The study examined the clinical profile of five hundred TB patients admitted to the Rajan Babu TB Hospital, Delhi and determined the clinical and socio-economic factors important in hospitalization, default and failure of therapy. An attempt was also made to judge the health awareness in these patients and from that the success or failure of the health education programme. It was found that the percentage of cases who had relapsed or who were drug failures was quite high in hospitalized patients. Socio-economic factors were solely or partially responsible for the patients seeking admission in almost 20% of the cases. These factors as well as lack of education and proper motivation were responsible for drug default and subsequent failure in a large number of cases. Health awareness was quite low even in patients who had stayed in the hospital for a prolonged period pointing towards a failure of health education.

Selected data from the Philippines TB Survey (1981-1983) are presented to study the relationship between epidemiological and social aspects of TB, specifically, awareness of certain symptoms and prevalence of TB. Qualified sociological interrogators were drilled for several weeks prior to the survey in setting interview situations, non-suggestive questioning followed by a few leading questions, anatomy of the questionnaire and the standard way of handling it, testing for consistency both prior to use and during the survey. Individuals 20 years and above were asked if they had any suggestive symptoms, namely, cough, fever, chest and/ or back pain, or haemoptysis during 4 weeks prior to an interview. Of 9,090 such persons interviewed, 2,515 (28%) had one or more of the stated symptoms. Of those with symptoms, 3.6% had positive smear results compared with 0.5% among the asymptomatics. For culture positivity, the corresponding proportions were 4.2% and 0.9% and, for radiographic TB, 11.4% and 4.1% respectively. These differences were highly significant and applicable to all age groups. There appears to be a fairly close relationship between the epidemiological parameters and suffering awareness of symptoms produced by TB. This conclusion was supported by the finding that, when both symptomatics and asymptomatics were equally pressed to attend for the investigations, the presence of symptoms appeared to have increased the suspects' likelihood to attend for the investigations (P<0.0001).

Further, the data suggested that eliciting suggestive symptoms in a manner to reflect suffering awareness had a reasonably high degree of sensitivity and specificity; the highest level of sensitivity (74%) was reached with respect to smear-positive cases. Thus, using the symptom suffering as a useful sociological parameter is feasible. Concerning action-taking, on analysis, the pattern varied with age, gender, urban/rural habitat, nature and duration of symptoms, whether a symptom occurred alone or in combination, etiology of the symptom and social perception of what needs to be done for a particular kind of symptom and how an individual/ family should proceed if an action taken was unsuccessful. Nevertheless, the choice of action was related to the TB/ non-specific etiology of symptoms. Based on these findings, there appears to be a good case to develop an objective measurement of cough, of a selected duration and action taking as a sociological parameter of suffering to go along with the epidemiological measurement of TB in a community.

A study was undertaken to explore the knowledge, attitudes and perception of TB and their influence on the adherence to preventive therapy for TB. During 1997, 24 subjects were interviewed by using a semistructured questionnaire which included demographic details, background information on TB, knowledge and perception of TB and chemoprophylaxis. The persons were interviewed in the outpatient clinic in London at the start of the treatment and at monthly intervals thereafter. They were given INH daily for 6 months. The data was analysed descriptively and thematically. The outcome was assessed ? 6 months after the start of preventive treatment.

The sample was representative of age, ethnicity and previous BCG vaccination status. The study results revealed that 63% were aware of TB before starting chemoprophylaxis indicating a medium level of awareness. None mentioned health centre as the source of information. Knowledge of TB was gained outside the family. About 63% of them knew about transmission of the disease but few symptoms of active TB were recognized. Most (92%) were aware that TB was infectious. The perceived threat from TB was high (71% believed that TB was potentially fatal), although the estimated risk was low. Over half of the subjects (66.6%) suggested that TB was preventable. Knowledge of preventive therapy exceeded the general knowledge of TB, although the latter was associated with better adherence. Most denied knowledge of the risk of hepatitis from isoniazid. Defaulters failed to attend their first appointment, attributed more side effects to isoniazid and perceived a longer waiting time in clinic. The rate of non-attendance for appointment at the TB clinic was high.

