellent
Good
Average
Bad
Not applicabel
programme
0% 0%
1ST Qtr
Excellent Bad
57%
Good Average Not applicabel
North
East
23%
28% 44%
3%
Risk of treating TB patients
57%
• 22% said that treating TB constitites
4% 30%
11%
risk to others and 58% said no to this
No
• 76% of the HSPs responded that
Don’t know/ Can’t say West
South
9%
visit HSPs who are also seeing TB
Not recorded
patients • 53% HSPs, maintain distance from TB patients and protect themselves • 34% wear masks and gloves and 52% wash hands with soap while treating
Treating TB constitutes risk to others
18%
21%
other patients still continue to
10%
55%
65%
7%
15%
TB patients.
Practices towards TB patients 100 90
North
87
80
76
73
East
West
South
79
Diagnosis
Percentage
70
• 80% refer patients to government
60
facility for diagnosis
50
• Only 7% refer to private hospitals or
40
nursing homes
30 20 11
10
9
8
3
2
0
Nearest government facility including DMC
Private hospital/ nursing home/ local private labs
North
0
2
0
1
1
0
0
Patients choose themselves
1
0
2
HSP conduct themselves
East
7%
4% 23%
18% 43%
40% 13%
14% 5%
0
Private collection centers
1%
13% 0%
Refer patient to government center/DOTS provider/DOTS center
Other Not applicable
18%
13%
1%
Refer to NGO Start treatment on my own
West
Refer patient to another doctor
South
Refer patient to private facility
3%
5% 18%
Post diagnosis activity • Post diagnosis, nearly half (45% overall) send the patients to a government facility/DOTS centre for treatment • 12% of those who diagnose TB, treat patients on their own. • Of those who treat on their own, 71% follow allopatic system of medicine
27% 43%
50%
15% 0%
19%
0%
9% 5%
5%1%
Conclusion Health service providers at village or ward levels are initial point of contact for TB patients. Since most of the time, the primary health services are not functioning well, the patients are forced to seek health care from basic health care workers, unqualified (quacks), the local chemist or visit the nearest district hospital. Hence the role of this workforce in TB care and control becomes inevitable. Empowering this group of health workers with correct knowledge about TB, its transmission, diagnosis and treatment will contribute in better outcomes and TB control program as such.
CHAPTER
5 Results: Opinion Leaders
Demographic Profile The bulk of opinion leaders are in the working age profile, with 69% of them being between 36 and 46 years old (Table 5.1). Position-wise, most opinion leaders across India are teachers (23%), followed by ward members (predominant in the east) and then village pradhans (16%), which is corroborated by the fact that TB in India is a disease found mostly in rural areas as per this survey’s data. Not surprisingly, the bulk of opinion leaders are reasonably well-educated. 49% of all opinion-leaders have some high school training – 24% at the secondary level, and 25% educated to the senior secondary level but without having graduated. About a fourth have had some college education. TABLE 5.1: General profile of opinion leaders interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
69 66
(51) (49)
93 87
(52) (48)
75 88
(46) (54)
79 54
(59) (41)
316 295
(52) (48)
9 44 41 41
(7) (33) (30) (30)
10 46 54 70
(6) (26) (30) (39)
8 42 63 50
(5) (26) (39) (31)
6 27 48 51
(5) (20) (36) (38)
33 159 206 212
(5) (26) (34) (35)
0
(0)
0
(0)
0
(0)
1
(1)
1
(0)
23 22
(17) (16)
20 22
(11) (12)
40 9
(25) (6)
14 23
(11) (17)
97 76
(16) (12)
18 1 3
(13) (1) (2)
53 8 1
(29) (4) (1)
18 8 2
(11) (5) (1)
30 6 3
(23) (5) (2)
119 23 9
(19) (4) (1)
20 36 9
(15) (27) (7)
25 44 3
(14) (24) (2)
47 30 2
(29) (18) (1)
20 28 5
(15) (21) (4)
112 138 19
(18) (23) (3)
1 2 15
(1) (1) (14)
4 0 17
(2) (0) (13)
5 2 3
(3) (1) (4)
4 0 36
(3) (0) (18)
14 4 71
(2) (1) (14)
GENDER Male Female AGE 18-25 years 26-35 years 36-45 years 46 years and above Not recorded OCCUPATION Village pradhan Panchayat member Ward member Religious leader Auxiliary Nurse Midwife Anganwadi worker Teacher Gaon Kalyan Samiti member Others Missing Chemist/druggist
TYPE OF SETTLEMENT Rural
114
(84)
117
(65)
89
(55)
98
(74)
418
(68)
Urban
21
(16)
63
(35)
74
(45)
35
(26)
193
(32)
Contd...
61
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
North
%
East
%
West
%
South
%
Total
%
10 3
(7) (2)
6 13
(3) (7)
6 4
(4) (2)
0 0
(0) (0)
22 20
(4) (3)
5 27
(4) (20)
12 42
(7) (23)
8 39
(5) (24)
0 15
(0) (11)
25 123
(4) (20)
31
(23)
30
(17)
35
(21)
52
(39)
148
(24)
20
(15)
35
(19)
26
(16)
33
(25)
114
(19)
38
(28)
39
(22)
43
(26)
32
(24)
152
(25)
1 135
(1) (100)
3 180
(2) (100)
2 163
(1) (100)
1 133
(1) (100)
7 611
(1)
EDUCATION Illiterate Literate but no formal education Less than primary Primary but less than secondary Secondary but less than senior secondary Senior secondary but not graduate Graduate and above Missing Total
Knowledge about TB
What do those who are opinion-shapers actually know about TB? In terms of top-of-the-mind recall, TB is not recalled, but it is mentioned by leaders in the north (37%) and the east (31%) (Table 5.2). With those who did mention TB (without prompting), we find that over half of these leaders do know about TB but a strikingly low mention of this is common amongst opinion leaders in the south (only 38% mention TB). This is probably because of the relatively lower incidence and prevalence of TB in the south.
Symptoms and Diagnosis Place
Most opinion leaders are aware of two key TB symptoms: a cough of 2 weeks and coughing up of blood. 75% of them know that TB is transmitted through the air, while only 55% of those in the south knew this. Wrong knowledge of the modes of TB transmission are prevalent amongst opinion leaders: 42% think it is transmitted by sharing a cigarette or beedis while 41% think it is transmitted by sharing food with the infected person. This requires correcting and would be a clear ‘to-do’ for TB control to be really effective, and to buttress training efforts of other health service providers. All the same, there is consistently good knowledge of where TB diagnosis can take place, with 90% of opinion leaders stating that the PHC or a government hospital or a DMC is the place to go.
Treatment Place and Duration
Almost all opinion leaders have heard of TB and they knew that TB is curable. This correlates with their educational background as most opinion leaders are educated (Table 5.3). In contrast, although the opinion leaders from the south zone were educated they had less knowledge that TB is curable than in other zones. Strikingly, almost half of the opinion leaders from all zones didn’t hear about DOTs which is the currently being practiced in India and elsewhere and Government of India is advocating for TB care and control. The RNTCP is adopting WHO’s DOTS strategy for TB treatment and this uses anti-TB drugs supplied from the DOTS centre and the community DOTS provider. Almost half of the opinion leaders surveyed knew that TB treatment was through DOTS and this is true for north, east and west zones. The opinion leaders (28%) from the south zone seemed less knowledgeable about the DOTS and TB treatment and a significant proportion knew that TB is treated by other allopathic medicines. More than 80% of opinion leaders knew that TB treatment is for longer duration and the place of treatment is in the Government sector.
62
Chapter 5 Results: Opinion Leaders
TABLE 5.2: Knowledge about TB, symptoms, mode of transmission and diagnosis of TB among opinion leaders interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
HEARD OF TB - SPONTANEOUS RECALL TB mentioned
50
(37)
55
(31)
31
(19)
55
(41)
191
(31)
TB not mentioned
84
(62)
124
(69)
132
(81)
77
(58)
417
(68)
Yes
76
(56)
125
(69)
132
(81)
51
(38)
384
(63)
No
7
(5)
0
(0)
0
(0)
11
(8)
18
(3)
Not applicable
50
(37)
55
(31)
31
(19)
55
(41)
191
(31)
A cough of 2 weeks
113
(90)
156
(87)
162
(99)
89
(84)
520
(90)
Pain in the chest
32
(25)
50
(28)
50
(31)
64
(60)
196
(34)
HEARD OF TB - ON PROBING
SYMPTOMS OF TB*
Coughing up blood
62
(49)
114
(63)
88
(54)
61
(58)
325
(57)
Night sweat
3
(2)
6
(3)
7
(4)
37
(35)
53
(9)
Weight loss
26
(21)
51
(28)
59
(36)
65
(61)
201
(35)
Loss of appetite
22
(17)
44
(24)
34
(21)
34
(32)
134
(23)
Through air when infected person cough's or sneezes
98
(78)
135
(75)
150
(92)
65
(61)
448
(78)
Through sharing cigarettes/beedis with infected person
66
(52)
73
(41)
47
(29)
63
(59)
249
(43)
Through sharing food with infected person
57
(45)
79
(44)
82
(50)
24
(23)
242
(42)
Through sharing bed/ clothes with infected person
38
(30)
41
(23)
31
(19)
13
(12)
123
(21)
Through hand shake with infected person
14
(11)
14
(8)
15
(9)
2
(2)
45
(8)
Sputum smear test
94
(75)
122
(68)
124
(76)
72
(68)
412
(72)
X-ray
89
(71)
99
(55)
96
(59)
72
(68)
356
(62)
Mantoux skin test
2
(2)
3
(2)
10
(6)
37
(35)
52
(9)
Don't know/can’t say
8
(6)
29
(16)
13
(8)
19
(18)
69
(12)
Government hospital/PHC/ DOTS centre
114
(90)
166
(92)
160
(98)
94
(89)
534
(93)
Private hospital/clinic
44
(35)
71
(39)
31
(19)
12
(11)
158
(27)
Total
126
(100)
180
(100)
163
(100)
106
(100)
575
MODE OF TB TRANSMISSION*
DIAGNOSIS OF TB*
PLACE OF TB DIAGNOSIS*
* Multiple response question
63
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TABLE 5.3: Knowledge on treatment of TB opinion leaders interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
119
(94)
171
(95)
155
(95)
91
(86)
536
(93)
7
(6)
9
(5)
8
(5)
15
(14)
39
(7)
Heard of DOTS
67
(53)
105
(58)
116
(71)
57
(54)
345
(60)
No/others
59
(47)
75
(42)
47
(29)
49
(46)
230
(40)
Herbal remedies
1
(1)
2
(1)
0
(0)
2
(2)
5
(1)
Home remedies
2
(1)
1
(1)
2
(1)
2
(2)
7
(1)
DOTS or TB drugs
89
(66)
96
(53)
105
(64)
36
(27)
326
(53)
Other allopathic medicines
45
(33)
97
(54)
43
(26)
71
(53)
256
(42)
Ayurvedic
3
(2)
5
(3)
3
(2)
2
(2)
13
(2)
Homeopathy
1
(1)
6
(3)
10
(6)
1
(1)
18
(3)
Don’t know/can't say
6
(4)
8
(4)
6
(4)
1
(1)
21
(3)
Less than 2 weeks
0
(0)
0
(0)
2
(1)
0
(0)
2
(0)
2-4 weeks
0
(0)
5
(3)
1
(1)
1
(1)
7
(1)
1-5 months
7
(5)
11
(6)
7
(4)
4
(3)
29
(5)
6-8 months
65
(48)
93
(52)
113
(69)
51
(38)
322
(53)
More than 8 months and others
36
(27)
47
(26)
25
(15)
52
(39)
160
(26)
DKCS
18
(13)
24
(13)
15
(9)
3
(2)
60
(10)
Not applicable
7
(5)
0
(0)
0
(0)
11
(8)
18
(3)
Missing
2
(1)
0
(0)
0
(0)
11
(8)
13
(2)
Government hospital/ PHC/DOTS centre
115
(85)
161
(89)
158
(97)
106
(80)
540
(88)
Private hospital/clinic
27
(20)
48
(27)
15
(9)
7
(5)
97
(16)
Total
135
(100)
180
(100)
163
(100)
133
(100)
611
TB IS CURABLE Yes No/Others HEARD OF DOTS
TREATMENT OF TB*
DURATION OF TREATMENT
PLACE OF TB TREATMENT*
* Multiple response question
The study showed that the opinion leaders from east and south zones had low levels of knowledge on TB treatment (DOTS and TB drugs). The general population and TB patients in the communities look up to these leaders and seek their guidance for health related issues. Hence it is essential that the opinion leaders be equipped with correct knowledge about TB and its treatment. 63% of the opinion leaders who do know about TB have knowledge levels that are generally good except for the relatively lower level of knowledge about DOTS (only 40% know about DOTS). DOTSrelated brand-building efforts can be targeted at health service providers, and opinion leaders.
64
Chapter 5 Results: Opinion Leaders
Role in Community
Only one third the opinion leaders knew about TB patients in their community which is true across all zones (Table 5.4). More than 80% of them from north, west and south zones gave advice to TB patients to go to the closest Government hospital, which correlated well with the level of knowledge they had on the place of TB treatment. However, 14% of the opinion leaders from the east zones advise their community members to go to private hospital which is noticeable and may have significant implications in the context of TB. The private sector are still not engaged in RNTCP for TB case notification in the country and if these leaders still recommend to seek treatment in the private sectors then this will add to the 1 million cases which are missing in a year. Most of the opinion leaders (83%) didn’t take any initiative to create awareness on TB in the community neither they take initiative to organise camps, rallies, lectures, seminar or workshops for TB. Almost 20% of the opinion leaders had worked as a DOT provider in the past. Level of knowledge about TB seems adequate among the opinion leaders. However, the practices related to TB in terms of generating awareness on TB in the community are still low. TABLE 5.4: Role played by opinion leaders in their communities to address TB North
%
East
%
West
%
South
%
Total
% (29)
KNOW TB PATIENTS IN NEIGHBOURHOOD Yes
39
(29)
57
(32)
51
(31)
33
(25)
180
Total
135
(100)
180
(100)
163
(100)
133
(100)
611
GIVE ADVICE TO TB PATIENTS IN NEIGHBOURHOOD Go to government hospital
35
(90)
45
(79)
46
(90)
31
(94)
157
(87)
Go to private hospital
2
(5)
8
(14)
2
(4)
0
(0)
12
(7)
None/not applicable
2
(5)
4
(7)
3
(6)
2
(6)
11
(6)
Total
39
(100)
57
(100)
51
(100)
33
(100)
180
TAKE INITIATIVE TOWARDS GENERATING AWARENESS Yes
23
(17)
35
(19)
33
(20)
15
(11)
106
(17)
No
112
(83)
145
(81)
130
(80)
118
(89)
505
(83)
Total
135
(100)
180
(100)
163
(100)
133
(100)
611
Organised camps
8
(35)
9
(26)
5
(15)
11
(73)
33
(31)
Organised rallies
3
(13)
13
(37)
8
(24)
6
(40)
30
(28)
Organised lectures/ seminar/workshops
3
(13)
12
(34)
6
(18)
3
(20)
24
(23)
Worked as DOT provider
3
(13)
10
(29)
6
(18)
2
(13)
21
(20)
Nukkad nataks/street plays/skits
3
(13)
7
(20)
4
(12)
0
(0)
14
(13)
Total
23
(100)
35
(100)
33
(100)
15
(100)
106
TYPE OF INITIATIVES*
* Multiple response question
65
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Seriousness of TB and People Prone to it
Almost over half of the opinion leaders knew TB was a serious disease (Table 5.5). More than one third of the opinion leaders perceived people exposed to cough and cold for a long time, smokers and alcoholics are prone to TB and nearly one third of them perceived that people living in the unhygienic condition, malnourished, family members of TB are prone to TB. In reality, although those who are HIV positive are more prone to TB and the mortality of HIV patients is high due to TB; very few opinion leaders’ perceived HIV-infected people as being less prone to TB. In terms of general behaviour towards TB patients, most of the opinion leaders did not have any negative behaviours (46%) and one third of them helped and supported the TB patients.
Attitudes towards TB Patients
A majority of the opinion leaders have positive attitudes towards TB patients or their families. A noticeable observation is that majority agree that female TB patients face marital problems. TABLE 5.5: Seriousness about TB disease, awareness about those prone to TB among opinion leaders and behaviour of community towards TB patients North
%
East
%
West
%
South
%
Total
%
DO YOU THINK TB IS A SERIOUS DISEASE IN YOUR COMMUNITY? TB is a serious disease
92
(68)
117
(65)
102
(63)
40
(30)
351
(57)
No
32
(24)
63
(35)
61
(37)
29
(22)
185
(30)
WHO DO YOU THINK ARE PRONE TO TB?* Those living in unhygienic conditions
15
(11)
66
(37)
40
(25)
36
(27)
157
(26)
Poor people
27
(20)
27
(15)
27
(17)
12
(9)
93
(15)
Malnourished
28
(21)
59
(33)
56
(34)
9
(7)
152
(25)
Children
11
(8)
9
(5)
40
(25)
24
(18)
84
(14)
Women
8
(6)
8
(4)
18
(11)
9
(7)
43
(7)
Family members of TB
48
(36)
33
(18)
40
(25)
57
(43)
178
(29)
Exposed to cough and cold for long time
76
(56)
78
(43)
60
(37)
38
(29)
252
(41)
HIV +ve
12
(9)
16
(9)
5
(3)
13
(10)
46
(8)
Smokers
77
(57)
93
(52)
80
(49)
92
(69)
342
(56)
Alcoholics
33
(24)
72
(40)
74
(45)
66
(50)
245
(40)
IN YOUR COMMUNITY, HOW IS THE PERSON SUFFERING WITH TB TREATED?* Most people reject him/her
16
(12)
45
(25)
23
(14)
30
(23)
114
(19)
Most people are friendly but generally avoid them
63
(47)
41
(23)
69
(42)
31
(23)
204
(33)
Community mostly helps and supports him/her
56
(41)
87
(48)
70
(43)
71
(53)
284
(46)
Normal behaviour
0
(0)
2
(1)
0
(0)
0
(0)
2
(0)
None
0
(0)
2
(1)
0
(0)
0
(0)
2
(0)
Not recorded
0
(0)
2
(1)
0
(0)
0
(0)
2
(0)
135
(100)
180
(100)
163
(100)
133
(100)
611
Total * Multiple response question
66
Chapter 5 Results: Opinion Leaders
Detailed studies need to be conducted to document the kind of problems the female TB patients face, whether they are spouse-related, issues with children (including conception), taking care of household chores or in-laws related. Targeted and culturally sensitive solutions need to be provided to facilitate treatment completion and post treatment care for female TB patients. These could also include family counseling. About 40% of the opinion leaders agree that daily wage labourers should not be allowed to work (Table 5.6). The reasons are not clear as the survey does not capture the reasons. However it could be either to prevent infection to others or even for the patient to have physical rest and recover. TABLE 5.6: Attitudes of towards TB and TB patients among opinion leaders interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
A FAMILY WITH TB PATIENT SHOULD NOT BE ALLOWED TO PARTICIPATE IN ANY SOCIAL Strongly agree
23
(17)
23
(13)
28
(17)
2
(2)
76
(12)
Somewhat agree
24
(18)
18
(10)
12
(7)
9
(7)
63
(10)
Disagree
88
(65)
139
(77)
123
(75)
122
(92)
472
(77)
MARRIED FEMALE TB PATIENT SHOULD BE SENT OFF TO HER PARENTS HOUSE Strongly agree
1
(1)
11
(6)
14
(9)
4
(3)
30
(5)
Somewhat agree
10
(7)
9
(5)
8
(5)
6
(5)
33
(5)
Disagree
124
(92)
160
(89)
141
(87)
123
(92)
548
(90)
CHILDREN WITH TB SHOULD NOT BE ALLOWED TO GO TO SCHOOL Strongly agree
18
(13)
21
(12)
37
(23)
9
(7)
85
(14)
Somewhat agree
21
(16)
31
(17)
38
(23)
13
(10)
103
(17)
Disagree
96
(71)
128
(71)
88
(54)
111
(83)
423
(69)
DAILY WAGE LABOURERS SUFFERING FROM TB SHOULD NOT BE ALLOWED TO WORK Strongly agree
30
(22)
28
(16)
46
(28)
10
(8)
114
(19)
Somewhat agree
31
(23)
55
(31)
29
(18)
15
(11)
130
(21)
Disagree
73
(54)
97
(54)
88
(54)
108
(81)
366
(60)
HUSBANDS/IN-LAWS DO NOT ACCOMPANY FEMALE TB PATIENTS TO HOSPITAL/DOTS CENTRE Strongly agree
10
(7)
5
(3)
11
(7)
10
(8)
36
(6)
Somewhat agree
19
(14)
33
(18)
14
(9)
20
(15)
86
(14)
Disagree
104
(77)
142
(79)
138
(85)
103
(77)
487
(80)
FEMALES ACCOMPANY THEIR SPOUSE SUFFERING FROM TB TO HOSPITALS/DOTS CENTRE Strongly agree
94
(70)
154
(86)
130
(80)
90
(68)
468
(77)
Somewhat agree
21
(16)
14
(8)
15
(9)
24
(18)
74
(12)
Disagree
18
(13)
12
(7)
18
(11)
19
(14)
67
(11)
FEMALES SUFFERING FROM TB FACE PROBLEM IN MARRIAGE Strongly agree
116
(86)
112
(62)
135
(83)
106
(80)
469
(77)
Disagree
17
(13)
67
(37)
27
(17)
25
(19)
136
(22)
Total
135
(100)
180
(100)
163
(100)
133
(100)
611
67
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TABLE 5.7: Health seeking behaviour among opinion leaders interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
HEALTH SEEKING BEHAVIOUR Government health facility
107
(79)
147
(82)
153
(94)
119
(89)
526
(86)
Private clinic
30
(22)
42
(23)
13
(8)
16
(12)
101
(17)
Ayurvedic or Siddha treatment
1
(1)
3
(2)
1
(1)
1
(1)
6
(1)
Government centres
111
(82)
149
(83)
151
(93)
125
(94)
536
(88)
Private hospitals
23
(17)
36
(20)
8
(5)
5
(4)
72
(12)
DOTS/TB centres
17
(13)
26
(14)
15
(9)
7
(5)
65
(11)
Government centres
118
(87)
134
(74)
143
(88)
122
(92)
517
(85)
Private hospitals
16
(12)
34
(19)
7
(4)
4
(3)
61
(10)
DOTS/TB centres
21
(16)
40
(22)
23
(14)
10
(8)
94
(15)
Total
135
(100)
180
(100)
163
(100)
133
(100)
611
TABLE 5.8: Potential practices towards TB patients among opinion leaders interviewed during midline KAP survey, 2013* North
%
East
%
West
%
South
%
Total
%
SHARE A MEAL WITH PERSON YOU KNOW HAD TB Yes
20
(15)
53
(29)
21
(13)
27
(20)
121
(20)
No
110
(81)
118
(66)
141
(87)
80
(60)
449
(73)
IF YOU SUSPECT ONE OF THE FEMALE MEMBER IS SUFFERING FROM TB WILL YOU TAKE HER TO HOSPITAL Yes
128
(95)
179
(99)
151
(93)
124
(93)
582
(95)
No
5
(4)
1
(1)
11
(7)
6
(5)
23
(4)
MARRY ONES DAUGHTER TO A BOY WHO YOU KNOW HAD TB Yes
8
(6)
49
(27)
23
(14)
21
(16)
101
(17)
No
123
(91)
110
(61)
135
(83)
70
(53)
438
(72)
ISOLATE YOUR FAMILY MEMBER HAVING TB FROM THE HOUSEHOLD Yes
46
(34)
23
(13)
27
(17)
10
(8)
106
(17)
No
86
(64)
148
(82)
135
(83)
88
(66)
457
(75)
MARRY ONES SON TO A GIRL WHO YOU KNOW HAD TB Yes
10
(7)
51
(28)
20
(12)
18
(14)
99
(16)
No
121
(90)
104
(58)
141
(87)
83
(62)
449
(73)
SEND ONES DAUGHTER-IN-LAW TO PARENTS HOUSE IF SHE HAD TB Yes
14
(10)
12
(7)
21
(13)
19
(14)
66
(11)
No
117
(87)
155
(86)
140
(86)
89
(67)
501
(82)
* Total percentage does not add up to 100 as ‘not recorded/missing’ values not include in the table.
68
Chapter 5 Results: Opinion Leaders
TABLE 5.9: Sources of general and TB related information among opinion leaders interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
SOURCE OF GENERAL INFORMATION* Radio
29
(21)
35
(19)
28
(17)
39
(29)
131
(21)
Television
109
(81)
118
(66)
132
(81)
112
(84)
471
(77)
Newspaper/magazines
86
(64)
93
(52)
81
(50)
71
(53)
331
(54)
Cinema
6
(4)
4
(2)
2
(1)
9
(7)
21
(3)
Hoardings/posters/ leaflets
35
(26)
31
(17)
28
(17)
34
(26)
128
(21)
Melas/nukkad nataks etc
6
(4)
13
(7)
9
(6)
5
(4)
33
(5)
Internet/web advertising
4
(3)
7
(4)
8
(5)
6
(5)
25
(4)
Word of mouth (interpersonal)
66
(49)
84
(47)
64
(39)
39
(29)
253
(41)
Local health service providers
35
(26)
58
(32)
52
(32)
48
(36)
193
(32)
Mobile phone advertising
5
(4)
5
(3)
5
(3)
4
(3)
19
(3)
SOURCE OF INFORMATION FOR AWARENESS OF TB* Television
110
(81)
110
(61)
127
(78)
107
(80)
454
(74)
Radio
23
(17)
35
(19)
20
(12)
30
(23)
108
(18)
Cinema
2
(1)
5
(3)
5
(3)
8
(6)
20
(3)
Newspaper/magazines
80
(59)
75
(42)
62
(38)
71
(53)
288
(47)
Hoarding/posters/ billboards
39
(29)
48
(27)
40
(25)
25
(19)
152
(25)
Internet
5
(4)
3
(2)
2
(1)
1
(1)
11
(2)
Public service announcements
7
(5)
9
(5)
17
(10)
14
(11)
47
(8)
Drama/skit/street play
4
(3)
12
(7)
6
(4)
4
(3)
26
(4)
Hospital/doctor
80
(59)
114
(63)
116
(71)
71
(53)
381
(62)
Friends/relatives
27
(20)
54
(30)
43
(26)
24
(18)
148
(24)
Teachers/peer educators
3
(2)
10
(6)
4
(2)
18
(14)
35
(6)
SEEN/HEARD ADVERTISEMENT REGARDING TB/DOTS Yes
88
(65)
105
(58)
105
(64)
54
(41)
352
(58)
No
39
(29)
65
(36)
49
(30)
71
(53)
224
(37)
Don't know/can’t say
8
(6)
10
(6)
9
(6)
8
(6)
35
(6)
WHERE DID YOU SEE/HEAR THE ADVERTISEMENT REGARDING TB/DOTS* Newspaper/magazines
45
(33)
52
(29)
55
(34)
36
(27)
188
(31)
Radio
9
(7)
10
(6)
10
(6)
30
(23)
59
(10)
Television
73
(54)
75
(42)
84
(52)
44
(33)
276
(45)
Hoarding/posters/leaflets
21
(16)
50
(28)
26
(16)
26
(20)
123
(20)
Total
135
(100)
180
(100) 163
(100)
133
(100)
611
* Multiple response question
69
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
In spite of having fairly good knowledge about TB transmission and prevention, majority (73%) of the opinion leaders refused to share meals with a person they know had TB. And the situation is the same when it comes to marrying one’s daughter or son to a person they knew had TB. However, the underlying factors of fear of infection due to closeness cannot be ruled out.
Media Practices
The key source of general information among opinion leaders is television (77%) followed by newspaper/magazines (54%) and word of mouth (41%) (Table 5.9). These are the major habits of opinion leaders of getting information. For conveying any information to opinion leaders the above mentioned sources should be considered. However if the information is related to TB, they most often get it from television (74%) followed by hospital or doctors (62%) and newspaper or magazines (47%). This information is very important especially when advocacy programmes for TB control are being designed. Either for general information or TB related information, radio still has around 20% penetration. 58% of the leaders saw or heard advertisements regarding TB or DOTS either in television or newspaper or magazines and posters or hoardings or leaflets. Only 10% got the information through radio.
Summary In summary, almost all the opinion leaders heard about TB, knew that a cough over 2 weeks could be TB, know that TB spreads through air and know that TB was curable. However, the knowledge gap on treatment duration and DOTS needs special attention. Opinion leaders at local level can play a significant role in TB care and control in their communities. Efforts must be made to leverage the strengths of this group for TB control in India. TABLE 5.10: Summary of key indicators of knowledge about TB among opinion leaders interviewed during midline KAP survey, 2013 North
%
East
%
West
(0)
0
%
South
%
Total
%
HEARD OF TB SPONTANEOUS/ON PROBING No
9
(7)
0
(0)
27
(20)
36
(6)
Yes
126
(93)
180
(100) 163
(100)
106
(80)
575
(94)
113
(90)
156
(87)
162
(99)
89
(84)
520
(90)
98
(78)
135
(75)
150
(92)
65
(61)
448
(78)
94
(75)
122
(68)
124
(76)
72
(68)
412
(72)
KEY SYMPTOM OF TB A cough of 2 weeks MODE OF TB TRANSMISSION Through air when infected person coughs or sneezes DIAGNOSIS OF TB Sputum smear test
Contd...
70
Chapter 5 Results: Opinion Leaders
North
%
East
%
West
%
South
%
Total
%
119
(94)
171
(95)
155
(95)
91
(86)
536
(93)
67
(53)
105
(58)
116
(71)
57
(54)
345
(60)
117
(93)
167
(93)
140
(86)
92
(87)
516
(90)
63
(50)
93
(52)
113
(69)
40
(38)
309
(54)
115
(85)
161
(89)
158
(97)
106
(80)
540
(88)
(19)
33
(20)
15
(11)
106
(17)
TB IS CURABLE Curable HEARD OF DOTS Heard of DOTS TREATMENT OF TB Allopathic medicines DURATION OF TREATMENT 6-8 months PLACE OF TB TREATMENT Government hospital/PHC/ DOTS centre
TAKE INITIATIVE TOWARDS GENERATING AWARENESS Take initiative towards generating awareness
23
(12)
35
71
Summary Results: Opinion Leaders Demographic Profile
• 69% of the opinion leaders are in the age group 36-46 years • 43% have high school education and one-fourth were graduates and above
• Majority of opinion leaders included village pradhans (16%), panchayat members (12%) ward members (19%) anganwadi workers (18%) and teachers (23%)
Knowledge about TB
97 86
86
38
50 52
54
58
69
71
76 68
75
60
53
17 19 20
40
Place of TB treatment (Goverment hospital/ PHC/DO TS centre)
Duration of treatment is 6-8 months
Heard of DOTS
Aware that TB is
Diagnosis of TB through Sputum smear test
Aware of main symptom (cough of 2 weeks or more)
Heard of TB (spontaneous/probing)
0
Mode of TB transmission through air
13
20
Take initiative towards generating awareness
Percentage
61
68
80
South
90 89
94 95 95
92 78 75
80
84
90 87
93
100
West
East
99
100 100
North
Knowledge of TB • • • • •
94% heard of TB on either probing or spontaneous recall Most opinion leaders are aware of atleast two key TB symptoms: a cough of 2 weeks (90%) and coughing up of blood (57%) 75% of them know that TB is transmitted through the air 93% stated that the PHC or a government hospital or a DMC is the place for diagnosis 93% knew that TB is curable
• Only 60% of opinion leaders heard of DOTs
Attitudes towards TB disease and TB patients 80 70
No Consider TB as a serious disease
68
65
63
Percentage
60
Consider TB is a serious disease in community
50 40
35
37
• Over half (57%) of the opinion leaders 30
30
24
22
20 10 0
North
East
West
South
know that TB was a serious disease • 56% consider smokers more prone to TB followed by those exposed to cough & cold for long time (41%) and alcoholics (40%)
South
60
East
West
North
Treatment of TB patients in the community
53 50
48
47 42
43
41
• Less than one-fifth of the respondents mentioned that TB patients are rejected in their community with least incidents in North (12%) and highest in East (25%) • 46% felt that community mostly helps & supports TB patients • One-third of them said that people are friendly to TB patients but generally avoid them.
