baseline kap study under rntcp project - cms

BASELINE KAP STUDY UNDER

RNTCP PROJECT

Submitted to

CENTRAL TB DIVISION,MINISTRY OF HEALTH & FAMILY WELFARE

GOVERNMENT OF INDIA

Submitted By

R K SWAMY BBDO Advertising Pvt. Ltd.

In Association With

Centre for Media Studies

March 4, 2003

CONTENTS

Page No.Chapter. I: Introduction

1.0. Background 1 1.2. The Research Component 3 1.3. Baseline Report 4 1.4. Methodology 5 1.5. Choice of Indicators- Rationale 7 1.6. Tools for Study 10 1.7. Limitation 10 Chapter. II: Respondent Profile 2.1. Socio Demo Graphic Profile of Respondent 11 Chapter. III: Knowledge Attitude And Practice About TB and DOTS 3.1. TB is Common 16 3.2. Aware about the Symptoms 18 3.3. Myth about mode of spread still exist 21 3.4. Perception about who are prone to TB 22 3.5. TB is curable 23 3.6. Availability of TB related health facility in the vicinity 24 3.7. Preference for system of medicine 25 3.8. Diagnosis of TB suspect 27 3.9. Treatment of TB Patients 30 3.10. Precautions 33 3.11. Gender bias/Stigma & Discrimination 35 3.12. Knowledge about DOTS/Dot Centre 38 3.13. Facilities available at Dot Centre 38 3.14. Initiative taken by OL, NGO 42

Chapter. IV: Information Sources 4.1. Information Sources 44 4.2. Visit by a health personnel to make people aware of TB 45 4.3. Information Sought on 46 4.4. Information Source for HSPs 47 Chapter. V: Media Habits 5.1. Ownership of asset 48 5.2. Preferred Time slot for Radio 48 5.3. Preferred Radio Station 49 5.4. Preferred Time slot for Television 49 5.5. Preferred Channel in Television 50 5.6. Preferred Programme in Television 51 5.7. Readership Pattern 52 Annexure 1. Schedule for Public and Private Health Service Providers

2. Schedule for Opinion Leaders

3. Schedule for Households

LIST OF TABLES Page No.

Table. 2.1: Sample covered 11 Table. 2.2: Urban rural representation of Household 11 Table. 2.3: HSP category 12 Table. 2.4: Level of Education – Household 13 Table. 2.5: Level of Education – Opinion Leaders 13 Table. 2.6: Educational Qualifications of Health Service Providers 13 Table. 2.7: Occupation 14 Table. 2.8: Nature of Dispensing 14 Table. 2.9: Household Income 15 Table. 3.1: Heard of TB 16 Table. 3:2: Getting TB Patients 17 Table. 3.3: Prevalence of TB in the family or neighbourhood 17 Table. 3.4: Sex wise distribution of patients 17 Table. 3.5: Symptoms mentioned by HSPs 20 Table 3.5a : Breakup of Private and Govt. doctors looking for coughing up blood 20 Table. 3.6: HIV + People (PLWA) prone to TB 23 Table. 3.7: TB curable in HIV + people 24 Table. 3.8: TB Hospital in the Vicinity 24 Table. 3.9: System of medicine preferred 25 Table. 3.10: Preferred centre for treatment 25 Table. 3.11: Reasons for not going to Govt. Hospital 26 Table. 3.12: TB Suspect 27 Table. 3.13: Investigation 29

Page No.

Table 3.13a Breakup of Private and Public doctors advising only sputum test when given only one choice

29

Table. 3.14: Why 29 Table. 3.15: Frequency of Sputum test for TB suspect 29 Table. 3.16: Where sent for Sputum Exam 29 Table. 3.17: Problem for sputum Examination 30 Table. 3.18: What are the problems 30 Table. 3.19: Duration of Treatment 31 Table. 3.20: Treat Pulmonary TB 32 Table. 3.21: System of Medicine followed 32 Table. 3.22: MDR-TB 32 Table. 3.23: Symptoms of Cure 32 Table. 3.24: How many completed treatment (in a year) 33 Table. 3.25: Difficulties in treating 33 Table. 3.26: Precautions 33 Table. 3.27: TB constitutes any risk to health of other patients 34 Table. 3.28: Precaution suggested to avoid spread of TB 35 Table. 3.29: Allowed to attend 36 Table. 3.30: Difference in Concern Noticed 37 Table. 3.31: Who accompanies a TB Patient? 37 Table. 3.32: Facilities provided dat DOT centre 39 Table. 3.33: About DOTS – Household 39 Table. 3.34: About DOTS – Opinion Leaders 39 Table. 3.35: Would like to become a DOT Provider 40

Page No.

Table. 3.36: If yes, Why? 40 Table. 3.37: If No, Why? 40

Table. 3.38: DOTS Regime 40 Table. 3.39: About DOTs 40 Table. 3.40: Involvement in DOTS 41 Table. 3.41: Interested in DOTS 41 Table. 3.42: If yes, Why? 42 Table. 3.43: If no, Why? 42 Table. 3.44: What do you advice 43 Table. 3.45: Have you taken any initiative 43 Table. 3.46: If yes, What? 43 Table. 4.1: Update knowledge from 47 Table. 4.2: Best medium to generate awareness among the community about TB 47 Table. 5.1: Ownership of assets 48 Table. 5.2: Top Two Preferred Slots for Listening Radio 48 Table. 5.3: Top Two Preferred stations of Radio 49 Table. 5.4: Top Two Preferred Radio Programme 49 Table. 5.5: Top Two Preferred slot of watching Television 49 Table. 5.6: Readership among male female household 52

LIST OF GRAPHS Page No. Graph. 2.1 11 Graph. 2.2 12 Graph. 2.3 12 Graph. 3.1 16 Graph. 3.2 17 Graph. 3.3 18 Graph. 3.4 18 Graph. 3.5 19 Graph. 3.6 19 Graph. 3.7 19 Graph. 3.8 19 Graph. 3.9 19 Graph. 3.10 19 Graph. 3.11 20 Graph. 3.12 20 Graph. 3.13 21 Graph. 3.14 21 Graph. 3.15 21 Graph. 3.16 21 Graph. 3.17 22 Graph. 3.18 22 Graph. 3.19 22 Graph. 20 23

LIST OF GRAPHS Page No. Graph. 3.21 23 Graph. 3.22 23 Graph. 3.23 24 Graph. 3.24 26 Graph. 3.25 27 Graph. 3.26 27 Graph. 3.27 28 Graph. 3.28 28 Graph. 3.29 28 Graph. 3.30 28 Graph. 3.31 30 Graph. 3.32 31 Graph. 3.33 31 Graph. 3.34 31 Graph. 3.35 34 Graph. 3.36 34 Graph. 3.37 35 Graph. 3.38 35 Graph. 3.39 35 Graph. 3.40 36 Graph. 3.41 37 Graph. 3.42 38

LIST OF GRAPHS Page No. Graph. 4.1 44 Graph. 4.2 44 Graph. 4.3 45 Graph. 4.4 45 Graph. 4.5 46 Graph. 4.6 46 Graph. 5.1 50 Graph. 5.2 50 Graph. 5.3 51 Graph. 5.4 51 Graph. 5.5 52

A Baseline Report by CMS i

EXECUTIVE SUMMARY Tuberculosis (TB) is the single largest infectious cause of death in the world, accounting for about 500,000 deaths per year in India alone. TB inflicts significant socio-economic costs. It affects persons during their most productive age. Studies suggest that on an average there is a loss in potential earnings of about 30% of annual household income. The AIDS epidemic is making the situation more threatening as 70% of HIV mortality is likely to be through TB. India’s National Tuberculosis Programme (NTP) was established in 1962 and after more than three decades of operation, the NTP can justly claim to have established an infrastructure and raised awareness of TB and TB treatment. However, with a treatment completion rate of only 30 percent, the programme did not make a significant dent in the problem.

The Revised National Tuberculosis Control Programme (RNTCP) is designed to address the limitations of the earlier NTP i.e., lack of coverage coverage, shortages of essential drugs, poor cure and completion rates, poor quality of sputum microscopy, and a series of factors that have resulted in a non-friendly atmosphere for the patients. The goal of RNTCP is to achieve a cure-rate of at least 85% of new smear-positive cases of tuberculosis and a detection rate of at least 70% of such patients, after the desired cure rate has been achieved.

RNTCP is essentially a patient focused programme and presently covers 600 million populations in the country. The programme lays equal emphasis on creating a system that reliably cures the patient and moves beyond simply detecting cases. The programme believes that cured patients act as one of the best motivators promoting case detection and patient adherence to treatment. In this backdrop the Central TB Division (DGHS), MoH&FW has contracted M/s RK SWAMY BBDO Advertising Pvt Ltd to develop and implement the IEC strategy for RNTCP. The IEC is aimed to promote better understanding of TB and its cure, improve the quality of TB patient care (patient-friendly) and help reduce stigma. RK SWAMY BBDO Advertising Pvt Ltd and Centre for Media Studies (CMS) have, in consultation with CTD and the international donor agencies, designed the research component to help shape, monitor, evaluate and measure the impact of communication.

A Baseline Report by CMS ii

The research has been conceptualized as a process keeping in mind the need for flexibility. The process has three components of Baseline; where a Communication Needs Assessment of the target audience including KAP related to TB their media habits and information sources used and preferred will be collected, Tracking ; where impact of IEC strategy will be tracked once every six months and the Endline; where IEC strategy will be evaluated and changes in KAP will be recorded. The present report of the Baseline Study aims to understand the KAP of beneficiaries, Opinion Leaders and health Service Providers related to TB; tries to assess the interest of the Opinion leaders and Health service providers in becoming a part of the RNTCP / DOTS programme; identifies the information needs and the preferred sources of the beneficiaries for receiving messages related to TB and to map Media habits/preferences of the Beneficiaries. For conducting the study a multi-stage random sampling procedure was used for selection of 9 states, 18 districts, urban rural locations and convenient sampling were done for each group in consultation with CTD, World Bank and WHO. Impact & process indicators were cautiously chosen to measure the level of knowledge, the attitude and practices of the three segments at the baseline, monitored at a regular interval and evaluated at the Endline study.

The study covered 1444 beneficiaries, 180 opinion leaders and 211 health service providers. As per the methodology 50:50 ratio among male female beneficiaries and HSPs were attempted. About 23% of the beneficiaries across the states were illiterate but the opinion leaders were mostly literates and majority were graduates and above. More than half of the doctors contacted were MBBS qualified. The household income of 78% of the respondents across the states was less than Rs 4000/- per month (40.8% reported less than Rs 2000/- per month).

Between 1-20% of the Householders / Beneficiaries spontaneously mentioned TB as a common infection and nearly all of them said that they have heard about TB when aided. Almost all doctors reported treating TB patients. Very low percentage of household and opinion leaders mentioned about someone in the family or neighbourhood whom they knew had TB. TB in female was comparatively less known by our respondents.

A Baseline Report by CMS iii

Symptoms People were aware about the symptoms of TB but quite alarmingly a considerable percentage of the general population, opinion leaders and even doctors associate coughing up blood as a symptom of TB. HSP’s in all the states mainly come across Pulmonary TB patients. However, a very small percentage of doctors mentioned having come across genetic TB. HIV-TB and MDR TB was also quite common among the doctors across the states. Doctors from all the states except Chattisgarh reported to have treated PLWH with TB. Myths about mode of Spread Myths about mode of spread still exist among the beneficiaries and opinion leaders. The study highlighted that about 15% of the community was totally unaware of the mode of spread of TB. A few associated spread with unsafe sex, defecation at open field, unhygienic living condition and even inheritance. Prone to TB Both the beneficiaries and opinion leaders had varied opinion about people who are prone to TB. Those living in congested locality and unhygienic conditions and persons having low immunity were identified by most of the respondents. More interestingly male respondents in some states mentioned people smoking tobacco to be prone to TB.

A few respondents both among household and opinion leaders feel that TB is a poor man’s disease and are not clear about women being more prone to TB or not. TB is curable Majority of the respondents in both the categories feel that TB is completely curable and agreed that only medicine can cure TB completely. Majority also felt that once cured a TB patient can lead a normal life. Majority of the doctors opined that TB in PLW HIV is curable.