The study has shown that there is an important lack of knowledge of the symptoms of TB. A better general knowledge of TB is more helpful than merely an understanding of the treatment regimen in promoting adherence. It recommends a single daily tablet, prior warning of dizziness and an open discussion of the problems of keeping to treatment for 6 months encouraging adherence to preventive treatment.

It was hypothesised that cognitive and affective reactions towards TB were based on perceived prevalence, perceived seriousness and perceived social stigma. The objectives of the study were to ascertain the underlying dimensions that were used when people reacted cognitively and emotionally to TB, and to determine possible restricting social influence factors on voluntary presentation and case holding. Therefore, a questionnaire was designed to obtain information on background details, perceptions of TB (transmission, prevention, diagnosis and treatment), and a 19-item cognitive affective scale. 19 trained interviewers administered the questionnaire. Interviews were conducted with 487 black adults (67 TB patients on ambulatory therapy and 420 non-TB community members), from two urban townships in the Transvaal, South Africa.

The results indicated that the majority of respondents were aware of the infectious nature of TB, that it could be cured and the length of treatment. The most problematic issues were isolation for TB sufferers and the harm TB sufferers did to others. Cognitive/affective reactions were similar for TB patients and community members. Ten items out of the 19-item cognitive affective scale had communality estimates equal to or greater than 0.30. Three factors were extracted. The first factor seemed to combine personal threat (high personal and family risk) with social rejection by the immediate family and community for TB sufferers. Factor 2 had strong overtones of social stigma, with its emphasis on dirt, poverty and poor nutrition. Factor 3 rejected alcohol and tobacco consumption as causal agents of TB.

The conclusions were that the predominant cognitive/affective reactions towards TB were personal threat, social rejection and social stigma, providing partial support for the hypothesis. The powerful force of social rejection and social stigma cannot be underestimated. These inhibiting factors require urgent attention to improve voluntary presentation and compliance behaviour.

The setting is a voluntary health worker programme, in the Western Cape South Africa, utilizing volunteers to administer directly observed therapy to TB patients. This study describes the perceptions of health team members regarding the voluntary community health worker project. A qualitative, participatory research study utilizing focus groups.

TB was perceived by the health team to be a stigmatized disease causing some patients to be reluctant to be associated with the TB control programme. Despite the project’s dedicated approach to case-holding volunteers expressed the need to develop skills in providing more comprehensive care. The volunteers appear to administer a more personalized service to TB patients and can bridge the gap between TB patients and the health agency. Sustained evaluation and support seem to be a vital tool in integrating a volunteer project into a health team approach. Its effectiveness appears to depend to a large degree on the people involved.

This study was undertaken in 34 villages and 4 town blocks where a few weeks earlier an epidemiological survey was carried out. All persons above 20 years whose photofluorograms were read as inactive, probably active, or active by at least one reader, were age-sex matched with an equal number of X-ray normals, to form the experimental and control groups respectively. Thus, a total of 2,106 were eligible for social investigation. Interview sheets, with particulars of the name and location of village, household number and individual number and the identifiable data of the interviewees were made available to the Social Investigators at random for contacting and interviewing them at their homes. The interviews were non-suggestive in nature and deep-probing on the details of symptoms experienced by the respondent, which were fully recorded. About 79% of the experimental group and 83% of the control group were satisfactorily interviewed, which constituted the data further analysed. Of the numerous symptoms recorded, only that were associated with pulmonary TB were considered, of which cough occurring for one month or more, fever for a month or more, pain in the chest, haemoptysis and all combination of these four symptoms were analysed statistically.

Cough was found to be the most important single symptom. It was not only the most frequent symptom alone or in combination in the experimental group but was less frequent in the control group that 69% of sputum positive and 46% of radiological positive had cough while only 9% of the control group had it. Considerably fewer people had fever and pain in the chest. Pain in the chest appears to be non-specific, giving a ratio of only 2:1 among the experimental and control groups, while fever was in the ratio of 6:1 and haemoptysis was 11:1. It was seen that 69% of the sputum positive cases, 52% of the X-ray active or probably active, 29% of the inactive and 15% of the normals (control group) had at least one of the above mentioned symptoms. In all the groups, the proportion of symptoms was higher among males than among females. In both males and females the prevalence of symptoms was higher in the middle age groups than among the younger or older groups. This age variation was more marked in the females. The findings of the study were analysed further along with the data obtained from a couple of minor investigations conducted in the rest of the 28 villages which formed the total of the villages surveyed epidemiologically. This brought out further that 95% of bacteriologically positive cases are aware of symptoms, 72% experience 'worry awareness' and 52% form the action-taking group. The above findings have been of considerable importance in planning further studies and in formulating the NTP.