Percentage
40
30 25
23
23
23
20 14
12 10
0 Most People reject him/her
Most People are friendly but generally avoid them
Community mostly helps and support him/her
Practices towards TB patients & TB Disease North 5%
East
5%
14% 7% 79%
90%
Refer TB patients for treatment
Refer govt hospital
• 87% of opinion leaders refer TB patients
West
Refer private hospital
6%
None/not applicable
4%
to government hospitals.
South
• It is noticeable that 14% in East zone
0%
refer to private hospitals.
6%
90%
94%
80 73
South
70
West East
60
North Percentage
50 40 30 20
40
37
35
34 29
26
24 15
18 13
20
13
20
18 13
13
13
12
10 0
Organised camps
Conclusion
Organised rallies
Organised lecturers/ seminar/workshops
Worked as DOT provider
Nukkad nataks/Street Play/Skits
Type of initiatives towards awareness generation • Most of the opinion leaders (83%) didn't take any initiative to create awareness on TB in the community • Only around one-fourth took intitiative in organising camps (15% in West and around 73% in South). • Almost 20% had worked as a DOT provider in the past • Less than 10% showed interest in activities like street plays/ workshops/seminars.
Almost all the opinion leaders who had heard about TB knew that a cough over 2 weeks could be TB, knew that TB spreads through air, knew that TB was curable. This is a highly potential unengaged group, which can play key role in TB control in India.
CHAPTER
6 Results: NGO/CBO Representatives
Demographic Profile The core characteristic of NGO and CBO representatives interviewed is that the bulk of them are female, and about evenly spread in terms of age between the 26-35, 36-45 and 46+ age groups. Most have worked for 5 years or less, and about a fourth had experience of between 6 years and a decade. In terms of the NGO or CBOs area of core focus, there is clear variation by region. NGOs and CBOs in the north focus on TB, rural development, education and disease, while those in the western region focus overwhelmingly on health issues (80%). Sanitation, education and rural development are the core areas of work for those in the south; in the east, NGOs and CBOs focus on sanitation, education and disease-related issues. Very few of the NGOs and CBOs focused on economic (35% work on income generation) or gender issues (5%). Regarding the distribution of the NGO/CBO, unfortunately, in the north zone not many were found during the survey implementation. Hence, this may not be representative of north zone and not comparable with other zones (Table 6.1).
Knowledge about TB Of the NGOs and CBOs interviewed, two thirds had TB on top of their mind in terms of recall. Nearly 90% of the representatives knew a cough of over two weeks as key symptom for TB and that TB transmission is through air (Table 6.2). TABLE 6.1: General profile of NGO/CBO representatives interviewed during midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
(50) (50)
13 12
(52) (48)
5 0
(100) (0)
23 38
(38) (62)
42 51
(45) (55)
(0) (100) (0) (0)
3 10 8 4
(12) (40) (32) (16)
2 2 1 0
(40) (40) (20) (0)
1 14 28 18
(2) (23) (46) (30)
6 28 37 22
(6) (30) (40) (24)
YEARS OF EXPERIENCE OF NGO/CBO 1-5 years 2 (100) 6-10 years 0 (0) 11-15 years 0 (0)
17 1 7
(68) (4) (28)
3 1 1
(60) (20) (20)
31 21 7
(53) (36) (12)
53 23 15
(58) (25) (16)
8
(32)
0
(0)
12
(20)
21
(23)
9 10 10 11
(36) (40) (40) (44)
0 1 2 4
(0) (20) (40) (80)
40 45 46 20
(66) (74) (75) (33)
50 56 59 36
(54) (60) (63) (39)
9 4 25
(36) (16) (100)
0 0 5
(0) (0) (100)
24 1 61
(39) (2) (100)
33 5 93
(35) (5)
GENDER Male Female
1 1
AGE OF THE RESPONDENT 18-25 years 0 26-35 years 2 36-45 years 0 46 years and 0 above
ISSUES ADDRESSED BY NGO/CBO TB specific/DOTS 1 (50) programme Rural development 1 (50) Sanitation 0 (0) Education 1 (50) Other health and 1 (50) disease related Income generation 0 (0) Gender issue 0 (0) Total 2 (100)
74
Chapter 6 Results: NGO/CBO Representatives
TABLE 6.2: Knowledge about TB, symptoms, mode of transmission and diagnosis of TB among NGO/CBO representatives who heard of TB North
%
East
%
West
%
South
%
Total
%
WHAT ARE THE COMMON DISEASES IN YOUR COMMUNITY** TB mentioned
1
(50)
11
(44)
0
(0)
49
(80)
61
(66)
TB not mentioned
1
(50)
14
(56)
5
(100)
11
(18)
31
(33)
Total
2
(100)
25
(100)
5
(100)
60
(100)
92
IF TB IS NOT MENTIONED, HAVE YOU HEARD OF TB?** Yes
1
(50)
13
(52)
5
(100)
10
(16)
29
(31)
No
0
(0)
1
(4)
0
(0)
0
(0)
1
(1)
Not applicable
1
(50)
11
(44)
0
(0)
49
(80)
61
(66)
A cough of 2 weeks
1
(50)
20
(83)
5
(100)
54
(92)
80
(89)
Pain in the chest
0
(0)
13
(54)
1
(20)
49
(83)
63
(70)
Coughing up blood
0
(0)
18
(75)
3
(60)
52
(88)
73
(81)
Night sweat
0
(0)
3
(13)
4
(80)
42
(71)
49
(54)
Weight loss
1
(50)
15
(63)
2
(40)
43
(73)
61
(68)
Loss of appetite
0
(0)
11
(46)
0
(0)
25
(42)
36
(40)
Through air when infected person cough's or sneezes
0
(0)
19
(79)
4
(80)
56
(95)
79
(88)
Through sharing cigarettes/beedis with infected person
0
(0)
8
(33)
0
(0)
47
(80)
55
(61)
Through sharing food with infected person
1
(50)
9
(38)
1
(20)
6
(10)
17
(19)
Through sharing bed/ clothes with infected person
0
(0)
6
(25)
1
(20)
7
(12)
14
(16)
Through hand shake with infected person
0
(0)
1
(4)
1
(20)
0
(0)
2
(2)
Sputum smear test
2
(100)
24
(100)
4
(80)
46
(78)
76
(84)
X-ray
1
(50)
12
(50)
2
(40)
51
(86)
66
(73)
Mantoux skin test
0
(0)
4
(17)
1
(20)
39
(66)
44
(49)
Blood test
0
(0)
7
(29)
2
(40)
44
(75)
53
(59)
Don’t know/can’t say
0
(0)
0
(0)
0
(0)
2
(3)
2
(2)
Government hospital/PHC/ DOTS centre
2
(100)
23
(96)
5
(100)
56
(95)
86
(96)
Private hospital/clinic
0
(0)
9
(38)
2
(40)
3
(5)
14
(16)
Total
2
(100)
24
(100)
5
(100)
59
(100)
90
SYMPTOMS OF TB*
MODE OF TB TRANSMISSION*
DIAGNOSIS OF TB*
PLACE OF TB DIAGNOSIS*
* Multiple response question ** Percentages do not add up to 100 as ‘not recorded/missing’ values not included in the table 75
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
More than 80% know that TB can be diagnosed by the sputum smear test. However, there are disturbingly high levels of misperception of the efficacy of blood tests to detect TB amongst the respondents, especially in the south (75% of NGOs in the south think that a blood test can help diagnose TB).
Knowledge about TB Treatment The overall portrait that emerges from this survey is this. The NGOs and CBOs knowledge about TB is somewhat bleak. While most representatives think that TB is curable (94% all India), it is striking to note that they appear to think that this can be achieved through home remedies or Ayurveda (in the north) (Table 6.3). Perhaps this is due to the small sample of NGO representatives interviewed (N=94). A strikingly low number of NGO representatives know about DOTS – 34%, but the bulk of these are in the south or the east, with only 1 representative in the north and the south stating that the DOTS course could cure TB. Most do know that TB can be treated at a government facility and most have heard of DOTS. The prescriptive lesson that clearly emerges by taking a panoramic view of this data is somewhat as follows. Working carefully with NGOs, health service providers and opinion leaders would best commence by starting with the basics and reinforcing the need to diagnose TB accurately, initiate treatment rapidly and also inform all of the above about the risks of MDR TB in the event of incomplete treatment. TABLE 6.3: NGO/CBO representatives knowledge about treatment of TB among those who heard of TB North
%
East
%
West
%
South
%
Total
%
(92)
5
(100)
56
(95)
85
(94)
ACCORDING TO YOU WHETHER TB IS CURABLE Fully Curable
2
(100)
22
TREATMENT OF TB* Home remedies
1
(50)
5
(21)
4
(80)
0
(0)
10
(11)
DOTS or TB drugs
0
(0)
15
(63)
1
(20)
18
(31)
34
(38)
Other allopathic medicines
0
(0)
7
(29)
0
(0)
54
(92)
61
(68)
Ayurvedic
1
(50)
0
(0)
0
(0)
0
(0)
1
(1)
Less than 2 weeks
0
(0)
0
(0)
0
(0)
1
(2)
1
(1)
1-5 months
0
(0)
0
(0)
1
(20)
1
(2)
2
(2)
6-8 months
2
(100)
14
(58)
4
(80)
9
(15)
29
(32)
More than 8 months and others
0
(0)
6
(25)
0
(0)
43
(73)
49
(54)
Don't Know/cant Say
0
(0)
4
(17)
0
(0)
3
(5)
7
(8)
Government hospital/ PHC/DOTS centre
2
(100)
19
(79)
5
(100)
55
(93)
81
(90)
Private hospital/clinic
0
(0)
2
(8)
1
(20)
2
(3)
5
(6)
DURATION OF TREATMENT
t PLACE OF TB TREATMENT
Contd...
74
Chapter 6 Results: NGO/CBO Representatives
North
%
East
%
West
%
South
%
Total
%
HEARD OF DOTS Yes
1
(50)
16
(67)
5
(100)
54
(92)
76
(84)
No
1
(50)
8
(33)
0
(0)
2
(3)
11
(12)
Government hospital/ PHC/DOTS centre
1
(50)
11
(46)
5
(100)
53
(90)
70
(78)
Total
2
(100)
24
(100)
5
(100)
59
(100)
90
PLACE OF DOTS
* Multiple response question
Role in TB Care and Control NGOs and CBOs are key stakeholders who work close to those TB patients residing in the community. They contribute significantly in raising awareness about diseases including TB and can significantly contribute to TB case detection, improving treatment and care services. However, the present study revealed that NGOs/CBOs taking initiatives in raising awareness on TB is minimal (37%) (Table 6.4). Amongst those who took initiatives, one third of them organised health camps to generate awareness on an average. Almost half of them in the north organised health camps for generating TB awareness. Other initiatives like organising rallies, lectures, seminar, workshops, working as a DOT provider are minimal. Almost 90% of these organisations had actually carried activities for spreading messages, educating communities on TB prevention and treatment. More than two third of these organisation have provided community-based TB care and have worked for reducing stigma and discrimination. Only one third of these organisations carried training of health care workers and volunteers, helped in the resettlement of TB patients, motivated TB patients to get treated under DOTS and spread messages about DOTS. The present study showed gaps in the knowledge on the general population, TB patients opinion leaders which can be filled by adequate involvement of these NGOs/CBOs. Most organisations (74%) are also not aware that they have schemes to collaborate with RNTCP (74%) and a low number of these are involved in such schemes (only 5 out of 13, 38%) like advocacy communication and social mobilisation and sputum collection & transportation (4 out of 5). The level of awareness of these organisations on such schemes seemed low, hence awareness should be generated among NGO/CBO representatives so that they collaborate with RNTCP through specific schemes and engage in TB care and control. Almost all are still willing to work for TB control (84%) and collaborate with the RNTCP (70%). If adequately involved in RNTCP, they can bridge the gap in accessing diagnosis in the marginalised and vulnerable communities.
75
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TABLE 6.4: Role played by NGO/CBO representatives in their communities to address TB North
%
East
%
West
%
South
%
Total
%
TAKEN INITIATIVES IN GENERATING AWARENESS ON TB/DOTS Taken initiatives in generating awareness on TB/DOTS
1
(50)
11
(44)
2
(40)
20
(33)
34
(37)
No
1
(50)
14
(56)
3
(60)
40
(66)
58
(62)
TYPE OF INITIATIVES* Organised camps
1
(100)
7
(64)
2
(100)
17
(85)
27
(79)
Organised rallies
0
(0)
2
(18)
0
(0)
1
(5)
3
(9)
Organised lectures/ Seminars/Workshops
0
(0)
8
(73)
0
(0)
1
(5)
9
(26)
Worked as DOT provider
0
(0)
2
(18)
0
(0)
2
(10)
4
(12)
Nukkad nataks/street plays/skits
0
(0)
1
(9)
0
(0)
1
(5)
2
(6)
Total
1
(50)
11
(44)
2
(40)
20
(33)
34
(37)
DOES YOUR ORGANISATION WORK FOR TUBERCULOSIS CONTROL Missing
0
(0)
0
(0)
0
(0)
1
(2)
1
(1)
Yes
1
(50)
9
(36)
1
(20)
18
(30)
29
(31)
No
1
(50)
16
(64)
4
(80)
42
(69)
63
(68)
TYPE OF ACTIVITIES UNDERTAKEN FOR TB CONTROL* Spreading awareness about TB, educating communities on its prevention and treatment
1
(100)
7
(78)
1
(100)
17
(94)
26
(90)
Provide community based care to TB patients
0
(0)
5
(56)
1
(100)
17
(94)
23
(79)
Training to TB care health workers and volunteer
0
(0)
3
(33)
1
(100)
7
(39)
11
(38)
Help in reducing stigma and discrimination form the community on TB
1
(100)
6
(67)
0
(0)
14
(78)
21
(72)
Help resettlement of TB patients
0
(0)
2
(22)
1
(100)
6
(33)
9
(31)
Motivating TB patients to treat under DOTS programme
1
(100)
6
(67)
0
(0)
4
(22)
11
(38)
Spreading awareness about DOTS
1
(100)
6
(67)
0
(0)
1
(6)
8
(28)
As DOT provider
0
(0)
2
(22)
0
(0)
0
(0)
2
(7)
Total
1
(100)
9
(100)
1
(100)
18
(100)
29
Contd...
76
Chapter 6 Results: NGO/CBO Representatives
North
%
East
%
West
%
South
%
Total
%
AWARE OF SCHEMES TO COLLABORATE WITH RNTCP Yes
1
(50)
7
(28)
1
(20)
4
(7)
13
(14)
No
0
(0)
14
(56)
4
(80)
51
(84)
69
(74)
Not recorded
1
(50)
4
(16)
0
(0)
6
(10)
11
(12)
Total
2
(100)
25
(100)
5
(100)
61
(100)
93
INVOLVED IN SCHEMES WITH RNTCP IN TB CONTROL Yes
0
(0)
4
(57)
1
(100)
0
(0)
5
(38)
No
1
(100)
3
(43)
0
(0)
4
(100)
8
(62)
Total
1
(100)
7
(100)
1
(100)
4
(100)
13
TYPE OF SCHEMES WHERE NGO/CBO ARE INVOLVED Advocacy, Communications and Social Mobilisation
-
-
1
(25)
1
(100)
-
-
2
(40)
Sputum Collection Scheme
-
-
2
(50)
0
(0)
-
-
2
(40)
Designated microscopy centres
-
-
1
(25)
0
(0)
-
-
1
(20)
Total
-
-
4
(100)
1
(100)
-
-
5
WILLINGNESS TO WORK ON TB CONTROL Willingness to work on TB control
0
(0)
9
(56)
3
(75)
42
(98)
54
(84)
No
1
(100)
5
(31)
1
(25)
1
(2)
8
(13)
Not recorded
0
(0)
2
(13)
0
(0)
0
(0)
2
(3)
Total
1
(100)
16
(100)
4
(100)
43
(100)
64
WILLINGNESS TO COLLABORATE WITH RNTCP Willingness to collaborate with RNTCP
1
(50)
18
(72)
2
(40)
44
(72)
65
(70)
No
1
(50)
7
(28)
3
(60)
17
(28)
28
(30)
Total
2
(100)
25
(100)
5
(100)
61
(100)
93
* Multiple response question
77
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Seriousness of TB, Risk Groups for TB and Community’s Behaviour towards TB Patients
On average, NGOs and CBOs perceive that TB is not a serious disease in the community (83%) (Table 6.5). Most of the representatives from south zones did not think TB is a serious disease. However, almost half of the organisations from the east zones perceive TB as a serious disease. The organisations, who perceive TB is not a serious disease, might have less knowledge on the severity of the disease and the danger to the community. On an average, more than half of NGOs are clear that smokers, alcoholics and HIV positive people are prone to TB. It is striking that organisations in west zone do not think that alcoholics are prone to TB. There are many high risk groups like migrant and tribal populations in the west zone, hence it becomes essential that NGO/CBO representatives in the west zone be made adequately aware on the risk factors for TB disease and treatment. Over 80% of the NGO/CBO representatives in south zone perceive that alcoholics and smokers are prone to TB and one third perceive that HIV infected people are prone to TB. This could be due to higher education level of people representing the organisations which simultaneously correlates with the higher level of education among general population in the south. In the communities where these organisations are working, over 50% of TB patients are well supported by the community and only less than 20% responded that TB patients are rejected and people are not friendly with them. Though at lower levels, stigma and discrimination towards TB patients still exists. TABLE 6.5: Attitudes towards TB disease and TB patients among NGO/CBO representatives who heard of TB interviewed in the midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
DO YOU THINK TB IS A SERIOUS DISEASE IN YOUR COMMUNITY Yes
0
(0)
11
(46)
1
(20)
4
(7)
16
(18)
Those living in unhygienic conditions
1
(50)
11
(46)
3
(60)
18
(31)
33
(37)
Poor people
0
(0)
1
(4)
0
(0)
0
(0)
1
(1)
Malnourished
1
(50)
10
(42)
2
(40)
2
(3)
15
(17)
Children
0
(0)
1
(4)
0
(0)
12
(20)
13
(14)
Women
0
(0)
1
(4)
0
(0)
11
(19)
12
(13)
WHO ARE PRONE TO TB*
Family members of TB
1
(50)
6
(25)
4
(80)
11
(19)
22
(24)
Exposed to cough and clod for long time
0
(0)
3
(13)
0
(0)
15
(25)
18
(20)
HIV +ve
0
(0)
11
(46)
1
(20)
19
(32)
31
(34)
Smokers
1
(50)
14
(58)
1
(20)
47
(80)
63
(70)
Alcoholics
0
(0)
11
(46)
0
(0)
48
(81)
59
(66)
Total
2
(100)
24
(100)
5
(100)
59
(100)
90
IN YOUR COMMUNITY, HOW IS THE PERSON SUFFERING FROM TB Most people reject him/ her
0
(0)
6
(24)
4
(80)
7
(11)
17
(18)
Most people are friendly but generally avoid them
2
(100)
6
(24)
1
(20)
6
(10)
15
(16)
Community mostly helps and support him/her
0
(0)
13
(52)
0
(0)
37
(61)
50
(54)
Total
2
(100)
25
(100)
5
(100)
60
(100)
90
* Multiple response question 78
Chapter 6 Results: NGO/CBO Representatives
Attitudes towards TB Patients and their Families The NGOs and CBOs responded that TB patients should be allowed to attend all social functions showing a positive attitude towards them. In south zone almost 92% of the representatives had positive attitude (Table 6.6). Almost all representatives strongly disagree that married female TB patients should be sent to their parent’s house. They also think that children with TB should be allowed to go to school (85%) and over 80% of the organisations think that daily wage labourers should be allowed to work. TABLE 6.6: Attitudes towards TB patients and their families among NGO/CBO representatives interviewed in the midline KAP survey, 2013 Attitude towards TB Patients
North
%
East
%
West
%
South
%
Total
%
A FAMILY WITH TB PATIENT SHOULD NOT BE ALLOWED TO PARTICIPATE IN ANY SOCIAL FUNCTION Strongly agree
0
(0)
3
(12)
2
(40)
0
(0)
5
(5)
Somewhat agree
1
(50)
2
(8)
0
(0)
5
(8)
8
(9)
Disagree
1
(50)
20
(80)
3
(60)
56
(92)
80
(86)
MARRIED FEMALE TB PATIENT SHOULD BE SENT OFF TO HER PARENT’S HOUSE Somewhat agree
0
(0)
1
(4)
0
(0)
4
(7)
5
(5)
Disagree
2
(100)
24
(96)
5
(100)
57
(93)
88
(95)
CHILDREN WITH TB SHOULD NOT BE ALLOWED TO GO TO SCHOOL Strongly agree
0
(0)
2
(8)
1
(20)
1
(2)
4
(4)
Somewhat agree
0
(0)
7
(28)
1
(20)
2
(3)
10
(11)
Disagree
2
(100)
16
(64)
3
(60)
58
(95)
79
(85)
DAILY WAGE LABOURERS SUFFERING FROM TB SHOULD NOT BE ALLOWED TO WORK Strongly agree
0
(0)
2
(8)
1
(20)
3
(5)
6
(6)
Somewhat agree
1
(50)
10
(40)
0
(0)
1
(2)
12
(13)
Disagree
1
(50)
13
(52)
4
(80)
57
(93)
75
(81)
HUSBANDS/IN-LAWS DO NOT ACCOMPANY FEMALE TB PATIENTS TO HOSPITAL/DOTS CENTRE Strongly agree
0
(0)
3
(12)
0
(0)
0
(0)
3
(3)
Somewhat agree
0
(0)
6
(24)
0
(0)
8
(13)
14
(15)
Disagree
2
(100)
16
(64)
5
(100)
53
(87)
76
(82)
FEMALES ACCOMPANY THEIR SPOUSE SUFFERING FROM TB TO HOSPITALS/DOTS CENTRE Strongly agree
2
(100)
16
(64)
3
(60)
40
(66)
61
(66)
Somewhat agree
0
(0)
5
(20)
0
(0)
11
(18)
16
(17)
Disagree
0
(0)
4
(16)
2
(40)
10
(16)
16
(17)
FEMALES SUFFERING FROM TB FACE PROBLEM IN MARRIAGE Strongly agree
1
(50)
14
(56)
2
(40)
48
(79)
65
(70)
Disagree
1
(50)
11
(44)
3
(60)
13
(21)
28
(30)
Total
2
(100)
25
(100)
5
(100)
61
(100)
93
79
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
More than 60% of the representatives responded that TB patients are taken to the hospital/DOTS centre by their spouse/in-laws across all zones. In the society where these organisations work, female TB patients do face marital problems (70%). It is highly encouraging to observe that the representatives from the local NGOs/CBOs have positive attitude towards the TB patients. They could play a significant role in the community in reducing stigma and discrimination towards TB patients. They can also contribute in generating awareness about TB among different stakeholders in the community. RNTCP has a wonderful opportunity to utilise these organisations and bridge gaps in the knowledge about TB, attitudes and practices towards TB patients among general population and other stakeholders in the community.
Health Seeking Behaviour
The general health seeking behaviour of NGO/CBO representatives is to go to government hospital for any sickness. In case of presumptive or confirmed TB, the representatives suggest the individuals to seek health care at government health centres (Table 6.7).
Potential Practices towards TB Patients
Only one –fifth of the representatives were willing to share meals with TB patients. And again only one-fifth of the representatives are willing to give their sons/daughter in marriage to individuals who had TB (Table 6.8). Responses to sharing meals or giving sons/daughters in marriage to those who had TB are observed to be similar among general population, opinion leaders and NGO/CBO representatives. There is a possibility that whether one has right knowledge about TB or not, response to these situations is similar. Examining the reasons behind these possible practices needs a well-planned qualitative study to explore and understand in local context. This also suggests the inclusion of community members in TB care and control to bring change in individuals thought processes. TABLE 6.7: General health seeking behaviour among NGO/CBO representatives interviewed during midline KAP survey, 2013 Health Seeking Behaviour
North
%
East
%
West
%
South
%
Total
%
WHEN SOMEONE FALLS SICK, WHERE WILL YOU GENERALLY GO? Government health facility
2
(100)
20
(80)
4
(80)
39
(64)
65
(70)
Private clinic
0
(0)
5
(20)
1
(20)
21
(34)
27
(29)
Clinic run by NGO
0
(0)
0
(0)
0
(0)
1
(2)
1
(1)
IF A PERSON WITH SYMPTOMS LIKE TB, WHERE ACCORDING TO YOU SHOULD YOU GO? Government centres
1
(50)
18
(72)
5
(100)
58
(95)
82
(88)
Private hospitals
0
(0)
4
(16)
0
(0)
0
(0)
4
(4)
DOTS/TB centres
1
(50)
3
(12)
0
(0)
1
(2)
5
(5)
IF A PERSON IS DIAGNOSED WITH TB, WHERE ACCORDING TO YOU SHOULD YOU GO?* Government centres
1
(50)
16
(64)
4
(80)
58
(95)
79
(85)
Private hospitals
0
(0)
7
(28)
3
(60)
0
(0)
10
(11)
DOTS/TB centres
1
(50)
11
(44)
1
(20)
5
(8)
18
(19)
Total
2
(100)
25
(100)
5
(100)
61
(100)
93
* Multiple response question
80
Chapter 6 Results: NGO/CBO Representatives
TABLE 6.8: Potential practices towards TB patients by NGO/CBO representatives among those interviewed in midline KAP survey, 2013 North % East SHARE A MEAL WITH PERSON YOU KNOW HAD TB Yes No Don’t know/Cant say
0 2 0
(0) (100) (0)
12 10 3
%
West
%
South
%
Total
%
(48) (40) (12)
0 5 0
(0) (100) (0)
6 51 4
(10) (84) (7)
18 68 7
(19) (73) (8)
IF YOU SUSPECT ONE OF THE FEMALE MEMBER IS SUFFERING FROM TB, DO YOU TAKE HER TO HOSPITAL Yes No Don’t know/Cant say
2 0 0
(100) (0) (0)
24 1 0
(96) (4) (0)
5 0 0
(100) (0) (0)
57 3 1
(93) (5) (2)
88 4 1
(95) (4) (1)
1 4 0
(20) (80) (0)
5 51 5
(8) (84) (8)
18 66 9
(19) (71) (10)
MARRY ONES DAUGHTER/SON TO A PERSON KNOWING HAD TB Yes No Don’t know/Cant say
1 1 0
(50) (50) (0)
11 10 4
(44) (40) (16)
ISOLATE YOUR FAMILY MEMBER HAVING TB FROM THE HOUSEHOLD Yes
1
(50)
1
(4)
0
(0)
3
(5)
5
(5)
No
1
(50)
22
(88)
5
(100)
43
(70)
71
(76)
Don’t know/Cant say
0
(0)
2
(8)
0
(0)
15
(25)
17
(18)
SEND ONES DAUGHTER-IN-LAW TO PARENT’S HOUSE IF SHE HAD TB IN ORDER TO PROTECT OTHER MEMBERS OF FAMILY Yes 1 (50) 0 (0) 0 (0) 5 (8) 6 No 1 (50) 23 (92) 5 (100) 47 (77) 76
(6) (82)
Don’t know/Cant say
0
(0)
2
(8)
0
(0)
9
(15)
11
(12)
Total
2
(100)
25
(100)
5
(100)
61
(100)
93
Practices in Media behaviour
Television continues to be the key source of general or TB-related information across all the groups including NGO/CBO representatives. Interestingly in this group, radio also seemed to be a significant source of information (39%) along with hoardings/posters/leaflets (59%) (Table 6.9). 81% of the survey respondents had seen/heard advertisement on TB/DOTS. The source where they heard about TB is television, followed by newspapers or magazines and hoardings/leaflets. TABLE 6.9: Source of general and TB related information among NGO/CBO representatives interviewed in midline KAP survey, 2013 (All are multiple response questions) North
%
East
%
West
%
South
%
Total
%
SOURCE OF GENERAL INFORMATION* Cinema
0
(0)
0
(0)
0
(0)
9
(15)
9
(10)
Hoardings/posters/ leaflets
1
(50)
9
(36)
3
(60)
42
(69)
55
(59)
Internet/web advertising
0
(0)
3
(12)
0
(0)
7
(11)
10
(11)
Local health service providers
0
(0)
10
(40)
1
(20)
16
(26)
27
(29)
Melas/nukkad nataks etc
0
(0)
3
(12)
0
(0)
2
(3)
5
(5)
Mobile phone advertising
0
(0)
0
(0)
0
(0)
1
(2)
1
(1)
Newspaper/magazines
1
(50)
11
(44)
4
(80)
50
(82)
66
(71)
Contd...
