Predictors of Knowledge about Tuberculosis: Results from SANHANES I, a National, Cross-Sectional Household Survey in South Africa

"To reduce the burden of tuberculosis in South Africa, media campaigns targeting both rural and urban communities should include conveying accurate information about the disease. Policy makers should also address structural barriers that vulnerable communities face."

Noting that an understanding of the social and psychological factors associated with tuberculosis (TB) onset can help health practitioners design behaviour change interventions for disease prevention, treatment adherence, and access to health care services, this study sought to address the gap between biomedical and social research by investigating the level of knowledge of TB at a population level among people aged 18-64 in South Africa (SA). The study was based on the data obtained from the South African National Health and Nutrition Examination Survey (SANHANES I), which included a module that ascertained the knowledge, attitudes, beliefs, and practice (KABP) related to TB.

The researchers note that SA ranks as the sixth highest in generating new cases of TB in the world and is among the 22 high TB-burden countries that contribute about 80% of the global cases of TB. Among the factors that make it difficult for people to effectively use TB prevention information is that TB literature is mostly presented from biomedical perspectives. Yet knowledge and awareness of the infectiousness of TB as a disease is the basis for individuals taking protective measures to avoid becoming infected or transmitting it to others for those with active disease.

Of the 5,945 participants aged between 18 and 64 years who completed the interviews and answered questions relating to TB and socio-economic status:

• When respondents were asked through what methods they had initially learned about TB (multiple responses were permissible), the most commonly reported responses were via radio (49.2%), television (45.8%), and through health workers (38.2%). Almost a quarter (23.9%) of respondents first learned about TB from teachers, 23.2% in newspapers and magazines, 17.7% from friends, family, colleagues, or neighbours, and 8.9 % from brochures. A tenth (10.6 %) of the respondents reported other sources of information, which included information from billboards, religious leaders, at work, in prison, and knowing someone who was diagnosed with TB. A further 0.7% reported not knowing about or having never heard of TB.
• 21.5% correctly identified any 3 of the 6 key symptoms of TB from the World Health Organization (WHO) standard list of TB symptoms. Knowledge of symptoms was significantly higher among those who initially learnt about TB from newspapers and magazines (28.9%) than those who did not (19.2%). In addition, for the following channels of information, knowledge of symptoms was significantly higher among those who were exposed to TB information from these sources compared to those who were not: radio (27.2% vs 15.9%), TV (27.7% vs 16.2%), brochures (37.3% vs 19.9%), and health workers (28.8% vs 17.0%).
• 63.0% correctly identified the primary transmission route of TB, i.e. through the air when a person sneezes or coughs, without any misconceptions.
• 79.0% correctly identified the main TB prevention method (covering the mouth when coughing or sneezing). Knowledge of prevention was significantly higher among those who were first exposed to TB information from these channels/sources compared to those who were not: radio (83.6% vs 74.7%), television (86.1% vs 73.0%), brochures (90.5% vs 77.9%), and health workers (83.7% vs 76.1%). In contrast, respondents who were exposed to TB information from family, friends, neighbours, and colleagues had lower levels of correct knowledge of prevention that those who did not report learning about TB from these people (71.6% vs 80.6%).
• A large proportion (83.9%) displayed correct knowledge that TB is curable and knew about the correct treatment without any misconceptions - i.e., that TB can be cured by specific drugs given by a health centre or by the Directly Observed Treatment Short-Course (DOTS). Knowledge of curability and treatment was significantly higher among those who were initially exposed to TB information from health workers (88.7% vs 80.9%) compared to those who did not receive information from health workers.
• 83.1% correctly responded that TB patients should be tested for HIV.
• Over three-quarters of participants correctly responded that people with HIV are more likely to develop TB. Significantly more adults who had initially learnt about TB from teachers (85.1%) knew that people with HIV are more likely to develop TB than those who did not learn about TB from teachers (73.3%).
• Respondents were asked to select 3 sources of information they thought can most effectively reach people like themselves with information on TB, and were asked to choose the 3 most effective sources in their opinion. Radio (69.0%) and television (64.8%) were regarded as the most effective sources of information, followed by health workers (43.3%) and newspapers and magazines (39.2%). Other sources that respondents chose were social media, campaigns, workshops, and community programmes.

The researchers conclude that, overall, there was a relatively good level of TB knowledge in this study especially with respect to TB prevention, cure, and TB and HIV co-existence. However, the low level of knowledge of TB symptoms is of concern due to the fact that TB is an easily transmittable disease, and a lack of knowledge of the symptoms is likely to result in delayed health seeking (which in turn can result in on-going TB transmission and poorer health outcomes when individuals eventually access treatment).

In the final analysis, the factors that were the strongest predictors of higher levels of TB knowledge were race (mixed race vs black African), gender (being male), education (completion of high school), being employed, having been diagnosed with TB in a lifetime, and learning about TB through the media (TV) and public service staff (namely, health workers and teachers). The fact that being of mixed race compared to being black African is a predictor of higher levels of TB knowledge is perhaps due to the fact that individuals of mixed race have been historically affected by TB and continue to have high prevalence rates of the disease in the country. The results of the study also highlight the fact that better socio-economic status are associated with better TB knowledge. "In a country, such as SA, that has a high index of inequality...a more concerted effort has to be made to provide educational and employment opportunities to underserved communities."

According to the researchers, given the fact that HIV counselling and testing (HCT) in SA now includes education about TB co-morbidity, and the fact that there has recently been an increase in media coverage about TB, media programmes have the potential to disseminate accurate information about the disease (e.g., symptoms and treatment) as well as promote treatment-seeking behaviour and adherence to treatment. They cite studies from Pakistan and Bangladesh that explore the role of broadcast media on TB and their influence on health-seeking practices. "These results can be used to inform the media, as an agent of change, about their role in reducing TB disease burden in SA."