KEYWORDS: SOCIAL AWARENESS; INDIA.

The study, made by means of questionnaires in 1964-66, dealt with the problem of acceptance of methods of prevention and treatment of TB by various social groups of population.

Awareness of symptoms of pulmonary TB and promptness of action taken to seek the treatment by the sufferers in an urban area, Madras, was studied. A total of 796 patients were administered questionnaires, out of whom, 600 were men and 196 were women. The mean age for men and women were 37 years and 32 years respectively. The proportion of patients drawn from all the 3 selected areas who took action within a month was 40 percent, within 3 months 65 percent and within 6 months 84 percent. The proximity of the medical facility in the city enabled a sizable proportion (53%) to take action within a month. Among symptomatics reporting within a month, the bacillary cases were proportionately low which tended to increase as time elapsed. Regarding the psychological impact of the disease on the patients, there was a sense of optimism in a large proportion of patients due to a very favourable response to good treatment. Varied attitudes of the relatives towards the patients, consistent with Indian stereotypes were elicited.

A study on awareness of symptoms of pulmonary TB and action taking was repeated in the 62 villages and 4 town blocks of Tumkur district of Karnataka after an interval of 12 years. In the earlier study, 2106 persons formed the study population. In the present study, 1752 were intaken to obtain a comparison of these 1752 intaken persons who were eligible for interview, 875 were X-ray positive and 877 X-ray normal (matched control).

The study showed that 95% of patients having radiologically active TB by both X-ray readers, 70% by one reader, 49.5% inactive by both readers, were aware of symptoms. According to the bacteriological status 79.5% had symptoms among those who were sputum positive by both microscopy and culture, 62.2% among those positive by culture alone and 73.7% among patients sputum positive by any method. Regarding action taking it was observed that 49.5% of the bacteriologically positive patients took some action compared by 70% of those found to have radiologically active disease by both X-ray readers. Thus, action taking was higher among the latter category in both the studies. It may be due to the fact that extent of lesions are less advanced among those bacteriologically positive than among those who were in radiologically positive stage.

The findings of the study are similar to the earlier awareness study carried out in 1963 in the same area (Tumkur). This also indicates that in spite of having advantage of DTP for a decade actual and total benefits have not reached the people.

Illness is mostly a subjective awareness of an individual, the relief of which may be sought within or outside medical or health facilities. Perception of illness vary from people to people depending upon cultural, ethnic and socio-economic differences. Perception of symptoms by persons suffering from TB is very high yet only half of them approach modern medical facility for alleviation of their suffering. A survey was carried out in rural area of Hoskote taluk, Bangalore district to determine perceived morbidity and accessible medical relief in 1433 households belonging to 18 villages; of them, 1393 (97%) were successfully interviewed. Selected households belonged to three types of villages i.e., those being within 3 kms of a i) PHC, ii) taluk headquarters hospital and iii) non governmental health centre.

Of the 9286 individuals belonging to 1393 households satisfactorily interviewed regarding health, 1201 (12.9%) were found to be ill at some point of time during the reference period of one month. No differences were observed in the perception of morbidity or in the health seeking behaviour in the three groups of villages. Persons with symptoms/disease accounted for 88.8% of the total sickness, 3.4% for injuries and 9.3% for disabilities, while action taking was 61.6%, 90% and 13.5% respectively. Age sex distribution showed no difference in illness occurrence. Sputum was collected from 147 chest symptomatics and seven were found to be sputum positive. Government health facilities were utilized by 37.6% of the sick persons, private doctors by 36.4%, nature medicine by 10.6% and home remedies by only 9.9%. In conclusion, the services at the government health facilities were acceptable and were utilized if accessible. Prompt and adequate relief for injuries and acute indispositions ensures confidence of the people and better utilization.