81
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
North
%
East
%
West
%
South
%
Total
%
Radio
0
(0)
5
(20)
2
(40)
29
(48)
36
(39)
Television
2
(100)
17
(68)
4
(80)
56
(92)
79
(85)
Word of mouth (interpersonal)
1
(50)
13
(52)
1
(20)
13
(21)
28
(30)
SOURCE OF INFORMATION FOR AWARENESS OF TB* Cinema
0
(0)
1
(4)
0
(0)
7
(11)
8
(9)
Drama/skit/street play
0
(0)
1
(4)
2
(40)
8
(13)
11
(12)
Friends/relatives
0
(0)
3
(12)
1
(20)
4
(7)
8
(9)
Hoarding/posters/ billboards
0
(0)
8
(32)
4
(80)
16
(26)
28
(30)
Hospital/doctor
1
(50)
11
(44)
1
(20)
21
(34)
34
(37)
Newspaper/magazines
1
(50)
5
(20)
4
(80)
50
(82)
60
(65)
Public service announcements
0
(0)
0
(0)
1
(20)
7
(11)
8
(9)
Radio
0
(0)
3
(12)
3
(60)
14
(23)
20
(22)
Teachers/peer educators
0
(0)
1
(4)
1
(20)
9
(15)
11
(12)
Television
2
(100)
10
(40)
5
(100)
54
(89)
71
(76)
SEEN/HEARD ADVERTISEMENT REGARDING TB/DOTS Yes
2
(100)
18
(72)
5
(100)
50
(82)
75
(81)
No
0
(0)
5
(20)
0
(0)
10
(16)
15
(16)
Don't know/can’t say
0
(0)
2
(8)
0
(0)
0
(0)
2
(2)
WHERE DID YOU SEE/HEARD THE ADVERTISEMENT REGARDING TB/DOTS* Newspaper/magazines
0
(0)
7
(28)
1
(20)
45
(74)
53
(57)
Radio
0
(0)
2
(8)
1
(20)
8
(13)
11
(12)
Television
2
(100)
10
(40)
5
(100)
47
(77)
64
(69)
Hoarding/posters/leaflets
1
(50)
12
(48)
3
(60)
36
(59)
52
(56)
PREFERRED SOURCE OF INFORMATION FOR AWARENESS OF TB* Cinema
0
(0)
0
(0)
0
(0)
6
(10)
6
(6)
Drama/skit/street play
0
(0)
1
(4)
0
(0)
7
(11)
8
(9)
Friends/relatives
1
(50)
0
(0)
0
(0)
4
(7)
5
(5)
Hoarding/posters/ billboards
0
(0)
2
(8)
2
(40)
21
(34)
25
(27)
Hospital/doctor
1
(50)
8
(32)
2
(40)
25
(41)
36
(39)
Internet
1
(50)
1
(4)
0
(0)
6
(10)
8
(9)
Newspaper/magazines
0
(0)
3
(12)
1
(20)
51
(84)
55
(59)
Public service announcements
0
(0)
0
(0)
0
(0)
10
(16)
10
(11)
Radio
0
(0)
1
(4)
0
(0)
17
(28)
18
(19)
Teachers/peer educators
0
(0)
1
(4)
0
(0)
14
(23)
15
(16)
Television
0
(0)
8
(32)
2
(40)
52
(85)
62
(67)
Total
2
(100)
25
(100)
5
(100)
61
(100)
93
* Multiple response question
82
Chapter 6 Results: NGO/CBO Representatives
Summary In general, NGO/CBO representatives in all the zones (except north) have knowledge about TB symptoms and transmission however there is lack of knowledge in treatment duration especially in the south (only 15% knew correct duration). This trend was observed in opinion leaders as well. The duration of treatment is long and if a patient does not complete the treatment, he will be at high risk of developing MDR-TB. Hence it is important that the stakeholders in a community know the right facts about TB care and control. TABLE 6.10: Summary of key indicators of knowledge about TB among NGO/CBO representatives interviewed in midline KAP survey, 2013 North
%
East
%
West
%
South
%
Total
%
(44)
0
(0)
49
(80)
61
(66)
13
(52)
5
(100)
10
(16)
29
(31)
WHAT ARE THE COMMON DISEASES IN YOUR COMMUNITY? TB mentioned
1
(50)
11
IF TB IS NOT MENTIONED, HAVE YOU HEARD OF TB? Yes
1
(50)
HEARD OF TB SPONTANEOUS/ON PROBING Yes
2
(100)
24
(96)
5
(100)
59
(97)
90
(97)
1
(50)
20
(83)
5
(100)
54
(92)
80
(89)
0
(0)
19
(79)
4
(80)
56
(95)
79
(88)
2
(100)
24
(100)
4
(80)
46
(78)
76
(84)
SYMPTOMS OF TB A cough of 2 weeks MODE OF TB TRANSMISSION Through air when infected person coughs or sneezes DIAGNOSIS OF TB Sputum smear test
ACCORDING TO YOU WHETHER TB IS CURABLE Fully curable
2
(100)
22
(92)
5
(100)
56
(95)
85
(94)
Partially curable
0
(0)
2
(8)
0
(0)
1
(2)
3
(3)
1
(50)
16
(67)
5
(100)
54
(92)
76
(84)
0
(0)
19
(79)
1
(20)
57
(97)
77
(86)
2
(100)
14
(58)
4
(80)
9
(15)
29
(32)
Government hospital/ PHC/DOTS centre
2
(100)
19
(79)
5
(100)
55
(93)
81
(90)
Taken initiatives in generating awareness on TB/DOTS
1
(50)
11
(44)
2
(40)
20
(33)
34
(37)
HEARD OF DOTS Heard of DOTS TREATMENT OF TB Allopathic medicines DURATION OF TREATMENT 6-8 months PLACE OF TB TREATMENT
83
Summary Results: NGO/CBO Representatives Demographic Profile • 55% NGO and CBO representatives interviewed were female • Most have worked for 5 years or less (58%) years • The core focus area varies from TB, rural development & education in North, health issues in West, sanitation, education & rural development in South and East • Very few of the NGOs and CBOs focused on economic (35% work on income generation) or gender issues (5%)
Knowledge about TB North 100
100
100 97 96
95
100 100
100 92
79 80
80
100
100
95
97
92
80 78
East 100
80
79
West 100
South 100 93 79
Percentage
67 58
60 50 40 20
20
0
0 Heard of TB Mode of TB (spontaneous/ transmission on probing) through
Diagnosis of TB (sputum smear test)
Fully curability of TB
Heard of DOTS
0 Treatment Duration Place of TB of TB of treatment treatment using allopathic (6-8 months) (Goverment medicines hospital/PHC /DOTS centre)
Knowledge about TB among NGO/CBO representatives • • • • • •
Close to all the respondents heard of TB as either spontaneous recall or on probing Nearly 90% of the representatives knew a cough of over two weeks as key symptom for TB 88% knew that transmission of TB is through air More than 80% know that TB can be diagnosed by the sputum smear test 84% were aware of DOTS Most respondents think that TB is curable (94%)
Attitudes towards TB disease and TB patients East
Family of TB patients should not be allowed to participant in social functions
20%
Attitudes towards TB patients 80%
Agree Disagree South
West
8% 40% 60% 92%
• Majority (86%) said family of TB patients should be allowed to participate in social functions. • 70% strongly agree that female suffering from TB free problem in marriage. • 18% agree that husband/in-laws do not accompany female TB patient to hospital.
East 19%
Most people are friendly but generally aavoid them
40% 41%
Treatment of person suffering from TB in the community
Most people reject him/her
South
West
12%
20%
• 54% said community mostly helps supports TB patient
Community mostly helps and support him/her
• Nearly one fifth (18%) said most people reject TB patients
14% 80%
74%
East
48%
Daily wage labourers suffering from TB should not be allowed to work
52%
• Majority of the respondents (overall 81%) were of opinion that daily wage labourers should not be stopped from their routine work/employment
Agree West
Disagree
South
• 40% of respondents in East are in favour of disallowing wage labourers suffering from TB from their work
7%
20%
• With proper awareness initiatives, precautions and treatment, these challenges could be overtaken and NGO/ CBOs can play a decisive role here.
93%
80%
Practices towards TB patients & TB Disease Practices towards TB patients North
West
East
• Only one fifth TB (19%) said they will share a meal with a person they know had TB
South
120
100
100
Percentage
• 95% said they will take a female member of the family suffering from TB like symtoms to hospital
85
80
60
100
73 64
• Only one fifth (19%) will get their sons/ daughters married to a person who they know had TB
40
0
0 Organised camps
0
Initiatives taken
18
18
20
5
Organised rallies
10
5 0
0
Organised lectures/ Seminars/Workshops
0
0
Worked as DOT pro
9 0
5 0
Nukkad natak/ street plays/skits
• Only 37% undertook initiatives to generate awareness of TB/DOTS • Of these 79% organised camps, 26% organised lectures of seminars.
Conclusion • Overall, though there is reasonably good knowledge about TB symptoms and transmissions, there is a huge gap in knowledge of treatment duration. • Focus on equipping NGO/CBO representatives with correct knowledge about TB is the need of the hour.
CHAPTER
7
Comparison of KAP About TB among Target Groups in Baseline and Midline Surveys
General Population The key knowledge indicators were compared between baseline and midline surveys to measure the change in knowledge about TB among the general population. A significant increase was observed from baseline to midline in proportions of general population who had heard of TB, who knew that cough of over 2 weeks is key symptom for TB, who knew that TB is transmitted through air, who had the knowledge that TB can be diagnosed by sputum examination and who knew that the treatment duration for TB is 6-8months (Table 7.1). There was no change in the proportion of those who knew TB was curable and those who had heard of DOTS. The level of knowledge about TB was also compared among those who had correct knowledge and those who had partial knowledge. All those individuals who had heard of TB, knew cough of over 2 weeks could be TB, knew TB is curable, and had heard of DOTS were identified as having correct knowledge. All those were aware of any one of the parameters were identified as those having partial knowledge about TB. In baseline survey, 18% of the total general population interviewed had correct knowledge. In midline survey, the proportion of those with correct knowledge increased to 32%, and is statistically significant (p 2 weeks is TB
2843 (62)
61-64
3443 (72)
70-73
Having knowledge that TB is transmitted through air
2283 (50)
49-51
3008 (63)
61-64
Having knowledge that TB can be diagnosed by sputum examination
2515 (55)
54-57
2778 (58)
56-59
Having knowledge that TB is curable
3346 (73)
72-75
3526 (73)
72-75
Having knowledge that the duration of TB treatment is 6-8 months
1724 (38)
36-39
2044 (43)
41-44
Have heard of DOTS
1059 (23)
22-24
1094 (23)
22-24
Know that TB treatment is free under DOTS
849 (19)
18-20
961 (20)
19-21
1535 (32)
31-33
OVERALL CORRECT KNOWLEDGE ABOUT TB Correct knowledge
819 (18)
86
17-19
Chapter 7 Comparison of KAP About TB among Target Groups in Baseline and Midline Surveys
TB Patients
A total of 609 patients were identified in baseline survey and 496 patients were identified in midline survey. The proportion of male TB patients slightly decreased, proportion of those who were illiterate considerably decreased from 43% in baseline to 34% in midline and proportion of patients with monthly income less than Rs.2000 decreased from 35% in baseline to only 15% in midline survey. This is consistent with the shift in standard of living index and the household assets of the group. Regarding knowledge indicators, the proportion of patients who knew that TB is caused due to germs or microorganisms increased from 33% in baseline to 44% in midline. There was no difference in the proportion of patients who heard of free diagnosis and treatment. However there was a considerable increase in proportion of those who got diagnosed in government facility (60% in baseline and 68% in midline) and in those receiving treatment freely under DOTS (53% in baseline and 59% in midline). The proportion of patients who visited two providers or less for diagnosis of TB increased significantly from 67% in baseline to 81% in midline survey. This is a significant change which has implications on reduction in delay in diagnosis and out of pocket expenditure. The proportion patients who were diagnosed within 1 month of onset of symptoms also increased from 74% in baseline to 81% in midline. TABLE 7.2: Key indicators of knowledge about TB among TB patients in the midline KAP survey compared with baseline KAP survey across the 30 districts from 15 states in India Characteristics
Baseline
Midline
N=609
N=496
Total number of TB patients
N (%)
95% CI
N (%)
95% CI
TB patients who were male
389 (64)
60-68
302 (61)
57-65
TB patients who were illiterate
264 (43)
39-47
167 (34)
30-38
TB patients with household monthly income less than Rs. 2000
212 (35)
31-39
75 (15)
12-19
Aware that TB is caused by micro-organisms
201 (33)
29-37
219 (44)
40-49
Heard of free diagnosis and treatment of TB
426 (70)
66-73
351 (71)
67-75
Underwent diagnosis in a government health facility
366 (60)
56-64
337 (68)
64-72
No. of TB patients who visited two providers or less for the diagnosis of TB
411 (67)
64-71
400 (81)
77-84
TB patients diagnosed within 1 month of the onset of symptoms
448 (74)
70-77
401 (81)
77-84
Proportion of TB patients initiated on treatment within 7 days of diagnosis
418 (69)
65-72
233 (47)
43-51
TB patients aware that treatment has to be taken regularly
488 (80)
77-83
378 (76)
72-80
TB patients aware that the duration of treatment is for 6-8 months
356 (58)
55-62
275 (55)
51-60
TB patients receiving treatment free of cost under DOTS
324 (53)
49-57
295 (59)
55-64
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
The indicators regarding treatment initiation have shown a decrease which is a matter of concern. In midline survey, it was observed that though 81% were diagnosed within one month of onset of symptoms, only 47% were initiated on treatment within 7 days of diagnosis. There was no difference the treatment initiation time between those who are taking treatment freely under DOTS or those paying for their treatment. In the baseline survey, 74% were diagnosed within one month and 69% were initiated on treatment within 7 days. When compared, the situation became worse in 2 years. There is an urgency to establish the reasons for the delay in treatment initiation and implement interventions to prevent such provider and patient related delays. Another important issue that needs immediate attention is patient’s knowledge regarding treatment duration and regularity. In baseline survey 80% of the patients knew that treatment has to be taken regularly however in midline this proportion reduced to 76% and those who knew the correct duration of treatment (6-8 months) decreased from 58% in baseline to 55% in the midline. Though it may seem as marginal decrease, the lack of knowledge regarding treatment regularity and duration could lead to non-adherence to treatment, irregularity and loss to follow up contributing to increased risk of developing drug resistance.
Health Service Provider A total of 614 providers in baseline and 523 providers in midline were interviewed. However, as there was a significant difference in the profile of the providers, both the groups are not comparable.
Opinion Leaders A total of 511 opinion leaders were interviewed in baseline survey and 611 were interviewed in the midline survey. Though higher proportion of leaders recalled hearing about TB in midline survey (22% in baseline and 31% midline), overall proportion who heard of TB in midline survey (94%) was less than that in baseline survey (100%) (Table 7.3). More number of opinion leaders were aware that cough of over 2 weeks is key symptom for TB in midline (88%) than in baseline (78%) and know that treatment of TB is through allopathic medicines in midline (86%) than in baseline (71%). However for all the other key indicators like transmission of TB through air, sputum test for TB diagnosis, and duration of TB treatment there was a decrease in proportions (Table 7.3). This pattern shows that though there seems an increase in knowledge on some key facts about TB still there is a lack of awareness on many other key facts. The awareness programmes whether through group discussions, sensitisation programmes or through media (radio/television or print media) are not providing holistic knowledge about TB. Opinion leaders are an important group of people who have influence over their communities and if we are not able to reach them with correct knowledge of TB in a holistic manner, we are failing at an important task of protecting our communities from the effects of lack of knowledge. There is a need to focus on this group and involve in them in TB control programme actively. It is observed that the proportion of leaders who played a role in TB awareness decreased from 22% in baseline to only 17% in midline.
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Chapter 7 Comparison of KAP About TB among Target Groups in Baseline and Midline Surveys
TABLE 7.3: Key indicators of knowledge about TB among opinion leaders in the midline KAP survey compared with baseline KAP survey across the 30 districts from 15 states in India Characteristics
Baseline
Midline
N=511
N= 611
N (%)
95% CI
N (%)
95% CI
Spontaneous recall (TB included in the top health priorities of their community)
113 (22)
19-26
191 (31)
28-35
Heard of TB
511 (100)
99-100
575 (94)
92-96
Mode of transmission: through the air when the infected person coughs or sneezes
422 (90)
87-92
456 (75)
71-78
Know that the major symptom of TB is cough of 2 weeks or more
400 (78)
74-82
538 (88)
85-90
Know that sputum smear test is necessary for the diagnosis of TB
407 (80)
76-83
423 (69)
65-73
Consider TB as fully curable disease
468 (92)
89-94
554 (91)
88-93
Heard of DOTS
300 (59)
54-63
351 (58)
54-62
Know that treatment of TB is through allopathic medicines
362 (71)
67-75
526 (86)
83-89
Know that the duration of TB treatment is 6-8 months
319 (62)
58-67
322 (53)
49-57
Know that the treatment of TB is available at government hospital
462 (90)
88-93
540 (88)
86-91
Have played a role in creating awareness for DOTS
113 (22)
19-26
106 (17)
15-21
Know that DOTS is free of cost
345 (68)
63-71
367 (60)
56-64
NGO/CBO Representatives
The NGO/CBO representatives included individuals who are working with NGOs or in civil society bodies like the self-help groups based at the village or ward level. A total of 51 representatives were interviewed in baseline survey and 93 have been interviewed in midline survey. It is observed that except for a couple key indicators rest all showed a decrease in knowledge about TB from baseline to midline. There was a significant increase in proportion of representatives who knew that treatment of TB is through allopathic medicines (51% in baseline to 85% in midline) (Table 7.4). However, there was an equal decrease in proportions who knew the correct duration of TB treatment as 6-8 months (80% in baseline to 31% in midline). All the other key indicators showed marginal decrease (Table 7.4). The situation suggests that the information regarding TB is being provided in a fragmented approach. Efforts must be made to provide clear, complete and correct knowledge essential for TB control and care in the communities to all key stakeholders who are significantly placed in their communities. It was also observed that the number of agencies involved in TB control decreased from 51% (N=26) in baseline to 31% (N=29) in midline. Interestingly more number of agencies are addressing TB related stigma and resettlement of TB patients in midline survey (23%, 10%) than that observed in baseline (12%, 6%). There is poor awareness among the representatives in midline (14%) regarding RNTCP PPM schemes than among the representatives in baseline (51%). Systematic approach to equip the village or ward level NGO/CBO representatives with knowledge about TB is need of the hour. This approach will in-turn place the representatives in a better place to be involved in TB care and control at community level. Empowering the stakeholders before engaging them in the TB control programmes, will ensure the efforts to be effective and efficient.
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TABLE 7.4: Key indicators of knowledge about TB among NGO functionaries in the midline KAP survey compared with baseline KAP survey conducted across the 30 districts from 15 states in India Characteristics
Baseline
Midline
N=51
N=93
N (%)
95% CI
N (%)
95% CI
Spontaneous recall (TB included in the top health priorities of their community)
51 (100)
93-100
61 (66)
55-74
Heard of TB
51 (100)
93-100
90 (97)
91-99
Mode of transmission: through the air when the infected person coughs or sneezes
48 (94)
84-98
81 (87)
79-92
Know that the major symptom of TB is cough of 2 weeks or more
47 (92)
81-97
86 (88)
80-93
Know that sputum smear test is necessary for the diagnosis of TB
47 (92)
81-97
78 (84)
75-90
Consider TB as fully curable disease
51 (100)
93-100
87 (94)
87-97
Heard of DOTS
46 (90)
79-96
77 (83)
74-89
Know that treatment of TB is through allopathic medicines
26 (51)
38-64
79 (85)
76-91
Know that the duration of TB treatment is 6-8months
41 (80)
68-89
29 (31)
23-41
Know that the treatment of TB is available at government hospital
50 (98)
90-100
83 (89)
81-94
Have played a role in creating awareness for DOTS
29 (57)
43-69
34 (37)
27-47
Know that DOTS is free of cost
46 (94)
83-98
73 (78)
69-86
NGO working in the area of TB control
26 (51)
38-64
29 (31)
23-41
Spread awareness about TB, prevention & treatment
23 (45)
32-59
26 (28)
20-38
Provide community based care to TB patients
16 (31)
20-45
23 (25)
17-34
Training to TB care health workers & volunteers
6 (12)
6-23
11 (12)
7-20
Help in reducing stigma & discrimination
6 (12)
6-23
21 (23)
15-32
Help resettlement of TB patients
3 (6)
2-16
9 (10)
5-17
10 (20)
11-32
11 (12)
7-20
Spread awareness on DOTS
6 (12)
6-23
8 (9)
4-16
Act as a DOTS provider
2 (4)
1-13
2 (2)
1-8
Aware of RNTCP PPM schemes
26 (51)
38-64
13 (14)
8-22
Involvement in RNTCP schemes
21 (41)
29-55
5 (5)
2-12
Motivating TB patients to get treated under DOTS
90
Comparison of KAP among target groups in Baseline and Midline surveys Comparison of Baseline and Midline findings of TB Knowledge among general population An increase was observed from baseline to midline in proportions of general population who have heard of TB who knew that cough of over 2 weeks is key symptom for TB, who knew that TB is transmitted through air, who had the knowledge that TB can be diagnosed by sputum examination and who knew that the treatment duration for TB is 6-8months. It’s a positive and satisfactory trend observed among general population. 100% 80%
72
84
60%
63
58
62
43
55
50
40%
38
20%
23
0%
Heard of TB
Knowledge that cough of > 2 weeks is key symptom of TB
40
Percentage
Midline
Baseline
88
0
Knowledge that the duration of TB treatment is 6-8 months
Have heard of DOTS
The proportion of respondents with correct knowledge about TB i.e. those heard of TB, know that cough of over 2 weeks is key symptom of TB, know that TB is curable and heard of DOTS increased from 18% in baseline to 32% in midline.
18
Baseline
Knowledge that TB can be diagnosed by sputum examination
Correct Knowledge about TB
32 20
Knowledge that TB is transmitted through air
Midline
Baseline and Midline findings treatment specific indicators among TB patients The indicators regarding treatment have shown a decrease which is a matter of concern. In midline survey, it was observed that though 81% were diagnosed within one month of onset of symptoms, only 47% were initiated treatment within 7 days of diagnosis. This has serious implications in transmission of TB. In baseline survey, 74% were diagnosed within one month and 69% were initiated on treatment within 7 days. This situation needs immediate attention.
100% 80% 60%
Baseline 81
69
76
74
40%
Midline
80
47
58
59
55
53
20% 0%
TB patients diagnosed within 1 month of the onset of symptoms
Proportion of TB patients initiated on treatment within 7 days of diagnosis
Aware that treatment has to be taken regularly
Aware that the duration of treatment is for 6-8 months
Receiving treatment free of cost under DOTS
Knowledge of key facts about TB among opinion leaders More number of opinion leaders were aware that cough of over 2 weeks is key symptom for TB in midline (88%) than in baseline (78%) and know that treatment of TB is through allopathic medicines in midline (86%) than in baseline (71%). However for all the other key indicators like transmission of TB through air, sputum test for TB diagnosis, and duration of TB treatment there was a decrease in proportions. This pattern shows that though there seems an increase in knowledge on some key facts about TB still there is a serious lack on many other key facts. Midline
Baseline
91 92
Consider TB as fully curable disease 69
Know that sputum smear test is necessary for the diagnosis of TB
80 88
Know that the major symptom of TB is cough of 2 weeks or more
78 75
Key mode of transmission i.e. through the air when the infected person coughs/sneezes
90 0
20
40 60 Percentage
100
80
Knowledge on treatment related indicators among opinion leaders Opinion leaders are an important group of people who have influence over their communities and if we are not able to reach them with correct knowledge of TB in a holistic manner, we are failing at an important task of protecting our communities from the effects of lack of knowledge. The RNTCP and the civil society agencies need to focus on this group and involve in them in TB control program actively. As it is observed, the proportion of leaders who played a role in TB awareness decreased from 22% in baseline to only 17% in midline. 90
86
80 Percentage
Midline
Baseline
100
88
71
60
62 53
40
68
59 58
60 22
20
17
0
Know that Know that the Know that the Heard of DOTS treatment duration of TB treatment of TB is through treatment is of TB is available allopathic medicines 6-8 months at government hospital
Know that Have played DOTS is free a role in creating of cost awareness for DOTS
TB control activities performed by NGOs/CBOs representatives Across the indicators for TB control, there is a uniform decline as compared to baseline findings which is a matter of serious concern and seeks serious attention. There is a 20% decrease seen in area of awareness role played by them specific to DOTS, overall awareness activity for TB prevention and treatment (17% decrease). The situation suggests that the information regarding TB is being provided in a fragmented approach. Efforts must be made to provide clear, complete and correct knowledge essential for TB control and care in the communities to all key stakeholders who are significantly placed in their communities. 80 Baseline
Percentage
60
Midline
57
51
45 40
41
37 28
20
31
25
23 12
12
14
12 4
0
2
5
Training to Help in Act as a Aware of Involvement Have played Spread Provide TB care reducing DOTS provider RNTCP PPM in RNTCP a role in awareness community stigma & schemes schemes creating about TB, based care to health awareness prevention & TB patients workers & discrimination for DOTS treatment volunteers
ANNEXURES Annexure 1: L ist of 30 districts selected for the baseline survey Annexure 2: Interviewer Reference Manual
95 96-126
Annexure 3: General Population
127-141
Annexure 4: People Affected with TB
142-160
Annexure 5: Health Service Providers
161-174
Annexure 6: Opinion Leaders
175-185
Annexure 7: NGO/CBO
186-198
Annexure
1
List of 30 districts selected for the baseline survey is as follows: Zone
Principal recipient
State
District
North
The Union
Uttar Pradesh
Agra
Population in Lakhs
North
The Union
Uttar Pradesh
Banda **
18
North
The Union
Uttar Pradesh
Faizabad
20
North
The Union
Uttar Pradesh
Maharajganj**
33
42
North
The Union
Punjab
Hoshiarpur
16
North
The Union
Haryana
Panipat
11
North
The Union
Haryana
Sirsa
13
South
World Vision
Andhra Pradesh
Medak
29
South
The Union
Karnataka
Bijapur
20
South
The Union
Tamil Nadu
Erode
28
South
The Union
Tami Nadu
Vellore
38
South
The Union
Tami Nadu
Nagapattinam
38
South
The Union
Kerala
Thiruvananthapuram
35
South
The Union
Kerala
Kollam
28
East
The Union
Mizoram
Aizwal
4
East
The Union
Bihar
Lakhisarai **
9
East
The Union
Bihar
Nalanda **
27
East
The Union
Bihar
Purnia **
29
East
World vision
Bihar
Saran **
37
East
The Union
West Bengal
Uttar Dinajpur
27
East
World vision
Orissa
Bhubaneshwar Corp
7
East
World vision
Orissa
Koraput
13
West
The Union
Madhya Pradesh
Bhopal
21
West
The Union
Madhya Pradesh
Hoshangabad **
13
West
World vision
Madhya Pradesh
Sehore **
13
West
The Union
Madhya Pradesh
Sagar **
24
West
World vision
Madhya Pradesh
Barwani †
13
West
World vision
Chhattisgarh
Kanker *
8
West
The Union
Maharashtra
Mumbai
133
West
The Union
Rajasthan
Jhunjhunun
22
95
Annexure
2
Interviewer Reference Manual
Tuberculosis (TB) is a major public health problem in India. India accounts for one-fifth of the global TB incident cases. Each year nearly 2 million people in India develop TB, of which around 0.87 million are infectious cases. It is estimated that annually around 330,000 Indians die due to TB. Project Axshya (meaning ‘TB-Free’) adds a new dimension to TB control in India through community ‘ownership’ and civil society-led public health programming. The project is managed by the International The Union Against Tuberculosis and Lung Disease (The Union) through The Union South-East Asia Office (USEA), and implemented by USEA’s nine core sub-recipient partners across India. It is a landmark project funded by The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) as part of its larger Round 9 TB grant to India, with The Government of India. As a part of Project Axshya, (Global fund Round 9 India TB project), a baseline, midline and end line TB related knowledge, Attitude and Practices (KAP) surveys are proposed to be conducted to assess the changes in the parameters among various stakeholders during the course of Project period. The baseline survey was a cross sectional study undertaken during the period of January – March, 2011 in a representative sample of 30 districts.
Survey Objective The prime objective of the study is to conduct a midterm survey of Knowledge, Attitude and Practice on Tuberculosis in India and compare with baseline to assess the change. The other specific objectives are given below: l
Information
on TB related knowledge, attitude and practices among general population, newly affected persons, opinion leaders, health services providers and NGO/CBO workers.
l
Attitudes
l
The
l
Individual,
l
Health
l
The
l
Media
l
Determine
l
The
l
The
and experiences of stigma and discrimination related to TB among general public and persons/relations affected by the disease. attitude of the segments towards TB patient with particular reference to gender.
social and environmental barriers including provider and patient delay that contribute to low TB case detection and poor completion of TB treatment. seeking behaviour of women and men, especially the vulnerable groups such as people living in hard to reach areas, backward communities etc., with reference to TB related symptoms. inter-personal relationship between TB health care providers and the persons affected with TB and the role of key community influencers and NGOs in RNTCP. habits/preferences of the beneficiaries, sources of information on TB and exposure to mass media channels. the preferred/trusted communication channels of the beneficiaries for receiving messages related to TB. knowledge, attitude and practice of health care providers on ‘Point of Care tests’.
knowledge, attitude and practice of general public and TB patients towards tobacco use/ control.
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Annexure 2 Interviewer Reference Manual
The prevalence of TB among the general population who report cough of >2 weeks and screen by routine smear test, to be performed at a designated microscopy centre.
l
Geographic Coverage The survey is a cross-sectional survey of 30 Axshya districts covering from the 15 states of India. The list of states are given below 1
Andhra Pradesh
10
Orissa
2
Bihar
11
Punjab
3
Chhattisgarh
12
Rajasthan
4
Haryana
13
Tamil Nadu
5
Karnataka
14
Uttar Pradesh
15
West Bengal
6
Kerala
7
Madhya Pradesh
8
Maharashtra
9
Mizoram
Questionniares This Midline survey collected information on various indicators that would assist policy makers and programme managers to formulate and implement the goals set for Global Fund Round 9 TB India Project. Specific questionnaires (QRE) were designed for different target groups of: General Population, TB patients, Health Service Providers (HSP), NGO/CBO and Opinion Leaders. These questionnaires were finalised in consultation with both GfK & The Union team members. l
General Population QRE: The information collected some basic demographic details like Age, Sex, marital status, education, source of drinking water, toilet, type of fuel. The other key information included Health seeking behaviour, Knowledge on Tuberculosis, symptoms and treatment, stigma and discrimination associated with it and media habits of respondents are also collected. TB Patients QRE: TB patients QRE was designed to collect information from the people who are diagnosed with TB in the past one year (Both who are undergoing the treatment and those who have completed the treatment) at the time of the survey. The QRE covered the demographic details, health seeking behaviour, TB disease related questions like type of diagnosis, kind of symptoms suffering from, number of health care providers visited for diagnosis, treatment taken etc. The information on Health related awareness, stigma and discrimination faced, tobacco use and media habits were also captured.
l
l
Health Service Provider QRE: The information was collected from the health service providers
who are first point of contact for health care. The main information captured is education details, knowledge on type of TB, symptoms & Treatment. Details with special reference to TB patients like average no. of TB patients, advise on drug, detection of TB patient, medicine etc. l
NGO/CBO:
Non-Governmental organisations and community based organisations’ representatives working in the area is also interviewed using NGO/CBO QRE. Apart from other necessary details on knowledge and awareness on TB, information is also sought on the type of NGO, area of work, whether working in the TB advocacy, awareness etc.
97
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Opinion Leaders: The information collected included some basic demographic details like age, sex, marital status, education. The information like Health seeking behaviour, Knowledge on Tuberculosis, symptoms and treatment, stigma and discrimination associated with it and media habit of respondents were also collected.
l
Role of Interviewers The interviewer occupies the central position in this survey because she/he collects information from respondents. Therefore, the success of the survey depends on the quality of each interviewer’s work. In general, the responsibilities of an interviewer include the following: Listing of each household to identify TB patients
l l
To
interview the target respondents and use relevant individual questionnaire
l
To check completed interviews so that all questions were asked and the responses are recorded
clearly l
Returning
to households to interview the respondents who were absent during the initial visit
Role of Supervisor The team supervisor plays a very important role for ensuring the quality and consistency of the data surveyed by you. Following are the responsibilities: l
Make
contact with members of Gram Panchayat (in case of rural settlement) in the beginning which will help in finding the stakeholders
l
Searching
l
Back
l
Observe
l
Address
for different categories of stakeholders
checking some of the interviews to ensure that the interviewee is genuine
some of the interviews to check whether you are conducting the interview in the right manner and also recording the answers correctly any problems faced by you during the survey and preparing your future work assignments
How to conduct an interview
An interview is not a mechanical process and hence it is important for you to make it interesting and pleasant. This art is developed with practice and certain fundamental principles must be followed. Few of the guidelines on how to build rapport with the respondent and how to conduct an interview are briefly described.
Building rapport with the respondent
One of the most important things for an interviewer is to build a very good rapport with the respondent. One needs to have a friendly and cordial behaviour towards the interviewee. Before the start of your work, the team supervisor will be informing the people/stakeholders in the area about yourself.
Make a good impression
Effort should be made to make the interviewer comfortable and at ease. An interview should start with a greeting and a suitable salutation.
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Annexure 2 Interviewer Reference Manual
Stress confidentiality of responses and be positive
If it is observed that the respondent is hesitant to reveal information and is skeptical whether the data will be shared with other people, then it is the responsibility of the interviewer to allay his/her fears. It should be stressed that the information collected will remain confidential and no names will be used for any purpose. The interviewee should also keep a positive and friendly approach and should ask questions accordingly.
