EMHJ • Vol. 20 No. 2 • 2014
Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale
Tuberculosis awareness in Gezira, Sudan: knowledge, attitude and practice case–control survey M.M.A. Suleiman,1 N. Sahal,1 M. Sodemann,2 A. Elsony 3 and A.R. Aro 1
واملامرسات اخلاصة، واملواقف، مسح للحاالت والشواهد حول املعارف: السودان،الوعي بمرض السل يف والية اجلزيرة . والسامت االجتامعية والديموغرافية املصاحبة له يف اجلزيرة بالسودان، هتدف دراسة احلاالت والشواهد هذه إىل تقييم مدى الوعي بالسل:اخلالصة ) والشواهد الذين425 = (العدد2010 واعتمدت عينة الدراسة عىل مرىض السل اجلدد إجيابيي اللطاخة املسجلني يف والية اجلزيرة بالسودان يف عام وتم قياس مدى الوعي باستخدام املقياس املعدّ ل.)850 = يضاهون احلاالت يف السن ممن حرضوا إىل املرافق الصحية نفسها ألسباب أخرى (العدد ومل يكن هناك أي فروق يعتد هبا بني حاالت السل والشواهد من حيث املستوى الكيل.ملنظمة الصحة العاملية لقياس املعارف واملواقف واملامرسات وأن جنس املستجيب للدراسة يؤ ِّثر عىل مدى. ولقد اتضح أن ثلثي حاالت السل والشواهد لدهيا مستوى جيد من الوعي بالسل.للوعي بالسل يف حني نجد أن، ومستوى التعليم ونمط اإلقامة ونوع املهنة كلها من األمور التي ترتبط بشكل كبري بمدى الوعي بالسل، فالسن.الوعي بني الشواهد ِّ ثم فإن مستوى الوعي اجليد بالسل لدى احلاالت املصابة به ولدى الشواهد مت ثل خط األساس إلذكاء املزيد َّ ومن.احلالة الزواجية مل يكن هلا أي أثر .من الوعي بالسل لدى سكان والية اجلزيرة
آريا أرو، أسامء السني، مورتن سودمان، نجالء هاشم سهل،حممد مصطفى أمحد سليامن
ABSTRACT This case–control study aimed to assess tuberculosis (TB) awareness and its associated sociodemographic characteristics in Gezira, Sudan. New smear-positive TB patients registered in Gezira in 2010 (n = 425) and agematched controls who attended the same health facilities for other reasons (n = 850) formed the study sample. Awareness was measured using a modified standard World Health Organization TB knowledge, attitude and practice instrument. There was no significant difference between TB cases and the controls in overall levels of TB awareness. About two-thirds of TB cases and controls had good TB awareness. Respondents’ sex was associated with awareness among the controls. Age, level of education, type of residence and type of occupation were significantly associated with TB awareness, whereas marital status had no effect. The good level of TB awareness found among TB cases and controls is a baseline for further TB awareness-raising among the Gezira population.