A survey was carried out in the population of Bisnupur Blocks I and II in the south 24 parganas district of West Bengal to find out the level of general knowledge and awareness about TB and also the prevalent social attitudes towards the disease. The target population was classified into two broad groups comprising persons living within and outside the research project area respectively. The results showed that the general knowledge of TB was high in both groups and about 24% of the new patients did not know the correct duration of treatment. The majority of people interviewed, favored hospitalization of the TB patients and the patients' belief that consuming anti-TB drugs without taking a high protein diet was futile contributed to default on drug collection. Women with TB denied breast-milk to their babies, making the babies vulnerable to different diseases including TB. Health education increased the awareness of TB while negative social attitudes for TB patients persisted because most people were not convinced of the curability of the disease.

The above findings led to the conclusion that community leaders should be actively involved in any TB control programme and that health education should be an important component of the TB programme.

Three sets of questions pertaining to general aspects, diagnosis and treatment and, preventive aspects of TB were introduced to the general population, in Jaipur, to assess the extent of their knowledge about TB. A total of 1,000 persons, consisting of 740 males and 260 females, were interrogated in this survey. 380 belonged to rural areas and the rest to urban areas; 860 persons were literates and 140, illiterates; 650 came from a low socio-economic group in comparison to 350 from a better economic status. Responses in all the three sets were separately categorised as correct when more than 50 percent of the answers were correct. Analysis of all the answers was correlated with socio-economic factors. Though the urban population had better knowledge about general and diagnostic aspects of TB, both populations were poorly acquainted with its preventive aspects. General knowledge about TB was poor in the illiterate, low socio-economic population and high in the literate, high socio-economic group.

The inquiry into people's awareness of TB has largely followed two schools of thought. The earlier conception about the awareness of TB was centered on the extent of people's knowledge about the disease and its characteristics, how the infection spread, when and where it typically occurred etc. However, several studies such as the one conducted by the NTI in rural Anantapur district in the late '50s and which led to the formulation of the DTP, demonstrated that, in contrast to the hypothesis, knowledge about the main features of TB was quite high. Other, more recent studies conducted in India and, studies from S. Korea and Japan, where socio-economic conditions are very different, obtained similar results.

The second, more recent approach to awareness focussed on physical suffering caused by the symptoms of TB. This approach was highlighted by the series of NTI studies beginning with their seminal 1963 study titled, "A sociological study of awareness of symptoms among persons with pulmonary TB". Based on the results, it was suggested that awareness of symptoms and action-taking, by way of contacting institutions of modern medicine, be used as parameters for measuring the problem of TB in the community, sociologically and for TB programme assessment. Further, it was emphasized that this approach must be pursued vigorously through action research as it appeared to show great promise in breaking down the barriers of traditional thinking, prejudices and unhelpful attitudes better and more quickly.

The TRC, Madras, undertook a sample survey in rural (18,395 persons), urban (17,409 persons) and metropolitan areas (37,290 persons) to identify the chest symptomatics as defined in the NTP. The symptomatics were interviewed by medical social workers to obtain information about the action taken for relief, the type of health facilities utilised and the reason for the choice. Questions were also asked to find out the symptomatics' knowledge about TB. Based on an analysis of the results, more than 80% of the symptomatics were aware, over 75% had taken action, although most had no idea about its causation. Yet, more than 90% had contacted health facilities of which one-half were governmental.

A questionnaire on source of information regarding TB, signs and symptoms, diagnostic methods, treatment duration and personal and community hygiene relating to TB, was administered to 446 students and employees with an educational status of high school certificate and above.

The main source of information were books and magazines and 86% were aware that the TB germ was the causative agent. Symptoms of TB such as cough (85%) and loss of weight (74%) were well known. Other symptoms such as chest pain (29%), fever (27%) were less known. Sputum examination as a diagnostic tool was known to 68% , while 80% knew about radiograph being used to diagnose the disease. Cough as a method of spread was known to 91%. In this questionnaire the duration of treatment was the least known fact. 28% felt that treatment could be stopped if symptoms disappeared. 16% were aware that the method of sputum disposal was by incineration. The implications are discussed.