Interview the respondent alone
Efforts should be made to conduct the interview of the respondent privately and all the questions should be answered by the interviewee himself/herself. In case the respondent is a TB patients, then extra effort is required to gain privacy. Similarly, if there is more than one eligible person in the household then the interview should be conducted in the absence of the other. In case the respondent is surrounded by lot many people and you are unable to find a secluded/secure place, then you have to use your tact and ingenuity to “get rid” of the people.
Tips for Conducting Interview Be neutral throughout the interview and never suggest answers to the respondent
During the interview, it is very important for you to maintain a neutral stand. You should be careful that the expression on your face and the tone of your voice does not reveal your stance which in a way would affect the answers of the interviewer.
Do not change the wording or sequence of questions
The wording of the questions as well as the sequence is carefully thought and documented beforehand. You are not expected to change the order of the sentences. In case the respondent is having trouble then you can rephrase the questions for his/her better understanding. Provide only the minimum information required to get an appropriate response.
Do not form expectations and do not rush the interview
You should ask the questions slowly and clearly so that the respondent is able to understand the questions properly before answering. Effort must be made to keep the interviewee at ease.
Language of the interview The questionnaires have been translated into all major languages in which interviewing will take place. However it is very important for you to not change/modify the meaning of the questions when you rephrase it or interpret it into another language. Following is the list of all the languages in which the questionnaires are translated. l
Telugu
l
Hindi
l
Kannada
l
Malayalam
l
Marathi
l
Mizo
l
Odiya
l
Tamil
l
Bengali
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
General Population Schedule Questionnaire ID Number: A unique ID will be provided at the time of data entry. State: Following is the list of 17 states with their state codes in which survey will be conducted. State Code
States
State Code
States
01
Andhra Pradesh
02
Bihar
03
Chhattisgarh
04
Haryana
07
Kerala
06
Karnataka
09
Mizoram
08
Maharashtra
11
Odisha
12
Punjab
13
Rajasthan
14
Tamil Nadu
15
Uttar Pradesh
16
West Bengal
17
Madhya Pradesh
District Code: A unique district code is assigned to each district. District Specification: Whether the district is tribal or non tribal. Tehsil/block/city: Name of the tehsil/block/city. Village/ward: A unique village code/ward code is assigned. Type of settlement: Whether the settlement is rural or urban. Distance from the nearest PHC/CHC/DH (kms): Closest government health centre (in kilometers). Name of the respondent: Name of the interviewee. Name of the head of the household: Interviewee’s household head’s name. Serial No. from listing: Number to be written which is assigned in the household listing.
1. Informed Consent The respondent’s consent for participation in the survey must be obtained before you begin the interview. Read the informed consent statement exactly as it is written. This statement explains the purpose of the survey. It assures that respondent participation in this survey is completely voluntary and that he/she can refuse to answer any questions or stop the interview at any point. You will also need to clarify that this information will be kept completely confidential. It will be used for research purpose only. If there is any confusion in the interviewee’s mind then you are expected to make him understand his/her voluntary participation in the language which he/she is familiar with without distorting the meaning.
2. General Information Q.1: Name of the respondent Q.2: Gender: Whether the respondent is male or female.
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Q.3: Age: Age of the respondent must be asked during the interview and should be observed and recorded. In case of any doubt you should ask the age of the respondent on his/her last birthday. Note that age is one of the most important questions since most of the analysis of the data depends on the respondent’s age. Q.4: Number of family members: The number of people living in the house is to be recorded. Q.5: Marital Status: Marital status of the respondent as on the date of survey to be recorded Item
Description
Married
If the person is married and living together with current spouse.
Code 1
Unmarried
If the person is not married
2
Divorced
If the person is divorced
3
Widowed
If the person was married but his/her spouse is died
4
Separated
If the person was married, but has legally obtained a divorce from
5
his/her spouse
Q.6: Number of children: The number of children of the respondent to be recorded. Q.7: Family type: The family type of the respondent is to be recorded. This has been coded for better understanding. Item
Code
Single
1
Joint
2
Extended
3
3. Health Seeking behaviour Q.8: Healthcare services availed in case of a minor illness: This question asks the respondent what all healthcare facility is used by them in case of minor illnesses. Q.9: Reasons for not going to a Government Health facility: In case the respondent does not avail government health services in question 8 then the reasons of not availing the same is recorded. Q.10: Healthcare services availed in case of a major illness: This question asks the respondent what all healthcare facility is used by them in case of major illnesses. Q.11: Healthcare facilities availed in case any family member develops cough for more than 2 weeks.
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Q.12: Whether suffering from cough (past 7 days): This question records whether the respondent or any of their family members have been suffering from cough in the past 7 days. In case the response is ‘Yes’, then the duration is also recorded. Q.13: Healthcare services availed: In continuation to question 12 (if the response recorded is ‘Yes’), the respondent is asked whether they or their family members seek any help or visited any health care centre. In case the response is ‘Yes’ then the name of the health care facility is also recorded. Q.14: Health facility availed during the last treatment: This question asks the respondent about the name of the health care provider where he/she visited for his/her last treatment.
4. Knowledge and awareness about Tuberculosis and treatment Q.15 – Q.18: Knowledge of common diseases and awareness of TB: This set of questions asks the respondent to list all the common diseases which he/she is aware of. A brief description of TB by the respondent is also recorded. Q.18 (a) – Q.19: Causes and symptoms of TB: This set of questions asks the respondent about the various causes and symptoms of TB. Q.20: Spread of TB: This question asks the respondent of all possible means which can aid the spread of TB. Q.21Most vulnerable people: The respondent is asked about the people who can easily contract TB. Q.22 – Q.23 & Q.33 – Q.34: General perception about TB: This question deals with the general perception of the respondent. Whether TB is a serious disease or not and can a TB patients be cured or not. Whether the respondent can contract this disease is also asked and in case the response is ‘No’ then what is/are the reason(s) behind. Q.24 – Q.25: Treatment and its duration: This set of questions asks the respondent about the various treatments to cure TB and also the ideal duration of treatment. Q.26 – Q.27: Diagnosis of TB: This set of questions captures the response on the various methods of diagnosis of TB and also the place where it can be diagnosed. Q.28 – Q.29: Place of treatment: This set of questions examines whether the respondent is aware of the places where TB can be treated and also whether regular and complete treatment of TB is important for cure. Q.30 – Q.32: Awareness of DOTS: This set of questions investigates whether the respondent has heard of DOTS and what are the places where DOTS are available. Also it is asked whether they know that DOTS TB treatment is available free of cost.
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5. Stigma and Discrimination As was defined in “Project Axshya Baseline Knowledge, Attitude and Practices on Tuberculosis in India”, stigma is a process of producing and reproducing inequitable power relations, where negative attitudes towards a group of people, on the basis of particular attributes such as their TB status, HIV status, gender, sexuality or behaviour, are created and sustained to legitimatised dominant groups in society. Similarly discrimination is defined as manifestation of stigma. Discrimination is any form of arbitrary distinction, exclusion or restriction, whether by action or omission, based on a stigmatised attribute. Q.35 – Q.39: Stigma and discrimination: This set of questions collects information on stigma and discrimination mainly on social stigma and gender discrimination. Q.40 – Q.41: Self initiative to control TB: This set of questions records whether the respondent has ever taken any initiatives towards generating awareness about TB & DOTS within the community. Q.42 – Q.45: Frequency and usage of tobacco: This set of questions inquires the respondents of tobacco usage i.e. whether they consume it in the form of cigarette/beedis or chewing. Frequency and the age of starting this practice are also recorded.
6. Media habit and preferences Q.46: Sources of news/information: This question inquires the respondent about all the existing sources of information. Q.47 – Q.48: Radio listening: This set of questions examines the radio listening habits of the respondent. What are the channels heard and how much health related interest is generated. Q.49 – Q.50: TV preference: This set of questions examines the TV preferences of the respondent. What are the channels viewed and how much health related interest is generated. Q.51 – Q.52: Newspaper preference: This question asks about the newspaper reading habit of respondent. If they read newspaper, then its preferred language is also recorded. Q.53 – Q.54: Advertisement/information on TB or DOTS: This set of questions inquires about the advertisement/information and its sources. Q.55 – Q.58: Sources of TB and health related information: This set of questions records the common sources of health related information and information specific to TB.
7. Information sources Q.59 – Q.59 (a): Sources of TB related information: The respondent will be asked on the sources of information for awareness on TB related issues and also on the specific aspects of TB.
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Q.60 – Q.62: Dissemination of TB related information: The respondent will be inquired about the visit of people to their house/neighbourhood for spreading TB related information in the family/community. In case of ‘Yes’, the person who visited along the information provided by them will also be recorded. Q.63 – Q.64: Sources of TB related information – Preferences: This set of questions will measure the preferences of the respondent in obtaining TB related information.
8. Socio, cultural, economic and demographic characteristics Q.65: Place of Birth: The place of birth of respondents is recorded here Q.66: Mother Tongue: It is an open ended question. The mother tongue of respondent is also recorded Q.67: Religion practiced: Ask the respondents about the religion. Do not try to guess the religion of the woman by either name or by appearance. If the respondent follow Hindu, Muslim, Christian religion. In others case, if respondent follow any other religion like Jainism, Buddhism Q.68: Caste : If the respondent belongs to Schedule caste or scheduled tribe category, OBC or General category, circle the appropriate response. Q.69: Educational level: The term “school” means formal schooling, which includes primary, secondary, and postsecondary schooling and any other intermediate levels of schooling in the formal school system. However, it does include technical or vocational training beyond the primary-school level, such as long-term courses in mechanics or secretarial work or ITI course. Q.70: Occupation: Item
Description
Code
Wage labourer
A manual worker who works for wages in kind or cash in agriculture and non-
1
agriculture activities. Skilled worker
Persons who got certain skills like carpenter, Tailor, shoemaker etc
2
Self employed
Persons who are engaged in their own enterprises or are engaged
3
independently in a profession or trade on own account or with one or a few partners. Service (Govt. &
The regular employees working in others enterprises (Government and
Private)
Private) and getting in return salary or wages on a regular basis
Business
Person who is doing their own business
Agriculture/cultivator A person who is engaged in cultivation of land owned or leased in from
4 5 6
government or from private person(s) or institution for payment in money, kind or share. Cultivation also includes effective supervision or direction in cultivation. Unemployed
Did not work but was seeking and/or available for work
7
House wife
Attending routine domestic chores, etc.
8
Student/
Attending educational institutions/Not able to work due to disability
9
Beggars, Pensioners, Too old to work etc.
10
Handicapped/etc Any other (specify)
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Q.71: Average household income Q.72: Type of house: Please ask this question from respondent and if interviewer is visiting his/her home then one can also confirm from their observation. See the responses and circle accordingly on Item
Description
Code
Pucca House
Flooring, roof & walls should be cemented/Concrete etc.
1
Semi – Pucca House
Temporary roofs could be with cemented floor & wall or any one of it.
2
Kutcha House
Thatched roofs, mud walls with no floorings.
3
Q.73: Number of rooms in the house: The total number of rooms excluding kitchen is recorded in this question. Q.74: Type of locality: The locality may be village community, town, urban slum, urban township/ society or others. Q.75: Ownership of house Ask whether anyone in your family owns a house – whether it is the house where you are residing or any other house and circle on respective code. Q.76: List of household items: The answers to these questions on ownership of certain items will be used as a rough measure of the Socio economic status of the household. Read out each item and circle the answer given after each item. Do not leave the codes for any item(s) blank. It does not matter who in the household owns the item; only that the item is owned by the household or one of its usual members. Q.77: Main source of drinking water The purpose of this question is to assess the cleanliness of the household’s drinking water by asking about the household’s main source of water. If drinking water is obtained from several sources, probe to determine the source from which the household obtains the majority of its drinking water. If the source varies by season, record the main source used at the time of interview. Item
Description
Code
Private Tap
Pipe connected with in-house plumbing to one or more taps, e.g. in the Kitchen and bathroom. Sometimes called a house connection. In-house pipes connected to a public or private water distribution system. Pipe connected to a tap outside the house in the yard or plot (and the Water is coming from a public or private water distribution system). Sometimes called a yard connection. Private Hand Pump Private hand pump which may be inside the house and may be used to pull the water from ground through hand pump.
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Item
Description
Code
Public water point from which community members may collect water (and the water is coming from a public or private water distribution system). A standpipe may also be known as a public fountain or public tap. Public standpipes can have one or more taps and are often made of brickwork, masonry or concrete. Public Hand Pump Public hand pump which will be outside and community members may collect water. People have to pull the water from ground through hand pump. Tube Well A deep hole that has been driven, bored or drilled with the purpose of reaching ground water supplies. Water is delivered from a tubewell or borehole through a pump which may be human, animal, wind, electric, diesel or solar-powered. Supply tanker Water is obtained from a provider who uses a truck to transport water into the community. Typically the provider sells the water to households. River/pond/Steam/ Water located above ground and includes rivers, dam Rain Waterfalls that is collected or harvested from surfaces by roof or ground catchment and stored in a container, tank or cistern, lakes, well, ponds, streams, canals, and irrigation channels
3
Rain water
8
Public Tap
Packaged Water
Water located above ground and includes rivers, dams, lakes, well, ponds, streams, canals, and irrigation channels Bottled water; Water that is bottled and sold to the household in bottles.
4
5
6
7
9
Q.78: Type of toilet system: This question asks the respondent of the type of toilet system he/ she is using. Following the code list: Item
Code
Public
1
Personal
2
Open field/space
3
Shared toilet
4
Others (specify)
99
Q.79: Proper drainage system: Whether there is a proper drainage system in the locality. Q.80: Separate space/room for cooking : If the cooking is done in the house, the respondent is asked whether there is a separate room that is used as a kitchen. This question provides additional information on the hygiene and air quality status of the household Q.81: Type of fuel: This question inquires about the type of fuel used in case of cooking. Following is the code list:
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Item
Code
Electricity
1
Wood
2
Coal/lignite
3
Kerosene
4
LPG/Natural Gas
5
Charcoal
6
Bio–gas
7
Dung cakes
8
Agricultural crop waste
9
Straw/shrubs/grass
10
Other (specify)
99
Q.82 – Q.83: BPL/Aadhaar card: The respondent is asked whether they are in possession of BPL card and/or UID/Aadhaar Card.
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Opinion Leaders Schedule Questionnaire ID Number: A unique ID will be provided at the time of data entry. State: Following is the list of 17 states with their state codes in which survey will be conducted. State Code
States
State Code
States
01
Andhra Pradesh
02
Bihar
03
Chhattisgarh
04
Haryana
07
Kerala
06
Karnataka
09
Mizoram
08
Maharashtra
11
Odisha
12
Punjab
13
Rajasthan
14
Tamil Nadu
15
Uttar Pradesh
16
West Bengal
17
Madhya Pradesh
District Code: A unique district code was assigned to each district. List of district code is as under: District Specification: Whether the district is tribal or non tribal. Tehsil/block/city: Name of the tehsil/block/city. Village/ward: A unique village code/ward code was assigned. List of village code/ward code is as under: Type of settlement: Whether the settlement is rural or urban. Distance from the nearest PHC/CHC/DH (kms): Closest government health centre (in kilometers). Name of the respondent: Name of the interviewee. Respondent category: The respondent’s category was recorded. Following is the code list for convenience. Item
Code
Village Pradhan
1
Panchayat member
2
Ward member
3
Religious leader
4
ANM
5
AWW
6
Teacher
7
GKS member
8
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1. Informed Consent The respondent’s consent for participation in the survey must be obtained before you begin the interview. Read the informed consent statement exactly as it is written. This statement explains the purpose of the survey. It assures that respondent participation in this survey is completely voluntary and that he/she can refuse to answer any questions or stop the interview at any point. It will also need to clarify that this information will be kept completely confidential. It will be used for research purpose only. If there is any confusion in the interviewee’s mind then you are expected to make him understand his/her voluntary participation in the language which he/she is familiar with without distorting the meaning.
2. General Information Q.1: Name of the respondent Q.2: Gender: Whether the respondent is male or female. Q.3: Age: Age of the respondent must be asked during the interview and should be observed and recorded. In case of any doubt you should ask the age of the respondent on his/her last birthday. Note that age is one of the most important questions since most of the analysis of the data depends on the respondent’s age. Q.4 (a) – Q.4 (b): Address of the respondent and duration of stay: This question asks the respondent their current address and the number of years of his/her stay in the address recorded.
3. Knowledge and awareness about Tuberculosis and treatment Q.5: Common diseases in the community: A list of common diseases prevalent in the community is to be asked from the respondent. The interviewee is to observe and note if TB is mentioned or not. Q.6 – Q.7: In case TB is not mentioned in the above question, the respondent is to be asked whether they are aware of TB. A brief verbatim is also to be recorded and the interviewer needs to skip to the next section i.e. ‘Health seeking behaviour’. Q.8: TB description: In case TB is mentioned as one of the diseases in question number 5, then the respondent is asked to briefly describe the disease. Q.8 (a): Causes of TB: This question examines the respondent’s knowledge on the causes of TB. Following code list records the same. Item
Code
Germs/Microorganism
1
DK/CS
3
Others (specify)
99
Q.9: Symptoms of TB: This question asks the respondent of the various symptoms. Q.10 – Q.12: Knowledge and awareness: This set of questions examines the knowledge and awareness of TB amongst the respondent. Ways of getting infected, vulnerable people and TB being a serious disease in the community is asked here. 109
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Q.13 – Q.15: TB treatment and duration: This set of questions inquires about the treatment which can be given to a TB patients. The duration of the treatment is also recorded. Q.16 – Q.18: TB Diagnosis: This set of question investigates the various means of diagnosis as well as the places where one can be diagnosed and be provided medication. Q.19 – Q.25: Awareness about DOTS: This set of questions asks the respondent about their current level of awareness pertaining to DOTS and the places where it is provided.
4. Health seeking behaviour Q.26 – Q.27: Place of treatment – common diseases: This set of questions asks the respondent the place where he/she refers the patients to go for treatment and also the reason(s) if the referred place is not a government health centre. Q.28 – Q.29: Place of treatment – TB: This set of questions inquires the respondent about the place of diagnosis and treatment for TB.
6. Stigma and discrimination Q.30 – Q.34: Stigma and discrimination: This set of questions collects information on stigma and discrimination mainly on social stigma and gender discrimination. Q.35 – Q.36: Self initiative to control TB: This set of questions records whether the respondent has ever taken any initiatives towards generating awareness about TB & DOTS within the community.
7. Media habit and preferences Q.37: Sources of news/information: This question inquires the respondent about all the existing sources of information. Q.38 – Q.39: Radio listening: This set of questions examines the radio listening habits of the respondent. Q.40 – Q.41: TV preference: This set of questions examines the TV preferences of the respondent. Q.42 – Q.43: Newspaper preference: This question asks about the newspaper reading habit of respondent. If they read newspaper, then its preferred language is also recorded. Q.44 – Q.45: Advertisement/information on TB or DOTS: This set of questions inquires about the advertisement/information and its sources.
8. Information sources Q.46 – Q.46 (a): Sources of TB related information: The respondent will be asked on the sources of information for awareness on TB related issues and also on the specific aspects of TB.
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Q.47 – Q.49: Dissemination of TB related information: The respondent will be inquired about the visit of people to their house/neighbourhood for spreading TB related information in the family/community. In case of ‘Yes’, the person who visited along the information provided by them will also be recorded. Q.50– Q.52: Sources of TB related information – Preferences: This set of questions will measure the preferences of the respondent in obtaining TB related information.
9. General, Socio, cultural and demographic information Q.53: Marital Status: Marital status of the respondent as on the date of survey to be recorded. Item
Description
Code
Married
If the person is married and living together with current spouse.
1
Unmarried
If the person is not married
2
Divorced
If the person is divorced
3
Widowed
If the person was married but his/her spouse is died
4
Separated
If the person was married, but has legally obtained a divorce from his/her spouse
5
Q.54: Number of children: The number of children of the respondent to be recorded. Q.55: Number of family members: The number of people living in the house (including yourself) to be recorded. Q.56: Family type: The family type of the respondent is to be recorded. This has been coded for better understanding. Item
Code
Single
1
Joint
2
Extended
3
Q.57 (a) – Q.57 (b): Place of birth and mother tongue The place of birth of respondents and mother tongue of respondent is recorded in this question. Q.58: Religion practiced Ask the respondents about the religion. Do not try to guess the religion of the woman by either name or by appearance. If the respondent follow Hindu, Muslim, Christian religion. In others case, if respondent follow any other religion like Jainism, Buddhism Q.59: Caste : If the respondent belongs to Schedule caste or scheduled tribe category, OBC or General category, circle the appropriate response.
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Q.60: Educational level : The term “school” means formal schooling, which includes primary, secondary, and postsecondary schooling and any other intermediate levels of schooling in the formal school system. However, it does include technical or vocational training beyond the primary-school level, such as long-term courses in mechanics or secretarial work or ITI course. Q.61: Occupation: The nature of occupation of a worker or activity status of a non-worker as the case may be is to be recorded here. Item
Code
Village Pradhan
1
Panchayat member
2
Ward member
3
Religious leader
4
ANM
5
AWW
6
Teacher
7
GKS member
8
Any other
99
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NGO/CBO Schedule 1. Midline knowledge, attitude and practice (KAP) survey on Tuberculosis Questionnaire ID Number: A unique ID will be provided at the time of data entry. State: Following is the list of 17 states with their state codes in which survey will be conducted. State Code
States
State Code
States
01
Andhra Pradesh
02
Bihar
03
Chhattisgarh
04
Haryana
07
Kerala
06
Karnataka
09
Mizoram
08
Maharashtra
11
Odisha
12
Punjab
13
Rajasthan
14
Tamil Nadu
15
Uttar Pradesh
16
West Bengal
17
Madhya Pradesh
District Code: A unique district code was assigned to each district. List of district code is as under: District Specification: Whether the district is tribal or non tribal. Tehsil/block/city: Name of the tehsil/block/city. Village/ward: A unique village code/ward code is assigned. List of village code/ward code is as under: Type of settlement: Whether the settlement is rural or urban. Distance from the nearest PHC/CHC/DH (kms): Closest government health centre (in kilometers). Name of the respondent: Name of the interviewee.
2. Informed Consent The respondent’s consent for participation in the survey must be obtained before you begin the interview. Read the informed consent statement exactly as it is written. This statement explains the purpose of the survey. It assures that respondent participation in this survey is completely voluntary and that he/she can refuse to answer any questions or stop the interview at any point. It will also need to clarify that this information will be kept completely confidential. It will be used for research purpose only. If there is any confusion in the interviewee’s mind then you are expected to make him understand his/her voluntary participation in the language which he/she is familiar with without distorting the meaning.
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3. General Information Q.1: Name of the respondent Q.2: Gender: Whether the respondent is male or female. Q.3: Age: Age of the respondent must be asked during the interview and should be observed and recorded. In case of any doubt you should ask the age of the respondent on his/her last birthday. Note that age is one of the most important questions since most of the analysis of the data depends on the respondent’s age. Q.4 (a) – Q.4 (b): Address of the respondent and duration of stay: This question asks the respondent their current address and the number of years of his/her stay in the address recorded.
4. Knowledge and awareness about Tuberculosis and treatment Q.5: Common diseases in the community: A list of common diseases prevalent in the community is to be asked from the respondent. The interviewee is to observe and note if TB is mentioned or not. Q.6 – Q.7: In case TB is not mentioned in the above question, the respondent is to be asked whether they are aware of TB. A brief verbatim is also to be recorded and the interviewer needs to skip to the next section i.e. ‘Health seeking behaviour’. Q.8: TB description: In case TB is mentioned as one of the diseases in question number 5, then the respondent is asked to briefly describe the disease. Q.8 (a): Causes of TB: This question examines the respondent’s knowledge on the causes of TB. Following code list records the same. Item
Code
Germs/Microorganism
1
DK/CS
2
Others (specify)
99
Q.9: Symptoms of TB: This question asks the respondent of the various symptoms. Q.10 – Q.12: Knowledge and awareness: This set of questions examines the knowledge and awareness of TB amongst the respondent. Ways of getting infected, vulnerable people and TB being a serious disease in the community is asked here. Q.13 – Q.15: TB treatment and duration: This set of questions inquires about the treatment which can be given to a TB patients. The duration of the treatment is also recorded. Q.16 – Q.18: TB Diagnosis: This set of question investigates the various means of diagnosis as well as the places where one can be diagnosed and be provided medication. Q.19 – Q.24: Awareness about DOTS: This set of questions asks the respondent about their current level of awareness pertaining to DOTS and the places where it is provided.
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5. Health seeking behaviour Q.25 – Q.26: Place of treatment – common diseases: This set of questions asks the respondent the place where he/she refers the patients to go for treatment and also the reason(s) if the referred place is not a government health centre. Q.27 – Q.28: Place of treatment – TB: This set of questions inquires the respondent about the place of diagnosis and treatment for TB.
6. Stigma and discrimination Q.29 – Q.33: Stigma and discrimination: This set of questions collects information on stigma and discrimination mainly on social stigma and gender discrimination. Q.34 – Q.35: Self initiative to control TB: This set of questions records whether the respondent has ever taken any initiatives towards generating awareness about TB & DOTS within the community.
7. Media habit and preferences Q.36: Sources of information: This question inquires the respondent about all the existing sources of information. Q.37 – Q.38: Radio listening: This set of questions examines the radio listening habits of the respondent. Q.39 – Q.40: TV preference: This set of questions examines the TV preferences of the respondent. Q.41 – Q.42: Newspaper preference: This question asks about the newspaper reading habit of respondent. If they read newspaper, then its preferred language is also recorded. Q.43 – Q.44: Advertisement/information on TB or DOTS: This set of questions inquires about the advertisement/information and its sources.
8. Information sources Q.45 – Q.45 (a): Sources of TB related information: The respondent will be asked on the sources of information for awareness on TB related issues and also on the specific aspects of TB. Q.46 – Q.48: Dissemination of TB related information: The respondent will be inquired about the visit of people to their house/neighbourhood for spreading TB related information in the family/community. In case of ‘Yes’, the person who visited along the information provided by them will also be recorded. Q.49 – Q.51: Sources of TB related information – Preferences: This set of questions will measure the preferences of the respondent in obtaining TB related information.
9. Only for NGO/CBO Q.52: Name of the NGO
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Q.53: Duration: This question records the respondent’s duration of association with the NGO. Q.54: Issues taken by NGO: This question asks the respondent about the issues tackled by their NGO in recent times. Q.55 – Q.56: TB issues taken by NGO: This set of questions examines whether the respondent’s NGO is involved in TB control and TB related activities. Q.57 – Q.62: Awareness of TB related schemes: Whether the respondent is aware of various TB related schemes will be recorded here. If answer to the previous question is positive, then their NGOs involvement in these schemes will also be recorded. Q.63: Marital Status: Marital status of the respondent as on the date of survey to be recorded. Item
Description
Code
Married
If the person is married and living together with current spouse.
1
Unmarried
If the person is not married
2
Divorced
If the person is divorced
3
Widowed
If the person was married but his/her spouse is died
4
Separated
If the person was married, but has legally obtained a divorce from his/
5
her spouse
Q.64: Number of children: The number of children of the respondent to be recorded. Q.65: Number of family members: The number of people living in the house (including yourself) to be recorded. Q.66: Family type: The family type of the respondent is to be recorded. This has been coded for better understanding. Item
Code
Single
1
Joint
2
Extended
3
Q.67 (a) – Q.67 (b): Place of birth and mother tongue The place of birth of respondents and mother tongue of respondent is recorded in this question. Q.68: Caste: If the respondent belongs to Schedule caste or scheduled tribe category, OBC or General category, circle the appropriate response. Q.69: Religion practiced: Ask the respondents about the religion. Do not try to guess the religion of the woman by either name or by appearance. If the respondent follow Hindu, Muslim, Christian religion. In others case, if respondent follow any other religion like Jainism, Buddhism
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TB Patients Schedule Questionnaire ID Number: A unique ID will be provided at the time of data entry. State: Following is the list of 17 states with their state codes in which survey will be conducted. State Code
States
State Code
States
01
Andhra Pradesh
02
Bihar
03
Chhattisgarh
04
Haryana
07
Kerala
06
Karnataka
09
Mizoram
08
Maharashtra
11
Odisha
12
Punjab
13
Rajasthan
14
Tamil Nadu
15
Uttar Pradesh
16
West Bengal
17
Madhya Pradesh
District Code: A unique district code was assigned to each district. List of district code is as under: District Specification: Whether the district is tribal or non-tribal. Tehsil/block/city: Name of the tehsil/block/city. Village/ward: A unique village code/ward code is assigned. List of village code/ward code is as under: Type of settlement: Whether the settlement is rural or urban. Distance from the nearest PHC/CHC/DH (kms): Closest government health centre (in kilometers). Name of the respondent: Name of the interviewee. Name of the head of the household: Name of the head of the household
Informed Consent The respondent’s consent for participation in the survey must be obtained before you begin the interview. Read the informed consent statement exactly as it is written. This statement explains the purpose of the survey. It assures that respondent participation in this survey is completely voluntary and that he/she can refuse to answer any questions or stop the interview at any point. It will also need to clarify that this information will be kept completely confidential. It will be used for research purpose only. If there is any confusion in the interviewee’s mind then you are expected to make him understand his/her voluntary participation in the language which he/she is familiar with without distorting the meaning. Q.1 Name of the Respondent: Please ask the name of respondent interviewed for the study. Q.2 Gender: Male or Female.
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Q.3 Age: This is one of the most important questions in the interview, since almost all analysis of the survey data depends on the respondent’s age. Please ask how old you were in your last birthday. (If the person is aged 18 years or less, then make sure that the consent of the parent or guardian is also taken. Interview parent/guardian if the person is less than 15 years old.) Q.4: Number of family members: The number of people living in the house is to be recorded. Q.5: Marital Status: This question refers to the marital status as on the date of survey Item
Description
Code
Currently Married
If the person is married and living together with current spouse.
1
Unmarried
If the person is not married
2
Divorced
If the person is divorced
3
Widow/Widower
If the person was married but his/her spouse is died.
4
Separated
If the person was married, but has legally obtained a divorce from his/her
5
spouse.
If coded ‘2’ – “unmarried” then skip the next question Q.6: Number of children: The number of children of the respondent to be recorded. Q.7: Family type: The family type of the respondent is to be recorded. This has been coded for better understanding. Item
Code
Single
1
Joint
2
Extended
3
Q.8 Medication for disease other Tuberculosis: Health Seeking Behaviour Q.9: Healthcare services availed in case of a minor illness: This question asks the respondent what all healthcare facility is used by them in case of minor illnesses. Q.10: Reasons for not going to a Government Health facility: In case the respondent does not avail government health services in question 9 then the reasons of not availing the same is recorded. Q.11: Healthcare services availed in case of a major illness: This question asks the respondent what all healthcare facility is used by them in case of major illnesses. Q.12: Healthcare facilities availed in case any family member develops cough for more than 2 weeks.
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Annexure 2 Interviewer Reference Manual
Q.13: Health facility availed during the last treatment: This question asks the respondent about the name of the health care provider where he/she visited for his/her last treatment. It’s an open ended response.