Sensibilisation à la tuberculose dans l'état de Gézira (Soudan) : enquête cas-témoin sur les connaissances, les attitudes et les pratiques RÉSUMÉ La présente étude cas-témoin visait à évaluer la sensibilisation à la tuberculose et les caractéristiques sociodémographiques associées dans l'état de Gézira (Soudan). L’échantillon de l’étude était composé de nouveaux patients à frottis positifs pour la tuberculose au Gézira en 2010 (n = 425) et de témoins appariés pour l’âge qui consultaient dans les mêmes établissements de santé pour d’autres motifs (n = 850). Le degré de sensibilisation à la maladie a été mesuré à l’aide de l’instrument standard modifié de l’Organisation mondiale de la Santé évaluant les connaissances, les attitudes et les pratiques en matière de tuberculose. Aucune différence significative n’a été observée entre les patients tuberculeux et les témoins dans les niveaux généraux de sensibilisation à la tuberculose. Environ deux tiers des patients tuberculeux et des témoins avaient un niveau de sensibilisation à la tuberculose satisfaisant. Dans le groupe des témoins, les hommes et les femmes n’avaient pas le même niveau de sensibilisation à la question. L’âge, le niveau d’études, le type de résidence et la profession étaient des facteurs nettement corrélés à la sensibilisation à la tuberculose, contrairement à la situation matrimoniale. Le niveau satisfaisant de sensibilisation à la tuberculose observé chez les patients atteints de tuberculose est un point de départ pour l’augmentation de la sensibilisation à cette maladie dans la population du Gézira. Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark (Correspondence to M.M.A. Suleiman: msuleiman@ health.sdu.dk). 2Department of Infectious Diseases, Odense University Hospital, Odense, Denmark. 3Epidemiological Laboratory, Khartoum, Sudan. 1
Received: 28/11/12; accepted: 07/05/13
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املجلد العرشين العدد الثاين
املجلة الصحية لرشق املتوسط
Introduction Tuberculosis (TB) is among the top 10 causes of global mortality [1,2], and in Africa the situation has worsened over the past 2 decades owing to the HIV/ AIDS epidemic [3,4]. In Sudan the incidence of TB is 180 cases per 100 000 population at risk, which puts Sudan among the high-prevalence countries for TB in the Eastern Mediterranean Region [5]. Gezira State is one of the high TB burden states of Sudan, and further, there is high default rate from treatment (12.8% in the year 2010). In 2007 Sudan overall was reported to have a TB case detection rate of 30% [6], far below the global target of 70%, and the case detection rate in Gezira State in the same year was 39.7% [7]. This low detection rate may in part be due to factors which hinder patients’ access to care and increase default rates among those who start treatment. The role of human behaviour in health and illness has been increasingly recognized [8–10]. Knowledge, attitude and practice surveys concerning TB can identify knowledge gaps, cultural beliefs or behavioural patterns that may facilitate understanding and action as well as pose problems or create barriers for TB control. The data collected enable programme managers to set TB programme priorities, to estimate the resources required for various activities, to select the most effective communication channels and messages, to establish baseline levels and to measure change that result from interventions [11]. Based on the literature we know that poorer socioeconomic conditions and lack of awareness of TB prevention and symptoms are risk factors for TB infection [12]. In addition, psychosocial issues such as lack of knowledge, low risk perception and illness perceptions such as social and cultural stigma as well as poor access to treatment facilities are associated with poorer TB-related behaviours and poorer adherence to TB treatment [6,13].
The aims of the study were to assess TB awareness among TB cases and controls in Gezira, Sudan, and to determine the relationship between respondents’ sociodemographic characteristics and their level of TB awareness. The goal was to contribute to knowledge about barriers to the success of the TB control programme, to inform programme managers and decision-makers and to provide a baseline for needed health promotion strategies and activities to reduce TB incidence among the Gezira population. The information gathered will facilitate the development of effective interventions that fit the socioeconomic, cultural and psychosocial characteristics of the local population and societal context.