Availability of TB related health facility

Public health services for treatment of TB was mentioned to be available in the vicinity but not that all the respondents knew about it.

A Baseline Report by CMS iv

Preference for system and place of treatment Clear preference for Allopathic system of medicine and Government Hospitals and Private Practitioners for treatment emerged out of the study. Distance from residence, non-availability of medicine and unfriendly behaviour of staff were stated by the staff, who do not prefer Government hospitals. Diagnosis of TB suspect Govt. Hospital was preferred for diagnosis as well as treatment by household respondents and opinion leaders with minor variations across the states. DOT /TB center was mentioned by quite a few. Method of diagnosis and practice Respondents were quite familiar with Sputum examination but a significant percentage still recognizes X-ray as a reliable method for diagnosing TB. Doctors also confirmed that they advise sputum test and chest X-ray for diagnosing Pulmonary TB. On further probing about 22% of the HSP still chose X-ray.

Treatment of TB Majority of the respondents preferred government hospital for seeking treatment for TB except for West Bengal where households mentioned DOTS center. Similar trend was noticed among the opinion leaders. They felt that completing full course of TB treatment is essential on failure of which the disease becomes untreatable. Cure In most of the states, doctors look for positive sputum turning negative to confirm whether the patient is cured or not. Most of the doctors stated that people hesitate to come for treatment and do not reveal previous history of TB in the family easily. The doctors also reported that more than two-third of the patients that went for treatment of TB completed the treatment. Precautions The respondents pointed out that covering face while coughing and using separate utensils was the major precautions that patients and their family took to control the spread the infection. They also opined that TB patient should be kept in isolation to prevent spread of infection. Although more than half of the doctors in all the states felt that TB do not pose any risk either to their own health or to other patients visiting them, they wear mask & gloves and maintain distance from the patients. A few doctors in some states mentioned that patients avoid visiting them because they treat TB patients. Precautions suggested by doctors to their patients varied from state to state. The three most commonly advised precautions include cover face while coughing, use separate utensils and not to spit anywhere.

A Baseline Report by CMS v

Gender bias/Stigma & Discrimination The responses of the beneficiaries reflecting gender bias and discrimination was quite contrary to our hypothesis that there still exists considerable gender bias in society, related to treatment of TB. However according to the opinion leaders and HSP’s discrimination still exists in the society. Knowledge about DOTS /DOT CENTER

Very few could spontaneously mention about DOTS as a center for treatment. On probing they could recall and remember the facilities specifically associated with DOT center. The study found a wide variation on the issue. All opinion leaders in West Bengal have mentioned DOT center. Except for AP, doctors have heard of DOTS and mostly among them informed that DOT service is available in their locality. Facilities available at DOT center Free diagnosis followed by free medicine was spontaneously indicated as special facilities or features available in DOTS center by the beneficiaries. Very few among the opinion leaders actually had the correct idea about free medicine and DOTS being surest way of cure for TB. Involvement with DOTS Majority of the opinion leaders showed their keenness to become a DOT Provider because they wanted to serve the community, and wanted to ensure free and good quality drugs for the patients. Private practitioners were interested in becoming a part of DOTS programme as they felt that DOTS is the surest way to complete cure. HSP’s and DOTS DOTS regimen was widely known among the HSPs and most of them follows it for treating TB patients. They are also aware of the schemes to involve private practitioners in DOTS programme. Andhra Pradesh in all cases and Tamil Nadu in some are exceptions. Majority of government doctors in all the states, excluding AP are involved in DOTS scheme. Information Sources Hospital, television and in some cases friends were the main sources of information on TB. Newspaper was also mentioned by quite a few in some states. Journals is the most used source by the doctors for updating knowledge on TB

A Baseline Report by CMS vi

Apart from mass media sources in most of the states, village health worker followed by doctor was recalled as the Inter personal Communication Sources (IPC) who visited the respondents to make them aware on TB.

Information sought on When the respondents were probed on the kind of information they would like to have on TB, majority asked for prevention, precaution and treatment. Preferred time, format, programme and channel in Electronic media Preferred time slot for listening radio in all the states was early morning (6-8 pm) while for watching television was late evening (7-9 pm) among majority of the respondents.

Vividh Bharti for beneficiaries and regional station among opinion leaders came out as the most preferred station on radio. On the other hand, on television Doordarshan’s National Network was singled out as the most preferred channel in all the states. News in radio and television and serials in television emerged as the most preferred programme. Readership pattern Readership varied among states among the beneficiaries. However almost all the opinion leaders read newspaper.

A Baseline Report by CMS 1

CHAPTER I INTRODUCTION

1.0 BACKGROUND Tuberculosis (TB) is the single largest infectious cause of death in the world, accounting for about two to three million deaths per year. In India alone, 500,000 people die of TB every year - one person dying every minute. The public perception is that TB is a ‘poor man’s disease’; however a significant proportion of those infected are literate, educated and are economically better off. TB inflicts significant socio-economic costs. It affects persons during their most productive age. The largest indirect cost of TB for a patient is income lost by being too sick to work. Studies suggest that on an average, 3 to 4 months of work time are lost resulting in average loss in potential earnings of about 29% to 30% of annual household income. The AIDS epidemic is making the situation more threatening. Between 1993 and 1996, there was a 13% increase in estimated tuberculosis cases worldwide, one third of which can be attributed to HIV. 70% of HIV mortality is likely to be through TB. After independence in 1947, India began to shape its own health programmes, and two pioneering institutions – the Tuberculosis Chemotherapy Centre in Chennai and the National Tuberculosis Institute in Bangalore – were established under the sponsorship of the Indian Council of Medical Research (ICMR) and the Government of India, respectively. These two institutions have contributed world-class research that not only shaped India’s subsequent tuberculosis policies; they also contributed to tuberculosis control the world over. India’s National Tuberculosis Programme (NTP) was established in 1962 and provided a system for TB control throughout the country. After more than three decades of operation, the NTP can justly claim to have established an infrastructure for tuberculosis treatment in India. The NTP created an extensive infrastructure for tuberculosis control, with a network of 446 District TB Centres, 330 TB Clinics and more than 47,600 TB beds. The NTP also raised awareness of TB and TB treatment facilities, and has succeeded in placing more than 13 lakh patients on treatment on a yearly basis. However, with a treatment completion rate of only 30 percent, the programme did not make a significant dent in the problem.

In 1992, a review of the National Tuberculosis Programme by national and international experts –in coordination with the World Health Organization and the Swedish International Development Association – determined that the programme had not had the desired impact on tuberculosis in India.


The review observed that less than 30% of the patients enrolled under the NTP completed their treatment and thus the pool of infection was not declining whereas the danger of drug resistance was developing. The review also noted the following issues: inadequate budgets, a lack of coverage in some parts of the country, shortages of essential drugs, poor administration, varying standards of care at the district centres, unmotivated and unevenly trained staff, lack of equipment, poor quality of sputum microscopy, and focus on case detection without an accompanying emphasis on treatment outcomes. The Revised National Tuberculosis Control Programme (RNTCP) was designed to address these and other issues.

Patient-centred: RNTCP has been designed placing the patient as both the starting point and as focus of the programme. It recognizes the need to understand the patterns of diagnosis and treatment from the patient’s perspective. It also builds on the very substantial strengths and accomplishments of the National Tuberculosis Programme (NTP).

The goal of RNTCP is to achieve a cure-rate of at least 85% of new smear-positive cases of tuberculosis and a detection rate of at least 70% of such patients, after the desired cure rate has been achieved. Estimates in India indicate that not more than 20 percent of patients who develop tuberculosis in India each year are cured. Many of the remaining patients remain chronically ill or die slowly from the disease, infecting others with strains of the disease, which may have developed drug resistance. Thus RNTCP lays equal emphasis on creating a system that reliably cures the patient and moves beyond simply detecting cases. This is based on experience that clearly shows that reliably curing patients results in a “recruitment effect”; ie, wherever effective services are offered, case detection rates steadily increase. Cured patients act as one of the best motivators promoting case detection and patient adherence to treatment.

This Programme has been introduced in phases in the country. It presently covers over 450 million. It is hoped that entire country will be covered by 2005 under this programme. Experience of over a year now shows a detection rate of 127 per lakh and cure rates of 84% (in new cases), which is a remarkable achievement. Estimates suggest that the introduction of DOTS (Directly Observed Treatment, Short-course) could halve the current potential national economic loss from TB.

Fear / Stigma: Studies reveal that most patients are reluctant to admit that they have TB because they fear stigma, and they prefer not to discuss the disease in the presence of family or neighbors. This has been recorded more so in urban than in rural areas. Family support for treatment was more frequent among cured patients than among those who had defaulted.


IEC: The Central T.B Division (DGHS), Ministry of Health and Family Welfare has contracted M/s R.K Swamy BBDO Pvt Ltd for developing and implementing IEC strategy for RNTCP. The IEC activities under RNTCP are fashioned as a response of the health system towards such behavior. They aim to promote better understanding of TB and its cure (KAP), improve the quality of TB patient care (patient-friendly), and to reduce stigma. It is understood that IEC activities at the national and state levels are complementary. While mass media activities are planned at the national level, state-level activities are more specific and need-based, with emphasis on sensitization of the health provider, production of state-specific IEC material, and dissemination of this material to local levels and optimum use of folk media at the district levels. Effective, regular and consistent IEC activities are expected to enhance the performance of the RNTCP. Research: Recognizing the need to map and track the Knowledge, Attitudes and Practices of the a)Beneficiaries b)Health Service Providers and c)Influencers as part of the overall IEC strategy, R.K Swamy BBDO and Centre for Media Studies (CMS) have, in consultation with CTD and the international donor agencies, designed the research component to help shape, monitor, evaluate and measure the impact of communication . 1.2 THE RESEARCH COMPONENT The research component, which has been formulated to give direction to the mass media campaign IEC strategy, has been conceptualized as a process. The process – keeping in mind the need for flexibility - has three components: Baseline, Tracking and Endline. Baseline The Baseline study undertakes Communication Needs Assessment based on the knowledge level, behavior patterns and habits of the target audience, i.e. Beneficiaries / Patients, Health service Providers and Influencers / Opinion leaders. It is comprised of a field survey on i) KAP based on the indicators developed (refer to page 9) ii) Media habits and iii) Information sources used by the audience.


Tracking Tracking the impact of the designed and implemented IEC strategy, (approximately once every six months), ensures effective monitoring and proper feedback for strategic flexibility. The IEC strategy would be tracked by monitoring the implementation, execution and delivery of the campaign. This would be done by interviewing State IEC officials. Impact on the audience and exposure to the campaign are additionally to be assessed by means of Rapid Assessment Survey (RAS). Endline The Endline study is intended to be an evaluation of the IEC strategy after rounds of Tracking. It would record the change in KAP of the target audience using the same indicators that were used for the Baseline. The present report is of the Baseline on KAP, Media Habits, Information sources and Communication Needs Assessment pertaining to TB across nine states in the country. 1.3 BASELINE REPORT 1.3.1 Statement of Aim To understand the knowledge, attitude and practices (KAP) of Beneficiaries, opinion leaders and health service providers related to Tuberculosis towards guiding the mass media campaign strategy. 1.3.2 Specific Objective 1. To assess the Awareness level of the Beneficiaries, Opinion leaders and Health Service

Providers regarding Tuberculosis and DOTS 2. To understand the Attitude of the three segments towards TB patient with particular

reference to gender. 3. To know the tuberculosis-related Practices prevailing in the three segments. 4. To assess the interest of the Opinion leaders and Health service providers in becoming a

part of the RNTCP / DOTS programme. 5. To identify the Information Needs and the Preferred Sources of the Beneficiaries for

receiving messages related to TB. 6. To map the Media habits/preferences of the Beneficiaries.


1.4 METHODOLOGY The Baseline was carried out based on a sample survey in the states/districts where RNTCP has been implemented. In consultation with CTD, WHO and the World Bank, the following approach was formulated: Coverage A multi stage random sampling procedure was used for the Baseline Survey. Officials of Central TB Division, RK Swamy/BBDO and Centre for Media Studies, unanimously decided upon all the scope, sample category, size etc.