TB Disease related questions Q.14: What is TB? : This questions asks the respondents about their prompt response on TB. It’s an open ended question. Q.15: Cause of TB: The cause of TB is asked from the respondent; whether Germs or microorganism or any other responsible for causing TB. Q.16 & 17: Diagnosis of TB: This question asks the respondents about number of times diagnosed with TB in the past. Q.18: Source of Treatment: The question asks the respondents about the source of treatment after getting diagnosed with TB. Item
Code
Government Hospital
1
Private hospital/clinic
2
Both government and private
3
DOTS Centre
4
Clinics run by NGOs
5
Others (Specify)
99
Q.19 intends to find out whether the person who is affected from TB completed a minimum treatment of 6 months of 6 months or not. In case, the respondent had not completed the treatment for 6 month, then next question Q.20 asks about the reason for it. Item
Code
No improvement in health
1
Developed side effects
2
The centre is too far from house
3
Treatment too expensive (in case of private patients)
4
Others (specify)
99
Q.21 – Q.25: Symptoms of Tuberculosis and Treatment Q.21 is about knowing the symptoms of tuberculosis developed in the current episode by tuberculosis affected person and its duration
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Item
Code
Cough
1
Fever
2
Chest Pain
3
Blood in sputum
4
Weight Loss
5
Don’t know/Can’t Say
6
Others Specify
99
Q.22 asks the respondents about the duration of visit to local service provider after the onset of symptom. This health care provider can be anyone from ASHA to local chemist. This question refers to the current episode of TB. Q.23 intends to know the number of days usually take for diagnosis of Tuberculosis. After how many days of onset of symptom the TB patients come to know that he is suffering from TB. The response is to be recorded in number of days. Q.24 asks the respondents about their visit to number of health care providers before getting diagnosed with TB. The approximate time interval between each visit is to be recorded. Q.25 The purpose of this question is to assess the first point of contact after developing symptoms of tuberculosis. The questions contain multiple responses. Item
Code
Knowledgeable person in community
1
Unqualified Healer in locality (quack)
2
Faith healer
3
Other Family Member
4
Spouse
5
Friends/Relatives/Colleagues/Employer
6
Medicine retail outlet/Chemist
7
Qualified private doctor/clinic
8
Local Health Care Provider
9
Govt. dispensary/health centre
10
Any other (specify)
99
Q.26 a) Place of Diagnosing TB: Q.26 b) Availability of Medical Record: Ask the respondents about the medical records or drugs prescription to substantiate the facts. Record the response accordingly Q.27 Part of Organ Affected: Ask the respondents about the organ affected with tuberculosis if it is lung or any other organ Q.28 a - Q.28 d: Test of Sputum: This set of questions asks the respondents about the test of sputum for confirmation of tuberculosis, place of testing, amount paid for test and medical records available to substantiate the fact. Q.29 a – Q.29 d: X-Ray for TB confirmation: This set of questions asks the respondents about X –ray done by the TB patients for confirmation of tuberculosis, place of doing X –ray, amount paid for X-ray and medical records available to substantiate the fact. 120
Annexure 2 Interviewer Reference Manual
Q.30 a – Q.30 d: Blood Testing : This set of questions asks the respondents about blood test done by the TB patients for confirmation of tuberculosis, place of doing blood test, amount paid for blood test and medical records available to substantiate the fact. Q. 31: Time between Diagnosis and Treatment: This question tries to capture the average time required to initiate the TB treatment after getting diagnosed Q.32 – Q.33: Diagnosis and Treatment of TB: This set of question enquires respondents if they have heard of free diagnosis and treatment of tuberculosis. If coded ‘yes’ then place of free diagnosis and treatment available for TB. Q. 34 – Q. 37: Medicine of TB: This set of question asks the respondents about the place of taking TB medicines, still taking TB medicine, if paying for the medicine or not. If the respondent has already completed the course of treatment then ask for the prescription or medical records to substantiate the fact. If TB affected is not taking medicine then reasons for not taking the medicine. Q.38 – Q.46: TB Drug Regularity: This set of question asks the respondents about the regularity of treatment, if respondents missing any doses, if treatment is taken under the supervision and if they are satisfied with the provider. Q. 47 – 50: Time & Cost incurred for TB Treatment These set of questions capture the information on the time and cost incurred for taking treatment of tuberculosis. Cost of treatment per day for travelling as well as on medicines. Q. 51– 53 Government’s Initiative for TB Treatment These questions ask the respondents whether anybody visit their house to check the regularity of medicine. If there is any child less than 6 yrs. If coded ‘Yes’ then ask whether these children receiving any medicine for prevention of TB or not
Stigma and Discrimination Q.57 – Q.70: This set of questions collects information on stigma and discrimination mainly on self-stigma, social stigma and gender discrimination. Q.57 – Q.58: record the information about self –stigma; whether the respondents disclosed their diseases status to family members and record their reaction Q.60 – Q.65: record the information about self –stigma and social stigma; whether the respondents disclosed their diseases status to friends and record their reaction Q. 66 – Q.68: record the information about the community’s perception on the stigma associated with people affected with Tuberculosis Q.69 – Q.70: record the information about the stigma faced by TB patients in the workplace after disclosing the disease status.
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Tobacco Use: Q.71 – Q.73: This question inquires the respondents about their tobacco use, its form and for how long they have been using tobacco and at what age they started using tobacco. Q.74 – Q. 75: These questions capture the type of tobacco used by the TB patient. Q.75 – Q. 80: These questions enquire about the TB patient’s knowledge on association of TB and tobacco. Q.81a – Q.81b: This set of questions enquire patient’s exposure to second hand smoking and its harmful effects on them.
Media habit and preferences Q.82: Sources of news/information: This question inquires the respondent about all the existing sources of information. Q.83 – Q.84: Radio listening: This set of questions examines the radio listening habits of the respondent. What are the channels heard and how much health related interest is generated. Q.85 – Q.86: TV preference: This set of questions examines the TV preferences of the respondent. What are the channels viewed and how much health related interest is generated. Q.87 – Q.88: Newspaper preference: This question asks about the newspaper reading habit of respondent. If they read newspaper, then its preferred language is also recorded. Q.89 – Q.90: Advertisement/information on TB or DOTS: This set of questions inquires about the advertisement/information and its sources. Q.91 – Q.92: Sources TB and health related information: This set of questions records the common sources of health related information and information specific to TB. Q.93 – Q.94: Recall of Message on Tuberculosis: This questions asks the respondents if they can recall any message on TB, If yes, record the message (open ended question) Q. 95 - Q.96: These questions enquire about any advertisement about smoking and its dangers noticed by the TB patients.
Information sources Q.97 – Q.97 (a): Sources of TB related information: The respondent will be asked on the sources of information for awareness on TB related issues and also on the specific aspects of TB. Q.98 – Q.100: Dissemination of TB related information: The respondent will be inquired about the visit of people to their house/neighbourhood for spreading TB related information in the family/community. In case of ‘Yes’, the person who visited along the information provided by them will also be recorded. Q.101 – Q.102: Sources of TB related information – Preferences: This set of questions will measure the preferences of the respondent in obtaining TB related information. 122
Annexure 2 Interviewer Reference Manual
Socio, cultural, economic and demographic characteristics Q.103 (a) and 103 (b): Place of Birth: The place of birth of respondents is recorded here
The mother tongue of respondent is also recorded Q.104: Religion practiced: Ask the respondents about the religion. Do not try to guess the religion of the woman by either name or by appearance. If the respondent follow Hindu, Muslim, Christian religion. In others case, if respondent follow any other religion like Jainism, Buddhism Q.105: Caste: If the respondent belongs to Schedule caste or scheduled tribe category, OBC or General category, circle the appropriate response. Q.106: Educational level: The term “school” means formal schooling, which includes primary, secondary, and postsecondary schooling and any other intermediate levels of schooling in the formal school system. However, it does include technical or vocational training beyond the primary-school level, such as long-term courses in mechanics or secretarial work or ITI course. Q.107: Occupation: Item
Description
Code
Wage labourer
A manual worker who works for wages in kind or cash in agriculture and
1
non-agriculture activities. Skilled worker
Persons who got certain skills like carpenter, Tailor, shoemaker etc
2
Self employed
Persons who are engaged in their own enterprises or are engaged
3
independently in a profession or trade on own account or with one or a few partners. Service (Govt. &
The regular employees working in others enterprises (Government and
Private)
Private) and getting in return salary or wages on a regular basis
Business
Person who is doing their own business
Agriculture/cultivator A person who is engaged in cultivation of land owned or leased in from
4 5 6
government or from private person(s) or institution for payment in money, kind or share. Cultivation also includes effective supervision or direction in cultivation. Unemployed
Did not work but was seeking and/or available for work
7
House wife
Attending routine domestic chores, etc.
8
Student/
Attending educational institutions/Not able to work due to disability
9
Beggars, Pensioners, Too old to work etc.
10
Handicapped/etc Any other (specify)
Q.108: Average household income Q.109: Type of house: Please ask this question from respondent and if interviewer is visiting his/her home then one can also confirm from their observation. See the responses and circle accordingly on
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Item
Description
Code
Pucca House
Flooring, roof & walls should be cemented/Concrete etc.
1
Semi – Pucca
Temporary roofs could be with cemented floor & wall or any one of it.
2
Thatched roofs, mud walls with no floorings.
3
House Kutcha House
Q.110: Number of rooms in the house: The total number of rooms excluding kitchen is recorded in this question. Q.111: Type of locality: The locality may be village community, town, urban slum, urban township/ society or others. Q.112: Ownership of house Ask whether anyone in your family owns a house – whether it is the house where you are residing or any other house and circle on respective code. Q.113: List of household items: The answers to these questions on ownership of certain items will be used as a rough measure of the Socio economic status of the household. Read out each item and circle the answer given after each item. Do not leave the codes for any item(s) blank. It does not matter who in the household owns the item; only that the item is owned by the household or one of its usual members. Q.114: Main source of drinking water The purpose of this question is to assess the cleanliness of the household’s drinking water by asking about the household’s main source of water. If drinking water is obtained from several sources, probe to determine the source from which the household obtains the majority of its drinking water. If the source varies by season, record the main source used at the time of interview. Item
Description
Code
Private Tap
Pipe connected with in-house plumbing to one or more taps, e.g. in the Kitchen and bathroom. Sometimes called a house connection. In-house pipes connected to a public or private water distribution system. Pipe connected to a tap outside the house in the yard or plot (and the Water is coming from a public or private water distribution system). Sometimes called a yard connection.
1
Private Hand Pump
Private hand pump which may be inside the house and may be used to pull the water from ground through hand pump.
2
Public Tap
Public water point from which community members may collect water (and the water is coming from a public or private water distribution system). A standpipe may also be known as a public fountain or public tap. Public standpipes can have one or more taps and are often made of brickwork, masonry or concrete.
3
Public Hand Pump
Public hand pump which will be outside and community members may collect water. People have to pull the water from ground through hand pump.
4
Tube Well
A deep hole that has been driven, bored or drilled with the purpose of reaching ground water supplies. Water is delivered from a tubewell or borehole through a pump which may be human, animal, wind, electric, diesel or solar-powered.
5
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Annexure 2 Interviewer Reference Manual
Item
Description
Code
Supply tanker
Water is obtained from a provider who uses a truck to transport water into the community. Typically the provider sells the water to households.
6
River/p o nd/Steam/ Water located above ground and includes rivers, dam Rain that is collected Waterfalls or harvested from surfaces by roof or ground catchment and stored in a container, tank or cistern, lakes, well, ponds, streams, canals, and irrigation channels
7
Rain water
Water located above ground and includes rivers, dams, lakes, well, ponds, streams, canals, and irrigation channels
8
Packaged Water
Bottled water; Water that is bottled and sold to the household in bottles.
9
Q.115: Type of toilet system: This question asks the respondent of the type of toilet system he/ she is using. Following the code list: Item
Code
Public
1
Personal
2
Open field/space
3
Shared toilet
4
Others (specify)
99
Q.117: Proper drainage system: Whether there is a proper drainage system in the locality. Q.118: Separate space/room for cooking : If the cooking is done in the house, the respondent is asked whether there is a separate room that is used as a kitchen. This question provides additional information on the hygiene and air quality status of the household Q.119: Type of fuel: This question inquires about the type of fuel used in case of cooking. Following is the code list: Item
Code
Electricity
1
Wood
2
Coal/lignite
3
Kerosene
4
LPG/Natural Gas
5
Charcoal
6
Bio–gas
7
Dung cakes
8
Agricultural crop waste
9
Straw/shrubs/grass
10
Other (specify)
99
Q.120 – Q.121: BPL/Aadhaar card: The respondent is asked whether they are in possession of BPL card and/or UID/Aadhaar Card.
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Operational Issues on the Field l
The most common problem faced at the time of fieldwork was in the identification of people affected with TB. Certain factors made people reluctant to reveal their disease status. Due to societal dread, the villagers were not open enough to discuss TB related issues with outsiders. At the time of survey, some of the people affected with TB were either found unavailable as they had gone out for medication or some other work. We found that many people wanted to keep their disease status confidential. Also friends and relatives of the patient did not wish to share this information.
l
The availability of Health Service Providers (mainly doctors) was found to be very less at the PSU level. In most PSUs, the primary health centres were just for the name sake; doctors rarely visited in these centres. Even the other health staff refused to give interviews outright. This has led to increase in the number of interviews in other categories of health service providers. This fact was confirmed from the Respondents belonging to General Population segments where a large number of people said as there is no service available at PHC or sub centre level, to see a qualified doctor they need to go to the district hospital.
l
A
l
There
l
Another
similar situation was encountered in interviewing the NGOs/CBO at PSU level. We did not find many NGOs operating in many villages selected for the study. Thus, we managed to take interviews of some of the self-help groups operating at village level. are certain PSUs where number of households was found to be less than number of households documented in the census sheet. In some of the PSUs, number of households was found more. The major reason for this is the use of Census 2001 data for the purpose of sampling. There is one PSU in District Purnia, Bihar where we found that the entire village was washed off due to floods; only 40 households were left. Some of the PSUs/village had similar names; there are two cases where we found two villages with same name which caused confusion in selecting the right one. This confusion wasted a lot of time in the field. problem was refusal from Panchayat or ward member to conduct survey in their village/ward. In one of the village of Punjab (HOSHIYARPUR DISTRICT), the sarpanch refused to conduct survey in their village. In Maharashtra, one PSU was replaced because it did not exist in Sendhwa block of (BARWANI DISTRICT). The same PSU was replaced with another PSU of Sendhwa block.
Strengths of Field Work l
As
the study deals with the sensitive issue of TB disease in the community, which is still stigmatised, we asked our field teams to seek the support or consent of Panchayat/Ward Member before entering any PSU. This step helped in the building the rapport with the community members. The field teams first focused on the interview of Opinion leaders; then moved on with the listing of Households. This exercise made the data collection process easier in the community.
l
At the time of listing of households, each interviewer was allocated with each Tola of PSU and assigned a unique number. During listing, each interviewer wrote its unique number in the wall of each house listed for the allocated Tola. This modus operandi helped in household identification and prevented the household from duplication.
l
Data
quality was enhanced by checking about 10% of questionnaire in the field by field supervisor. A separate supervisor questionnaire was prepared for all the segments. This supervisor questionnaire was filled after completion of interview by interviewer.
126
ANNEXURE
3 General Population
Midline Knowledge, Attitude and Practice (KAP) Survey on Tuberculosis QUESTIONNAIRE ID NUMBER
________________________
STATE
1. Andhra Pradesh 2. Bihar 3. Chhattisgarh 4. Haryana 5. Karnataka 6. Kerala 7. Maharastra 8. Mizoram 9. Orrisa 10. Punjab 11. Rajasthan 12. Tamil Nadu 13. Uttar Pradesh 14. West Bengal 15. Madhya Pradesh
DISTRICT CODE DISTRICT SPECIFICATION
TRIBAL………………………..1
NON-TRIBAL…………………………2
TEHSIL/BLOCK/CITY VILLAGE/WARD TYPE OF SETTLEMENT
RURAL………………………..1
URBAN……………………………………2
Distance from the nearest PHC/ CHC/DH (kms) Name of Respondent Name of the head of the household Serial No. from Listing
Date of Interview FIELD CONTROL INFORMATION
Starting Time of Interview
AM 1 PM 2
Ending Time of Interview Interview
By
AM 1 PM 2 Code
Sign Spot/back check Yes
1
No
By 2
Scrutiny Yes
1
No
Code
Sign By
2
Code
Sign
If more than one visit made record: * Status of interview First visit
Time:_________
1
2
3
4
Second visit
Time:_________
1
2
3
4
Third visit
Time:_________
1
2
3
4
* Refused...........1 Not available.......2 Partly Completed..3 Completed..........4
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Good Morning/Evening, My name is _________ I am from a social research organisation GfK Mode. We are conducting a study on behalf of an international Non-Government Organisation called, The International Union Against Tuberculosis and Lung Diseases (The Union). The Union is working with the Government of India, and supporting its Revised National Tuberculosis Control Programme in spreading awareness about tuberculosis in the community. The International Union Against Tuberculosis and Lung Diseases (The Union) an international NGO, is conducting a research study entitled, “Midline Survey on Knowledge, Attitude and Practice (KAP) towards Tuberculosis in 45 districts from 16 states in India.” Through this study we want to get some information on knowledge, attitude & practices regarding Tuberculosis among General Public, so that this information could help design appropriate strategies that will help in TB care and control programmes. All of your responses will be treated as confidential and will be used only for research purposes and also to help policy makers to understand the bottlenecks in functioning, if any, to streamline the functioning You are being invited to take part in this research study. Please ask the researcher any questions that you do not fully understand. It is very important that you are fully satisfied and clearly understand what this research entails and how you could be involved. Your participation is entirely voluntary and you are free to decline to participate. There are no financial incentives given for taking part in this study. If there is anything else that you want to know, if you have any further queries or encounter any problems you can contact Dr. Sarabjit Singh Chadha, Project Director, The Union, New Delhi, contact No : 011-46054400
CONSENT FORM I ……………………………………………, agree to take part in the above mentioned study.
I declare that:
I have read this information and consent form and understand the contents = I have had a chance to ask questions and all my questions have been adequately answered = I understand that taking part in this study is voluntary and I have not been pressurised to take part = I may choose to leave the study at any time and will not be penalised or prejudiced in any way =
Do you have any questions about the survey? (Instruction To Investigator: In Case Of Any Questions Raised By Respondent, Kindly Respond To His/Her Satisfaction) Participant:
Investigator:
Name: - _______________________________
Name: - _________________________
Date: - ________________________________
Date: - __________________________
Signature or thumbprint: - _________________
Signature or thumbprint: - ___________
128
Annexure 3 General Population
General Information Q. No 1
Questions
Response
Skip
What is your Name? ____________________
2 3
Observe and record the interviewee’s sex.
Male
1
Female
2
One
1
Two
2
Three
3
Four
4
More than four
5
Married
1
Unmarried
2
Divorced
3
Widowed
4
Separated
5
One
1
Two
2
Three
3
More than three
4
No children
5
Single
1
Joint
2
Extended
3
How old are you? (Age in completed years)
4
5
6
7
How many people live in your house including yourself?
What is your marital status?
How many children do you have?
What is your family type?
If code 2 Skip to Q. 7
The next few questions are about the HEALTH SEEKING BEHAVIOUR of your family. Please do not get offended by some of the questions. They are just intended to know the access to different types of health facilities Questions 8
When someone falls sick in your family and it is a minor illness, where do they generally go for healthcare? (Please provide them clues and mark the most appropriate answer)
Response
Skip
Government health facility (Including PHC,CHC, district hospital/sub centre/ANM
1
Private Clinic
2
Private Hospital or nursing home
3
Ayurvedic or Siddha treatment
4
Homeopathic treatment
5
Traditional healer/Quacks/informal provider
6
Clinic run by NGOs
7
Local chemist or pharmacy
8
ASHA worker in your village
9
Any other (Specify
129
99
If coded 1 then skip to Q. 10
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
9
If you do not generally go to a Government Health facility? Why not? (please provide clues to the responses and Multiple responses possible)
10
Facility is far from home
1
Unavailability of doctors
2
Unfriendly behaviour
3
Long Waiting Hours
4
Lack of Qualified Doctor
5
Lack of Diagnostic facility
6
Private clinics offer better service
7
Inconvenient timings
8
Any Other (Specify)
99
When someone falls sick in your family and it is a major or serious illness that may need hospital admission, where do they generally go for healthcare?
Government health facility (district hospital or community health centre/sub centre/ANM
1
Government medical college
2
Private Hospital or nursing home
3
(Single coding)
Private medical college hospital
4
Corporate, super speciality hospital
5
Private Ayurvedic treatment
6
Private Homeopathic treatment
7
Traditional healer/Quacks
8
Any other (Specify 11
If someone in your family develops cough for more than 2 weeks, where might they generally go for healthcare?
Government health facility (Including PHC,CHC, district hospital)
1
Sub Centre/ANM
2
Private Clinic
3
Private Hospital or nursing home
4
Ayush
5
Dots Centre
6
Traditional healer/Quacks/informal provider
7
Clinic run by NGOs
8
Local chemist or pharmacy
9
Any other (Specify) 12
13
14
99
99
Have you or your family members been suffering from cough in the past 7 days? If yes, what is the duration?
Yes
1
No
2
If yes, from Q.12, did you or your family member seek any help/visited any health care centre? If yes, where did you go?
Yes
1
No
2
The last time you fell sick and had to seek medical care, where exactly did you go?
Write response verbatim:
If coded 2, skip to Q.14
Duration in days
Record answer
Knowledge and awareness about tuberculosis and treatment 15 16
What are the most common diseases you are aware of? If TB is not mentioned, have you heard of TB? (Please use the alternate terms for TB that is locally used as well)
TB Mentioned
1
TB Not mentioned
2
Yes
1
No
2
DK/CS
3
130
IF coded (1) then skip to Q. 18
Annexure 3 General Population
17
Record verbatim and skip to Q. 35
If No, in your opinion what could be TB? (Record verbatim)
18
If yes, what is TB? (Record verbatim)
19
Could you mention few symptoms or features of TB? If the person is not able to understand the term ‘symptom’, then give a few examples like pain that occurs when any part of the body is affected (Multiple Response Possible)
A cough of 2 weeks Pain in the chest
2
Coughing up blood
3
Fever
4
Night sweat
5
Weight loss
6
Loss of appetite
7
Don’t know
8
Any other 20
Do you know how a person can get infected with TB? (Please prompt and select the responses, multiple responses possible)
Who do you think are more prone to get TB? (Prompt for multiple Response by asking ‘and’ and record them till the person says no more, multiple responses possible)
22
23
Do you consider TB as a serious disease?
According to you whether TB diseased person can be cured? (Single Response)
24
What is the best treatment for TB? (Single Response)
99
Through handshake with infected person
1
Through the air when the infected person cough or sneeze
2
Through sharing food with infected person
3
By sharing bed/clothes with infected person
4
By smoking cigarettes/beedis
5
Don’t Know
6
Any Other (Specify) 21
1
99
Those living in unhygienic condition
1
Poor people
2
Malnourished
3
Children
4
Women
5
Family members of TB person
6
Exposed to cough and cold for long time
7
HIV +ve
8
Smokers
9
Alcoholic
10
DK/CS
11
Any other
99
Yes
1
No
2
DK/CS
3
Yes, Completely
1
Yes , Partially
2
No
3
DK/CS
4
Herbal Remedies
1
Home Remedies
2
DOTS or TB drugs
3
Other Allopathic medicines
4
Ayurvedic
5
Homeopathy
6
DK/CS
7
Any other (specify) 131
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Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
25
How long should the treatment be taken to cure TB?
Less than 2 weeks
1
2-4 weeks
2
1-5 months
3
6-8 months
4
More than 8 months (specify)
5
DK/CS
6
How can TB be diagnosed?
Sputum Smear Test
1
(Multiple Response Possible)
X–Ray
2
Mantoux Skin Test
3
Blood test
4
DK/CS
5
(Single Response)
26
27
Are you aware of the place where Tuberculosis can be diagnosed? (Multiple Response Possible)
Any Other (Specify)
99
Government Hospital
1
Private Hospital/Clinic
2
NGO
3
Private lab
4
DK/CS
5
Other 99 28
Are you aware of the place where one can be treated for Tuberculosis? (Multiple Response Possible)
29
Government Hospital
1
CHC/PHCs
2
ANM/ASHA/AWW
3
Private Hospital/Clinic
4
DOTS Provider
5
NGO
6
DK/CS
7
Other
99
In your opinion, is regular and complete treatment for TB important for cure?
Yes
1
No
2
DK/CS
3
30
Have you heard of DOTS?
Yes
1
No
2
31
Are you aware of the place where DOTS is available?
Government Hospital
1
CHC/PHCs
2
ANM/ASHA/AWW
3
Private Hospital/Clinic
4
DOTS Provider/DOTS Centre
5
NGO
6
DK/CS
7
Other
99
(Multiple Response Possible)
32
33
Do you know that under DOTS TB treatment is available free of cost?
Yes
1
No
2
DK/CS
3
Do you think you can get TB?
Yes
1
No
2
DK/CS
3
132
If coded 2, then skip to Q 33
If coded 1, then skip to Q. 35
Annexure 3 General Population
34
If no, what are the reasons?
I am healthy and strong
1
(Multiple Response)
I do not fall sick easily
2
No one in my family have suffered from TB
3
I have not come in contact with a TB patient
4
I stay away from poor/sick people
5
I do not smoke
6
Others (specify)
99
STIGMA AND DISCRIMINATION The next few questions are related to documenting your opinion on tuberculosis patients Some of the issues are quite sensitive. Please do not get offended by them. Strongly Agree
Somewhat agree
Disagree
A family with TB patient should not be allowed to participate in any social function
1
2
3
B
Married female TB patient should be sent off to her parent’s house
1
2
3
C
Children with TB should not be allowed to go to school
1
2
3
D
Children of parents suffering from TB should not be allowed to go to school
1
2
3
E
TB patient are threat to community
1
2
3
F
TB patients should be left isolated in the community
1
2
3
G
Daily wage Labourer, suffering from TB should not be allowed to work
1
2
3
36
Which of the following you would agree to do?
Yes
No
DK/CS
A
Share a meal with person you know had TB
1
2
3
B
If you suspect one of the female member of your family is suffering from TB, would you take her to hospital
1
2
3
C
Marry your daughter to a boy knowing he had TB
1
2
3
D
Isolate your family member having TB in the house
1
2
3
E
Marry your son to a girl who you know had TB
1
2
3
F
Send your daughter in law to parent’s house if she had TB in order to protect other family members from TB
1
2
3
35
Now I will make some statements about People suffering from TB. Please let me know how much you agree to these?
A
133
Can’t Say/Don’t Know
4
4
4 4
4 4 4
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
37
In your community, how do other people interact/react with a person suffering from TB? (Multiple response possible)
Most people reject him or her
1
Most people are friendly but they generally try to avoid him/her
2
Community (societal) support and help him/her
3
Husbands/in-laws do not accompany female patients to hospital/DOTS centres 4 Female accompany their spouse to hospitals suffering from TB to hospitals/DOTS centre 5 Females suffering from TB face problem in marriage 6
38
39
No change in the reaction
7
Don’t know
8
Do you know anyone in your family/neighbourhood suffering from TB during the last 2 years?
Yes
1
No
2
DK/CS
3
If yes, what advice have you given them?
Go to government hospital
1
Go to private hospital
2
(Multiple Response)
40
41
DOTS Centre
3
None
4
Have you ever taken any initiatives towards generating awareness about TB & DOTS within your community?
Yes
1
No
2
DK/CS
3
If yes, what are they?
Advised people suffering from cough to go and get checked up
1
Participated in TB awareness rallies/Nataks/ Melas etc
2
(Multiple Response Possible)
Worked as DOT provider
IF coded 2 & 3 skip to Q. 42
3
Other (specify 42
If coded 2 & 3 skip to Q. 40
99
Do you use tobacco in any form ?
Smoking
1
Chewing
2
Dual
3
None
4
43
If you use, how many times do you use in a day?
Cigarettes/Beedis
44
Since how long have you been using tobacco?
45
At what age did you start using tobacco?
Age in years:...................................
MONTH
134
Chewing
YEAR
If coded 4, skip to Q. 46
Annexure 3 General Population
Media Habit and Preferences Questions 46
Which source of news/ information you are exposed to? (Multiple Response PossibleProbe)
47
Which channels of Radio do you generally listen to? (Multiple Response Possible)
48
Which programme do you like on Radio? (Multiple Response Possible)
49
Which Television channel do you generally watch? (Multiple Response Possible)
50
Which programmes do you like the most on TV? (Probe for two most liked programmes)
Response Newspaper & Magazine
1
Radio
2
TV
3
Hoardings/posters/leaflets
4
Melas/Nukkad Nataks etc
5
Internet/Web advertising
6
Word of mouth (Interpersonal communication)
7
Mobile phone advertising/SMS
8
Cinema
9
None
10
Any Other
99
Do not listen to Radio
1
Vividh Bharti
2
FM
3
Regional Channel
4
Other (specify)
99
News
1
Drama/Serial
2
Film Songs
3
Folk Songs
4
Health Discussion
5
Discussion on any other issues
6
Advertisement
7
Other (specify)
99
Do not watch TV
1
Other Specify
52
Do you read newspaper? Which language paper generally you read? (Multiple Response Possible)
53
In general, have you ever seen/heard an advertisement/ information on TB or DOTS?
99
News
1
Drama/Serial
2
Entertainment
3
Health Related Programmes
4
Advertisements
5
Folk music
6
Music
7
Films
8
Sports
9
Other (Specify) 51
Skip
If the response is coded as 1 then skip to Q. 51
.99
Yes
1
No
2
English
1
Hindi
2
Any other language
3
Yes
1
No
2
135
If the response is coded 1, then skip to Q. 49
If coded 2, skip to Q. 53
If coded 2, skip to Q. 55
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
54
If Yes, where did you see/hear such advertisement and/or information on TB/DOTS? (Multiple Response Possible)
55
What are the common sources of getting health-related message? (Multiple Response Possible)
Radio
1
TV
2
Newspaper & Magazines
3
Cinema
4
Hoardings/posters/leaflets/Wall painting
5
Melas/Nukkad Nataks etc
6
Internet/Web advertising
7
Word of mouth (Interpersonal communication
8
Local Health Service providers
9
Mobile phone advertising/SMS
10
None
11
TV
1
Radio
2
Cinema
3
Newspaper/Magazines
4
Hoarding/Posters/billboards/Wall writing/Brochure/ other printed material 5
56
From whom did you receive any message on TB? (Multiple Response Possible)
Internet
6
Public service announcements
7
Drama/Skits/Street plays
8
Hospital/doctor
9
Friends & Relatives
10
Teachers/peer educator/colleagues
11
Health camp
12
Health workers
13
DOTS providers
14
Local leaders/religious leader
15
Sarpanch/Panchayat Member
16
None of these
17
Other (specify)
99
Friends
1
Family
2
Neighbours
3
Colleague
4
Teachers
5
Newspaper/Magazines/Leaflets
6
Radio
7
TV
8
Wall prints & Bill-boards
57 58
Can you recall any message on TB?
9
Posters/Brochures/Other printed materials
10
Health workers
11
Others (specify)
99
Yes
1
No
2
If yes, the message (Record verbatim)
136
Annexure 3 General Population
Information Sources 59
What are your sources of information for awareness on Tuberculosis related issues? (Multiple Response Possible)
TV
1
Radio
2
Cinema
3
Newspaper/Magazines
4
Hoarding/Posters/billboards/Wall writing
5
Public service announcements
6
Drama/Skits/Street plays
7
Hospital/doctor
8
Friends & Relatives
59 a
In general, on what specific aspects of TB was the information provided? (Multiple Response)
9
Health & related workers
10
DOTS providers
11
Teachers/peer educator
12
Health camp
13
DOTS Centre
14
Local Dispensary
15
Don’t Know
16
None of these
17
Other (specify)
99
Symptoms of Tuberculosis
1
Prevention from Tuberculosis
2
Cure for Tuberculosis
3
DOTS
4
Place of Treatment
5
Information on prevailing myths about TB patients 6 Others (Specify) 60
61
62
99
Did anyone visit your house/ neighbourhood during last two years to make your family/ community aware and provide information on TB?
Yes
1
No
2
DK/CS
3
If yes, who visited?