to allow for non-response. Thus, the sample sizes were 425 patients and 850 controls. The sample size was divided between the health-care units according to the number of registered patients from January to December 2010. For each patient 2 age-matched controls were selected randomly from people attending the same heath facility for any other purpose. Other patients attending the health facility were used since there is no civil registry from which controls could be drawn. These control patients were selected randomly from the health facility clinic registry book during the same time period as the patients were selected. Data collection
Methods Study setting
This study was carried out in Gezira State, which is one of the 17 states in Sudan. Gezira State lies between the Blue and the White Nile rivers in the east-central region of Sudan. It has an area of 27 549 km2 and population of about 2 796 330. The structure of the health-care system in Gezira State is based on primary health care and the health area concept, which is conceived as a decentralized health-care system able to integrate at district level. Sample
A case–control study design was used. The cases were all new smear-positive TB cases diagnosed in the TB microscopy units in Gezira State in the period from January to June 2010, and for each case 2 controls were selected. The sample size was calculated for cases from the equation n = z2 pq/d2, where n = sample size, z = level of confidence = 1.96, P = 0.5, q = 1–p = 0.5, d = desired margin of error = 0.05. The required sample size was estimated as (1.96) (1.96) (0.5) (0.5)/(0.05)2 = 384 patients; 10% of the calculated sample size was added
The sociodemographic characteristics (age, sex, residence, occupation, level of education, crowding, housing condition, etc.) and the level of TB awareness of participants were measured using a standard modified World Health Organization TB instrument for knowledge, attitude and practice surveys (28 more questions were added to the questionnaire and 5 of the existing questions were modified) [11]. The interview instrument was tested in a pilot study. The fieldwork took place in Gezira State, Sudan, in the period from December 2010 to December 2011 by 14 health professionals who were trained in how to use the data gathering tools. A written consent was taken from the participants. The objectives, process and expected outcome of the research were explained to the participants and their right to withdraw from the study at any time without any consequences for their current care was explained. Absolute confidentiality of the information gathered was followed before, during and after finishing the study. Data analysis
The assessment of the level of TB awareness among the TB cases and controls was based on the summation of the correct answers for the questions which 121
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measured 9 aspects of awareness about cases were employees than the controls; TB: having enough information about somewhat less than half of both groups TB; types of TB; methods of transmis- were without work. sion; TB symptoms and signs; methods Both the cases and controls primarily of TB prevention; TB treatment; TB sought health care in government health vaccination; people at risk for TB; and facilities. Very few of either TB cases or cost of TB treatment and diagnosis. For controls sought health care either from analysis, awareness for all TB cases and traditional healers or in the private seccontrols was categorized into 4 levels tor. The TB cases had significantly more based on the Likert-scale responses (9 often attended health-care facilities in points): very poor (< 2 points), poor the past year than the controls (P < (2–4 points), good (5–7 points) and 0.05) (Table 1), although only 18% very good awareness (8–9 points). of them attended health facilities due Cronbach alpha was calculated for the to their TB disease (data not shown). TB awareness scale showing the reli- A quarter of the TB cases and 13% of ability of 0.73 for the 20 items included controls had a family member who had TB, less than 20% of both TB cases and in the scale. The analysis of the quantitative data controls had neighbour who had TB was done using SPSS, version 19.0. To and about 10% of both TB cases and calculate the frequency values descrip- controls had a friend who had TB. tive statistics was used, and percentages TB awareness were used to express the values for qualitative variables. The chi-squared test Almost everyone (98%) (both TB was used to compare between groups cases and the controls) had heard about for the qualitative data. P-values < 0.05 TB. On the other hand, the groups difwere considered statistically significant. fered significantly in the source of their Logistic regression was conducted to TB knowledge; 54% of the controls predict multivariate relation of soci- mentioned the media more often and 33% of the cases mentioned the family odemographic characteristics and TB slightly more often. As regards source of awareness. information, 34% of both the cases and controls