In India, TB appears to have been prevalent from the Vedic civilization, about 1000 B.C. The Indian medical treatises traceable to the period, contained directions for diagnosis based on symptoms, therapies based on herbs, metals, minerals and, the general management of daily life. In 1946, the country's needs were assessed by the Bhore Committee and subsequently by the Mudaliar Committee. At this time, the TB problem as a public health problem, was ignored. With independence, in the late forties, there was a realisation that large areas of the country were devoid of basic health services. The development plans of this period were extensive, appropriate and inter-related. As a result, the NTP and other health programmes were established. The NTP was formulated in 1961 by the NTI which was established for this purpose. The programme, based on a large number of studies, was to serve the community by providing diagnostic and treatment facilities throughout the country, through GHS. Currently, in the mid-seventies, due to several socio-political challenges faced by the country, the achievements of the NTP are far from expectations.

The article emphasises the importance of identifying human factors which result in the under-utilization of TB services. Two areas, highly influenced by human factors, aside from the personal and sociological factors that determine the sickness behaviour of TB patients are: (1) the disease and its attributes, (2) the health care delivery system. Reviving the approach that TB is a serious and major disease and integrating TB services as components of primary health care, as done in the DTP, are important in TB control.

The methods of measuring the dynamics of behaviour of the tuberculous patient, the social consequence of a TB case in the family and neighbourhood or the economic burden of the disease to the nation is still in the embryonic stage. Negative reactions from family and associates could lead to the patient's denial of having TB, thus endangering the patient and the community. Since the NTP came into being, TB patients can expect a correct diagnosis and prompt treatment. As the patient's interest in treatment will decline when suffering is reduced, it is urged that the patient be motivated (preferably, at the start of the treatment regimen) to acquire a compulsive, obsessive, daily habit for drug consumption for at least a year. As the social security measures in the country are meagre, domiciliary treatment rather than institutionalization should be offered to reduce the extent of disruption to the economic and social life of the patient.

Another important area of concern is the measurement of suffering. With the revolutionary changes in the treatment of TB, the prior acute, physical suffering and mental agony of the TB patient has given way to a generalised form of distress. Using behavioural techniques such as group interviews of the patient amidst his/ her family and projective techniques will provide a thorough knowledge of the personality, values, expectations and social interactions of the TB patient. This knowledge could help explain why patients fail to avail diagnostic and treatment services offered to them and, enable the NTP to continue the felt-need oriented approach.

Since 1850, voluntary organisations have largely benefited victims of TB. In India, the joint family system provided comfort and protection to the TB patient. However, there is an increased awareness for the patient to receive such protection and assistance from society as evidenced by the popularity of sanatoriums and other types of care provided outside homes and families. Christian missionaries took the initial step in providing systematised care of the tuberculous in India followed by several non-governmental efforts. The formation of the TAI in 1939 was a welcome centralised move on an all-India basis which also served as a link to international TB organisations. The Government of India provided active support to all voluntary activities in the country while evolving statutory TB services. The launching of the NTP in India was a turning point in the co-existence of government and voluntary agencies in the common fight against TB. The NTP’s approach to consider TB as one of many illnesses to be overcome within the GHS mobilised the services of thousands of health workers throughout the country. As the government exercises statutory powers over increasing areas of social services, there is a need for reappraisal of the concept and activities of the voluntary organisation. New ways by which the voluntary organisations can support the NTP, particularly, with the emphasis on domiciliary treatment, are recommended.

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.

NTP reaches people through PHCs and sub centres. A study was conducted to find out the perception of illness and utilisation of health facilities by the community. This study was conducted in a random sample of 48 villages selected according to Probability Proportioned to Size within 5 kms. of the selected PHIs in Kolar district using a multi stage sampling technique. Information on socio-economic status, availability of health services and their utilisation was collected. 13,323 individuals were interviewed. 706 were ill in a period of two months prior to survey. 71.3% had taken allopathic system of treatment. 69.1% had approached government hospital or PHC. 34 patients reported to have TB. All had attended either DTC or PHC.

The study indicated that morbidity was perceived much early and also followed by an action. Data indicates a high percentage of preferring allopathic system in general and from peripheral health centres and other government hospitals in particular. Data indicates that in spite of overall backwardness of the study area and very limited economic resources people have utilised the PHC to the maximum. The reason could be either high acceptance of PHC or inevitability. But, there is an evidence of higher utilisation of family welfare and MCH services. The data shows all TB patients have had exposure to standard regimens, all of them have approached either PHC or DTC for treatment. This confirms the felt need oriented concept of NTP. Also high level of morbidity among children below 4 years of age and action taken indicate an enhanced level of demand for health services.

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 paper emphasises the necessity for research on motivation, particularly, in the context of the NTP, to achieve the goal of getting TB patients to remain sufficiently long on treatment. For any such study, motivation needs to be viewed as a psychological process wherein various social, cultural and situational factors, either singly or in combination may influence motivation and thus, the patient’s behaviour, leading to regular or irregular patterns of treatment. The definition of a motive and its characteristics are presented in a model. The application of the model, explained in terms of the DTP, provides a broader focus in motivational research than the current, limited scope described in the DTP manuals. Viewing motivation as a psychological process allows for the identification of some of the patient’s intrinsic factors, the external factors in the patient’s environment and the factors pertaining to health institutions that could be manipulated for effective motivation. Therefore, the model can serve to make the NTP’s motivational research efforts, comprehensive.

This paper describes the need for a Health Education Component in the NTP. The potential achievement of the programme activities viz., prevention, case finding and treatment has been established by studies conducted by the NTI. Corrective measures to achieve the potential would no doubt have to tackle all the three constituents of the programme viz., objectives, activities and resources. However, incorporation of a health education component in the crucial activities of the programme would help, where, under-achievement is due to the lack of knowledge and proper attitude both on the part of the patient and the health worker. In order to evolve an effective methodology, the goals of the health education component should be synchronised with those of the programme. While the health education aspects in the case-finding and treatment activities can be incorporated at health institutions and on an individual or group basis, education for the preventive activities has to be on a mass or community basis. While the nucleus of the community education should be on BCG vaccination, the mass media could be utilised for the overall TB education in the general population. Thus, there is scope for employing a variety of material, methods and media of health education in the NTP.