Government Doctor
1
(Multiple Response Possible)
Private Doctor
2
AWW
3
ASHA
4
Health worker
5
Worker from an NGO
6
DOTS workers
7
Panchayat/ward member
8
What specific information did they provide? (Multiple Response Possible)
Don’t remember
9
Others (Specify)
99
Symptoms of Tuberculosis
1
Prevention from Tuberculosis
2
Cure for Tuberculosis
3
DOTS
4
Place of Treatment
5
Information on prevailing myths about TB patients 6 Others (Specify)
137
99
If coded 2 & 3 skip to Q. 63
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
63
Where from would you prefer to get information on TB and related issues? (Multiple Response Possible)
64
Which source of information, do you trust more? (Prompt and record the most appropriate response)
TV
1
Radio
2
Cinema
3
Newspaper/Magazines
4
Hoarding/Posters/billboards/Wall writing
5
Internet/Web Advertising
6
Public service announcements
7
Drama/Skits/Street plays
8
Hospital/doctor
9
Friends & Relatives
10
Teachers/peer educator
11
Health camp
12
Health & related workers
13
DOTS Centre
14
DOTS providers
15
Religious Leader
16
Local Dispensary
17
Don’t Know
18
Other (specify)
99
Popular leaders/Religious leaders
1
Health Staff
2
Print Media
3
Electronic Media
4
Folk Media
5
Friends/Relatives
6
Hoarding/Posters/billboards/Wall Painting
7
Public service announcements
8
Local Health workers
9
Inter Personal Communications
10
NGOs
11
None
12
Other (Specify)
99
BEFORE WE END THE INTERVIEW A FEW QUESTIONS ON SOCIO, CULTURE, ECONOMIC & DEMOGRAPHIC CHARACTERISTICS OF YOUR HOUSEHOLD please do not get offended by some of the questions. If you do not wish to answer any question please let the investigator know about it. 65
What is your place of birth?
66
What is your mother tongue?
67
Which religion do you practice?
Buddhism
1
Christianity
2
Hinduism
3
Islam
4
Jainism
5
Sikhism
6
Atheism
7
Others
99
138
Annexure 3 General Population
68
69
70
What is your caste?
What is the last level of education that you completed?
What is your occupation?
Not willing to share
1
Scheduled caste
2
Scheduled tribe
3
General
4
Other Backward Class
5
Other Caste (Specify)
99
Illiterate
1
Literate but no formal education
2
Less than Primary
3
Primary but less than Secondary
4
Secondary but less than Senior Secondary
5
Senior Secondary but not Graduate
6
Graduation & above
7
Wage labourer
1
Skilled worker
2
Migrant worker
3
Self employed
4
Business
5
Service (Govt. & Private)
6
Agriculture/cultivator
7
Unemployed
8
Housewife
9
Student
10
Any other (specify) 71
72
73
What is your average household income per month?
Observe and record :Type of House
How many rooms do you have in your house? (Excluding kitchen)
.99
Less than Rs. 2000
1
Rs. 2001 – Rs. 4000
2
Rs. 4001 – Rs. 8000
3
Rs. 8001 – Rs. 10,000
4
Rs. 10,001 - 25,000
5
Rs. 25,001 – 50,000
6
>50,000
7
DK/CS
8
Pucca house
1
Semi-pucca house
2
Kutcha house
3
One room
1
two room
2
three rooms
3
Others 74
What type of locality do you live in? (Observe and write)
99
Village community
1
Town
2
Urban slum
3
Urban township/society
4
Others 75 76
99
Does your household own this house or any other house?
Yes
1
No
2
Does your household have:
Yes.............1
139
No.............2
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
A
Electricity
1
2
B
Mattress
1
2
C
Pressure cooker
1
2
D
Chair
1
2
E
A cot or Bed
1
2
F
A table
1
2
G
Electric Fan
1
2
H
Radio Or Transistor
1
2
I
A black & white Television
1
2
J
A colour Television
1
2
K
A sewing Machine
1
2
L
A mobile Telephone
1
2
M
Land line
1
2
N
A computer/laptop
1
2
O
A Refrigerator
1
2
P
A Watch or Clock
1
2
Q
A Bicycle
1
2
R
A Motorcycle or Scooter
1
2
S
An Animal drawn cart
1
2
T
A Car
1
2
U
Water Pump
1
2
V
A Thresher
1
2
W
A Tractor
1
2
77
What is the main source of drinking water for your house?
78
What type of toilet system do you use?
Private Tap
1
Private Hand Pump
2
Public Tap
3
Public Hand Pump
4
Tube well
5
Supply tanker
6
Well/river/pond
7
Rain water
8
Packaged Water
9
Others (Specify
10
Public
1
Personal
2
Open field/space
3
Shared Toilet
4
Others (Specify) 79 80
Is there a proper drainage system in your locality? Is there a separate space/or room for cooking?
.99
Yes
1
No
2
Yes room
1
Yes separate space
2
No separate space
3
140
Annexure 3 General Population
81
82 83
Type of fuel mostly used for cooking.
Electricity
1
Wood
2
Coal/Lignite
3
Kerosene
4
LPG(Gas)/Natural Gas
5
Charcoal
6
Bio-gas
7
Dung Cakes
8
Agriculture Crop Waste
9
Straw/Shrubs/Grass
10
Others (Specify
99
Does your household have a BPL card?
Yes
1
No
2
Do you have an UID/Aadhaar card?
Yes
1
No
2
THANKS FOR YOUR VALUABLE TIME
141
ANNEXURE
4 People Affected with TB MIDLINE KNOWLEDGE, ATTITUDE AND PRACTICE (KAP) SURVEY ON TUBERCULOSIS
Questionnaire ID Number
________________________
State
1. Andhra Pradesh 2. Bihar 3. Chhattisgarh 4. Haryana 5. Karnataka 6. Kerala 7. Maharastra 8. Mizoram 9. Orrisa 10. Punjab 11. Rajasthan 12. Tamil Nadu 13. Uttar Pradesh 14. West Bengal 15. Madhya Pradesh
District Code District Specification
1. Tribal
2. Non-Tribal
1. Rural
2. Urban
Tehsil/Block/City Village/Ward Type of Settlement Distance from the nearest PHC/CHC/DH (Kms) Name of Respondent Name of the head of the household
DATE OF INTERVIEW STARTING TIME OF INTERVIEW
FIELD CONTROL INFORMATION
AM 1 PM 1
ENDING TIME OF INTERVIEW Interview Yes
1
No
By 2
Spot/back check Yes
1
No Scrutiny
Yes
1
No
Code
Sign By
2
Code
Sign By
2
AM 1 PM 2
Code
Sign
If more than one visit made record: * STATUS OF INTERVIEW First visit
Time:_________
1
2
3
4
Second visit
Time:_________
1
2
3
4
Third visit
Time:_________
1
2
3
4
* Refused.......... 1 Not available...... 2 Partly Completed..3 Completed........ 4
142
Annexure 4 People Affected with TB
Good Morning/Evening, My name is _________. I am from a social research organisation GfK Mode. We are conducting a study on behalf of an international Non-Government Organisation called, The International Union Against Tuberculosis and Lung Diseases (The Union). The Union is working with the Government of India, and supporting its Revised National Tuberculosis Control Programme in spreading awareness about tuberculosis in the community. The International Union Against Tuberculosis and Lung Diseases (The Union) an international NGO, is conducting a research study entitled, “Midline Survey on Knowledge, Attitude and Practice (KAP) towards Tuberculosis in 45 districts from 16 states in India.” Through this study we want to get some information on knowledge, attitude & practices regarding Tuberculosis among People Affected with TB, so that this information could help design appropriate strategies that will help in TB care and control programmes. All of your responses will be treated as confidential and will be used only for research purposes and also to help policy makers to understand the bottlenecks in functioning, if any, to streamline the functioning You are being invited to take part in this research study. Please ask the researcher any questions that you do not fully understand. It is very important that you are fully satisfied and clearly understand what this research entails and how you could be involved. Your participation is entirely voluntary and you are free to decline to participate. There are no financial incentives given for taking part in this study. If there is anything else that you want to know, if you have any further queries or encounter any problems you can contact Dr. Sarabjit Singh Chadha, Project Director, The Union, New Delhi, contact No : 011-46054400
CONSENT FORM I …………………………………..…………., agree to take part in the above mentioned study. I declare that: l I have read this information and consent form and understand the contents l I have had a chance to ask questions and all my questions have been adequately answered l I understand that taking part in this study is voluntary and I have not been pressurised to take part l I may choose to leave the study at any time and will not be penalised or prejudiced in any way Do you have any questions about the survey? (Instruction to Investigator: In case of any questions raised by respondent, kindly respond to his/her satisfaction) Participant:
Investigator:
Name: ____________________________
Name:________________________________
Date: _____________________________
Date:_________________________________
Signature or thumbprint: _______________
Signature or thumbprint: _________________
143
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
GENERAL INFORMATION Q. No.
Questions
Response
Skip
1
What is your Name?
____________________
2
Observe and record the interviewee’s sex.
Male ............................................... 1 Female ............................................ 2
3
How old are you? (Age in completed years)
4
How many people live in your house?
One................................................. 1 Two ................................................ 2 Three .............................................. 3 Four ................................................ 4 More than four ................................... 5
5
What is your current marital status?
Married............................................. 1 Unmarried ........................................ 2 Divorced .......................................... 3 Widowed .......................................... 4 Separated ......................................... 5
6
How many children do you have?
One ................................................ 1 Two ................................................ 2 Three .............................................. 3 More than three ................................. 4 No children ....................................... 5
7
What is your family type?
Single .............................................. 1 Joint ............................................... 2 Extended .......................................... 3
8
Are you taking medicines for any other conditions other than tuberculosis? (Do not prompt HIV/AIDS)
HIV/AIDS .......................................... 1 Diabetes ........................................... 2 None ............................................... 3 Any other ........................................ 99
If the person is aged 18 years or less, then make sure that the consent of the parent or guardian is also taken. Interview parent/guardian if the person is less than 15 years old.
144
If coded 2, Skip to Q. 7
Annexure 4 People Affected with TB
The next few questions are about the HEALTH SEEKING BEHAVIOUR of your family. Please do not get offended by some of the questions. They are just intended to know the access to different types of health facilities Q. No
Questions
Response
Skip
9
When someone falls sick in your family and it is a minor illness (e.g. cough, fever, diarrhea), where do they generally go for healthcare?
Government health facility (Including corporation hospital, PHC,CHC, district hospital/sub centre/ANM).. 1 Private Clinic.............................................. 2 Private Hospital or nursing home....................... 3 Ayurvedic or Siddha treatment......................... 4 Homeopathic treatment................................. 5 RMP..........................................................6 Traditional healer/Quacks/ informal provider/”Bengali doctor”........................................ 7 Clinic run by NGOs........................................ 8 Local chemist or pharmacy............................. 9 ASHA worker in your village............................10 Any other (Specify)......................................99
If coded (1) skip to 11
10
If you do not generally go to a Government Health facility? Why not?
Facility is far from home................................ 1 Unavailability of doctors................................. 2 Unfriendly behaviour of govt. staff.................... 3 Long Waiting Hours....................................... 4 Lack of Qualified Doctor................................. 5 Lack of Diagnostic facility............................... 6 Private clinics offer better service..................... 7 Inconvenient timings..................................... 8 Drugs are not available....................................9 Any Other (Specify)......................................99
11
When someone falls sick in your family and it is a major or serious illness that may need hospital admission, where do they generally go for healthcare?
Government health facility (corporation hospital, district hospital or community health centre/Sub centre/ANM).............................................. 1 Government medical college........................... 2 Private Hospital or nursing home....................... 3 Private medical college hospital....................... 4 Corporate, super speciality hospital.................... 5 Private Ayurvedic treatment............................ 6 Private Homeopathic treatment........................ 7 Traditional healer/Quacks............................... 8 Any other (Specify)......................................99
12
If someone in your family develops cough for more than 2 weeks, where might they generally go for healthcare?
Government health facility (Including corporation clinic, PHC,CHC, district hospital).................... 1 Sub Centre/ANM.......................................... 2 Private Clinic.............................................. 3 Private Hospital or nursing home...................... 4 Ayush....................................................... 5 Dots Centre ............................................... 6 RMP..........................................................7 Traditional healer/Quacks/ informal provide/”Bengali doctor”.........................................8 Clinic run by NGOs........................................9 Local chemist or pharmacy.............................10 ASHA worker in your village............................11 Any other (Specify)......................................99
13
The last time you fell sick (with any disease) and had to seek medical care, where exactly did you go?
Write response verbatim:
145
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
TB DISEASE RELATED QUESTIONS FOR TB PATIENTS Q. No
Questions
Response
Skip
14
Do you know what TB is?
Yes.......................................................... 1 No .......................................................... 2 If yes, .....................................................
15
Can you tell us what causes TB ?
Germs/Microorganisms.................................. 1 DK/CS...................................................... 3 Others (Specify).........................................99
16
Was this the first time you were diagnosed with TB?
Yes.......................................................... 1 No........................................................... 2
17
If no, then how many times in the past were you diagnosed with TB?
Once........................................................ 1 Twice....................................................... 2 Three times or more..................................... 3
18
Where did you take the treatment previously?
Government Hospital.................................... 1 Private hospital/clinic................................... 2 Both government and private.......................... 3 DOTS Centre.............................................. 4 Clinics run by NGOs...................................... 5 Others (Specify)..........................................99
19
Did you complete a minimum of 6 months of treatment each time?
Yes.......................................................... 1 No........................................................... 2
20
If no for the above question, could you tell the reasons for not completing the treatment?
No improvement in health............................. 1 Developed side effects.................................. 2 The centre is too far from house..................... 3 Treatment too expensive (in case of private patients).................................................. 4 Others (specify)..........................................99
21
What symptoms did you have for the current episode?
Cough (If mention, then for what duration _____ Days/weeks).............................................. 1 Fever (If mention then for what duration _____ Days weeks).............................................. 2 Chest pain (If mention then for what duration _____ Days/weeks).............................................. 3 Blood in sputum (If mention then for what duration _____Days/weeks)...................................... 4 Weight loss (If mention then for what duration _____ Days/weeks).............................................. 5 CS/DK...................................................... 6 Others(specify)...........................................99
22
How long after the onset of these symptoms did you visit a health care provider (anybody, including local drug store or ASHA worker or informal provider)? [this question refers to the current episode of TB]
Less than a week......................................... 1 1 week..................................................... 2 2 weeks.................................................... 3 3 weeks.................................................... 4 4 weeks.................................................... 5 4-6 weeks.................................................. 6 6-8 weeks.................................................. 7 8-12 weeks................................................ 8 >12 weeks................................................. 9 Not Visited................................................10 Do-not know..............................................11 Others (Specify).........................................99
146
If the response code is 1 then skip to Q. 21.
If yes come to Q 21
Annexure 4 People Affected with TB
Q. No
Questions
23
After how many days of the onset of symptoms did you come to know that you are/ were suffering from TB? [this question refers to the current episode of TB]
24
How many health care providers (any provider, including local drug shops and informal providers) did you visit before you were diagnosed with TB? What was the approximate time interval between each visit? Please name the type of provider in the order you visited them and time since you first developed TB symptoms (for current episode):
Response
Skip
______ Days
________ number of providers seen before diagnosis Time since onset of symptoms (in days)
Order of healthcare provider seen
Type of provider (enter code number from list below)
Did this person diagnose TB? (Y/N)
First Second Third Fourth Fifth Sixth Seventh (stop with the provider who diagnosed TB) Codes for type of provider: Government health facility (e.g. corporation clinic, PHC, CHC, district hospital)........................... 1 Sub Centre/ANM......................................... 2 Private Clinic............................................. 3 Private Hospital or nursing home..................... 4 Ayush practitioner....................................... 5 Dots Centre .............................................. 6 RMP..........................................................7 Traditional healer/Quacks/informal provide/ ”Bengali doctor” .........................................8 Clinic run by NGOs........................................9 Local chemist or pharmacy.............................10 ASHA worker in your village............................11 Any other (Specify) .....................................99
25
After getting these symptoms, whom all did you consult before seeking medical care? (multiple answers possible)
Knowledgeable person in community.................. 1 Unqualified Healer in locality (quack) ................ 2 Faith healer................................................ 3 Other Family Member.................................... 4 Spouse...................................................... 5 Friends/Relatives/Colleagues/Employer............. 6 Medicine retail outlet/Chemist......................... 7 Qualified private doctor/clinic......................... 8 Local Health Care Provider.............................. 9 Govt. dispensary/health centre........................10 Any other (specify).......................................99
147
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Q. No
Questions
Response
26a
Where were you diagnosed to be having tuberculosis? Or who made a diagnosis that you are suffering from TB?
At Government Hospital/Dispensary (Including PHC, CHC......................................................... 1 Government health worker.............................. 2 TB hospital/TB diagnostic Centre/DOTS centre/ Designated Microscopic Centre......................... 3 Government Medical college............................ 4 Private Clinic/Private Hospital/Private Doctor...... 5 Ayurvedic Doctor/Homeopathic doctor................ 6 Traditional healer/RMP/Bengali doctor................ 7 Clinics/hospitals run by NGOs.......................... 8 Any other Specify.........................................99
(Please cross check with the prescriptions or medical records if they are available)
Skip
26b
Are any medical records or drug prescriptions or TB drugs available to substantiate whatever the person tells?
Yes........................................................... 1 No........................................................... 2
27
What organ of your body was said to be affected by TB?
Lungs........................................................ 1 Any other (Specify) .....................................99
28 a.
Was your sputum tested by anyone before you were told that you had TB?
Yes........................................................... 1 No........................................................... 2
28.b
If yes, where was the sputum testing done? (record verbatim)
________________________________
28.c
How much did you pay for the sputum test? (record verbatim)
Rs. ______________________________
28 d
Are any medical records (Q.28b) or receipts (Q.28c) available to substantiate whatever the person tells?
Medical Records.......................................... 1 Receipts.................................................... 2 None.........................................................3
29a
Was a chest x-ray taken before you were told that you had TB?
Yes........................................................... 1 No........................................................... 2
29b
If yes, where was the x-ray taken? (record verbatim)
________________________________
29c
How much did you pay for x-ray? (record verbatim)
Rs. ______________________________
29d
Are any medical records (prescription/X-ray/X-ray report etc) or receipts available to substantiate whatever the person tells?
Medical records/X-ray/X-ray report................... 1 Receipts.................................................... 2 None.........................................................3
30a
Was your blood tested by anyone before you were told that you had TB?
Yes........................................................... 1 No........................................................... 2 If yes, was the blood test for TB antibodies using ELISA or rapid test (e.g. IgG/IgM serological test)? Yes........................................................... 1 No........................................................... 2
30b
If yes, where was the blood testing done? (record verbatim)
148
If No, then move to question no. 29
If No, then move to question no. 30
Annexure 4 People Affected with TB
Q. No
Questions
Response
Skip
30c.
How much did you pay for the blood test? (record verbatim)
Rs ___________ (approximately)…………….
30d
Are any medical records available to substantiate whatever the person tells?
Yes........................................................... 1 No........................................................... 2
31
After you were told that you had TB, how many days later did you begin TB treatment?
______ days
32
Have you heard of free diagnosis and treatment for tuberculosis?
Yes........................................................... 1 No........................................................... 2
33
If yes, then from where is it available? (Multiple Coding)
Government health facility............................. 1 Private health facility.................................... 2 Non-Governmental health facility...................... 3 Do not know............................................... 4 Not applicable............................................ 5 Others .....................................................99
34
From where are/were you taking medicines? (Single Coding)
From the Government health centres, free of cost under DOTS................................................ 1 From the Government health centres, with payment for medicines.............................................. 2 From non-government health centres, free of cost.... 3 From the non government health centres, with payment for medicines.................................. 4 DOTS Provider/Worker.................................. 5 ANM......................................................... 6 ASHA........................................................ 7 Do-not know............................................... 8 Informal providers/RMP/Bengali doctor...............9 I buy my medicines by myself..........................10 Medicine not started yet................................11
35a
Are you still taking TB medicines?
Yes........................................................... 1 No........................................................... 2 Treatment completed.................................... 3
35b
If yes, are you paying for your TB medicines?
Yes........................................................... 1 No........................................................... 2 Do-not know............................................... 3
35c.
If you have already completed TB treatment, did you pay for your TB medicines (at any time during treatment)?
Yes........................................................... 1 No........................................................... 2 Do-not know............................................... 3
35d
Are any medical records (Prescription or drugs) available to substantiate that this person took (or is taking) TB treatment?
Yes........................................................... 1 No........................................................... 2
36
If no in Q.35a, then why are you not taking medicines?
On the advice of the treating medical practitioner/ Completely Cured........................................ 1 Stopped by myself........................................ 2 Medicine is expensive and I stopped taking it....... 3 Side effect................................................. 4 Medicine not available Medicine .......................5 Not yet started ........................................... 6 Other.......................................................99
149
If No, then skip to Q.34
If No, then go to Q.36. If coded 3 the go to Q.35 c
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Q. No
Questions
Response
Skip
37
How many months of treatment did you take or how many months have you taken the treatment so far.?
38
Are you taking/Did you take the medicines regularly without missing any doses?
Yes........................................................... 1 No........................................................... 2
39
How long have you been advised to take medicines? Or how long were you advised to take the medications?
Less than 2 weeks........................................ 1 2-4 weeks.................................................. 2 1-3 months................................................. 3 4-5 months................................................. 4 6-8 Months................................................. 5 More than 8 months-Specify.............................6 Do-not know............................................... 7 Not applicable............................................ 8
40
Instruction : This question is applicable to TB patients currently on Treatment If coded 1 in 35 a Are you taking the medicines regularly without missing any doses in the last 2 weeks?
Yes........................................................... 1 No........................................................... 2 Not applicable 3
41
Did you know that missing your medicines could increase the severity of the disease/treatment failure?
Yes........................................................... 1 No........................................................... 2
42
How do you rate the regularity of your drug intake?
Completely regular ......................................1 Somewhat irregular.......................................2 Very irregular.............................................. 3 Not yet started............................................ 4
43
Why was there any break or irregularity in treatment?
Could not go for medicines............................. 1 Interrupted due to side effects........................ 2 Could not afford to buy medicines anymore......... 3 Discontinued as symptoms disappeared.............. 4 Forget/non seriousness.................................. 5 DOTS Provider was not available....................... 6 Any other (specify........................................99
44a
Are you taking/did you take the medicines on your own or under supervision
Under supervision........................................ 1 Independently............................................. 2
44b
Who is supervising/providing the medicines for you?
ANM from nearest sub-centre........................... 1 Anganwadi Worker........................................ 2 ASHA worker.............................................. 3 NGO volunteer in the community..................... 4 Directly from the health facility....................... 5 Community volunteer.................................... 6 Sarpanch/Panchayat Member.......................... 7 Neighbour/relatives/friends............................ 8 DOTS Provider............................................. 9 Not applicable............................................10 Any other (specify.......................................99
45
Were you given a choice to select your provider?
Yes........................................................... 1 No........................................................... 2 Not applicable............................................ 3
Days
150
Months
If taken medicines in the past, skip to Q.41
If coded 1 then go to Q.44 if 4 coded go to Q no. 45
If the response is coded 2 then go to 49.
Annexure 4 People Affected with TB
Q. No
Questions
Response
Skip
46
Are you satisfied with your provider?
Yes........................................................ 1 No......................................................... 2 Can not say 3
47
How much time does it take to reach your provider and how much does it cost?
Minutes_______________________ Rs. ………………………………………………….
48
Is timing/availability of the health service provider convenient to you?
Yes........................................................ 1 No......................................................... 2
49
Are you paying for your medicines/did you pay for your medicines?
Yes........................................................ 1 No......................................................... 2 Do-not know............................................. 3
50
How much does/did it cost per day?
________ (in Rupees)
51
Does/did anybody visit your house and check whether you are taking medicines regularly as prescribed or not?
Yes........................................................ 1 No......................................................... 2
52
Are there any children aged less than 6 years old in the house?
Yes........................................................ 1 No......................................................... 2
53
If yes, are/did they receiving/receive any medicines for the prevention of disease?
Yes........................................................ 1 No......................................................... 2 Not applicable (TB patient).......................... 3
If the response is coded 2, then skip the next question and go to 51
If coded 2 go to Q 54
The next few questions relate to identification of the sources of HEALTH INFORMATION for your family 54
For any health related information, who does your family contact?
If coded 10 Local Health care provider(ANM/RMP/ASHA /AWW).................................................. 1 then go to Neighbour/Friend/relative............................. Q 57 2 Doctor (Allopathic) .................................... 3 Community leader...................................... 4 Religious leader.......................................... 5 NGO Workers............................................ 6 Pharmacist............................................... 7 AYUSH Doctors........................................... 8 DOTS provider .......................................... 9 None.....................................................10 Other specify............................................99
55
Name of the person who the family contacts for any health related information
1. Name: _______________________ 2. Designation: ________________ 3. Relationship to the person: _________
56
Name of the person who the family contacts for any health/medical care
1. Name: _______________________ 2. Designation: __________________ 3. Address: ________________________
151
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
The next few questions are related to understanding other people’s reaction/response to your disease. They could be a little sensitive. Please do not feel bad. 57
Have you informed about your disease status to your household family members?
Yes........................................................ 1 No........................................................ 2 Do-not want to answer this question............... 3 Not applicable (in case of a child) .................. 4
58
If Yes then how do you rate their reaction?
Supportive............................................... 1 Not supportive.......................................... 2 Do not want to answer................................ 3
59
If No, why did you not inform them?
Fear....................................................... 1 Discrimination.......................................... 2 Others (specify) .......................................99
60
Have you informed your disease status to any of your friends?
Yes........................................................ 1 No........................................................ 2 Do-not want to answer this question’.............. 3
61
If yes, did you experience any discriminatory difference in their interaction with you after they knew that you have TB?
Yes........................................................ 1 No........................................................ 2 Do-not want to answer this question’.............. 3
62
If yes, then did you experience that your friends don’t want to have a meal with you?
Yes........................................................ 1 No........................................................ 2 Do-not want to answer this question’.............. 3
63
If yes, then did your friends refuse to enter into your house because of your disease status?
Yes........................................................ 1 No........................................................ 2 Do-not want to answer this question’.............. 3
64
If Yes, Did people refuse to shake hands with you?
Yes........................................................ 1 No........................................................ 2 Do-not want to answer this question’.............. 3
65
(Ask this question only if the person is married, if the person is un-married then skip this question and go to question 66) If married, did you see any discriminatory change in the relationship with your partner?
Yes........................................................ 1 No........................................................ 2 Do-not want to answer this question’.............. 3
66
In your community, do you think that if a boy is known to have suffered from TB, will he get married?
Yes........................................................ 1 No........................................................ 2 Do-not want to answer this question’.............. 3
67
In your community, do you think that if a girl is known to have suffered from TB, will she get married?
Yes........................................................ 1 No........................................................ 2 Do-not know............................................. 3
68
In your community, who do you think suffer more (socially) when they are affected by TB? Males or females
Males..................................................... 1 Females ................................................. 2 Both are equally affected............................ 3 Do-not know............................................. 4 No one suffers ......................................... 5
152
If no then go to question No. 59. If 3 or 4 then go to No. 60
If coded 2 & 3 go to question number 65.
Annexure 4 People Affected with TB
69
(Ask this question only if the person is employed) Have you disclosed your disease status at the place of your employment?
Yes........................................................ 1 No........................................................ 2 Do-not want to answer................................ 3 Not applicable.......................................... 4
70
Did you have to change your employment because of your disease status?
Yes........................................................ 1 No........................................................ 2 Do-not want to answer................................ 3 Not applicable.......................................... 4
The next few questions relate to TOBACCO USE (instruction ;_if respondent age is below 12 years go to Q 81A) 71
Do you currently use tobacco?
Yes No If yes, Smoke Smokeless Both
1 2
1 2 3 4
1 2 3
72
If Yes, for how long have you been using tobacco now?
< 1 year 1-3 year 4-10 years 10 years
73
At what age did you start using tobacco?
Age in years:
74
What type of tobacco do you smoke? (Multiple Coding)
Cigarette 1 Beedi 2 Hookah 3 Others (specify) ---------------------------------------99
75
What type of smokeless tobacco do you use?
Chewing 1 Sniffing 2 Others (specify)----------------------------------------99
76
Do you know the association (or link) between smoking and TB?
Yes No
1 2
77
Do you know smoking increases the risk of developing TB disease?
Yes No
1 2
78
Are you aware that smoking damages the defence mechanism of lungs and make you more prone to infections and TB disease?
Yes No
1 2
79
Are you aware of the consequences if you continue to smoke during treatment of TB or after the completion of your treatment?
Yes No
1 2
80
During your visit to a doctor/ health care provider, were you advised to quit smoking/ using tobacco?
Yes No
1 2
81a
Are you exposed to secondhand smoke (passive smoke) at your home?
Yes No
1 2
81b
If yes, do you know its harmful effects on you as a TB patient?
Yes No
1 2
153
If No, then skip all questions in this section and go to question 82
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
The next few questions relate to MEDIA HABIT & PREFERENCES Q. No
Questions
Response
Skip
82
Which source of information you are exposed to? (Multiple Response Possible-Probe)
Newspaper & Magazines 1 Radio 2 TV 3 Hoardings/posters/leaflets 4 Melas/Nukkad Nataks etc 5 Internet/Web advertising 6 Word of mouth (Interpersonal communication 7 Mobile phone advertising/SMS 8 Cinema 9 None----------------------------------------------------10 Any Other----------------------------------------------99
83a
Do you listen to radio?
Yes No
83b.
If Yes, Which channel of Radio do you generally listen to? (Multiple Response Possible)
Vividh Bharti 1 FM (specify) 2 Regional Channel 3 Community Radio 4 Other (specify)----------------------------------------99
84
Which programme do you like most on Radio? (Multiple Response Possible)
News 1 Drama/Serial 2 Film Songs 3 Folk Songs 4 Health related Discussion 5 Other (specify)----------------------------------------99
85a
Do you watch television
Yes No
85b
Which Television channel do you generally watch? (Multiple Response Possible)
Do not watch TV 1 Other (specify)----------------------------------------99
86
Which programmes do you like the most on TV? (Probe for two most liked programmes)
News 1 Drama/Serial 2 Entertainment 3 Health Related Programmes 4 Advertisements 5 Folk music 6 Music 7 Films 8 Sports 9 Other (Specify)----------------------------------------99
1 2
1 2
154
If the person does not listen the radio, please skip the next question and go to question no. 85
If the person does not watch television, then please go to question no 87
Annexure 4 People Affected with TB
Q. No
Questions
Response
Skip
87
Do you read newspaper?
Yes No
1 2
88
Which language paper generally you read?
English Hindi Any other Local language
1 2 3
89
Have you ever seen an advertisement/information on Tuberculosis or DOTS?
Yes No
1 2
90
If Yes, Where did you see/ hear such advertisement or/ and information on TB/DOTS? (Multiple Response Possible)
Newspaper & Magazines 1 Radio 2 TV 3 Hoardings/posters/leaflets 4 Melas/Nukkad Nataks etc 5 Any Other (specify)-----------------------------------99
91
What is your most common source of getting healthrelated message? (Multiple Response Possible)
TV 1 Radio 2 Cinema 3 Newspaper/Magazines 4 Hoarding/Posters/billboards/Wall writing/ Brochure/other printed material 5 Internet 6 Public service announcements 7 Drama/Skits/Street plays 8 Hospital/doctor 9 Friends & Relatives-----------------------------------10 Teachers/peer educator/colleagues-------------11 Health camp-------------------------------------------12 Health workers----------------------------------------13 DOTS providers----------------------------------------14 Local leaders/religious leader---------------------15 Sarpanch/Panchayat Member----------------------16 None of these ----------------------------------------17 Other (specify) ---------------------------------------99
92
From whom did you receive any message on TB? (Multiple Response Possible)
Friends 1 Family 2 Neighbours 3 Colleague 4 Teachers 5 Newspaper/Magazines/Leaflets 6 Radio 7 TV 8 Wall prints & Bill-boards 9 Posters/Brochures/Other printed materials------10 Health workers----------------------------------------11 Others (specify) --------------------------------------99
155
If coded 2 skip to Q.89
If coded 2, then skip to Q.91
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Q. No
Questions
Response
Skip
93
Can you recall any message on TB?