Educational programs targeted toward individuals at risk for TB are needed. As an initial step in developing future programs, the present study was designed to determine the baseline knowledge about TB in at-risk individuals.

Face-to-face surveys were conducted with 505 minority subjects in the Kansas City Metropolitan area; health care providers were excluded. Thirty six queries directed toward self-perceived and actual TB knowledge were asked. Data was tabulated and per cent correct response was determined.

Completed surveys were available from 505 subjects: 342 females and 163 males. Most (97%) of the subjects were African Americans, with 57% between the ages of 21-40. Over two-thirds were high school graduates, and 77% reported an estimated total household annual income of <$20000. Self-perceived knowledge about TB was rated as 'little' or 'nothing' by 60% of respondents. The overall correct response score was 61%, with 55% correct response to queries related to etiology, 53% for identification of high-risk populations, 57% for possible routes of transmission, 89% for symptoms, and 49% for treatment. Males, those with annual incomes >$20000, and individuals 51-70 years old had the highest scores.

In this high-risk inner-city population surveyed, knowledge deficits in the etiology, transmission, and treatment of TB were identified.

Case finding under the NTP in India is a passive process limited to chest symptomatics in the community who attend government health institutions on their own for relief of symptoms. It is, therefore, essential that the community is aware of the basic facts about TB. This study was undertaken in 24 randomly selected villages of Sri Perumbudur (Tq), Chengai Anna (Dist) Tamil Nadu to assess the initial level of knowledge about TB and again after providing health education on TB to evaluate its effectiveness after 2 years. Every fifth household starting from randomly chosen location was visited by Medical Social Worker (MSW) and a total of 466 respondents were interviewed. The head of the household or in his or her absence any other responsible family member was interviewed to find out the initial level of knowledge of TB using a pre-tested semi-structured interview schedule. The community was then educated about the important aspects of TB by means of pamphlets, film shows, exhibitions, role plays and group discussions. After two years, in the same households, 433 (93%) respondents were interviewed using the same interview schedule.

Two-thirds of the respondents were females and half of them were in the age group of 25-45 years. As regards literacy status, 53% were illiterates. There was an overall increase of knowledge on various aspects of TB, ranging from 18-58%. In all, 45% respondents initially and 91% after health education answered correctly that both rich and poor are affected by TB, 38% initially were aware that both adults and children are affected by TB and afterwards 93% were aware of these facts. Prior to health education, 37% knew prevalence of TB is similar in urban and rural areas, this increased to 95% after health education. Regarding knowledge that investigation and treatment facilities are available free of cost at Govt. Health Institutions 67% to begin with and almost all 98% afterwards responded correctly. About the need of examining the close family members of TB patients, 67% were initially aware and after health education, it increased to 98%. Further 15% were aware of cough hygiene prior to health education, which increased to 48% subsequently.

As regards the source of information on TB, 70% mentioned verbal communication, i.e., through TB patients and others, as the major source followed by pamphlets (21%), mass media (14%) and others (15%).

It is necessary to consider the type of community and the available resources while planning health education strategies. For health education to be effective, and sustained, it should be a continuous process.

A socio-epidemiological study was undertaken by the NTI on out-patients attending the LWTDTC at Bangalore to understand the main reasons why people attended TB diagnosis and treatment centers so as to know why they default in treatment subsequently. During February-May 1966, a 50% random sample (comprising 2,653 persons of which 1% of the interviews were rejected) of the new out-patients attending the TB Center for diagnosis were interviewed by experienced social investigators before their X-ray examination. Eighty-three percent of the out-patients came from the city while only 17% came from the rural areas.

While a number of sociological characteristics such as profession, religion and literacy were found not to have any significant relationship with the patients' attendance, distance from patient's home to the city TB Center proved to be crucial. Further analysis of the data suggested that even in a city, a majority of the persons with symptoms first contacted, for treatment, the nearest health institution which typically happened to be a general health institution. This delayed early diagnosis or referral. Of those patients who subsequently attended the city TB Center, 37% had not received any treatment for TB from the general health institutions, 50% got non-specific treatment and only 13% got likely or definite TB treatment. Nineteen percent who did not have TB also got likely or definite TB treatment. It was clear that a very complex and multi-lateral relationship existed between the symptomatic patients, the institutions of general health and the established specialized services. Sociological or operational studies to examine this "complex" were suggested.