knew about TB from healthcare workers. Results Only about 30% of both the cases Sociodemographic and controls stated that they had enough characteristics of TB cases and information about TB (Table 2). The controls cases and controls were similar in the The proportion of men was slightly extent to which they understood the TB higher among the TB cases than among information that they had received. TB the controls. Marital status distribu- was viewed as a common disease in Sution was similar as half of the cases and dan by almost half of the TB cases and half of the controls were married and the controls. TB was agreed to be very one-third of them were single. There serious by around one-third of both the was a statistically significant difference TB cases and controls. The cases more in the level of education between the often than controls answered that they groups (Table 1); 35% of the cases had did not know how common TB was no school education and 21% had high or how serious it was. Most of the TB education level whereas the respective cases and the controls knew some of TB percentages among the controls were symptoms while one-third of both cases 18% and 54%. Significantly more cases and controls knew all TB symptoms. lived in the rural area than did the conAround 70% of both TB cases and trols. Furthermore, significantly fewer the controls knew the methods of TB 122
transmission (Table 2). The methods of TB prevention were known by about two-thirds of both TB cases and controls. Around 80% of both TB cases and controls mentioned that anyone can get TB while 10% of both thought that TB was a disease only of poor people. Nearly 90% of both TB cases and controls considered TB as a treatable disease and most knew that TB was treated by specific drugs given by government health facilities (Table 2). TB treatment and diagnosis was known to be free of charge by about 90% of TB cases and 80% of controls; a quarter of both TB cases and the controls stated that TB treatment was for 6 months while the others gave answers ranging from 1 month to lifelong. Some of the TB cases and the controls considered the duration of TB treatment as long or short without knowing exactly the period. Regarding TB vaccination, only one-third of TB cases and half of controls knew about the availability of vaccination against TB. More than two-thirds of those who knew about TB vaccination thought that the vaccine would prevent TB occurring. Two-thirds of both TB cases and the controls had good awareness of TB, while around 21.9 of TB cases and 16.7% of controls had very good awareness while around 1% of both groups had very poor awareness (Table 3). There was no significant difference between TB cases and controls in their overall level of their awareness about TB. Univariate and multivariate analyses
In the univariate analysis of the relationship of sociodemographic characteristics to TB awareness separately among cases and controls it was found that a respondent’s sex was a factor among the controls but not among the TB cases, with men having better awareness than women (Table 4). Younger age, higher
املجلد العرشين العدد الثاين
املجلة الصحية لرشق املتوسط
Table 1 Sociodemographic characteristics of tuberculosis (TB) cases (n = 425) and controls (n = 850) in Gezira State, Sudan Variable No. Age group (years) < 30 31–50 > 50 Sex Male Female Marital status Married Single Divorced or widowed Education level No school Middle level of education High level of education Type of residency Town Village Other Occupation Non-worker Employee Labourer Self-employed Other Distance from nearest health facility (km) <5 5–10 > 10 Not near facility No. of times seeking health care last year 0 1–3 4–7 >7 Type of health facilities for seeking health care Government Non-government Other 327 12 7 79 258 83 6 (n = 346) 94.5 3.5 2.0 449 15 6 18.8 61.3 19.7 0.2 381 430 37 2 (n = 470) 95.5 3.2 1.3 < 0.001 44.8 50.6 4.4 0.2 < 0.001 244 79 31 71 57.4 18.6 7.3 16.7 547 149 58 96 62.0 17.9 6.8 11.3 0.032 199 21 98 91 16 46.8 4.9 23.1 21.4 3.8 364 143 157 162 24 42.8 16.8 18.5 19.1 2.8 < 0.001 151 242 32 35.5 56.9 7.5 392 429 29 46.1 50.5 3.4 < 0.001 148 155 122 34.8 36.5 21.1 152 242 455 17.9 28.5 53.6 < 0.001 235 148 42 55.3 34.8 9.9 442 292 116 53.1 34.5 12.4 0.15 262 163 61.6 38.4 480 370 58.2 41.8 0.04 158 194 73 37.2 45.6 17.2 329 390 131 38.7 45.9 15.4 0.69 TB cases % No. Controls % P-value
level of education, living in town settings and being an employer or employee were significantly associated with higher level of TB awareness among both the TB cases and controls, while marital
status had no effect on the level of TB awareness among TB cases or controls (Table 4). In the multinomial logistic regression analysis, to avoid unexpected