Yes No
94
If yes, then specify the message?
95
In the last 30 days, have you noticed information about the dangers of smoking cigarettes or that encourages quitting in newspapers or in magazines?
Yes No Not applicable
1 2 3
96
In the last 30 days, have you noticed information about the dangers of smoking cigarettes or that encourages quitting on televisions?
Yes No Not applicable
1 2 3
1 2
(Record verbatim)
INFORMATION SOURCES 97
What are your sources of information for awareness on Tuberculosis related issues? (Multiple Response Possible)
TV Radio Cinema Newspaper/Magazines Hoarding/Posters/billboards/Wall writing Public service announcements Drama/Skits/Street plays Hospital/doctor Friends & Relatives Health & related workers DOTS providers Teachers/peer educator Health camp DOTS Centre Local Dispensary Don’t Know None of these Other (specify)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 99
97a
In general, on what specific aspects of TB was the information provided?
Symptoms of Tuberculosis Prevention from Tuberculosis Cure for Tuberculosis DOTS Place of Treatment Information on prevailing myths about TB patients Others (Specify)
1 2 3 4 5
Yes No DK/CS
1 2 3
98
Did anyone visit your house/ neighbourhood during last two years to make your family/ community aware and provide information on TB?
156
6 99 If coded 2 & 3 skip to 101
Annexure 4 People Affected with TB
99
If yes, who visited? (Multiple Response Possible)
Government Doctor 1 Private Doctor 2 AWW 3 ASHA 4 Health worker 5 Worker from an NGO 6 DOTS workers 7 Panchayat/ward member 8 Don’t remember 9 Others--------------------------------------------------99
100
What specific information did they provide? (Multiple answers)
Symptoms of Tuberculosis 1 Prevention from Tuberculosis 2 Cure for Tuberculosis 3 DOTS 4 Place of Treatment 5 Information on prevailing myths about TB patients 6 Others--------------------------------------------------99
101
Where from would you prefer to get information on TB and related issues? (Multiple Response Possible)
TV 1 Radio 2 Cinema 3 Newspaper/Magazines 4 Hoarding/Posters/billboards/Wall writing 5 Internet/Web Advertising 6 Public service announcements 7 Drama/Skits/Street plays 8 Hospital/doctor 9 Friends & Relatives-----------------------------------10 Teachers/peer educator-----------------------------11 Health camp-------------------------------------------12 Health & related workers----------------------------13 DOTS Centre-------------------------------------------14 DOTS providers----------------------------------------15 Religious Leader---------------------------------------16 Local Dispensary---------------------------------------17 Don’t Know --------------------------------------------18 Other (specify)-----------------------------------------99
102
Which source of information, do you trust more?
Popular leaders/Religious leaders 1 Health Staff 2 Print Media 3 Electronic Media 4 Folk Media 5 Friends/Relatives 6 Hoarding/Posters/billboards/Wall Painting 7 Public service announcements 8 Local Health workers 9 Inter Personal Communications---------------------10 NGOs----------------------------------------------------11 None----------------------------------------------------12 Other (Specify)----------------------------------------99
(Prompt and record the most appropriate response)
157
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
BEFORE WE END THE INTERVIEW A FEW QUESTIONS ON SOCIO, CULTURE, ECONOMIC & DEMOGRAPHIC CHARACTERISTICS OF YOUR HOUSEHOLD Please do not get offended by some of the questions. If you do not wish to answer any question please let the investigator know about it. 103a
What is your place of birth?
103b
What is your mother tongue?
104
Which religion do you practice?
Buddhism 1 Christianity 2 Hinduism 3 Islam 4 Jainism 5 Sikhism 6 Atheism 7 Others--------------------------------------------------99
105
What is your caste?
Not willing to share 1 Scheduled caste 3 Scheduled tribe 4 General 5 Other Caste (Specify)-------------------------------99
106
What is the last level of education that you completed?
Illiterate Literate but no formal education Less than Primary Primary but less than Secondary Secondary but less than Senior Secondary Senior Secondary but not Graduate Graduation & above
107
What is your occupation?
Wage labourer 1 Skilled worker 2 Migrant worker 3 Self employed 4 Business 5 Service (Govt. & Private) 6 Agriculture/cultivator 7 Unemployed 8 Housewife 9 Student-------------------------------------------------10 Any other (specify)-----------------------------------99
108
What is the average household income per month?
Less than Rs. 2000 Rs. 2001 – Rs. 4000 Rs. 4001 – Rs. 8000 Rs. 8001 – Rs. 10,000 Rs. 10,001 - 25,000 Rs. 25,001 – 50,000 >50,000 DK/CS
1 2 3 4 5 6 7 8
109
Observe and record : Type of House
Pucca house Semi-pucca house Kutcha house
1 2 3
110
How many rooms do you have in your house? (excluding kitchen)
One room 1 One room and kitchen 2 Two rooms and kitchen 3 Others--------------------------------------------------99
111
What type of locality do you live in?
Village community 1 Town 2 Urban slum 3 Urban township/society 4 Others--------------------------------------------------99
158
1 2 3 4 5 6 7
Annexure 4 People Affected with TB
112
Does your household own this house or any other house?
113
Does your household have:
A
Yes No
1 2 Yes
No
Electricity
1
2
B
Mattress
1
2
C
Pressure cooker
1
2
D
Chair
1
2
E
A cot or Bed
1
2
F
A table
1
2
G
Electric Fan
1
2
H
Radio Or Transistor
1
2
I
A black & white Television
1
2
J
A colour Television
1
2
K
A sewing Machine
1
2
L
A mobile Telephone
1
2
M
Land line
1
2
N
A computer/Laptop
1
2
O
A Refrigerator
1
2
P
A Watch or Clock
1
2
Q
A Bicycle
1
2
R
A Motorcycle or Scooter
1
2
S
An Animal drawn cart
1
2
T
A Car
1
2
U
Water Pump
1
2
V
A Thresher
1
2
W
A Tractor
1
2
114
What is the main source of drinking water for your house?
Private Tap 1 Private Hand Pump 2 Public Tap 3 Public Hand Pump 4 Tube well 5 Supply tanker 6 Well/river/pond 7 Rain water 8 Packaged Water 9 Others (Specify----------------------------------------10
115
What type of toilet system do you use?
Public 1 Personal 2 Open field/space 3 Shared Toilet 4 Others--------------------------------------------------99
117
Is there a proper drainage system in your locality?
Yes No
1 2
118
Is there a separate space/or room for cooking?
yes room Yes separate space No separate space
1 2 3
159
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
119
Type of fuel mostly used for cooking:
Electricity 1 Wood 2 Coal/Lignite 3 Kerosene 4 LPG(Gas)/Natural Gas 5 Charcoal 6 Bio-gas 7 Dung Cakes 8 Agriculture Crop Waste 9 Straw/Shrubs/Grass----------------------------------10 Others Specify-----------------------------------------99
120
Does your household have a BPL card?
Yes No
1 2
121
Do you have an UID/Aadhaar card?
Yes No
1 2
THANKS FOR YOUR VALUABLE TIME
160
5 Health Service Providers
ANNEXURE
Midterm Knowledge, Attitude and Practice (KAP) Survey on Tuberculosis QUESTIONNAIRE ID NUMBER
____________________________
STATE
1. Andhra Pradesh 2. Bihar 3. Chhatisgarh 4. Haryana 5. Karnataka 6. Kerala 7. Maharastra 8. Mizoram 9. Orrisa 10. Punjab 11. Rajasthan 12. Tamil Nadu 13. Uttar Pradesh 14. West Bengal 15. Madhya Pradesh
DISTRICT CODE DISTRICT SPECIFICATION
TRIBAL……………………………….1
NON-TRIBAL………………………………..2
TEHSIL/BLOCK/CITY VILLAGE/WARD TYPE OF SETTLEMENT
RURAL……………………………….1
URBAN……………………………………2
Distance from the nearest PHC/CHC/DH (kms) Name of Respondent Respondent Category
1. Private Practitioner 2. Government Doctor 3. Nurse 4. ANM worker 5. PHC worker 6. Anganwadi worker 7. Chemists/Druggist
Date of Interview Starting Time of Interview FIELD CONTROL INFORMATION
AM 1 PM 1
Ending Time of Interview Interview Yes
1
No
By 2
Spot/back check Yes
1
No
Scrutiny Yes
1
No
Code
Sign By
2
Code
Sign By
2
AM 1 PM 2
Code
Sign
If more than one visit made record * Status of interview First visit
Time:_________
1
2
3
4
Second visit
Time:_________
1
2
3
4
Third visit
Time:_________
1
2
3
4
* Refused 1 not available 2 Partly Completed 3 Completed 4
161
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Good Morning/Evening, My name is _________. I am from a social research organisation GfK Mode. We are conducting a study on behalf of an international Non-Government Organisation called, The International Union Against Tuberculosis and Lung Diseases (The Union). The Union is working with the Government of India, and supporting its Revised National Tuberculosis Control Programme in spreading awareness about tuberculosis in the community. The International Union Against Tuberculosis and Lung Diseases (The Union) an international NGO, is conducting a research study entitled, “Midline Survey on Knowledge, Attitude and Practice (KAP) towards Tuberculosis in 45 districts from 16 states in India.” Through this study we want to get some information on knowledge, attitude & practices regarding Tuberculosis among Health Service Providers, so that this information could help design appropriate strategies that will help in TB care and control programmes. All of your responses will be treated as confidential and will be used only for research purposes and also to help policy makers to understand the bottlenecks in functioning, if any, to streamline the functioning You are being invited to take part in this research study. Please ask the researcher any questions that you do not fully understand. It is very important that you are fully satisfied and clearly understand what this research entails and how you could be involved. Your participation is entirely voluntary and you are free to decline to participate. There are no financial incentives given for taking part in this study. If there is anything else that you want to know, if you have any further queries or encounter any problems you can contact Dr. Sarabjit Singh Chadha, Project Director, The Union, New Delhi, contact No : 011-46054400
Consent Form I …………………………………..…………., agree to take part in the above mentioned study. I declare that: l
I have read this information and consent form and understand the contents I have had a chance to ask questions and all my questions have been adequately answered l I understand that taking part in this study is voluntary and I have not been pressurised to take part l I may choose to leave the study at any time and will not be penalised or prejudiced in any way l
Do you have any questions about the survey? (Instruction raised by respondent, kindly respond to his/her satisfaction)
to Investigator: In case of any questions
Participant:
Investigator:
Name: - __________________________
Name: - __________________________
Date: - __________________________
Date: - __________________________
Signature or thumbprint: - _______________
Signature or thumbprint: - ____________
162
Annexure 5 Health Service Providers
GENERAL INFORMATION Q. No
Questions
1
What is your Name?
2
Observe and record the interviewee’s sex.
3
How old are you? (Age in completed years)
4a
What is your Educational Qualification?
Response
Skip
Male
1
Female
2
MBBS
1
BAMS
2
BHMS
3
BUMS
4
Degree/Diploma in Nursing
5
MD or specialist
6
B. Pharma/D Pharma
7
Graduate/Post Graduate
8
No formal qualifications
9
Other (specify)
99
4b
How long have you been working in healthcare as a service provider (years)?
__________ years
4c
What is the nature of your Practice ? (please prompt the responses and select the most appropriate answers)
Consultation 1 Dispensing 2 Consulting & Dispensing 3 Others (specify) 99
KNOWLEDGE, ATTITUDE & PRACTICE ON TUBERCULOSIS Now, the next few questions relate to the patients that you come across in your practice Q. No
Questions
5
On an average how many patients do you see per day?
6
7
Response
Skip
What are the 5 most common diseases you come across in your practice? (probe)
TB Mentioned 1
If coded 1 skip to Q.8
If TB is not mentioned in response to question 7, then ask: Do you come across TB patients in your practice?
Yes
8
If yes, at present, how many pulmonary TB patients in total are you personally treating?
8a.
What causes TB is?
9
How many of them are female TB patients?
10
What are the different kinds of TB patients that you have come across ? (please prompt and select the responses, multiple responses possible)
TB Not mentioned 2
No
1 2
No Response 3
Pulmonary TB (Chest/Lungs 1 Lymph node/Gland TB 2 Spinal TB
3
Bone TB
4
Abdominal TB 5 Any Other (specify) 163
99
IF coded 2 & 3, skip to Q.13a
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Q. No
Questions
Response
11
What other health conditions do you come across among the TB patients you treat?
Diabetes
1
None
2
12
What are the common s y m p t o m s y o u look for while diagnosing a person with TB? (multiple Response possible, please keep asking by adding ‘and’ and record them till the person says no more)
Skip
Others specify
A cough of 2 weeks or more
99
1
Pain in the chest
2
Coughing up Blood
3
Fever
4
Weight loss
5
Poor appetite
6
Any other –specify 13a
In the last one month, how many patients did you see that had cough for 2 weeks or more?
13b
How many of these patients were tested for tuberculosis?
13c
How many were found to have TB disease and started on TB treatment?
14
What tests do you usually advice for confirming diagnosis of Pulmonary TB? (Multiple Response Possible)
If 0 (zero patients), skip to Q14
Chest X –ray
1
Sputum smear examination
2
Mantoux skin Test
3
Sputum Culture
4
Serological or blood antibody tests (ELISA or card tests)
For these tests, where do you normally send your patients?
5
PCR or polymerase chain reaction
6
TB-Gold test (Quantiferon-TB Gold)
7
I do not order TB tests – I refer patients to others
8
DK/CS
9
Any other- specify 15
99
99
Nearest DOTS or government centre (e.g. PHC, DMC, district hospital)
1
Medical college or public hospital
2
Private hospital or nursing home
3
In house diagnostic lab of your own clinic or hospital
4
Local private lab
5
Collection centre for a private network lab (e.g. SRL, Lal Pathlabs, Metropolis 6 Patients choose themselves
7
We conduct the test ourselves in our clinic 8
164
Annexure 5 Health Service Providers
Q. No
Questions
Response
16
If you have to advice only one test for pulmonary TB, which one would you advice?
Chest X –ray
Skip 1
Sputum smear examination 2 Skin Test (tuberculin or Mantoux)
3
Sputum Culture
4
Serological or blood antibody tests (ELISA or card tests
5
PCR or polymerase chain reaction
6
TB-Gold test (Quantiferon-TB Gold) 7 DK/CS Any other- specify 17
What is the reason for selecting the test mentioned above?
(Prompt and please keep asking by adding ‘and’ and record them till the person says no more Multiple responses possible.)
8 99
They are affordable for my patients 1 Results are accurate
2
Quick time to results
3
Easily available in my setting 4 Recommended by national/international guidelines
5
Incentives for ordering the test associated 6 It does not require sputum specimens 7 It is helpful for childhood TB or extra pulmonary TB
8
My patients prefer this test 9
18
19
In your opinion, which sample test detects more number of pulmonary TB patients?
When you identify a patient with symptoms suggestive of pulmonary TB, how often do you advice a sputum smear test?
This is the test promoted by my local lab
10
I am not sure
11
Sputum Blood
2
Radiology (X-Ray
3
Other (specify):
99
Every time
1
Most of the time
2
Occasionally/Sometimes 3 Never
20
Where do you send your patient for sputum examination?
1
9
Nearest DOTS or government centre (e.g. PHC, DMC, district hospital 1 Medical college or public hospital
2
Private hospital or nursing home 3 In house diagnostic lab of your own clinic or hospital
4
Local private lab
5
Collection centre for a private network lab (e.g. SRL, Lal Path labs, Metropolis 6 Patients choose themselves 7 We conduct the test ourselves in our clinic 8
165
If the response is “never” (option 9) then skip to Q.23, otherwise continue with the next question
Q. No
Questions
Response
21a
Do you know about designated microscopy centres (DMC) established by the Government for FREE sputum testing?
Yes
1
No
2
Do you send your patients to these microscopy centres?
Yes
1
No
2
Do you face any problem in getting sputum smear examination done for your TB symptomatics in a DMC?
Yes
1
No
2
If yes, what type of problems do you face?
Non availability of facility
1
Non availability of staff
2
Patient is unable to pay for test
3
Poor quality result
4
21b
21c
22
Skip
If I send patients to DMC, they never come back to me 5 Any other (specify) 23
In your opinion, what are the biggest limitations or problems with existing TB tests? (Multiple response possible please keep asking by adding ‘and’ and record them till the person says no more)
24
If a new TB test were to be developed, what characteristics would you like to see in a new test?
99
They are not accurate enough
1
They take too much time
2
They require sputum samples
3
They are not easily available
4
They are too costly
5
They are only available in government facilities
6
They are not helpful for extra-pulmonary TB
7
They are not simple enough to be done in my clinic or by myself
8
They do not get me much incentives or referral fees
9
DK/CS
10
Other (specify):
99
It should be accurate and reliable
1
It should give results on the same day 2 It should not require sputum samples 3 It should be based on blood samples 4
(Multiple response possible please keep asking by adding ‘and’ and record them till the person says no more)
It should be easily available in my area 5 It should be cheap
6
It should be available in government and private facilities
7
It should be useful for extra pulmonary TB 8 It should be simple enough to be done in my clinic or by myself 9 It should get me incentives or referral fees 10 DK/CS
11
Other (specify):
99
If coded 2 skip to Q.23
Annexure 5 Health Service Providers
Q. No
Questions
Response
25
What do you do after diagnosing pulmonary TB?
Started TB treatment on my own
1
Refer patient to another doctor
2
Refer to private facility/Hospital
3
Refer to Government centre/DOTS provider/Centre
4
Refer to NGO
5
Not Applicable
7
(prompt the response and select the appropriate)
Any other (specify) 26
What system of medicine do you follow for the treatment of pulmonary TB?
1
Homeopathy
2
Ayurveda
3
Others (specify)
28
29
What is the average total duration of TB treatment?
1-2 weeks
1
2-4 weeks
2
1-5 months
3
6-8 months
4
more than 8 months
5
Record verbatim:
How do you know that your Pulmonary TB patient is cured?
Improvement in symptoms
1
Positive sputum test turned negative
2
Improvement in chest X – Rays
3
_______________________________________
Prescribed duration of treatment completed 4 All the above
31
4 99
For a new patient with pulmonary TB, what are the drugs you begin treatment with? (name all the drugs)
(multiple responses possible)
30
99
Allopathic
Traditional/Home remedies
27
Skip
How do you diagnose patients with Extra pulmonary TB?
5
X-ray
1
Ultra sound
2
Serological or blood tests
3
Biopsy
4
Sputum Culture
5
DK/CS
6
Others (specify
99
How many extra pulmonary TB cases do you diagnose in a month? (Record verbatim)
32
Are you aware of Multi Drug Resistant (MDR) TB?
Yes
1
No
2
167
If coded 1, then ask Q.26 or else skip to Q.27
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Q. No
Questions
33
How do you diagnose a patient as MDR-TB? (prompt the responses and select the appropriate, multiple response is possible)
34
35
36
Sputum Culture
1
Drug Susceptibility test
2
PCR or molecular test
3
Clinical Examination
4 99
When you see patients with long duration (chronic) fever, do you prefer to order a TB antibody blood test (IgG/IgM using ELISA or rapid test)?
Yes
1
No
2
Do you maintain any separate record (like record of TB drugs given, detailed address, next visit due etc.) for TB patients at your clinic?
Yes
1
No
2
How many of your TB patients completed their prescribed duration of treatment in the last 1 year?
Total Number of patients started on TB treatment:
What difficulties do you come across while treating TB patients? (Multiple Response Possible)
Number of patients who completed their TB treatment:
People hesitate to come for treatment
1
Non availability of anti TB drugs
2
No pathology or X ray Lab available in the vicinity
3
People do not reveal previous history of TB easily
4
Patients cannot afford TB drugs
5
Patients often do not complete treatment Any other (specify) 38
Skip
Any other- specify
(Record verbatim) 37
Response
6 99
In your opinion, what challenges do the patients face to come for the treatment? (Record verbatim)
39
40a
40b
Do you examine other family members of TB affected person, to check if they too have TB?
Yes
1
No
2
Do you ask TB affected patients, whether he/she is currently using any tobacco products ? if Yes, what type? ?
Yes
1
No
2
If yes, do you advise or insist them to stop using tobacco products?
Advice
Type:
1
Insist
2
None
3
168
Type = smoking (cigarette/ beedi/ hookah)/ chewing/ sniffing
Annexure 5 Health Service Providers
Q. No
Questions
Response
41
Do you think treating TB constitutes any risk to your health or health of your other patients?
Yes
1
No
2
DK/CS
3
What precautions do you take to protect yourself while examining/ treating TB patients?
Maintain distance
1
Wear masks & gloves
2
Wash hands with soap
3
None
4
42
(Multiple Response Possible)
Any Other (Specify) 43
What precautions do you suggest the TB patient to avoid the spread of disease? (Multiple Response Possible)
44
45
Have you heard of DOTS?
Which are two major sources from where you came to know about DOTS and related issues?
47
48
For treating TB: Do you feel; DOTS is … (Read out the option)
99
Cover mouth while coughing
1
Use separate utensils
2
Not to spit anywhere
3
Use separate towels/clothes
4
Isolate the patient
5
Any other (specify)
99
Yes
1
No
2
DK/CS
3
Television
1
Radio
2
Newspaper/Magazines
3
Pamphlets/Booklets/leaflets/posters etc
4
Awareness workshop, seminar
5
During studies/part of course
6
Internet
7
Medical Journals
8
NGO
9
Any other (specify) 46
Skip
99
Excellent
1
Good
2
Average
3
Bad
4
Are you aware of the schemes to involve private practitioners in the DOTS programme?
Yes
1
No
2
Are you involved in DOTS programme in any way?
Yes
1
No
2
(Ask only Private practitioners)
169
If 2 & 3 skip to Q. 47
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Q. No
Questions
Response
49
(Ask only Private practitioners)
Yes
1
No
2
Are there any public health services for TB patients available in your area?
DK/CS
3
Do patients of other diseases avoid visiting you because you also treat persons suffering with TB?
Yes
1
No
2
DK/CS
3
From where do you commonly update your knowledge on TB?
Medical journal
1
Colleague
2
CME/trainings
3
Professional bodies
4
Medical representatives
5
No need
6
50
51
(Multiple Response Possible)
Any other (specify) 52
According to you what should be the best medium to generate awareness amongst the community about TB? (Single Response)
99
Television
1
Radio
2
Newspaper/Magazine
3
Pamphlet/Booklet/Leaflet/Posters
4
Nukkad Nataks
5
Community meetings
6
IPC (Interpersonal Communication) Any Other(specify) 53
Skip
7 99
Do you have any suggestions to strengthen TB control services? (Record verbatim)
54
55
This year (2012), the government of India passed an order that requires all health providers to notify/report all cases of TB to government authorities. Are you aware of this governmental order?
Yes
1
No
2
If yes to the above question, are you notifying TB cases to local/ district health authorities?
Yes
1
No
2
Yes
1
No
2
(Ask other than government service providers) 56
This year, the government of India passed an order that bans the use of serological, antibody tests for TB (IgG/IgM antibodies using ELISA or rapid tests). Are you aware of this governmental order?
170
If coded 2, skip to Q. 56
Annexure 5 Health Service Providers
Point of Care Testing (POCT) Q. No
Questions and Filters
Coding Categories
Codes
Skip
This section is about use of simple, rapid, card, dipstick or strip tests that are available (like the home pregnancy test, urine sugar dipstick, or rapid HIV or malaria test) and can give results within minutes, and whether you use these tests in your clinical practice.
For example, below is a photograph or sample of a pregnancy test 57
In your clinical practice, when you need a diagnostic test done for your patient for any disease, do you do any rapid testing yourself (or by your assistant or nurse), right in your clinic or hospital setting or attached lab, while the patient is waiting, so that you can quickly make treatment decisions?
171
Yes
1
No
2
If coded 2 then skip to 60
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
58
Kindly answer the following; Rapid test for
Do you do this test in your clinic or practice? 1 = Yes 2 = No 3 = Not in the clinic, but a lab that is attached to the clinic
If code 1 & 3, on an average, how many tests do you do in a month?
Time to get the test results? [record number of minutes]
Who interprets or reads the results of the rapid test? 1 = provider 2 = support staff (e.g. nurse, compounder) 3 = lab that is attached
Do you make any treatment decisions only on the basis of the rapid test results? 1 = Yes 2 = No
How much do patients pay for each test? (INR) [if no charge, please write ZERO]
B. Pregnancy D. Glucose (blood or urine sugar) F. HIV H. Malaria J. Tuberculosis L. Syphilis N. Hepatitis (A, B, C) P. Influenza (flu) R. Dengue T. Typhoid V. Streptococcal pharyngitis (throat) X. Others (specify):
59
If you do any of the above rapid tests, what are the most important reasons for doing this in your practice or clinic, instead of sending your patients to an outside laboratory? Record Verbatim (multiple answers are possible) and list the most important reason first 1)
__________________________________________________________ 2)
__________________________________________________________ 3)
__________________________________________________________ 4) 5)
172
Annexure 5 Health Service Providers
60
If NO to Q.57 what are the most important reasons for NOT doing rapid testing in your practice? Record Verbatim (multiple answers are possible) and list the most important reason first 1)
__________________________________________________________ 2)
__________________________________________________________ 3)
__________________________________________________________ 4) 5) 61
Imagine a new rapid dipstick or strip TB test (just like a pregnancy or sugar test) that produces results within 20 minutes using blood finger-prick sample, and is more sensitive than sputum smears, and is simple enough to be done in your own clinic. No equipment or instrument is required, and no capital investments need to be made. Would you order this test for your patients?
Yes
1
No
2
Would you do it in your own clinic (by yourself or your assistant)?
Yes
1
No
2
Would you order this test for your patients if the cost to patients was Rs. 100?
Yes
1
No
2
Would you order this test for your patients if the cost to patients was Rs. 250
Yes
1
No
2
Would you order this test for your patients if the cost to patients was Rs. 500?
Yes
1
No
2
173
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
GENERAL SOCIAL & DEMOGRAPHIC INFORMATION Please do not get offended by some of the questions. If you do not wish to answer any question please let the investigator know about it. 62a
What is your place of birth?
62b
What is your mother tongue?
63
What is your marital status?
64
65
66
67
If married, how many children do you have?
Married
1
Unmarried
2
Divorced
3
Widowed
4
Separated
5
One
1
Two
2
Three
3
More than three
4
No children
5
How many people live in your house One including yourself? Two
What is your family type?
Which religion do you practice?
1 2
Three
3
Four
4
More than four
5
Single
1
Joint
2
Extended
3
Buddhism
1
Christianity
2
Hinduism
3
Islam
4
Jainism
5
Sikhism
6
Atheism
7
Others (specify
68
What is your caste?
Not willing to share
1
Scheduled caste
3
Scheduled tribe
4
General
5
Other Caste (Specify) 69
Could you please give your address?
70
How long have you been living at this address?
99
THANKS FOR YOUR VALUABLE TIME
174
99
If unmarried, Skip to Q.65
ANNEXURE
6 Opinion Leaders Midline Knowledge, Attitude and Practice (KAP) Survey on Tuberculosis
QUESTIONNAIRE ID NUMBER
____________________________
STATE
1. Andhra Pradesh 2. Bihar 3. Chhattisgarh 4. Haryana 5. Karnataka 6. Kerala 7. Maharastra 8. Mizoram 9. Orrisa 10. Punjab 11. Rajasthan 12. Tamil Nadu 13. Uttar Pradesh 14. West Bengal 15. Madhya Pradesh
DISTRICT CODE DISTRICT SPECIFICATION
1. TRIBAL
2. NON-TRIBAL
TEHSIL/BLOCK/CITY VILLAGE/WARD TYPE OF SETTLEMENT
1. RURAL
2. URBAN
Distance from the nearest PHC/CHC/DH (kms) Name of Respondent 1. Village Pradhan 2. Panchayat Member 3. Ward Member 4. Religious Leader 5. ANM 6. AWW 7. Teacher 8. GKS Member
Respondent Category
FIELD CONTROL INFORMATION
Date of Interview Starting Time of Interview
AM 1 PM 1
Ending Time of Interview Interview Yes
1
By No
2
Spot/back check Yes
1
No
Scrutiny Yes
1
Code
Sign By
2
Code
Sign By
No
2
AM 1 PM 2
Code
Sign
If more than one visit made record: * Status of interview First visit
Time:_________
1
2
3
4
Second visit
Time:_________
1
2
3
4
Third visit
Time:_________
1
2
3
4
* Refused...........1 Not available..............2
Partly Completed.............3
175
Completed.............4
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Good Morning/Evening, My name is _________ I am from a social research organisation GfK Mode. We are conducting a study on behalf of an international Non-Government Organisation called, The International Union Against Tuberculosis and Lung Diseases (The Union). The Union is working with the Government of India, and supporting its Revised National Tuberculosis Control Programme in spreading awareness about tuberculosis in the community. The International Union Against Tuberculosis and Lung Diseases (The Union) an international NGO, is conducting a research study entitled, “Midline Survey on Knowledge, Attitude and Practice (KAP) towards Tuberculosis in 45 districts from 16 states in India.” Through this study we want to get some information on knowledge, attitude & practices regarding Tuberculosis among General Public, so that this information could help design appropriate strategies that will help in TB care and control programmes. All of your responses will be treated as confidential and will be used only for research purposes and also to help policy makers to understand the bottlenecks in functioning, if any, to streamline the functioning You are being invited to take part in this research study. Please ask the researcher any questions that you do not fully understand. It is very important that you are fully satisfied and clearly understand what this research entails and how you could be involved. Your participation is entirely voluntary and you are free to decline to participate. There are no financial incentives given for taking part in this study. If there is anything else that you want to know, if you have any further queries or encounter any problems you can contact Dr. Sarabjit Singh Chadha, Project Director, The Union, New Delhi, contact No : 011-46054400
CONSENT FORM I …………………………………..…………., agree to take part in the above mentioned study.
I declare that:
I have read this information and consent form and understand the contents = I have had a chance to ask questions and all my questions have been adequately answered = I understand that taking part in this study is voluntary and I have not been pressurised to take part = I may choose to leave the study at any time and will not be penalised or prejudiced in any way =
Do you have any questions about the survey? (Instruction To Investigator: In Case Of Any Questions Raised By Respondent, Kindly Respond To His/Her Satisfaction) Participant:
Investigator:
Name: - _______________________________
Name: - _________________________
Date: - ________________________________
Date: - __________________________
Signature or thumbprint: - _________________
Signature or thumbprint: - ___________
176
Annexure 6 Opinion Leaders
General information Q. No
Questions
1
What is your Name?
2
Observe and record the interviewee’s sex.
3
Response
Skip
Male
1
Female
2
How old are you? (Age in completed years)
4a
Could you please give your address?
4b
How long have you been living at this address? Knowledge and awareness about tuberculosis and treatment
5 6
7
What are the common diseases in your community?
TB Mentioned
1
TB Not mentioned
2
If TB is not mentioned, have you heard of TB?