Selection of States The States were classified into three categories on the basis of RNTCP coverage.

Coverage States 1 >80% Delhi, Rajasthan, Kerala, HP, Gujarat, TN, Arunachal, Sikkim 2 50-80% Maharashtra, WB, Nagaland 3 <50% Haryana, UP, Bihar, Jharkhand, MP, Orissa, AP, Karnataka, Manipur,

Chattisgarh, Mizoram, Uttaranchal This was followed by a zone-wise plotting of the states.

Zone States 1 North Delhi, Himachal Pradesh, Haryana, Uttar Pradesh, Uttaranchal 2 South Kerala, Tamil Nadu, Karnataka, Andhra Pradesh, 3 East Bihar, Jharkhand, West Bengal, Orissa, Mizoram, Nagaland, Manipur,

Arunachal, Sikkim 4 West Gujarat, Madhya Pradesh, Chattisgarh, Maharashtra, Rajasthan, From each zone, a minimum of 2 states were identified:

Zone States 1 North Himachal Pradesh, Uttar Pradesh

2 South Tamil Nadu, Andhra Pradesh

3 East West Bengal, Manipur

4 West Chattisgarh, Maharashtra, Gujarat

The selected sample of 9 states ensured range of coverage of RNTCP as well as representation of all four zones.


Selection of Districts For selection of districts, only RNTCP-covered districts were considered for random selection. Thus two districts from nine states were chosen. The selected 18 districts are as follows:

Sl. no.

State District

1 Andhra Pradesh Mehbubnagar, Medak 2. Tamil Nadu Viluppuram, Cuddalore 3. Maharashtra Aurangabad, Solapur 4. Gujarat Amreli, Jamnagar 5. Chattisgarh Bilaspur, Raipur 6. Uttar Pradesh Meerut, Sitapur 7. Himachal Pradesh Una, Hamirpur 8. West Bengal Nadia, North 24 Pgns. 9. Manipur Imphal, Churachandpur

Selection of Location Since the mass media activities for RNTCP would be directed towards the Rural and the Urban Poor - two rural clusters and two urban slums within each of the selected districts were selected.

Of the two rural clusters, it was decided that one would be within a distance of 10 kilometers from the District Headquarters (DHQ) and another in the range of 25-50 kilometers. Of the two urban slums – one would be in the DHQ and the other in another town. Selection of Respondent Three specific respondent categories were derived from the terms of reference for the study. They are: i) Beneficiary households, ii) Opinion leaders and iii) Health service providers. Sample Size State District Category Respondents/district Total

9 9*2=18 Household 80*18 1440 9 9*2=18 Opinion Leader 10*18 180 9 9*2=18 Health Service Providers 12*18 216


Convenient sampling was done for each group. While covering the desired respondent category and numbers from Beneficiaries, equal gender representation was to be ensured. The sample of opinion leaders would include Pradhans, ANMs (Auxiliary Nurse – Male), AWW (Aanganwadi Worker), Mahila Mandal representatives, NGO workers, Religious Leaders and Teachers. Private and Public health care providers who are Registered Medical Practitioners (RMP) would be contacted for the survey. Where it was not possible to access private practitioners, it was decided to interview public practitioners.

The break-up quota followed is as follows: State

District 1 District 2 Urban Slum

HH Rural HH

Doctors Opinion Leaders

Urban Slum HH

Rural HH

Doctors Opinion Leaders

50 30 12 10 50 30 12 10 US1 US2 R1 R2 U R US1 US2 R1 R2 U R 25 25 15 15 5 5 25 25 15 15 5 5

12M 13M 7M 8M 13F 12M 8M 7M13F 12F 8F 7F

Pvt. – 6 (R&U) Pub - 6

12M 13F 7F 8F

Pvt. – 6 (R&U) Pub – 6

US1 � Urban Slum 1 , US2 � Urban Slum 2, R1 � Rural 1, R2 � Rural 2, M � Male Pub � Public Doctors, F � Female, Pvt. � Private Doctors

1.5 CHOICE OF INDICATORS –RATIONALE The indicators (Process & Impact Indicators) for the study were chosen so as to measure the level of Knowledge, the Attitude that the audience have towards the issues and also their Practices. These indicators or ‘markers’ will be measured at the baseline to create a benchmark, monitored at a regular interval after the launch of the campaign and finally be evaluated at the end line study to see the impact of the campaign on a whole. In addition to quantitative assessment of the KAP - the indicators would also provide additional learning and better insights for design of the mass media campaign through qualitative assessment of issues such as stigma, which has been built into the baseline process.


1.5.1 INDICATORS The indicators to assess the Knowledge of the audience (the community and opinion leader) included understanding whether TB is perceived by them as a common problem, their scientific understanding of the disease, who are prone to TB, how it can be diagnosed, the correct and surest way of diagnosis, cure and availability of services in their vicinity. The perception of the Opinion leaders and community is also tested with regards to the Sputum Smear Test and DOTS The knowledge of Health Service Providers is measured through their recognition of Sputum Smear Test as the surest method of diagnosis vis-à-vis other tests, their appreciation of TB being a threat to the community, DOTS as a facility and information about involvement in the scheme. The Attitude indicators were designed to assess the approach of the audience towards the disease, and towards the patient that influences treatment. The attitude indicators were also designed to test the mindset of the beneficiaries with regards to the stigma associated to the disease and the infected, and whether it differs with gender of the infected, the acknowledgement of the fact that it can happen to anybody. The preferences of the community with regards to treatment and health delivery system, their comfort level with private and public practitioners and the attitude DOTS as a method of treatment were considered while setting the indicators. The assessment of attitude of the HSPs includes their preferred method of diagnosis of TB and way of thinking about DOTs. The Practice indicators assessed the actual actions undertaken by the audience in coping with the disease. These included assessment and reliance of the beneficiaries and the HSP on the existing method of diagnosis and treatment, the individual and social stigma and discrimination practiced towards the infected patients. The practices of opinion leaders were also assessed by their intervention and initiative taken for the community for treatment of TB and DOTS. The practice of HSP also considered the precaution taken while treatment, reference to the available public health facilities, and the regimen followed. These indicators represented in a matrix form given below.


Indicator Matrix Beneficiaries HSPs Opinion Leaders (O/S) Knowledge 1. Is TB common problem /disease in one’s

community. 2. TB-How? What? Why? Cure? 3. Information source 4. Availability of Service (Public/Pvt.) 5. Smear Test 6. Full Course 7. DOTS is free 8. Is DOTS problematic because of the

Practitioners (Awareness) 9. Completely curable

1. Is TB a common problem/disease in one’s community? 2. How do they diagnose TB 3. Treatment categorization-regimen 4. Are HIV+s’ prone to TB 5. Schemes involving Private

1. Is TB becoming a problem for the community/country

2. Is TB Curable? 3. Awareness regarding Programme at

national level/among their vicinity 4. Smear Test is the best way to diagnose TB 5. DOTS is free 6. It is the surest way to complete cure 7. Advantages of completion of the treatment

(At individual & Community level both)

Attitudes 1. Denial / Indifference/Acknowledgement 2. Stigma (All Affected) 3. Gender Bias (Affected Women) end to a

patient with 3 weeks 4. Pvt. Vs Public HSPs. (Preference for

treatment-short or long) 5. No specific assured cure 6. Comfort levels with Public Health (in context

with TB also) Individual risk perception

1. TB is not in my consideration set (What would they recommend to a patient with 3 weeks of cough. Multiple answers to be sought.

2. X Ray – is the method for Diagnosis 3. Acceptability of DOTS 4. Willingness to play active role in DOTS

1. Towards detected cases 2. Gender 3. Social Status 4. Towards completion of disease 5. Capabilities of affected are handicapped 6. About DOTS as the method of treatment 7. TB is a poor man’s disease

Practice 1. TB is diagnosed with X-ray 2. Seeking treatment from Government health

Centers 3. Who accompanies ‘TB infected’ for treatment 4. Patient care environment (Are they given

proper treatment)

1. Comfort levels with X-ray as method to diagnose TB Vs. Smear Test

2. Behavioral pattern of Technicians 3. Practicing DOTS or not 4. No. of TB patients Private Practitioners treat in a year 5. Precautions taken while treating a TB patient 6. Private Practitioners referring patients to public HSPs.

Their reasons of referrals (Fear of losing patients, Better drugs, better facilities etc)

1. If TB is detected, then acceptability of patient at home/community level (Assess all patients with special reference to women)

2. Who is accompanying TB infected (ANM/ANW- Their methods of interacting with public: Behavior pattern)

3. Advocacy towards RNTCP/Patient friendly environment

4. Ensure implementation of DOTS


1.6 TOOLS FOR STUDY For the study it was agreed that essentially the study be quantitative. Three, pre-coded structured questionnaire were prepared for three identified respondent group on the basis of the indicators outlined in the previous section. Nonetheless some statements were measured on a 5-point scale to acquire the precise feeling of the respondent on the issues. (Sample questionnaire attached in Annexure-I) 1.7 LIMITATION

• Limited lead & process Time • Availability of HSP’s • Logistic difficulties eg. Manipur.


Household by sex

51%49%

Male Female

CHAPTER II RESPONDENT PROFILE

On the basis of the sample category and size the actual numbers being covered in each state is as follows: Table 2.1 Sample covered

Category AP TN MAH GUJ CH UP HP WB MAN TOTAL

Household 160 160 161 162 160 160 161 160 160 1444 Opinion Leader 19 20 21 20 20 19 19 20 22 180 HSP 23 24 25 24 24 24 24 24 19 211

2.1 SOCIO DEMOGRAPHIC PROFILE OF RESPONDENTS: 2.1.1 Age-sex composition

Graph-2.1

As per the methodology the investigators

attempted to maintain 50:50 ratio among male

female respondents. The representation from

rural and urban slums was also as decided.

Table 2.2 : Urban rural representation of Household. (in numbers) State Urban slum Rural State Urban slum Rural

(1) Andhra Pradesh 103 57 (6) Uttar Pradesh 98 62 (2) Tamil Nadu 107 53 (7) Himachal Pradesh 100 61

(3) Maharashtra 101 60 (8) WB 99 61

(4) Gujarat 102 60 (9) Manipur 100 60 (5) Chattisgarh 101 59


30.536.1

24.38.7

0.4

26.530.5

26.815

1.2

0 20 40 60

Male

Female

Household male female by age (%)

18-25 26-35 36-45 46-55 55 and above

Categories of Opinion Leader

Pradhan13%

ANM6%

AWW11%

Teacher40%

Religious Leader6%

Community Leader22%

NGO Worker2%

Graph-2.2 Majority of the respondents across the states were from the age group of 26-35 years followed by the age group of 18-25 years. Very few respondents in both the categories were 55 years and above.

Graph-2.3

Among the opinion leaders teachers community leaders and Panchayat Pradhans were mostly contacted.

Table 2.3: HSP category (in %) AP TN MAH GUJ CHA UP HP WB MAN TOTAL Private Doctors 73.9 66.7 48.0 50.0 50.0 54.2 45.8 50.0 52.6 54.5 Public Doctors 26.1 33.3 52.0 50.0 50.0 45.8 54.2 50.0 47.4 45.5

In the health service providers category almost equal number was covered except in Andhra Pradesh and Tamil Nadu where there was confusion in labeling a public doctor as public when s/he is interviewed in their private clinic.


Table 2.4: Level of Education (in %) Household AP TN MAH GUJ CHA UP HP WB MAN Total Illiterate 5.0 12.5 15.5 21.6 36.3 35.6 45.3 27.5 5.0 22.7 Literate but no schooling 1.3 5.0 2.5 2.5 4.4 5.0 3.7 6.3 3.1 3.7 Less than Primary 5.6 8.8 9.3 11.7 10.0 5.6 3.1 13.8 1.9 7.7 Primary but less than middle 10.6 18.8 8.7 19.8 15.0 14.4 6.8 13.1 6.3 12.6 Above Middle but less than Xth

13.1 15.0 24.2 19.1 8.8 14.4 10.6 20.6 5.0 14.5

Xth 12.5 20.6 18.6 11.1 13.8 7.5 16.8 8.1 31.9 15.7 XIIth 35.0 11.9 14.9 8.0 6.3 6.3 9.9 6.3 24.4 13.6 Graduate and above 16.9 7.5 6.2 6.2 5.6 11.3 3.7 4.4 22.5 9.3 99.8

About 23% of the household respondents across the states were illiterate followed by respondents of Xth standard and XIIth standard. About 22% of the respondents in Manipur were graduates and above.