singularity, the very poor and poor categories of awareness were merged (only 13 participants had very poor TB awareness). The crude odds ratios for the sociodemographic characteristics 123
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Table 2 Tuberculosis (TB) knowledge among TB cases (n = 425) and controls (n = 850) Item No. Know TB a common disease in Sudan Yes No Don’t know How serious a disease is TB Very serious Somewhat serious Not very serious Don’t know How serious is the problem of TB in Sudan Very serious Somewhat serious Not very serious Don’t know Know types of TB Yes No Know signs and symptoms of TB All Some None Have enough information about TB Yes No Don’t know Information about TB was understandable Yes, fully Yes, partially No Reasons for not understanding TB information Difficult Too much Incomplete Other Know methods of TB transmission All Some None Know methods of TB prevention All Some None Know people at risk All Some None 331 39 55 77.9 9.2 13.9 105 116 74.0 12.4 13.6 0.02 285 129 6 67.1 30.4 2.5 576 264 10 67.8 31.1 1.1 0.36 301 100 24 70.8 23.5 5.7 609 201 40 71.5 23.6 4.9 0.75 46 38 63 119 85 84 266 20.0 19.8 41.1 (n = 266) 17.3 14.3 23.7 44.7 70 100 189 25 144 322 384 18.0 37.9 45.2 (n = 730) 18.2 26.0 49.2 0.6 0.04 < 0.001 124 193 108 29.2 45.4 25.4 251 431 168 29.2 50.7 19.8 0.55 119 279 27 29.5 65.5 5.0 284 500 66 33.4 58.8 8.6 0.50 15 410 3.5 96.5 32 818 3.8 96.2 0.43 128 147 59 91 30.1 34.6 13.9 21.4 220 303 178 149 25.9 35.6 20.9 17.6 < 0.001 134 170 50 71 31.5 40.0 11.8 16.7 251 351 167 81 29.5 41.3 19.6 9.5 < 0.001 201 120 104 47.3 28.2 24.5 406 308 136 47.8 36.2 16.0 0.47 TB cases % No. Controls % P-value
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املجلة الصحية لرشق املتوسط
Table 2 Tuberculosis (TB) knowledge among TB cases (n = 425) and controls (n = 850) (concluded) Item No. Know TB curable Yes No Don’t know Know methods of TB treatment Yes No Know places where to find TB treatment Yes No Know vaccination against TB available Yes No Don’t know Know TB vaccination protective Yes No Don’t know Know cost of TB diagnosis in Sudan Yes No Know cost of TB treatment in Sudan Yes No 367 58 86.4 13.6 616 234 72.5 27.5 < 0.001 373 52 87.6 12.4 612 238 72.0 28.0 < 0.001 110 25 0 81.5 18.5 0.0 360 34 10 88.2 8.3 3.5 < 0.001 135 49 241 31.8 11.5 56.7 408 66 376 48.0 7.8 44.2 < 0.001 389 36 91.5 8.5 774 76 91.1 8.9 0.49 352 73 82.8 17.1 703 147 82.7 17.3 0.63 372 13 40 87.5 3.1 9.4 719 32 99 84.6 3.8 11.6 0.37 TB cases % No. Controls % P-value
associated with TB awareness showed that high education level and being married were associated with very good awareness among the TB cases. Younger age, living in town settings, high education level and being an employer were associated with very good awareness among the controls (Table 5). High education level, being married
and being an employer were associated with good awareness among the TB cases, while among controls high education was associated with good awareness. Respondents’ sex had no effect on the level of awareness among either the TB cases or controls. Marital status had no effect on the awareness among the controls.
Discussion Awareness is a very important parameter to be assessed in order to provide baseline data to assist decision-makers to plan and deliver of an effective TB control programme. The present study revealed some important aspects of TB awareness among the Sudanese population. In this study in Gezira State there was no significant difference between TB cases and controls in their overall levels of TB awareness. About twothirds of TB cases and controls had good TB awareness. Sex had an effect on awareness among the controls but not among the TB cases. Age, level of education, type of residence and type of occupation were significantly associated with the level of TB awareness, 125
Table 3 Level of tuberculosis (TB) awareness among TB patients (n = 425) and controls (n = 850) Level of TB awareness Very poor Poor Good Very good Total TB cases No. 5 48 279 93 425 % 1.2 11.3 65.6 21.9 100.0 Controls No. 8 124 576 142 850 % 0.9 14.6 67.8 16.7 100.0 0.81 P-value
126 Level of awareness TB cases Poor No. 15 25 8 26 22 26 21 1 15 26 7 22 21 5 10 15 15 8 71 136 64 17 46 28 8 2 < 0.001 12 13 166 55 < 0.001 101 25 23 3 4 7 1 0 3 2 3 0 175 39 < 0.001 4 81 51 0 26 15 0 17 7 82 35 73 49 2 38 27 46 13 94 31 0.17 2 41 159 47 6 66 104 36 0.57 2 70 237 304 198 74 105 335 136 264 294 18 91 115 240 130 175 57 6 54 339 38 27 1 9 95 130 35 0.02 2 69 266 53 26 81 61 66 51 25 40 81 21 48 85 9 11 13 75 43 < 0.001 < 0.001 < 0.001 0.53 111 31 5 46 215 63 0.02 No. No. No. No. No. No. Good Very P-value Very poor Poor Good Very Controls P-value 1 4 0 4 1 3 2 0 1 4 0 3 0 2 1 2 2 0 0.01
Table 4 Univariate analysis of the relation of sociodemographic characteristics and tuberculosis (TB) awareness among TB cases (n = 425) and controls (n = 850)
Variable
Very poor
No.