Yes
1
No
2
DK/CS
3 Record verbatim and skip to Q. 26
If No, in your opinion what could be TB? (Record verbatim)
8
If yes, what is TB? (Record verbatim)
9
Could you mention few symptoms of TB? (Multiple Response Possible)
A cough of 2 weeks
1
Pain in the chest
2
Coughing up blood
3
Fever
4
Night sweat
5
Weight loss
6
Loss of appetite
7
Don’t know Any other (Specify) 10
Do you think TB is a serious disease in your community?
Do you know how can a person get infected with TB? (Please prompt and select the responses, multiple responses possible)
8 99
Yes
1
No
2
DK/CS
3
Other (specify) 11
If coded 1 skip to Q.8
Through handshake with infected person
99 1
Through the air when the infected person cough or sneeze.. 2 Through sharing food with infected person
3
By sharing bed/clothes with infected person
4
By sharing cigarettes/beedis
5
Don’t Know Any Other (Specify)
177
6 99
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
12
Who do you think are more prone to get infected with TB? (Prompt for multiple Response by asking ‘and’ and record them till the person says no more, multiple responses possible)
13
14
According to you can TB affected person be treated?
How can a person affected with TB be treated? (Please prompt and select the responses, multiple responses possible)
Those living in unhygienic condition
1
Poor People
2
Malnourished
3
Children
4
Women
5
Family members of TB infected person
6
Exposed to cough and cold for long time
7
HIV +ve
8
Smokers
9
Alcoholics
10
DK/CS
11
Anyone
12
Any other (specify)
99
Yes, Fully
1
Yes , Partially
2
No
3
DK/CS
4
Herbal Remedies
1
Home Remedies
2
DOTS or TB drugs
3
Other Allopathic medicines
4
Ayurvedic
5
Homeopathy
6
DK/CS
7
Any other (specify 15
16
How long does it take to treat TB?
How can pulmonary TB be diagnosed? (Multiple Response Possible)
Less than 2 weeks
1
2-4 weeks
2
1-5 months
3
6 -8 months
4
More than 8 months and others
5
DK/CS
6
Sputum smear Test
1
X – Ray
2
Mantoux Skin Test
3
DK/CS 17
Are you aware of the place where one can get Tuberculosis diagnosed? (Multiple Response Possible)
99
4
Any Other (Specify)
99
Government Hospital
1
CHC/PHCs
2
Private Hospital/Clinic
3
NGO
4
RHCP
5
DOTS Centre
6
DK/CS
7
Any Other(Specify)
178
99
Annexure 6 Opinion Leaders
18
Are you aware of the place where one can get medicine for Tuberculosis? (Multiple Response Possible)
Government Hospital
1
CHC/PHCs
2
ANM/ASHA/AWW
3
Private Hospital/Clinic
4
DOTS Provider/Centre
5
NGO
6
DK/CS
7
Any Other(Specify 19
20
21 22
23
Are you aware that a specific treatment is available for Tuberculosis?
Yes
1
No
2
In your opinion, is regular and complete treatment for TB important for cure?
Yes
1
No
2
Have you heard of DOTS?
Yes
1
No
2
For treating Tuberculosis
1
If yes, what is this used for?
Are you aware of the place where you can get DOTS? (Multiple Response)
For treating other ailments
2
DK/CS
3
Government Hospital
1
CHC/PHCs
2
ANM/ASHA/AWW
3
Private Hospital/Clinic
4
DOTS Provider/Centre
5
NGO
6
DK/CS
7
Any Other(Specify) 24
(Instruction : If not coded 5 in Q.23, then ask) If DOTS/TB centre is not mentioned in response, have you heard of DOTS centre/provider?
25
99
Do you know that Government is providing DOTS free of cost?
If coded 2, then skip to Q. 23
99
Yes
1
No
2
DK/CS
3
Yes
1
No
2
DK/CS
3
Health seeking behaviour 26
When someone falls sick, where will you generally refer him/her to go?
Government health facility (Including PHC,CHC, district hospital/sub centre/ANM
1
Private Clinic
2
Private Hospital or nursing home
3
Ayurvedic or Siddha treatment
4
Homeopathic treatment
5
Traditional healer/Quacks/informal provider
6
Clinic run by NGOs
7
Local chemist or pharmacy
8
ASHA worker in your village
9
Any other (Specify
179
99
If coded (1) skip to Q.28
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
27
28
If not to a Government Health centre? Why?
Hospital is far from home
1
Unavailability of doctors
2
Unfriendly behaviour
3
Long Waiting Hours
4
Lack of Diagnostic facility
5
Lack of Qualified Doctor
6
Lack of Diagnostic Equipments in the facility
7
Private Clinic is nearby
8
Unhygienic Condition
9
Any Other (Specify)
99
If a person has TB like symptoms Government Centres/DMC where according to you, he should Private Hospitals go for diagnosis? DOTS/TB Centres
1 2 3
Any Other 29
If a person is diagnosed with TB, where according to you, he should go for treatment?
99
Government Centres
1
Private Hospitals
2
DOTS/TB Centres
3
Any Other
99
Stigma & Discrimination The following questions are for understanding your opinion on tuberculosis patients from the societal perspective. Some of the questions are sensitive. We request you to please do not get offended by any questions. You are free not to respond to any of the issues. 30
Now I will make some statements about People suffering from TB. Please let me know how much you agree to these?
Strongly Agree
Somewhat agree
Disagree
A
A family with TB patient should not be allowed to participate in any social function
1
2
3
B
Married female TB patient should be sent off to her parent’s house
1
2
3
C
Children with TB should not be allowed to go to school
1
2
3
D
Daily ware Labourers suffering from TB should not be allowed to work
1
2
3
E
Husbands/in-laws do not accompany female TB patients to hospital/DOTS centres
1
2
3
F
Female accompany their spouse to hospitals suffering from TB to hospitals/DOTS centre
1
2
3
G
Females suffering from TB face problem in marriage
1
2
3
31
Which of the following you would agree to do?
Yes
No
DK/CS
A
Share a meal with person you know had TB
1
2
3
B
If you suspect one of the female member is suffering from TB, do you take her to hospital
1
2
3
180
Reasons for their response: Record verbatim
Annexure 6 Opinion Leaders
C
Marry ones daughter to a boy knowing had a TB
1
2
3
D
Isolate your family member having TB from the household
1
2
3
E
Marry one’s son to a girl who you know had TB
1
2
3
F
Send one’s daughter in law to parent’s house if she had TB in order to protect other family members from TB
1
2
3
32
In your community, how is the person suffering from TB usually treated?
Most people reject him or her
1
Most people are friendly but they generally try to avoid him/her
2
Community mostly support and help him/her Others (specify) 33
34
Do you know anyone in your family and neighbourhood suffering from TB in the last 2 year
Yes
1
No
2
DK/CS
3
If yes, have you given any advise to them?
Go to Government Hospital
1
Go to Private hospital
2
Isolate the family from the community
3
None
36
Have you taken any initiative towards generating awareness about TB & DOTS within your community? If yes, what are they?
99
Yes
1
No
2
Organised camps
1
Organised rallies
2
Organised lectures/Seminars/Workshops
3
Worked as DOT provider
4
Nukkad Nataks/Street Plays/Skits
5
Any other (Specify)
99
Media Habit & Preferences 37
Which source of information you are exposed to? (Multiple Response PossibleProbe)
If coded 2 & 3 skip to Q.35
4
Any Other(Specify) 35
3 99
Radio
1
TV
2
Newspaper & Magazines
3
Cinema
4
Hoardings/posters/leaflets/Wall painting
5
Melas/Nukkad Nataks etc
6
Internet/Web advertising
7
Word of mouth (Interpersonal communication)
.8
Local Health Service providers
9
Mobile phone advertising/SMS
10
None
11
181
If coded 2 skip to Q.37
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
38
Which channel of Radio do you generally listen to? (Multiple Response Possible)
Do not listen to radio
1
Vividh Bharti
2
FM (Specify)
3
Regional Channel
4
Community Radio Any other (specify) 39
Which programme do you like most on Radio? (Multiple Response Possible)
Which Television channel do you generally watch? (Multiple Response Possible)
41
Which programmes do you like the most on TV? (Probe for two most liked programmes)
1
Drama/Serial
2
Film songs
3
Folk songs
4
Health discussion
5
Do not watch TV Any other (specify)
43
44
45
Which language paper generally is read by you?
99
News
1
Drama/Serial
2
Entertainment
3
Health Related Programmes
4
Advertisements
5
Folk music
6
Music
7 99
Yes
1
No
2
English
1
Hindi
2
Local language
3
Have you ever seen an advertisement/information on Tuberculosis or DOTS?
Yes
1
No
2
DK/CS
3
If Yes, where did you see such advertisement or/and information on TB/DOTS?
Newspaper & Magazines
1
Radio
2
TV
3
Hoardings/posters/leaflets
4
(Multiple Response Possible)
If the response is coded as 1 then skip the next question and go to Q.42
8
Any other (Specify) Do you read newspaper?
99 1
Films 42
99
News
Any other (specify) 40
5
If the response is coded 1, then skip the next question and go to question 40
Melas/Nukkad Nataks etc Any other(Specify)
182
5 .99
If coded 2, skip to Q.44
IF coded 2 or 3, then skip to Q.46
Annexure 6 Opinion Leaders
Information Sources 46
What are your sources of information for awareness on Tuberculosis related issues? (Multiple Response Possible)
TV
1
Radio
2
Cinema
3
Newspaper/Magazines
4
Hoarding/Posters/billboards/Wall writing/Brochure/ other printed material 5
46 a
In general, on what specific aspects of TB was the information provided? (Multiple Response)
Internet
6
Public service announcements
7
Drama/Skits/Street plays
8
Hospital/doctor
9
Friends & Relatives
10
Teachers/peer educator/colleagues
11
Health camp
12
Health workers
13
DOTS providers
14
Local leaders/religious leader
15
Sarpanch/Panchayat Member
16
None of these
17
Other (specify)
99
Symptoms of Tuberculosis
1
Prevention from Tuberculosis
2
Cure for Tuberculosis
3
DOTS
4
Place of Treatment
5
Information on prevailing myths about TB patients 6 Others (Specify) 47
48
Did anyone visited your house/ neighbourhood during last two years to make your family/ community aware and provide information on TB ?
Yes
1
No
2
DK/CS
3
If yes, who visited?
Government Doctor
1
(Multiple Response Possible)
Private Doctor
2
AWW
3
ASHA
4
Health worker
5
Worker from an NGO
6
Don’t remember
7
Any others 49
99
What specific information did they provide? (Multiple Response Possible)
99
Symptoms of Tuberculosis
1
Prevention from Tuberculosis
2
Cure for Tuberculosis
3
DOTS
4
Place of Treatment
5
Information on prevailing myths about TB patients 6 Any other (Specify)
183
99
If coded 2 & 3 skip to Q.50
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
50
Where from would you prefer to get information on TB and related issues? (Multiple Response Possible)
TV
1
Radio
2
Cinema
3
Newspaper/Magazines
4
Hoarding/Posters/billboards/Wall writing/Brochure/ other printed material 5 Internet
6
Public service announcements
7
Drama/Skits/Street plays
8
Hospital/doctor
51
According to you what are the two most important issues regarding tuberculosis which need utmost attention?
9
Friends & Relatives
10
Teachers/peer educator/colleagues
11
Health camp
12
Health workers
13
DOTS providers
14
Local leaders/religious leader
15
Sarpanch/Panchayat Member
16
None of these
17
Other (specify
99
1-------------------------------------------2-------------------------------------------
(Record verbatim) 52
Do you have any suggestions how you/your organisation could be more helpful in addressing Tuberculosis related issues? (Record verbatim)
GENERAL, SOCIO- CULTURAL & DEMOGRAPHIC INFORMATION Please do not get offended by some of the questions. If you do not wish to answer any question please let the investigator know about it. 53
54
55
What is your marital status?
How many children do you have?
How many people live in your house including yourself?
Married
1
Unmarried
2
Divorced
3
Widowed
4
Separated
5
One
1
Two
2
Three
3
More than three
4
No children
5
One
1
Two
2
Three
3
Four
4
More than four
5
184
If coded 2, then skip to Q. 55
Annexure 6 Opinion Leaders
56
What is your family type?
57 (a)
What is your place of birth?
57 (b)
What is your mother tongue?
58
Which religion do you practice?
Single
1
Joint
2
Extended
3
Buddhism
1
Christianity
2
Hinduism
3
Islam
4
Jainism
5
Sikhism
6
Atheist
7
Others (Specify) 59
60
61
What is your caste?
What is the last level of education that you completed?
What is your occupation?
99
Not willing to share
1
Scheduled caste
2
Scheduled tribe
3
General
4
Others
5
Not willing to share
6
Illiterate
1
Literate but no formal education
2
Less than Primary
3
Primary but less than Secondary
4
Secondary but less than Senior Secondary
5
Senior Secondary but not Graduate
6
Graduation & above
7
Village Pradhan
1
Panchayat Member
2
Ward Member
3
Religious Leader
4
ANM
5
AWW
6
Teacher
7
GKS Member
8
Any other (specify)
THANKS FOR YOUR VALUABLE TIME
185
99
ANNEXURE
7 NGO/CBO Midline Knowledge, Attitude and Practice (KAP) Survey on Tuberculosis
Questionnaire ID Number
____________________________
State
1. Andhra Pradesh 2. Bihar 3. Chhattisgarh 4. Haryana 5. Karnataka 6. Kerala 7. Maharastra 8. Mizoram 9. Orrisa 10. Punjab 11. Rajasthan 12. Tamil Nadu 13. Uttar Pradesh 14. West Bengal 15. Madhya Pradesh
District Code District Specification
TRIBAL………………………..1
NON-TRIBAL……………………………2
RURAL……………………….1
URBAN……………………………………2
Tehsil/Block/City Village/Ward Type of Settlement Distance from the nearest PHC/CHC/DH (kms) Name of Respondent
Date of Interview FIELD CONTROL INFORMATION
Starting Time of Interview
AM 1 PM 1
Ending Time of Interview Interview Yes
1
No
By 2
Spot/back check Yes
1
No
Scrutiny Yes
1
No
Code
Sign By
2
Code
Sign By
2
AM 1 PM 2
Code
Sign
If more than one visit made record:
* Status of interview
First visit
Time:_________
1
2
3
4
Second visit
Time:_________
1
2
3
4
Third visit
Time:_________
1
2
3
4
* Refused 1 Not available 2 Partly Completed 3 Completed 4
186
Annexure 7 NGO/CBO
Good Morning/Evening, My name is _________. I am from a social research organisation GfK Mode. We are conducting a study on behalf of an international Non-Government Organisation called, The International Union Against Tuberculosis and Lung Diseases (The Union). The Union is working with the Government of India, and supporting its Revised National Tuberculosis Control Programme in spreading awareness about tuberculosis in the community. The International Union Against Tuberculosis and Lung Diseases (The Union) an international NGO, is conducting a research study entitled, “Midline Survey on Knowledge, Attitude and Practice (KAP) towards Tuberculosis in 45 districts from 16 states in India.” Through this study we want to get some information on knowledge, attitude & practices regarding Tuberculosis among NGO/ CBOs, so that this information could help design appropriate strategies that will help in TB care and control programmes. All of your responses will be treated as confidential and will be used only for research purposes and also to help policy makers to understand the bottlenecks in functioning, if any, to streamline the functioning You are being invited to take part in this research study. Please ask the researcher any questions that you do not fully understand. It is very important that you are fully satisfied and clearly understand what this research entails and how you could be involved. Your participation is entirely voluntary and you are free to decline to participate. There are no financial incentives given for taking part in this study. If there is anything else that you want to know, if you have any further queries or encounter any problems you can contact Dr. Sarabjit Singh Chadha, Project Director, The Union, New Delhi, contact No : 011-46054400
CONSENT FORM I …………………………………..…………., agree to take part in the above mentioned study. I declare that: I have read this information and consent form and understand the contents I have had a chance to ask questions and all my questions have been adequately answered I understand that taking part in this study is voluntary and I have not been pressurised to take part I may choose to leave the study at any time and will not be penalised or prejudiced in any way
Do you have any questions about the survey? (Instruction to Investigator: In case of any questions raised by respondent, kindly respond to his/her satisfaction) Participant:
Investigator:
Name: ______________________________ Name:________________________________ Date: _______________________________ Date: ________________________________ Signature or thumbprint: ________________ Signature or thumbprint: _________________
187
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
GENERAL INFORMATION Q. No.
Questions
1
What is your Name?
2
Observe and record the interviewee’s sex.
3
Can you please tell me your age? (Age in completed years)
4a
Could you please give your address?
4b
How long have you been living at this address?
Response Male Female
Skip 1 2
KNOWLEDGE AND AWARENESS ABOUT TUBERCULOSIS AND TREATMENT Q. No.
Questions
Response
5
What are the common diseases in your community?
TB Mentioned TB Not mentioned
1 2
6
If TB is not mentioned, have you heard of TB?
Yes No DK/CS
1 2 3
7
If No, in your opinion what could be TB? (record verbatim)
Go to question 25
8
what is TB? (Record verbatim)
if q6 = 3 then skip to Q9
9
Could you mention few symptoms of TB? (Multiple Response Possible)
Skip
A cough of 2 weeks 1 Pain in the chest 2 Coughing up blood 3 Fever 4 Night sweat 5 Weight loss 6 Loss of appetite 7 Don’t know 8 Any other (Specify)-----------------------99
10
Do you think TB is a serious disease in your community?
Yes No
11
Do you know how can a person get infected with T.B?
Through handshake with infected person 1 Through the air when the infected person cough or sneeze.. 2 Through sharing food with infected person 3 By sharing bed/clothes with infected person 4 By sharing cigarettes/beedis 5 Don’t Know 6 Any Other (Specify)-----------------------99
(please prompt and select the responses, multiple responses possible)
188
1 2
If coded 1 skip to Q.8
Annexure 7 NGO/CBO
Q. No.
Questions
Response
12
Who do you think are more prone to get infected with TB?
Those living in unhygienic condition 1 Poor People 2 Malnourished 3 Children 4 Women 5 Family members of TB infected person 6 Exposed to cough and cold for long time 7 HIV +ve 8 Smokers 9 Alcoholics----------------------------------10 DK/CS---------------------------------------11 Anyone-------------------------------------12 Any other (specify)-----------------------99
(prompt for multiple Response by asking ‘and’ and record them till the person says no more, multiple responses possible)
Skip
13
According to you whether TB affected person can be treated?
Yes, Fully Yes , Partially No DK/CS
14
How can a person affected with TB be cured?
Herbal Remedies 1 Home Remedies 2 DOTS or TB drugs 3 Other Allopathic medicines 4 Ayurvedic 5 Homeopathy 6 DK/CS 7 Any other (specify------------------------99
(please prompt and select the responses, multiple responses possible)
1 2 3 4
15
How long does it take to cure TB?
Less than 2 weeks 2-4 weeks 1-5 months 6 -8 months More than 8 months and others DK/CS
16
How can TB be diagnosed? (Multiple Response Possible)
Sputum Smear Test 1 X–Ray 2 Mantoux Skin Test 3 Blood test 4 DK/CS 5 Any Other (Specify)-----------------------99
17
Are you aware of the place where you can get Tuberculosis diagnosed? (Multiple Response Possible)
Government Hospital 1 CHC/PHCs 2 Private Hospital/Clinic 3 NGO 4 RHCP 5 DOTS Centre 6 DK/CS 7 Any Other(Specify)------------------------99
189
1 2 3 4 5 6
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Q. No.
Questions
Response
18
Are you aware of the place where you can get medicine for Tuberculosis?
Government Hospital 1 CHC/PHCs 2 ANM/ASHA/AWW 3 Private Hospital/Clinic 4 DOTS Provider 5 NGO 6 DK/CS 7 Other--------------------------------------99
(Multiple Response Possible)
Skip
19
Are you aware that a specific treatment is available to treat Tuberculosis?
Yes No
1 2
20
Have you heard of DOTS?
Yes No
1 2
21
If yes, what for this is used?
For treating Tuberculosis For treating other ailments DK/CS
1 2 3
22
Are you aware of the place where you can get DOTS?
Government Hospital 1 CHC/PHCs 2 ANM/ASHA/AWW 3 Private Hospital/Clinic 4 DOTS Provider/Centre 5 NGO 6 DK/CS 7 Any Other (Specify-----------------------99
23
If DOTS/TB centre is not mentioned, have you heard of DOTS centre/ provider?
Yes No DK/CS
1 2 3
24
Do you know that Government is providing DOTS free of cost?
Yes No DK/CS
1 2 3
If coded 2, then skip to Q.25
HEALTH SEEKING BEHAVIOUR 25
When someone falls sick, where will you generally refer him/her to go?
Government health facility (Including PHC,CHC, district hospital/sub centre/ ANM 1 Private Clinic 2 Private Hospital or nursing home 3 Ayurvedic or Siddha treatment 4 Homeopathic treatment 5 Traditional healer/Quacks/informal provider 6 Clinic run by NGOs 7 Local chemist or pharmacy 8 ASHA worker in your village 9 Any other (Specify)----------------------99
26
If not to a Government Health centre? Why?
Hospital is far from home 1 Unavailability of doctors 2 Unfriendly behaviour 3 Long Waiting Hours 4 Lack of Diagnostic facility 5 Lack of Qualified Doctor 6 Lack of Diagnostic Equipments in the facility 7 Private Clinic is nearby 8 Unhygienic Condition 9 Any Other (Specify)----------------------99
190
If coded (1) skip to Q.27
Annexure 7 NGO/CBO
Q. No.
Questions
Response
Skip
27
If a person has TB like symptoms where according to you, he should go for diagnosis?
Government Centres/DMC 1 Private Hospitals 2 DOTS/TB Centres 3 Any Other(Specify)-----------------------99
28
If a person is diagnosed with TB, where according to you, he should go for treatment?
Government Centres 1 Private Hospitals 2 DOTS/TB Centres 3 Any Other(Specify)----------------------99
Stigma and Discrimination The next few questions are related to documenting your opinion on tuberculosis patients Some of the issues are quite sensitive. Please do not get offended by them. 29
Now I will make some statements about People suffering from TB. Please let me know how much you agree to these?
Strongly Agree
Somewhat agree
Disagree
A
A family with TB patient should not be allowed to participate in any social function
1
2
3
B
Married female TB patient should be sent off to her parent’s house
1
2
3
C
Children with TB should not be allowed to go to school
1
2
3
D
Daily wage labourers suffering from TB should not be allowed to work
1
2
3
E
Husbands/in-laws do not accompany female TB patients to hospital/DOTS centres
1
2
3
F
Wives accompany their spouse to hospitals suffering from TB to hospitals/DOTS centre
1
2
3
G
Females suffering from TB face problem in marriage
1
2
3
30
Which of the following you would agree to do?
Yes
No
DK/CS
A
Share a meal with person you know had TB
1
2
3
b
If you suspect one of the female member is suffering from TB, do you take her to hospital
1
2
3
C
Marry your daughter to a boy knowing had a TB
1
2
3
D
Isolate your family member having TB from the household
1
2
3
E
Marry your son to a girl who you know had TB
1
2
3
F
Send your daughter in law to parent’s house if she had TB in order to protect other family members from TB
1
2
3
191
Reasons for their response: Record verbatim
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Q. No.
Questions
Response
Skip
31
In your community, how is the person suffering from TB usually treated?
Most people reject him or her 1 Most people are friendly but they generally try to avoid him/her 2 Community mostly support and help him/her 3 Others (specify)----------------------------99
32
Do you know anyone in your family and neighbourhood suffering from TB in the last 2 year
Yes No DK/CS
33
If yes, what advice have you given any to them?
Go to Government Hospital 1 Go to Private hospital 2 Isolate the family from the community 3 None 4 Any other- (specify)-----------------------99
34
Have you taken any initiative towards generating awareness about TB & DOTS within your community?
Yes No
35
If yes, what are they?
Organised camps 1 Organised rallies 2 Organised lectures/Seminars/Workshops 3 Worked as DOT provider 4 Nukkad Nataks/Street Plays/Skits 5 Any other (Specify)-----------------------99
1 2 3
1 2
If coded 2 & 3 skip to 34
If coded 2 skip to 36
MEDIA HABIT & PREFERENCES 36
Which source of information you are exposed to? (Multiple Response Possible- Probe)
Radio TV Newspaper & Magazines Cinema Hoardings/posters/leaflets/Wall painting Melas/Nukkad Nataks etc Internet/Web advertising Word of mouth (Interpersonal communication Local Health Service providers Mobile phone advertising/SMS None
1 2 3 4 5 6 7 8 9 10 11
37
Which channel of Radio do you generally listen to? (Multiple Response Possible)
Do not listen to radio Vividh Bharti FM (Specify Regional Channel Community Radio Any other (specify)
1 2 3 4 5 99
38
Which programme do you like most on Radio? (Multiple Response Possible)
News Drama/Serial Film songs Folk songs Health discussion Any other (specify)
1 2 3 4 5 99
192
If coded 1, then skip to 39
Annexure 7 NGO/CBO
Q. No.
Questions
Response
Skip
39
Which Television channel do you generally watch? (Multiple Response Possible)
Do not watch TV Other (specify
1 99
40
Which programmes do you like the most on TV? (Probe for two most liked programmes)
News Drama/Serial Entertainment Health Related Programmes Advertisements Folk music Music Films Any other (Specify)
1 2 3 4 5 6 7 8 99
41
Do you read newspaper?
Yes No
1 2
42
Which language paper generally is read by you?
English Hindi Local language
1 2 3
43
Have you ever seen an advertisement/information on Tuberculosis or DOTS?
Yes No DK/CS
1 2 3
44
If Yes, where did you see such advertisement or/and information on TB/DOTS? (Multiple Response Possible)
Newspaper & Magazines Radio TV Hoardings/posters/leaflets Melas/Nukkad Nataks etc Any other (specify)
1 2 3 4 5 99
INFORMATION SOURCES 45
What are your sources of information for awareness on Tuberculosis related issues? (Multiple Response Possible)
45 a
In general, on what specific aspects of TB was the information provided? (Multiple Response)
TV 1 Radio 2 Cinema 3 Newspaper/Magazines 4 Hoarding/Posters/billboards/Wall writing/Brochure/other printed material 5 Internet 6 Public service announcements 7 Drama/Skits/Street plays 8 Hospital/doctor 9 Friends & Relatives-----------------------10 Teachers/peer educator/colleagues---11 Health camp-------------------------------12 Health workers----------------------------13 DOTS providers----------------------------14 Local leaders/religious leader----------15 Sarpanch/Panchayat Member-----------16 None of these------------------------------17 Other (specify) ---------------------------99 Symptoms of Tuberculosis 1 Prevention from Tuberculosis 2 Cure for Tuberculosis 3 DOTS 4 Place of Treatment 5 Information on prevailing myths about TB patients 6 Others (Specify)---------------------------99
193
If coded 1, then skip to 41
If coded 2, skip to Q.43
If the response is ‘no’ or ‘don’t know’ then skip to Q.45
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Q. No.
Questions
Response
46
Did anyone visit your house/ neighbourhood during last two years to make your family/community aware and provide information on TB
Yes No DK/CS
47
If yes, who visited? (Multiple Response Possible)
Government Doctor 1 Private Doctor 2 AWW 3 ASHA 4 Health worker 5 Worker from an NGO 6 Don’t remember 7 Any other-----------------------------------99
48
What specific information did they provide? (Multiple Response Possible)
49
Where from would you prefer to get information on TB and related issues? (Multiple Response Possible)
50
According to you what are the two most important issues regarding tuberculosis which need utmost attention? (Record verbatim)
51
Skip 1 2 3
Symptoms of Tuberculosis 1 Prevention from Tuberculosis 2 Cure for Tuberculosis 3 DOTS 4 Place of Treatment 5 Information on prevailing myths about TB patients 6 Any other (Specify) ----------------------99 TV 1 Radio 2 Cinema 3 Newspaper/Magazines 4 Hoarding/Posters/billboards/Wall writing/Brochure/other printed material 5 Internet 6 Public service announcements 7 Drama/Skits/Street plays 8 Hospital/doctor 9 Friends & Relatives-----------------------10 Teachers/peer educator/colleagues---11 Health camp-------------------------------12 Health workers----------------------------13 DOTS providers----------------------------14 Local leaders/religious leader----------15 Sarpanch/Panchayat Member----------16 None of these------------------------------17 Other (specify)----------------------------99 1-------------------------------------------2-------------------------------------------
Do you have any suggestions how you/your organisation could be more helpful in addressing Tuberculosis related issues? (Record verbatim)
194
If coded 2 & 3 skip to 49
Annexure 7 NGO/CBO
Q. No.
Questions
Response
Skip
Only for NGO/CBO 52
Name of NGO you are working for?
53
For how long this NGO is working?
No. of years:
54
What are the issues taken up by your NGO?
TB specific/DOTS programme 1 Rural Development 2 Sanitation 3 Education 4 Other Health & Disease Related issues 5 Income generation 6 Gender issue 7 Domestic violence 8 Any other (specify) ----------------------99
(Multiple Response Possible)
55(a)
Does your organisation work for tuberculosis control?
Yes No
55(b)
If Yes, what are different types of activities being addressed by your NGO (Those who are working in the field of TB)?
Spreading awareness about TB, educating communities on its prevention & treatment 1 Provide community based care to TB patients 2 Training to TB care health workers & volunteer 3 Help in reducing stigma & discrimination from the community on TB 4 Help resettlement of TB patients 5 Motivating TB patients to treat under DOTS programme 6 Spreading awareness about DOTS 7 As a DOTS provider 8 Other (specify) ---------------------------99
(Multiple Response Possible)
1 2
If the response is no, then skip to Q.56
56
If not addressing TB related issues, are you interested to work in the TB control area?
Yes No DK/CS
1 2 3
57
Are you aware of any schemes under which NGOs can collaborate with RNTCP?
Yes No DK/CS
1 2 3
If coded 2 & 3 skip to Q.61
58
If yes, are you also involved in any of the schemes?
Yes No DK/CS
1 2 3
If no, then skip to Q.61
59
If yes, what kind of schemes?
ACSM (Advocacy, Communication & Social Mobilisation 1 SC Scheme (Sputum Collection Centre 2 DMC (Designated Microscopy Centres 3 LT Scheme 4 CS Scheme 5 Adherence Scheme 6
60
If involved in ACSM Scheme, specify the activities. (Record Verbatim)
61
Do you want to collaborate with RNTCP to work in the field of Tuberculosis?
Yes No
195
1 2
If coded ‘1’, Do not ask Q.62
Knowledge, Attitude and Practice about Tuberculosis in India – A Midline Survey
Q. No.
Questions
Response
62
If no, what are the reasons? (Multiple Response Possible)
Insufficient grant under the schemes 1 People are not suffering from TB in this area 2 Do not have interest in working for People suffering from TB 3 Other (Specify)----------------------------99
63
What is your marital status?
Married Unmarried Divorced Widowed Separated
1 2 3 4 5
64
How many children do you have?
One Two Three More than three No children
1 2 3 4 5
65
How many people live in your house including yourself?
One Two Three Four More than four
1 2 3 4 5
66
What is your family type?
Single Joint Extended
1 2 3
67a
What is your place of birth?
67b
What is your mother tongue? (record verbatim)
68
What is your caste?
Not willing to share 1 Scheduled caste 2 Scheduled tribe 3 General 4 Other Backward Class 5 Other Caste (Specify) ------------------99
69
Which religion do you practice?
Buddhism 1 Christianity 2 Hinduism Islam 4 Jainism 5 Sikhism 6 Atheism 7 Others (specify)----------.----------------99
THANKS FOR YOUR VALUABLE TIME
196
Skip
If coded 2, skip to Q.65
The Union, South East Asia Office C-6, Qutub Institutional Area | New Delhi 110016 | India Tel: (+91) 11 46 05 44 00 | Fax: (+91) 11 46 05 44 30 | www.theunion.org |