The study was carried out at LWTDTC, Bangalore to inquire into the epidemiological and sociological characteristics of patients attending a city TB clinic for the first time, to ascertain the reason for attendance and the nature of previous treatment if any. It was also to see whether there was a preference for seeking specialists and specialised services for alleviation of the symptoms experienced and whether there were any differences amongst the urban and rural attenders. A fifty percent random sample of 2,658 out-patients during 61 working days, formed the study population. They were interviewed by using a questionnaire based on the above mentioned objectives. 247 were not eligible due to incomplete record and below 5 years of age.

Majority of the out-patients were in 20-30 years of age and were wage earners. Nearly 80% were aware of their symptoms and contained 95% of the TB cases detected at the clinic. Most of them were having 2-3 symptoms. No difference in time of reporting was observed among urban or rural patients; 61% of the urban and 42% of the rural patients attended the clinic within 3 months from the onset of their symptoms. Distance is a major obstacle. Upon 4.8 km the number of new out-patients was large but the case yield was poor. As the distance increased the out-patients decreased but the case yield was more, suggesting a selective process influenced by distance. It was also found that 20% of the out- patients came of their own without any prior contact with any other source of treatment, 32% had previous contact with other health institutions, 31% were actually referred by them and 17% were advised by BCG workers. Further analysis showed that of the 1,642 patients who had previous contact with health institutions, 84% were at general health institutions, 10% at specialised TB clinics and 6% were others. Of the remaining eligible 2,403 patients, 83% were from urban and 17% from rural areas. Sputum was collected from 2,308 patients. Of them, 179 (7.8%) were found to be positive by direct microscopy or culture or both and 169 were positive by culture (91% confirmation by culture). 131 (80%) were sensitive to isoniazid and 32 were isoniazid resistant.

The data obtained suggests that attendance at a specialized TB centre is not necessarily a function of awareness of symptoms and of the knowledge that such specialised services exist. It also does not support the theory that people prefer specialized institutions in cities. It is also seen that urban and rural patients behave in almost the same way in that their first contact for symptoms suggestive of TB, is initially at the general medical services and they should be strengthened with adequate means for diagnosis and treatment of TB.

Patients hospitalized in Kentucky (USA) TB sanatoriums were interviewed to determine the degree of understanding of their disease and its implications in preparation for ambulant care. Eighty percent knew their diagnosis and 56 percent recognized TB as contagious. Although two-thirds could give at least a visual description of their medication, at least 50 percent demonstrated a deficiency in knowledge that was needed to be corrected before adequate compliance away from the hospital environment could be expected. Further, only 25% knew the criteria for discharge. Among the several patient factors analyzed to explain the difference in knowledge levels, only age was consistently significant. Positive effort was recommended to educate the patient for adequate ambulant or home treatment.

A long term follow up study of symptom recurrence and action taking of TB patients of urban clinics in metropolitan cities may be of limited value. But such follow up studies based on a PHC, which is an important rural diagnostic and treatment unit in the TB programmes will be of a great value, because the center is responsible for comprehensive preventive and curative services to the community through family and household units. It is, therefore, important to know whether a TB patient, diagnosed and put on treatment by the centre, experiences recurrence of the symptom, for which he has sought relief at the centre and if so whether he goes in search of relief elsewhere.

The setting is a voluntary health worker programme, in the Western Cape South Africa, utilizing volunteers to administer DOT to TB patients. This study describes the perceptions of health team members regarding the voluntary community health worker project. A qualitative, participatory research study utilizing focus groups. TB was perceived by the health team to be a stigmatized disease causing some patients to be reluctant to be associated with the TB control programme. Despite the project’s dedicated approach to case-holding volunteers expressed the need to develop skills in providing more comprehensive care. The volunteers appear to administer a more personalized service to TB patients and can bridge the gap between TB patients and the health agency. Sustained evaluation and support seem to be a vital tool in integrating a volunteer project into a health team approach. Its effectiveness appears to depend to a large degree on the people involved.