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Age (years)
< 30
31–50
> 50
Sex
Male
Female
Marital status
Married
Single
Divorced or widowed
Education level
No school
Middle level of education
High level of education
Type of residence
Town
Village
Other
Occupation
Non-worker
Employee
Labourer
Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale
Employer
املجلد العرشين العدد الثاين
املجلة الصحية لرشق املتوسط
Table 5 Multivariate logistic regression analysis of level of tuberculosis (TB) awareness in relation to sociodemographic characteristics among TB cases (n = 425) and controls (n = 850) Level of TB awareness/ variable OR Poor awareness Age (years) < 30 31–50 Sex Male Marital status Married Single Education level No school Middle Residence Town Village Occupation Non-worker Employee Labourer Good awarenessa Age (years) < 30 31–50 Sex Male Marital status Married Single Education level No school Middle Residence Town Village Occupation Non-worker Employee Labourer a
TB cases 95% CI P-value OR
Controls 95% CI P-value
a
0.17 0.81 0.88 0.21 0.30 6.16 2.89 0.82 0.27 0.38 0.17 0.81
0.03–1.08 0.27–2.34 0.31–2.68 0.05–0.82 0.06–1.64 1.43–25.8 0.60–14.0 0.22–3.18 0.07–0.99 0.04–5.08 0.03–0.74 0.27–1.70
0.06 0.70 0.81 0.03 0.17 0.02 0.19 0.77 0.05 0.43 0.06 0.70
2.76 1.47 1.46 0.62 0.75 3.63 2.12 0.21 0.43 0.42 0.35 1.01
1.02–7.45 0.60–3.57 0.79–2.73 0.29–1.34 0.31–1.79 1.53–8.64 1.02–4.41 0.06–0.72 0.13–1.47 0.14–1.28 0.14–0.88 0.45–2.24
0.05 0.40 0.23 0.22 0.51 0.00 0.04 0.01 0.18 0.13 0.03 0.98
1.47 1.00 1.09
0.62–3.47 0.47–2.10 0.62–1.93
0.38 1.00 0.77
1.13 0.97 1.38
0.61–2.09 0.56–1.69 0.96–1.99
0.71 0.93 0.08
0.33 0.25 1.10 2.09 2.35 2.05 0.33 0.66 0.93
0.11–1.03 0.07–0.86 0.56–2.15 1.10–3.99 0.90–6.09 0.82–5.11 0.11–0.98 0.33–1.32 0.45–1.89
0.06 0.03 0.78 0.03 0.08 0.12 0.05 0.24 0.83
1.42 1.38 1.14 1.63 0.66 1.39 0.57 0.60 0.86
0.85–2.37 0.77–2.47 0.64–2.03 1.05–2.51 0.22–1.92 0.47–4.10 0.32–1.01 0.35–1.03 0.51–1.45
0.18 0.28 0.65 0.03 0.44 0.55 0.05 0.07 0.58
Reference category = very good awareness. Reference categories: age = > 50 years; sex = female; marital status = divorced/widowed; educational level = high school; residence = camp; occupation = employer. OR = odds ratio; CI = confidence interval.