Table 2.5: Level of Education (in %) State Opinion Leader

AP TN MAH GUJ CHA UP HP WB MAN Total Illiterate 0 0 0 0 5.0 5.3 10.5 0 0 2.2 Literate but no schooling 0 0 0 0 0 0 0 0 4.5 0.6 Less than primary 0 0 9.5 0 0 0 15.8 0 0 2.8 Primary but less than middle 0 0 0 5.0 0 31.6 10.5 0 0 5.0 Above Middle but less than Xth 5.3 25.0 14.3 15.0 15.0 10.5 0 5.0 0 10.0 Xth 5.3 5.0 23.8 30.0 20.0 15.8 31.6 0 9.1 15.6 XIIth 15.8 20.0 9.5 25.0 30.0 10.5 26.3 15.0 9.1 17.8 Graduate & above 73.7 50.0 42.9 25.0 30.0 26.3 5.3 80.0 77.3 46.1

On contrary to the respondents from household the opinion leaders were mostly literates and majority were graduates and above.

Table 2.6 : Educational Qualifications of Health Service Providers (in %) AP TN MAH GUJ CHA UP HP WB MAN Total MBBS 69.6 66.7 60.0 58.3 58.3 54.2 55.8 83.3 63.2 62.1 BAMS 17.4 4.2 12.0 20.8 25.0 20.8 29.2 ---- 15.8 16.1 BUMS ---- --- 8.0 ---- ---- 4.2 ----- -- ---- 1.4 Others (BEHMS) ---- ---- 4.0 ---- ---- ---- 8.3 --- --- 1.4 Diploma/ DAMS /DHMS 4.3 25.0 12.0 16.7 12.5 8.3 8.4 8.3 5.3 11.4 RMP ---- ---- ---- ---- 4.2 4.2 8.3 -- 5.3 2.4 BHMS 8.7 4.2 4.0 4.2 ---- 8.3 --- 8.3 10.5 5.2

More than half of the doctors contacted in each state were MBBS qualified. Quite a good number were BAMS.


Table 2.7: Occupation (in %)

Household AP TN MAH GUJ CHA UP HP WB MAN Total

Agricultural labour 4.4 18.8 9.3 15.4 18.1 7.5 5.6 7.5 3.8 10 Unskilled worker/non- Agriculture labourer

6.25 25.00 19.88 19.75 20.63 22.50 36.65 23.13 10.63 20.5

Business/shop owner 26.3 9.4 13.7 13.0 8.8 6.9 7.5 10.6 26.3 13.6 Housewife 41.9 38.8 31.7 27.8 40.6 38.8 31.1 43.1 22.5 35.1 Government servant 10.0 5.0 2.5 4.9 2.5 9.4 3.7 0.0 9.38 5.3 Student 11.3 1.9 11.8 8.6 6.9 11.3 6.2 6.3 19.4 9.3 Landowner/Farmer 0.0 0.0 0.0 0.0 0.0 0.6 0.0 1.9 0.0 0.3 Weaver 0.0 0.0 0.0 0.0 0.0 1.3 0.0 0.0 0.0 0.2 Skilled Worker 0.0 0.6 5.6 1.2 0.6 1.3 3.1 0.0 1.3 1.5 Pvt. Service 0.0 0.0 1.2 3.7 0.0 0.6 3.1 1.9 4.4 1.7 Unemployed/Retired 0.0 0.0 3.1 3.1 0.6 0.0 3.1 3.8 2.5 1.8 Driver 0.0 0.0 0.6 0.6 0.6 0.0 0.0 0.0 0.0 0.2 Priest 0.0 0.0 0.0 0.6 0.0 0.0 0.0 1.3 0.0 0.2 Advocate 0.0 0.0 0.0 0.6 0.0 0.0 0.0 0.0 0.0 0.1 Social Worker 0.0 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 NR 0.0 0.0 0.62 0.0 0.63 0.0 0.0 0.63 0.0 0.2

Except for Manipur where the highest percentage of respondents was from the business/ shop owners’ category, in case of rest of the states most of them were housewives. Next to the housewives the highest category of respondents were unskilled worker/ non-agricultural labourers, in case of all the states except Andhra Pradesh where 26.3% of the respondents were business/shop owners and Manipur where they were housewives. Table 2.8: Nature of Dispensing (in %)

AP

TN MAH GUJ CHA UP HP WB MAN Total

Dispensing GP 34.8 37.5 28 45.8 41.7 62.5 95.8 20.8 52.6 46.4

Prescribing GP 73.9 58.3 28 83.3 100 45.8 62.5 79.2 47.4 64.5

Consultants 8.7 12.5 48 29.2 0 16.7 4.2 0 5.3 14.2

In most of the states prescribing physicians were contacted. This was more with private practitioners. However the government doctors who dispense medicines did the same from the center where they practice.


Table 2.9 : Household Income (in %)

Level of income AP

TN MAH GUJ CHA UP HP WB MAN Total

NR 0.0 0.0 0.6 0.6 0.0 0.6 0.0 0.0 0.0 0.2 <2000 2.5 18.8 46.6 21.6 48.8 53.1 54.7 81.9 38.1 40.7 2001-4000 27.5 50.6 42.2 51.2 37.5 33.8 28.0 17.5 51.9 37.8 4001-8000 45.6 21.9 7.5 16.0 8.8 10.0 13.0 0.6 6.3 14.4 8001-10,000 23.1 6.9 1.9 6.2 3.1 0.6 2.5 0.0 3.8 5.3 10,001 and above 1.3 1.9 1.2 4.3 1.9 1.9 1.9 0.0 0.0 1.6

The household income of 78% of the respondents across the states was less than Rs 4000/- per month (40.8% reported less than Rs 2000/- per month).


CHAPTER III KNOWLEDGE ATTITUDE AND PRACTICE ABOUT TB AND DOTS

3.1 TB IS COMMON

Graph-3.1 Table 3.1 Heard of TB (in %)

State Of those who did not mention TB spontaneously AP TN MAH GUJ CHA UP HP WB MAN Household 99.2 100.0 98.7 98.7 100.0 100.0 100.0 100.0 100.0 Opinion Leader 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Although TB did not come spontaneously in the respondents mind when they spoke about the frequently suffered diseases in their community, almost all of them mentioned that they have heard of TB. However Tuberculosis is still viewed as a problem in the community in Andhra and West Bengal as we find that more than 20% respondents mentioning TB spontaneously while listing the frequently suffered diseases. TB as a problem was spontaneously identified by more than 70% HSPs of Tamil Nadu and West Bengal. This was well supported by the fact that almost all the doctors interacted with come across TB patients in their practice.

Mentioned TB –spontaneously as frequently suffered disease in family or neighbourhood (%)

26

7 3 4 3

12

20 21

8

47

15 19 15

0

11

16

10

5

71

28

13

20

25

42

100

4748

0102030405060708090

100

AP TN MAH GUJ CHA UP HP WB MAN

Household Opinion Leader Health Service Provider


Table 3.2 Getting TB Patients (in %) States AP TN MAH GUJ CHA UP HP WB MAN Total Getting TB Patients

95.7 100.0 100.0 91.7 95.9 100.0 95.9 100.0 100.0 95.8

Graph 3.2

In Uttar Pradesh and Maharashtra the average number of patients visiting the doctors clinic per month was quite high compared to the other states. The doctors contacted at Sitapur (UP) district hospital mentioned that they come across about 150 patients per day, which is too high than the average figure of the state. Although low in number out of the total patients doctors could clearly recall average number of female patients visiting their clinic.

3.1a Prevalence of TB in family or neighbourhood Very low percentage of household and opinion leaders mentioned about someone in the family or neighbourhood whom they knew had TB. TB in female was comparatively less known by our respondents.

Table 3.3 Prevalence of TB in the family or neighbourhood (in %) AP TN MAH GUJ CHA UP HP WB MAN Household 15.6 11.9 5.6 8.0 3.8 20.0 5.6 5.6 20.0 Opinion Leader 26.3 0.0 23.3 0.0 15.0 26.3 5.3 15.0 27.3

Table 3.4 Sex wise distribution of patients (in %)

AP TN MAH GUJ CHA UP HP WB MAN Male 53.7 65.0 66.7 92.3 66.7 65.6 44.4 66.7 68.8 Female 46.3 35.0 33.3 7.7 33.3 34.4 55.6 33.3 31.2

Number of patitnets per month (%)

5

3

35

13

7

62

10

9

2

1

16

6

2

23

3

4

0 20 40 60 80

AP

TN

AH

CHA

UP

HP

WB

MAN

TB Patients Female patients


3.2 AWARE ABOUT THE SYMPTOMS In all the states the most mentioned symptom was a cough that persists for three weeks, followed by fever. However it was alarming to know that still quite a high percentage of both general population and community leader associate coughing up blood as a symptom of TB indicating their ignorance about the graveness of the symptom.

Graph-3.3

Graph-3.4

Symptoms mentioned by House Hold (%)

050

100150200250300350400


A cough that persists for three weeks Coughing up blood FeverWeight Loss Night Sweats Constant tirednessLoss of appetite All the above BreathlessnessAny other** Cant Recall/mention any of the symptoms

Symptoms mentioned by Opinion Leaders (%)

050

100150200250300350400450


A cough that persists for three weeks Coughing up blood FeverWeight Loss Night Sweats Constant tirednessLoss of appetite All the above BreathlessnessAny other** Cant Recall/mention any of the symptoms


HSP’s in all the states mainly come across Pulmonary TB patients.

Graph -3.5 Graph -3.6

Graph -3.7

Graph -3.8


100 10092

100 100 96 92 96 95

0

20

40

60

80

100


Pulmonary TB (%)

1713

64

46

96

21

75

54

26

0

20

40

60

80

100


Lymph Glands TB (%)

1317

48

21

83

29

71

21

11

0

20

40

60

80

100


Spinal TB(%)

08

28 33

92

29

75

411

0

20

40

60

80

100


Bone TB (%)

30

8

52

21

71

38

75

42

50

20

40

60

80

100


Abdominal(%)

8 8.3 4.2 8.3 5.3

0

20

40

60

80

100


Genetic TB (%)


However, a very small percentage of doctors mentioned having come across genetic TB. HIV-TB and MDR TB was also quite common among the doctors across the states.


Surprisingly doctors from all the states except Chattisgarh informed that PLWH had visited their clinic for treatment of TB. MDR-TB was quite commonly known among the doctors. The knowledge of Sputum culture sensitivity for identifying MDR-TB varied from state to state. 3.2a Symptoms mentioned by HSPs Almost all the doctors contacted mentioned a cough that persists for three weeks as the main symptom they look for in a pulmonary TB suspect. Quite significantly, a considerable percentage of doctors look for coughing up blood as a symptom. Table 3.5 Symptoms mentioned by HSPs (in %)

Pulmonary TB AP TN MAH GUJ CHA UP HP WB MAN Total A cough of 3 weeks 87.0 95.8 100.0 100.0 100.0 100.0 100.0 100.0 100.0 98.0 Pain in the site 39.1 8.3 21.7 29.2 8.3 60.9 27.3 26.1 77.8 31.9 Coughing up blood 43.5 62.5 65.2 25.0 83.3 73.9 90.9 95.7 94.4 69.6 Fever 56.5 54.2 91.3 100.0 95.8 91.3 95.5 91.3 100.0 85.8 Weight loss 65.2 37.5 60.9 83.3 37.5 78.3 77.3 60.9 16.7 58.3 Night Sweats 8.7 8.3 13.0 16.7 45.8 21.7 22.7 13.0 0.0 11.8 Constant tiredness 26.1 33.3 21.7 50.0 25.0 13.0 13.6 13.0 0.0 25.0 Loss of Appetite 17.4 37.5 73.9 75.0 4.2 65.2 50.0 47.8 22.2 46.6 Any other 0 4.2 4.3 4.2 0.0 17.2 18.1 0.0 0.0

Table 3.5a Breakup of Private and Govt. doctors looking for coughing up blood (in %)

Coughing up blood AP TN MAH GUJ CHA UP HP WB MAN Total Private Practitioner 80.0 60.0 40.0 33.3 40.0 52.9 45.0 50.0 52.9 50.0 Govt. Doctor 20.0 40.0 60.0 66.7 60.0 47.1 55.0 50.0 47.1 50.0

44

4

64

25

013

17 1726

0

20

40

60

80

100


HIV-TB(%)

26

42

76 7967

79 79

100

53

0102030405060708090

100


MDR TB (%)


3.3 MYTH ABOUT MODE OF SPREAD STILL EXIST Although more than one third of the respondents across all the states identified cough of an infected person as a mode of spread of TB, fairly high percentage also felt that TB is spread by sharing dishes and clothing of an infected person. More than one third of opinion leaders in all the states except UP mentioned the right mode of spread of TB. Misconception about the same prevailed with more than one-fourth respondents in UP and HP.