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while marital status had no effect. Males, highly educated persons, those being either employers or employees had very good awareness and so did those living in towns. On assessing the degree of TB awareness, the majority of both TB cases and controls had good awareness. This was similar to the situation in Khartoum State [Osman A, unpublished report to Ministry of Health Khartoum, 2006]. The general good level of awareness among respondents can probably be explained by the high prevalence of TB in Sudan, which means that people have more experience of the disease or may seek out knowledge about the different aspects of the disease in order to avoid it. Another explanation might be an active TB control programme in Sudan, which uses the effective directly observed treatment, shortcourse (DOTS) for TB treatment. This might improve TB patients’ and their relatives’ knowledge about the disease through the regular educational and/or counselling sessions. Other methods might have a similar effect such as the World TB Day celebrations in Sudan and public education/health promotion messages. A diagnosis of TB may motivate cases to search for more information. Despite the good level of awareness, only one-third of both cases and controls reported having enough information about TB, indicating that there is a perceived need for more information. In this study respondents’ sex had a significant role in TB-related awareness among the controls but not among the TB cases. This could be because male and female TB cases had a similar level of education, as was found in Khartoum State [Osman A, unpublished report to Ministry of Health Khartoum, 2006]. This finding is similar to the findings reported in the literature, e.g. from China, where women were less likely than men to get information about TB and share it with others on their own initiative [14]. 128
Educational level affected the level of TB awareness among TB cases and the controls; the level of TB awareness increased when the educational level increased. Persons who had high secondary school or higher educational level were more likely to have very good awareness among both TB cases and controls. This was similar to what was found in Khartoum State [15] and in Libya, where the TB knowledge scores were directly proportional to level of education [16]. The controls in our study were more highly educated than TB cases and the media was their main source of their TB information whereas TB cases more often had their information from health-care workers, i.e. TB patients’ awareness came as a result of having the disease. We found that people who lived in towns among controls were more likely to have very good TB awareness than people who lived in rural areas. This can be explained by better accessibility to different sources of TB information, such the media, in town settings than in the rural areas. However, among the TB cases the area of residence did not have an effect on their TB awareness. These findings are similar to what was found in Pakistan, where healthseeking behaviour was better in the urban areas [17], and also to what was found in Ethiopia, where lack of TB knowledge was more evident among the rural population [18]. In this study, among the controls, being an employer or employee was related to very good awareness about TB compared with non-workers; however, among the cases occupational status did not make a difference in TB awareness. This result is in line with what was found in Khartoum State [Osman A, unpublished report to Ministry of Health Khartoum, 2006] as well as in West Africa [6]. The population’s level of the TB awareness is known to have a positive impact on prevention of TB [6]. Having more knowledge about methods
of TB transmission and about ways of preventing the disease helps in decreasing the TB risk [19]. However, this study found no significant difference in TB awareness among TB cases and controls in Gezira State. This similarity in the TB awareness can be justified by the fact that the TB cases probably acquired this knowledge after they were diagnosed with TB and received health education and/or counselling as a part of TB management using DOTS. The role of health education in raising knowledge about TB is highly appreciated in initiatives to fight TB [20]. This overall good level of TB awareness found among TB cases and the controls can function as a baseline for further TB awareness-raising among the Gezira population. Nevertheless there were important areas of knowledge missing, such as mode of TB transmission, especially among TB cases, TB prevention methods and types of TB, all of which are vital issues in TB knowledge. Health education and health promotion as continuous processes can maintain and further elevate the level of awareness [7] and thus also motivate patients both to seek treatment and to adhere to it. The strengths of the study were that it addressed patient-related factors influencing TB prevention and control strategies. It included a large proportion of participants (425 TB cases and 850 controls) and the data were collected by trained health-care workers. On the other hand, the study limitations were potential social desirability bias in answering the interview questions, and a possible bias by the health professionals collecting the data, who might have helped interviewees to answer the questionnaire. The study did not address health-care workers’ knowledge, attitudes and practices regarding TB and its treatment. Furthermore, the study was conducted only in Gezira State and the findings therefore may not be generalizeable to other Sudanese States.
املجلد العرشين العدد الثاين
املجلة الصحية لرشق املتوسط
Conclusion This study showed that TB cases and the controls in Gezira State, Sudan, had a good level of awareness about the disease. Male sex was associated with better awareness among the controls but not among the TB cases. Younger
age, higher level of education, living in town settings and being an employee or employer were significantly associated with better a level of TB awareness among both TB cases and controls, while marital status had no effect. This awareness needs to be maintained to facilitate future prevention and control
of the disease. Media and health-care workers were the most important sources of TB information; their health education resources and role need to be strengthened. There is a need to increase awareness among those with lower educational level and socioeconomic status and those living in rural areas.
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