Graph -3.15 Graph -3.16 Our survey also found that about 15% of the community was unaware of the mode of spread of TB. Few associated spread with unsafe sex, defecation at open field, unhygienic living condition and even inheritance.

0

10

20

30

40

50

60

70

80

90

100


From Infected person through cough (%)

Household Opinion leader

0

20

40

60

80

100


Talking(%)


0102030405060708090

100


By sharing dishes of the infected person(%)


0102030405060708090

100


By sharing bedding or clothing of the infected person(%)



3.4 PERCEPTION ABOUT WHO ARE PRONE TO TB

Graph-3.17 Both the household and opinion leaders had varied opinion about people who are prone to TB. Those living in congested locality and unhygienic conditions and persons having low immunity were identified by most of the respondents. However respondents from Gujarat, Chhattisgarh and West Bengal mentioned malnourished people to be more prone to TB. Interestingly male respondents in some states mentioned people smoking tobacco to be prone to TB.


Responses on the above statements indicates that a few respondents both among household and opinion leaders feel that TB is a poor man’s disease and are still not clear about women being more prone to TB or not.

Prone to TB (in %)

3628

34

9 5 2

16 15

5

3731 28

4 2 2

21

113

0

20

40

60

80

Persons havinglow immunity

Those living incongested

locality

Malnourished Children Women HIV+ person Familymembers of TB

Patients

Poor Any one

Household Opinion Leader

Rich people do not get TB (%)

0 10 20 30 40 50

SA

A

NAND

D

SD

DK/CS

Male Female Opinion

Women are more prone to TB (%)

0 5 10 15 20 25 30

SA

A

NAND

D

SD

DK/CS

Male Female Opinion Leader


TB usually affects the lungs/chest (%)

0 10 20 30 40 50 60

SA

A

NAND

D

SD

DK/CS


Graph -3.20 Respondents also tried to link smoking,

lungs and chest getting affected to

proneness to TB. Interestingly few also

pointed out that old person, people with

mental tension, people taking oily food,

people practicing unsafe sex, people

suffering from asthma, non-vegetarian

persons and, factory workers are more

prone to TB.

3.4a Perception of Health Service providers More than two-third of the doctors feel that people living with HIV are prone to TB. Table 3.6 HIV + People (PLWA) prone to TB (In %)

AP TN MAH GUJ CHA UP HP WB MAN YES 65.2 95.8 100 95.8 66.7 87.5 95.8 62.5 89.5

3.5 TB IS CURABLE


TB is completely curable (%)

0 20 40 60 80

SA

A

NAND

D

SD

DK/CS


Only medicine can cure TB completely (%)

0 20 40 60 80

SA

A

NAND

D

SD

DK/CS


Once cured a TB patient can lead a normal life (%)

0 10 20 30 40 50

SA

A

NAND

D

SD

DK/CS


Majority of the respondents in both the categories feel that TB is completely curable and agreed that only medicine can cure TB completely. Majority also felt that once cured a TB patient can lead a normal life.

Graph -3.23 Except for doctors in Himachal

Pradesh and Tamil Nadu, in rest of

the states majority of the doctors

opined that TB in PLW HIV is

curable.

Table 3.7 TB curable in HIV + people (in %) AP TN MAH GUJ CHA UP HP WB MAH YES 78.3 37.5 72.0 66.7 58.3 87.5 12.5 66.7 89.5

3.6 AVAILABILITY OF TB RELATED HEALTH FACILITY IN THE VICINITY

More than one third of the household respondents in Gujarat, Uttar Pradesh, West Bengal and Manipur mentioned of having a TB treatment facility in their vicinity. Similar trend was seen among the opinion leaders also. Table 3.8: TB Hospital in the Vicinity (in %)

TB Hospital in their vicinity AP TN MAH GUJ CHA UP HP WB MAN Household 20.6 15.6 16.8 31.5 6.9 36.3 6.8 30.6 35.6 Opinion Leader 5.3 15.0 9.5 25.0 5.0 36.8 5.3 20.0 45.5 HSP 28.6 42.9 50.0 91.7 75.0 46.2 90.9 83.3 90.0

More than half of the private practitioners informed that public health services for TB patients are available in their locality.


3.7 PREFERENCE FOR SYSTEM OF MEDICINE When probed on the system of medicine for treatment, there was a clear preference for Allopathic system of medicine in all the nine states except in Andhra where Ayurvedic system was equally preferred among the Household respondents. Table 3.9: System of medicine preferred (in %)

AP TN MAH GUJ CHA UP HP WB MAN U 58.8 67.1 62.1 63.9 65.8 60.4 59.1 62.7 62.1 R 41.2 32.9 37.9 36.1 34.2 39.6 40.9 37.3 37.9

Allopathic System of medicine preferred by

general community T 53.1 98.8 87.0 95.7 95.0 93.1 85.1 93.8 95.6

Government Hospitals and Private Practitioners both were preferred by respondents for place of treatment across all the states. However about 70% of urban respondents in Andhra preferred Ayurvedic treatment centers. The opinion leaders in HP, WB and Manipur preferred government health center. Table3.10 : Preferred center for treatment (in %)

AP TN MAH GUJ CHA UP HP WB MAN HH 33.1 73.8 23.0 62.3 41.9 20.6 57.8 86.3 84.4 Government Hospital OL 21.1 30.0 28.6 35 40.0 31.6 84.2 65.0 90.9 HH 28.1 26.3 75.2 37.7 58.1 71.3 41.6 12.5 15.6 Private practitioner OL 78.9 70.0 78.4 65.0 60.0 63.2 15.8 35.0 1.1 HH 6.3 - 0.6 - - 7.5 - - - Registered Medical

Practitioner OL - - - - - 5.3 - - - HH 24.4 - - - - 0.6 - 1.3 - ISM & H OL - - - - - - - - - HH 8.1 - 1.2 - - - - - - Traditional Healers OL - - - - - - - - -

Urban slum respondents had a clear preference for government hospitals for treatment while respondents from rural had a mixed response.


Graph –3.24

3.7a Why not to a Government Hospital? Amongst those who do not prefer Government hospitals the chief reasons put forth were - Distance from residence, Non-availability of medicine and Unfriendly behaviour of staff . The Opinion Leaders however cited varied reasons for not going to Government hospitals. Non-availability of medicine emerged as one major reason followed by distance from the place of stay.

Table 3.11: Reasons for not going to Govt. Hospital (in %) Why not to

Government Hospital AP TN MA

H GUJ CHA UP HP WB MAN

HH 25.0 21.4 9.5 17.3 9.0 7.3 2.7 18.4 0.0 Non availability of health personnel OL 0.0 30.4 12.0 27.3 11.8 25.0 16.7 25.0 0.0

HH 30.2 4.8 26.4 14.5 32.8 19.3 8.8 15.8 37.9 Far from place of stay OL 22.2 13.0 28.0 13.6 47.1 10.0 16.7 0.0 100.0 HH 20.8 14.3 19.6 22.7 11.5 24.8 14.2 7.9 13.8 Unfriendly behaviour of

staff OL 16.7 13.0 16.0 18.2 11.8 25.0 33.3 8.3 0.0 HH 15.6 32.1 10.6 12.7 19.7 30.3 43.4 28.9 13.8 Non availability of

medicine OL 44.4 30.4 16.0 22.7 23.5 35.0 33.3 8.3 0.0 HH 6.8 16.7 5.6 13.6 0.8 6.9 7.1 5.3 6.9 Lack of diagnostic

facility OL 11.1 8.7 8.0 4.5 0.0 0.0 0.0 33.3 0.0 HH 1.6 1.2 16.2 13.6 2.5 2.3 11.5 15.8 0.0 Long waiting hours OL 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 HH 0.0 0.0 9.6 5.4 0.0 7.4 12.4 7.9 0.0 Any Other ** OL 5.6 4.3 4.0 13.6 5.9 5.0 0.0 25.0 0.0

**Unaware of Govt. facilities, Facilities not proper, not reliable, No surveillance, Treatment is not good,

5149

6832

6535

6931

7525

5842

4555

6536

6337

0102030405060708090

100


Urban Rural Preference for Government Hospital among the community (%)

Urban Rural


0102030405060708090


Should go for Diagnosis of TB-Household (%)

Private Centre Govt. Hospital DOTS/TB Centre

0

20

40

60

80

100


Should go for Diagnosis of TB-Opinion leaders (%)


3.8 DIAGNOSIS OF TB SUSPECT

On being suspected of having TB, household respondents in all the states except Tamil Nadu indicated that a doctor should be consulted immediately.

Table 3.12 TB Suspect (in %) AP TN MAH GUJ CHA UP HP WB MAN

M 64.3 49.3 54.2 99 100 100 100 62.2 100 Should consult a doctor Immediately F 72.4 55.3 95.9 98.4 100 97.5 100 60.3 100

Govt. Hospital was preferred for diagnosis as well as treatment by household respondents with minor variations across the states. According to most of the opinion leaders a TB suspect should go to a govt. hospital for his/her diagnosis and treatment. DOT /TB center was mentioned by quite a few. All the respondents from WB suggested DOT/TB center as a place for treating TB.

Graph –3.25

Graph –3.26


3.8a Method of diagnosis Although sputum test was identified by majority of the respondents as a method of diagnosing TB, about 60% of the respondents still recognize X-ray as a reliable method for diagnosing TB.


3.8b Diagnosis of TB by HSP Doctors also confirmed that they advise sputum test and chest X-ray for diagnosing Pulmonary TB. On further probing majority of HSPs chose Sputum test for diagnosing Pulmonary TB as they felt that it is the most reliable method. About 22% of the HSP still chose X-ray.


Sputum test is the most reliable diagnosis of TB (%)

0 10 20 30 40 50 60

SA

A

NAND

D

SD

DK/CS


X ray is not a reliable method of diagnosing (%)

0 10 20 30 40

SA

A

NAND

D

SD

DK/CS


1810

54

9

5360

23

6678

0

20

40

60

80

100


Mentioned Sputum & X-Ray (%)

65

83

48

7567 67

54

92 95

0

20

40

60

80

100

AP TN Mah G Ch UP HP WB Man

Only one test- 'Sputum' (%)


Table 3.13 Investigation (in %) For Pulmonary TB AP TN MAH GUJ CHA UP HP WB MAN Total

Mentioned Sputum 42.9 48.4 25.0 39.4 0 12.0 36.4 0 22.2 29.8 Mentioned X-ray 25.0 25.8 17.9 9.1 3.1 8.0 4.5 0 0 13.0 Mentioned Mantoux Skin Test

10.7 3.2 0 0 0 0 4.5 0 0 2.4

Mentioned Sputum & X-Ray 17.9 9.7 53.6 9.1 53.1 60.0 22.7 65.5 77.8 46.2 Mentioned Sputum & Skin 0 9.7 0 6.1 0 0 0 0 0 2.4 Mentioned X-Ray& Skin 0 0 0 0 0 0 0 3.4 0 0.5 Only one Mentioned Sputum 65.2 83.3 48.0 75.0 66.7 66.7 54.2 91.7 94.7 71.1 Mentioned X-ray 21.7 12.5 48.0 20.8 29.2 20.8 33.3 4.2 0 21.8 Mentioned Mantoux test 13.0 4.2 4.0 0 0 4.2 4.2 4.2 0 3.8

Table 3.13a Breakup of Private and Public doctors advising only Sputum test when given

only one choice (in %) AP TN MAH GUJ CHA UP HP WB MAN TOTAL Private Doctors 80.0 65.0 33.3 33.3 31.3 37.5 23.1 45.5 55.6 46.0 Public Doctors 20.0 35.0 66.7 66.7 68.8 62.5 76.9 54.5 44.4 54.0

Table 3.14 Why (in %) AP TN MAH GUJ CHA UP HP WB MAN Sputum Reliable 46.7 82.4 50.0 78.3 66.7 66.7 65.0 91.3 100 X-Ray Reliable 33.3 11.8 50.0 21.7 29.2 23.8 35.0 4.3 0 Mantoux test Reliable 20.0 5.9 0 0 0 4.8 0 4.3 0

3.8c Practice related to sputum test Majority of the doctors mentioned that they advise Sputum test every time or most of the time if they suspect the patient to be TB infected. Except in TN, doctors refer them to government hospitals for sputum test. However very few doctors face problems in getting sputum test done. Table 3.15 Frequency of Sputum test for TB suspect (in %) AP TN MAH GUJ CHA UP HP WB MAN Every time 4.3 54.2 40.0 83.3 33.3 37.5 62.5 79.2 31.6 Most of the time 73.9 20.8 20.0 4.2 29.2 58.3 16.7 16.7 52.6 Occasionally 17.4 25.0 36.0 4.2 37.5 0 12.5 4.2 10.5 Never 4.3 0 4.0 8.3 0 0 0 0 0


Table 3.16 Where sent for Sputum Exam (In %)

AP TN MAH GUJ CHA UP HP WB MAN Govt. Hospital 47.8 16.7 64.0 75.0 20.8 54.2 75.0 58.3 26.3 Private Labs 26.1 83.3 36.0 16.7 37.5 41.7 4.2 41.7 15.8 Both 26.1 0 0 0 41.7 0 8.3 0 47.4

Table 3.17 Problem for sputum Examination (In %) AP TN MAH GUJ CHA UP HP WB MAN Yes 0 0 24.0 16.7 8.3 4.2 0 25.0 0

Table 3.18 What are the problems (In %) AP TN MAH GUJ CHA UP HP WB MAN Time consuming 0 0 0 0 0 0 0 16.7 0 Not economical 0 0 0 25 100 0 0 66.7 0 Difficult to collect first morning sputum

0 0 33.3 75 0 0 0 16.7 0

No facility available 0 0 66.7 0 0 100 0 0 0

3.9 TREATMENT OF TB

Majority of the respondents preferred government hospital for seeking treatment for TB except for West Bengal where households mentioned DOTS center.

Graph-3.31

0

20

40

60

80

100


Should go for Treatment of TB-Household (%)


Similar trend was noticed among the opinion leaders.


0

20

40

60

80

100


Should go for Treatment of TB-Opinion leader (%)


Graph-3.32

Majority of the respondent strongly disagreed to the statement that completing full course of TB treatment is not essential. They were also quite aware that the disease becomes untreatable once a patient stops taking medicine in between.


Majority of the opinion leaders rightly identified the duration of treatment as six months. Table 3.19 Duration of Treatment (in%)

How long it takes to get cured


< Three months 5.3 0.0 9.5 10.0 0.0 10.5 0.0 0.0 9.1 Three months 0.0 0.0 28.6 25.0 20.0 0.0 31.6 5.0 18.2 Six months 31.6 30.0 23.8 20.0 45.0 15.8 36.8 60.0 18.2 Nine Months 0.0 5.0 9.5 10.0 5.0 26.3 0.0 5.0 13.6 One year 10.5 30.0 9.5 15.0 10.0 31.6 10.5 15.0 0.0 < One year 0.0 10.0 14.3 10.0 20.0 15.8 15.8 15.0 27.3 DK/CS 52.6 25.0 4.8 5.0 0.0 0.0 5.3 0.0 13.6

If a person stops taking medicine in between, then the disease becomes

untreatable(%)

0 10 20 30 40 50

SA

A

NAND

D

SD

DK/CS


Completing the full course of TB treatment is not essential(%)

0 10 20 30 40 50 60 70

SA

A

NAND

D

SD

DK/CS



3.9a Treating Pulmonary TB Except for Manipur and Gujarat, more than half of the HSPs treat Pulmonary TB on their own. Allopathic was the preferred system of medicine for treating patients of Pulmonary TB. The average duration of treatment mentioned by majority (55.5%) of the physicians was 6–9months. However about 30.5 % of the HSP’s could not mention any specific duration as they felt that the duration varies for different patient. Table 3.20 Treat Pulmonary TB (in %)

AP TN MAH GUJ CHA UP HP WB MAN Yes 95.7 100 68.0 33.3 62.5 50.0 50.0 62.5 15.8

Table 3.21 System of Medicine followed (in %)

AP TN MAH GUJ CHA UP HP WB MAN Allopathic 72.7 79.2 82.4 100.0 100.0 91.7 100.0 80.0 66.7 Homeopathy 13.6 4.2 11.8 8.3 6.7 33.3 Traditional 6.7 Unani 6.7 Ayurvedic 13.6 16.7 5.9

Table 3.22 MDR-TB (in %)

AP TN MAH GUJ CHA UP HP WB MAN MDR TB Sputum culture sensitivity

100 80.0 57.9 40.0 31.3 57.1 73.7 33.3 100

Treats MDR-TB 16.7 40.0 47.4 20.0 100 9.5 15.8 16.7 20.0

Our survey also found that the doctors treat MDR-TB patients. Most of them could correctly identify the test to diagnose MDR-TB. In most of the states, doctors look for positive sputum turning negative to confirm whether the patient is cured or not. While treating patients, the difficulties mainly faced by doctors in most of the states were that (i) People hesitate to come for treatment and (ii) They do not reveal previous history of TB in their family easily. More than two-third of the patients that went for treatment of TB completed the treatment, except in WB where it was as low as one-fourth.


Table 3.23 Symptoms of Cure (in%) AP TN MAH GUJ CHA UP HP WB MAN Improvement in symptoms 13.3 6.5 21.5 22.3 25.7 36.6 31.0 34.1 57.2 Positive sputum turning -ve 50.0 51.6 39.3 44.4 40.0 30.0 31.0 34.1 42.9 Improvement in X-ray 23.3 12.9 25.0 16.7 31.4 23.3 13.8 29.5 0 Treatment completed 10.0 9.7 3.6 16.7 2.9 10.0 17.2 2.3 0 All 3.3 19.4 10.7 0 0 0 6.9 0 0

Table 3.24 How many completed treatment (in a year) (in%) AP TN MAH GUJ CHA UP HP WB MAN Average number of patients 59 34 62 34 10 433* 112 85 11

% Amongst them completed treatment

69.2 63.1 85.1 68.9 90.0 79.9 72.6 25.2 89.8

* Sitapur district hospital reported to treat around 150 TB patients per day

Table 3.25 Difficulties in treating (in%) AP TN MAH GUJ CHA UP HP WB MAN People hesitate to come 25.0 50.0 26.3 23.1 73.3 33.3 23.1 47.1 Non availability of anti TB Drugs No pathology or X-ray lab available in the vicinity

13.3 33.3

People do not reveal previous history of TB easily

57.1 42.3 36.8 27.8 23.1 35.3

Poverty 23.1 Failure cases 23.1 15.4 Illiteracy 66.7

3.10 PRECAUTIONS

The general population did have some clue about how to control spread of the disease. When asked about it they pointed out that covering face while coughing and using separate utensils was the major precautions that patients and their family took to control the spread the infection.

Table 2.26 Precautions (in %) Precautions AP TN MAH GUJ CHA UP HP WB MAN Cover face 55.6 29.4 15.4 15.0 33.3 22.0 27.8 28.6 22.0 Separate utensils 2.8 20.6 30.8 25.0 16.7 43.9 50.0 23.8 41.5 Not to spit anywhere 38.9 32.4 0.0 5.0 16.7 19.5 11.1 28.6 19.5 Isolate the patient 0.0 0.0 30.8 20.0 0.0 4.9 11.1 19.0 7.3 Avoid Non –veg. 0.0 0.0 7.7 25.0 0.0 7.3 0.0 0.0 2.4 NO precautions 0.0 2.9 0.0 0.0 16.7 0.0 0.0 0.0 0.0 DK/CS 2.8 14.7 7.7 0.0 16.7 2.4 0.0 0.0 7.3 Maintain Cleanliness 0.0 0.0 7.7 10.0 0.0 0.0 0.0 0.0 0.0


Both the household respondents and opinion leader opined that TB patient should be kept in isolation to prevent spread of infection. However they also knew that brief exposure to TB patient rarely infects a person.


3.10a Precautions taken by HSPs

More than half of the doctors in all the states felt that TB do not pose any risk either to their own health or to other patients visiting them. However, they wear mask & gloves and maintain distance from the patients. Majority of the doctors in UP and HP on the other hand mentioned that they do not take any precautions for protecting themselves.

Only few doctors in some states mentioned that patients avoid visiting them because they treat TB patients.

Precautions suggested by doctors to their patients varied from state to state. The three most commonly advised precautions include cover face while coughing, use separate utensils and not to spit anywhere. Table 3.27 TB constitutes any risk to health of other patients (in %) AP TN MAH GUJ CHA UP HP WB MAN Yes 8.7 16.7 40.0 41.7 20.8 4.2 8.3 16.7 31.6 Precautions to protect oneself Maintain Distance 34.5 29.6 10.7 29.7 71.0 12.5 19.2 58.3 81.0 Wear mask & gloves 62.1 51.9 53.6 16.2 22.6 25.0 19.2 4.2 9.5 None 3.4 3.7 32.1 8.1 6.5 58.3 61.5 37.5 4.8 Any other --- 14.8 3.6 45.9 -- 4.2 --- --- 4.8 Other patients avoid visiting you because you treat TB patients

4.3 20.8 12.0 8.3 -- -- -- 12.5 --

TB patient should be kept in isolation to prevent spread of infection (%)

0 10 20 30 40 50

SA

A

NAND

D

SD

DK/CS


Brief exposure to TB patient rarely infects a person (%)

0 10 20 30 40

SA

A

NAND

D

SD

DK/CS



Table 3.28: Precaution suggested to avoid spread of TB (in %) AP TN MAH GUJ CHA UP HP WB MAN Cover face while coughing 24.0 33.3 51.4 43.4 16.0 39.5 38.1 42.9 66.7 Use separate utensils 36.0 44.4 5.7 23.9 32.0 16.3 4.8 2.9 4.8 Not to spit any where 36.0 18.5 22.9 21.7 40.0 30.2 50.0 20.0 19.0 Isolate the patient 4.0 0 14.3 6.5 4.0 9.3 0 34.3 9.5 Any other - 3.7 5.8 4.4 8.0 4.7 7.2 --- ---

3.11 Gender bias/Stigma & Discrimination

Going contrary to our hypothesis that there still exists considerable gender bias in society, related to treatment of TB, a high percentage of responses seem to indicate that people are willing to take care of a TB patient irrespective of their gender. [Is there a tendency towards being ‘ politically correct’?]


Graph 3.39

Willing to take care of male relative (%)

0 10 20 30 40 50 60

SA

A

NAND

D

SD

DK/CS

Male Female

Not willing to take care of female relative (%)

0 10 20 30 40 50

SA

A

NAND

D

SD

DK/CS

Male Female

Treatment of a female TB patient is always delayed(%)

0 5 10 15 20 25

SA

A

NAND

D

SD

DK/CS

Opinion Leader

Female

Male


More than half of the household respondents opposed to the statement that treatment of female TB patient is delayed. On contrary it was interesting to note that more than one third of the opinion leaders feel that treatment is delayed.

Table 3.29 (in%) Household AP TN GUJ MAH CHA UP HP WB MAN

Allowed to attend 84 63.2 55.6 53.8 100 78.1 55.6 55.6 56.3

Beneficiary household also claimed that they have experienced no stigma attached to the TB patients and the patients were allowed to take part in social activities.

Graph-3.40

As many as two-thirds of the opinion leaders feel hesitant to marry off their wards to a person who had TB although majority of them opined that a person can lead a normal life once cured. (refer pg. 23-24 TB is curable) According to the opinion leaders however, discrimination still exists in the society. They pointed out that workers loosing jobs, difficulty in marrying off daughter who had TB and discrimination against students having TB still exists. Nonetheless non- participation in social functions and sending women TB patient to her maternal home was not very common. Nonetheless

Individual attitude of Opinion leaders(%)

21

12

34

32

36

9

0 5 10 15 20 25 30 35 40

Share a meal with a person you know had TB

If you suspect TB in one of your female family member you will wait forsometime before taking her to a doctor.

Marry off your daughter to a boy knowing that he had TB

Isolate your family member having TB from your household

Marry off your son to a girl who you know had TB

Send your daughter in law to her parents house for treatment if she had TBto protect your family members


Graph-3.41

From the HSP’s perspective also it was noticed that quite a significant percentage of them observe difference in concern in the family of female TB patient in Tamil Nadu, Maharashtra, Chattisgarh, Himachal Pradesh and West Bengal.

Table 3.30: Difference in Concern Noticed (in %)

AP TN GUJ MAH CHA UP HP WB MAN Total Yes 0.0 20.8 36.0 8.3 45.8 0.0 25.0 33..3 0.0 19.4

Table 3.31: Who accompanies a TB Patient? (in %)

Household AP TN GUJ MAH CHA UP HP WB MAN Total Alone 8.0 5.3 11.1 0.0 16.7 12.5 22.2 22.2 3.1 9.1 Parents 20.0 15.8 22.2 23.1 16.7 12.5 11.1 44.4 71.9 29.9 In laws 4.0 5.3 0.0 0.0 0.0 9.4 11.1 11.1 0.0 4.5 Friend 8.0 0.0 0.0 7.7 0.0 3.1 0.0 0.0 0.0 2.6 Whosoever was available 36.0 5.3 11.1 30.8 33.3 9.4 11.1 11.1 3.1 14.9 Spouse 16.0 57.9 22.2 15.4 0.0 21.9 44.4 11.1 6.3 21.4 I 4.0 5.3 22.2 15.4 0.0 6.3 0.0 0.0 6.3 6.5 DK/CS 4.0 5.3 11.1 15.4 33.3 25.0 0.0 0.0 9.3 11.7

The respondents from the household claimed that generally parents and spouse accompanied the TB patient to the hospital. Female patients in rural areas were accompanied by their parents and spouse mainly.

Practices(%)

18

11

56

36

23

63

66

0 10 20 30 40 50 60 70

A family with TB patient is not allowed to participate in any socialfunction

Married female TB patient is sent off to her parents house

It is difficult to marry off a daughter who has/had TB.

Children with TB are asked to discontinue studies.

Children of TB infected parents are asked to discontinue school.

Daily wage labourer suffering from TB looses their job.

Husbands / in-laws accompany female TB patient to thehospitals/DOTS centre.


3.12 KNOWLEDGE ABOUT DOTS /DOT CENTER

Among those who mentioned having heard about DOT center there was not much gender wise difference except for UP. Although the percentage of respondents spontaneously mentioning DOT as a center for treatment was meager, on probing they could recall and remember the facilities specifically associated with DOT center. We found a wide variation on the issue.

Except in West Bengal and Manipur around one-third of the opinion leaders claimed to have heard about DOT center. In West Bengal quite interestingly all the opinion leaders have mentioned DOT center.

Graph-3.42 Except for AP, more than two-third of the doctors have heard of DOTS and mostly among them opined that DOTS is good. Doctors in most of the states, other than AP and some in TN, informed that DOT service is available in their locality. 3.13 FACILITIES AVAILABLE AT DOT CENTER

Free diagnosis followed by free medicine was spontaneously indicated as special facilities or features available in DOTS center. However the opinion leaders contacted in Himachal Pradesh had no clue about the facilities.

Heard/ mentioned about DOT Centre(%)

0102030405060708090

100


HH OL HSP


Table 3.32: Facilities provided at DOT centre (in %) AP TN GUJ MAH CHA UP HP WB MAN

HH 29.5 20.0 26.8 33.0 37.5 27.8 34.5 - Free diagnosis (spontaneous) OL 25.0 30.0 - 30.0 40.0 21.4 - 28.1 16.7

HH 29.5 20.0 42.9 23.9 27.5 28.1 13.9 37.9 50.0 Free medicines (spontaneous)

OL 25.0 30.0 27.3 10.0 45.0 28.6 - 25.0 33.3

HH 11.4 14.3 18.3 1.1 25.0 16.7 - - Uninterrupted supply of medicines OL - 10.0 9.1 10.0 10.0 21.4 - 9.4 16.7

HH 22.7 40.0 14.3 19.7 11.0 3.1 13.9 6.9 - All the above OL 50.0 30.0 45.5 10.0 - - - 25.0 - HH 6.8 20.0 28.6 11.3 24.2 6.3 27.8 17.2 50.0 DK/CS OL 0.0 0.0 18.1 40.0 5.0 28.6 100.0 12.5 33.3

People’s perception about DOTS being the sure way of complete cure varied from state to state. However more than 50% from all the states except HP and Chhattisgarh were aware that medicines are for free under DOTS. Table 3.33 About DOTS (in %)

Household AP TN GUJ MAH CHA UP HP WB MAN Total DOTS is sure way of complete cure

48 25 83.3 68.6 8.5 73.3 10.4 28.7 0 30.7

Medicines are provided free under DOTS

56.0 50.0 50.0 76.4 9.6 73.3 6.25 60.6 50.0 34.4

It was surprising to know that very few among the opinion leaders actually had the correct idea about free medicine and DOTS being surest way of cure for TB. Table 3.34

Opinion Leader (%) SA A NAND D SD DKCS Medicine is provided free under DOTS 17.2 11.1 4.4 2.2 0.6 64.4 DOTS is the surest way of cure for TB. 13.3 11.7 6.1 2.8 66.1

Majority of the opinion leaders in 6 out of 9 states showed their keenness to become a DOT Provider. The reason mainly cited by them for so, was to serve the community, free and good quality drugs and the role of DOT provider to protect the patient’s family and community from TB.


Table 3.35 Would like to become a DOT Provider (in %) AP TN GUJ MAH CHA UP HP WB MAN Yes

26.3 45.0 23.8 80.0 80.0 73.7 84.2 85.0 90.9

Table 3.36 If yes Why? (in %)

AP TN GUJ MAH CHA UP HP WB MAN

To serve the community 40.0 39.1 45.5 50.0 59.3 40.6 31.0 36.4 57.7 Free & good quality drugs 21.7 27.3 21.9 7.4 15.6 21.4 27.3 Financial Incentive 4.3 9.1 9.4 3.7 12.5 11.9 18.2 Protects the patients family and community

26.1 18.2 18.8 25.9 21.9 21.4 15.2 38.5

DOTS is the surest way to complete cure 60.0 8.7 3.7 9.4 11.9 3.0 3.8

Those who are not interested in becoming DOT provider mentioned lack of time as a reason for it. Table 3.37 If No Why? (in %)


Lack of time 50.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 NO idea about DOTS center 50.0 100.0

3.13a HSP’s and DOTS Except for TN and Manipur, in rest of the states overwhelming percentage of HSPs knows about the DOTS regimen and among them most of them follow it for treating TB patients. On contrary, not a single doctor in AP mentioned that they know about DOTS regimen. Table 3.38 DOTS Regime (in %) AP TN GUJ MAH CHA UP HP WB MAN

Knows DOTS regime -- 37.5 76.5 100.0 86.7 91.7 100.0 80.0 33.3 Follows the same --- 22.2 92.3 75.0 92.3 63.6 83.3 83.3 100.0

Table 3.39 About DOTs (in %) AP TN GUJ MAH CHA UP HP WB MAN

Dots is good 20.0 40.0 73.9 94.4 93.8 73.7 85.7 81.0 100 DOTS is Bad --- 6.7 26.3 -- -- -- -- -- -- DOTS available in locality --- 46.7 89.5 88.9 87.5 78.9 85.7 90.5 100 Aware of the scheme to involve private practitioners

--- 13.3 63.2 50.0 75.0 68.4 33.3 71.4 8.3


Most of the doctors except in AP, TN and Manipur are aware of the schemes to involve private practitioners in DOTS programme. Majority of government doctors in all the states, excluding AP are involved in DOTS scheme. Those not involved mentioned more workload, not practicing allopathic system of medicine as reasons for not being a part of it. While doctors in Maharashtra, UP and HP gave no reasons for it. Table 3.40 Involvement in DOTS (in %)


Involved in DOTS (only govt. doctors)

0 100 92.3 58.3 83.3 90.9 46.2 75.0 88.9

If no, why Ayurvedic doctor -- --- --- 20.0 50.0 -- -- -- -- Continuing from my residence -- -- -- 20.0 -- -- -- -- -- Work load is more 50.0 -- -- 20.0 -- -- -- -- -- We have special deptt. for treating TB

-- -- -- 20.0 -- -- -- -- --

Being a lady -- -- -- -- 50.0 -- -- -- 100 Not interested 50.0 -- -- -- -- -- -- --- -- Dk/cs -- -- 100 20.0 -- -- 100 100 --

3.13b Interested to become DOTS Provider More than half of the private practitioners in 7 out of 9 states are interested in becoming a part of DOTS programme. Most of them showed their interest for it because free diagnosis is provided under it while some feel that DOTS is the surest way to complete cure.

Table 3.41 Interested in DOTS (in %) AP TN GUJ MAH CHA UP HP WB MAN

Yes 28.6 66.7 50.0 33.3 91.7 84.6 81.8 66.7 80.0


Table 3.42 If Yes, why (in %) AP TN GUJ MAH CHA UP HP WB MAN

Free diagnosis 0 23.9 11.1 10.0 28.1 27.5 32.1 30.8 29.4 Right drug in right doses 12.5 21.7 11.1 20.0 6.3 17.5 10.7 26.9 0.0 Uninterrupted supply of drugs 12.5 17.4 0.0 20.0 3.1 17.5 7.1 11.5 17.6 Make patient feel s/he is wanted 0.0 4.3 11.1 0.0 28.1 2.5 7.1 0.0 41.2 Ensure treatment under direct observation

0.0 8.7 22.2 10.0 3.1 10.0 7.1 11.5 5.9

Ensure that patients do not loose their wage

0.0 13.0 0.0 0.0 6.3 0.0 3.6 0.0 0.0.

Retrieve the default patient 0.0 6.5 11.1 0.0 3.1 5.0 10.7 3.8 0.0 DOTS is the surest way to complete cure

25.0 4.3 11.1 10.0 21.9 20.0 14.3 11.5 0.0

Others 0.0 0.0 22.2 30.0 0.0 0.0 7.2 3.8 5.9 * Social service, free distribution of medicine

Table 3.43 If no, why? (in %) AP TN GUJ MAH CHA UP HP WB MAN

Not practicing Allopathic system of medicine

0.0 0.0 20.0 37.5 0.0 0.0 0.0 0.0 0.0

Own practice will get affected 0.0 33.3 60.0 37.5 0.0 50.0 100 50.0 0.0 Fear of infection 30.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Very few TB suspects visit their clinic 70.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Don’t know about DOTs 0.0 16.7 0.0 25.0 0.0 0.0 0.0 0.0 0.0 DK/CS 0.0 50.0 20.0 0.0 100 50 0.0 50 100

Own practice getting affected was one of the reasons put forth by the doctors for not being interested in DOTS.

3.14 INITIATIVE TAKEN BY OL, NGO AND HSP

The opinion leaders claimed that they have advised the patients and their families’ patient to go to a government hospital. DOT center was also suggested by Opinion leaders of Maharashtra, West Bengal, and Andhra Pradesh as the place for seeking treatment.


Table 3.44 (in %) What do you Advice AP TN GUJ MAH CHA UP HP WB MAN

To go to the Govt. Hospital 62.5 0.0 40.0 0.0 75.0 80.0 100 60.0 71.4 DOT center 37.5 0.0 50.0 0.0 0.0 0.0 0.0 40.0 14.3 Isolate the patient 0.0 0.0 0.0 0.0 25.0 0.0 0.0 0.0 0.0 Proper food intake 0.0 0.0 10.0 0.0 0.0 20.0 0.0 0.0 0.0 Nothing 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 14.3

Only few respondents in some states did take some initiatives like organizing camps and lectures to make people aware about DOTS. Table 3.45 (in %)

Have you taken any initiative AP TN GUJ MAH CHA UP HP WB MAN

Yes 0 0 23.8 15.0 5.0 0 5.3 25.0 0

Table 3.46 If yes what? (in %)


Organised Camps 60.0 33.3 100.0 60.0 Organised Lectures 33.3 100.0 20.0 Monthly Meeting 20.0 33.3 Advised the patient 20.0 20.0


CHAPTER IV INFORMATION SOURCES

4.1 INFORMATION SOURCES Our survey probed for the source of information that the respondents had gathered on TB. Among the household hospital and television was identified as the principal source of information on TB. Friends and relatives also formed a major source among a few across all the states. The same among opinion leaders were Television and hospitals. Newspaper was also mentioned by quite a few in some states.

Graph-4.1

Graph-4.2

0

20

40

60

80

100


Top three sources of information on TB -Household (%)

TV Radio Hospital Friends/Relatives

0

20

40

60

80

100


Top three sources of information on TB -Opinion Leader (%)

TV Radio Hospital Friends/Relatives Newspaper/magazine Hoarding /Posters/placard/


4.2 VISIT BY A HEALTH PERSONNEL TO MAKE PEOPLE AWARE OF TB Apart from mass media sources in most of the states, village health worker followed by doctor was recalled as the health personnel who visited the respondents to make them aware on TB. However a negligible number of opinion leaders across the states mentioned about any person who came to make the community aware about TB. Those who did among them majority mentioned about doctors, health workers and AWW,s.

Graph-4.3

Graph-4.4

0

20

40

60

80

100


Top threeIPC sources of information on TB -Household (%)

Government Doctor Private DoctorDoctor / Nurse in Mobile Clinic Village Health Worker / Nurse from Govt. Hospital / ClinicHealth Worker from NGOs Aanganwadi workersMahila Mandal

0

20

40

60

80

100


Top threeIPC sources of information on TB -Opinion Leader (%)

Government Doctor Village Health Worker / Nurse from Govt. Hospital / Clinic Aanganwadi workers


4.3 INFORMATION SOUGHT ON When the respondents were probed on the kind of information they would like to have on TB, majority asked for prevention, precaution and treatment.

Graph-4.5

Graph-4.6

0

20

40

60


More Information Sought for -Household (%)

Prevention & precaution Symptoms Treatment Spread Availability of services Rehabilitation About Tb

0

20

40

60


More Information Sought for -Opinion Leader (%)

Prevention & precaution Symptoms Treatment Spread Rehabilitation About DOTS


4.4 INFORMATION SOURCE FOR HSP’s Journals is the most used source by doctors for updating knowledge while in few states CME

was also mentioned as source commonly opted by practicing physicians for the purpose.

According to one-fourth of the doctors in almost all the states television could be the best

medium for generating awareness among the community about TB while in some states other

materials like leaflets/ posters and organizing awareness camps were also mentioned by good

number of doctors.

Table 4.1: Update knowledge from (in % )

AP TN MAH GUJ CHA UP HP WB MAN Total CME 13.3 41.7 23.5 24.1 58.3 2.4 10.3 17.6 0 20.0 Journals 33.3 29.2 38.2 35.2 8.3 35.7 17.9 47.1 68.4 34.0 Colleagues 20.0 0 8.8 9.3 25.0 2.4 41.0 0 0 12.3 Professional bodies 13.3 8.3 14.7 20.4 0 21.4 17.9 26.5 0 15.7 Medical Representative 16.7 8.3 5.9 1.9 4.2 16.7 5.1 2.9 0 7.0 No need 3.3 8.3 0 0 0 2.4 0 0 0 1.3 Workshop/ 0 4.2 0 3.7 0 7.1 0 5.9 31.6 4.7 Seminar/ DOTS thearpy 0 0 5.9 1.9 0 0 0 0 0 1.0 Through internet 0 0 0 1.9 0 0 0 0 0 .3 RNTCP Training 0 0 0 1.9 4.2 0 7.7 0 0 1.7 Text book of medicine 0 0 2.9 0 0 9.5 0 0 0 1.7 NR 0 0 0 0 0 2.4 0 0 0 0.3

Table. 4.2: Best medium to generate awareness among the community about TB (in % )

AP TN MAH GUJ CHA UP HP WB MAN Total Television 23.1 30.8 30.0 28.1 32.4 22.7 22.2 16.7 22.0 25.4 Radio 23.1 4.6 11.7 5.3 0 4.5 9.7 6.7 14.0 8.7 Newspaper/Magazine 12.3 18.5 11.7 8.8 7.0 3.0 8.3 5.0 16.0 9.9 Leaflet, pamphlets, booklets, poster

3.1 9.2 8.3 7.0 21.1 25.8 19.4 15.0 16.0 14.8

Awareness camp 20.0 15.4 16.7 17.5 14.1 22.7 22.2 26.7 16.0 19.1 Nukkad Natak 6.2 3.1 5.0 1.8 0 13.6 2.8 15.0 0 5.3 Community Meetings 9.2 18.5 10.0 12.3 11.3 4.5 15.3 13.3 4.0 11.1 Health Workers 1.5 0 3.3 10.5 11.3 0.0 0.0 1.7 2.0 3.4 NO 0 0 1.7 1.8 0 0 0 0 0 0.4 Any other 0 0 1.7 5.3 2.8 3.0 0 0 0 1.5 DK/cs 1.5 0 0 1.8 0 0 0 0 2.0 .5


CHAPTER V MEDIA HABITS

5.1 OWNERSHIP OF ASSET About half the household respondents own a radio set while equal number of respondents (more

than two- third) have television with cable and without cable connection. Similarly more than

60% opinion leaders in all the states except Chhattisgarh own a Radio set. Ownership of

Television set with or without cable connection is comparatively low among the opinion leaders

of Uttar Pradesh

Table 5.1: Ownership of assets (in %) AP TN MAH GUJ CHA UP HP WB MAN Total

HH 51.9 43.1 34.8 36.4 39.4 51.9 48.4 40.0 56.9 48.1 Radio

OL 63.2 60.0 66.7 70.0 40.0 63.2 63.2 95.0 95.5 58.9

HH 16.9 5.0 44.1 30.2 48.8 41.9 69.6 25.0 40.6 35.8 Television without

cable connection OL 5.3 5.0 52.4 20.0 55.0 42.1 63.2 40.0 40.9 36.1

HH 73.8 69.4 39.1 40.1 15.6 21.9 5.0 18.8 42.5 35.2 Television with

cable connection OL 94.7 95.0 33.3 75.0 25.0 26.3 21.1 55.0 54.5 53.3

5.2 PREFERRED TIME SLOT FOR RADIO Preferred time slot for listening radio in all the states was early morning (6-8 pm) while for

watching television was late evening (7-9 pm) among majority of the respondents.

Table 5.2: Top Two Preferred Slots for Listening Radio (in %) AP TN MAH GUJ CHA UP HP WB MAN Early morning HH 71.8 45.8 30.3 38.8 33.1 32.4 37.1 35.9 32.7 OL 57.1 75.0 46.7 60.0 60.0 40.0 52.9 52.9 40.5 Mid- morning HH 7.8 23.4 30.9 18.1 OL 20.0 26.7 Evening HH 19.4 OL 26.7 Late evening HH 22.0 19.5 18.1 32.8 30.7 OL 19.1 18.8 20.0 32.4 29.7 Night HH OL 23.5


5.3 PREFERRED RADIO STATION

Vividh Bharti came out as the most preferred station on radio among household. The opinion

leaders preferred regional station. Table 5.3: Top Two Preferred stations of Radio (in %)

AP TN MAH GUJ CHA UP HP WB MAN Total HH 72.6 79.2 73.4 50.6 75.7 80.2 52.8 67.1 50.3 65.5 Vividh Bharti OL 52.6 35.0 33.3 40.0 10.0 52.6 52.6 45.0 36.4 39.4 HH 66.7 5.2 6.3 1.3 41.9 58.4 46.1 23.7 43.9 34.8 FM OL 47.4 10.0 4.8 0 5.0 31.6 57.9 20.0 18.2 21.1 HH Regional station OL 0.0 55.0 42.9 35.0 40.0 31.6 0.0 70.0 68.2 47.1

News and film songs were the two top preferred programmes among the respondents in Radio.

The opinion leaders identified news as the most preferred programme in the radio.

Table 5.4: Top Two Preferred Radio Programme (in %)

AP TN MAH GUJ CHA UP HP WB MAN HH 53.2 23.8 38.1 49.2 32.8 43.6 46.4 43.2 50.4 News OL 57.1 47.6 52.6 73.3 80.0 60.0 61.1 59.4 52.5 HH 14.7 Drama / serials OL 18.8 27.5 HH 33.9 69.3 27.8 31.4 32.8 45.1 49.6 24.5 Film songs OL 38.1 21.1 13.3 10.0 33.3 27.8 HH Folk Music OL 9.5 HH Discussion on health OL 9.5 10.0

5.4 PREFERRED TIME SLOT FOR TELEVISION

Preferred slot for watching television for majority of the both the category of respondents in all the states was late evening

Table 5.5: Top Two Preferred slot of watching Television (in %)

AP TN MAH GUJ CHA UP HP WB MAN HH 22.6 Early morning OL 29.4 25.0 30.8 21.1 HH 22.3 Afternoon OL 11.8 HH 17.1 Evening OL 11.8 HH 24.5 41.6 36.5 39.4 41.7 47.5 33.8 33.7 39.6 Late evening OL 32.4 52.9 45.8 41.2 35.5 55.0 32.1 28.2 42.1 HH 16.7 31.5 17.5 26.8 29.4 22.2 Night OL 11.8 25.0 47.1 35.5 15.0 25.0


5.5 PREFERRED CHANNEL IN TELEVISION On the other hand, on television Doordarshan’s National Network was singled out as the most

preferred channel in all the states except Tamil Nadu, where Sun TV emerged as the preferred

one. Among opinion leaders of West Bengal DD Regional channel was most watched channel.

Graph-5.1

Graph-5.2

Top Two Preferred Channels -household (%)

0

20

40

60

80


Doordarshan (National) Doordarshan (Regional) DD2 Sun TV Raj TV

Top Two Preferred Channels -Opinion Leader (%)

0

20

40

60


Doordarshan (National) Doordarshan (Regional) Sun TV Local cable channel

Aaj tak E Tv Zee news


5.6 PREFERRED PROGRAMME IN TELEVISION

The households mentioned Drama/ serials and News as the two most favoured programmes on

television. News emerged as the most preferred programme on television by most of the opinion

leaders.

Graph-5.3

Graph-5.4

0

20

40

60


Top Two preferred programmes-Household (%)

News Drama / serials Films

0

20

40

60


Top Two preferred programmes-Opinion Leader (%)

News Drama / serials Films


5.7 READERSHIP PATTERN

Except for Maharashtra, WB and Manipur, in rest of the states, the percentage of respondents

reading one newspaper or the other was around one-third. While in Manipur, more than 85%

read newspaper, only 23% respondents in WB are readers of newspaper. Except in Manipur

male readership was high both in urban and rural areas.

However almost all the opinion leaders read newspaper except in Uttar Pradesh where readership

was about 60%.

Graph-5.5

Table 5.6: Readership among male female household (in %)

AP TN Mah G Ch UP HP WB Man Male 53.6 62.3 72.7 60.9 56.3 45.8 39.6 30.0 91.7

URBAN Female 31.9 20.4 43.5 31.6 22.6 14.0 19.2 6.1 86.5

Male 39.3 77.3 78.1 59.5 40.0 54.5 86.7 34.4 76.7 RURAL

Female 20.7 32.3 67.9 21.7 24.1 13.8 54.8 27.6 83.3

0

20

40

60

80

100


Readership of Newspaper (%)

Household Opinion Leader

baseline kap study under rntcp project - cms

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