Community’s knowledge, attitudes and practices about tuberculosis in Itang Special District, Gambella Region, South Western Ethiopia

Tuberculosis (TB) is a chronic bacterial disease mainly caused by Mycobacterium tuberculosis (M.tb)[1]. The disease is mainly transmitted through air droplets, cough, and sneeze, when patient expels droplets containing bacilli and inhaled by healthy individuals. Although TB primarily affects the lungs it also affects any part of the body including kidney, brain, intestine, bone and lymph nodes [2].

Each year, an individual with active Pulmonary Tuberculosis (PTB) infects an average of 10–15 people [3]. Moreover, in a community with low levels of awareness about the cause, mode of transmission and preventive methods, the spreading of TB could be high [4, 5]. The estimates for the year 2010 global TB prevalence and incident cases were 12 and 8.8 million respectively [2]. The vast majority of the cases (95%) and deaths (98%) occur in resource limited countries [3]. This situation has been aggravating with growing problem of resistances to first line anti-TB drugs resulting in half million of new cases of multi drug resistances (MDR TB) [6, 7]. Therefore, TB situation is most likely to continue to deteriorate due to multiple factors such as HIV/AIDS pandemic, poverty, low level of awareness and adverse effect of poor quality TB program [3].

Ethiopia is among the 22 High Burden Countries (HBCs) [8] and TB accounts for the major proportion of hospital admissions and reported as being the third leading cause of hospital deaths next to malaria and obstetric cases [9]. In the year 2010,the national estimate of the prevalence and incidence and mortality rates of TB were 294, 261 and 35 per 100,000 population respectively, whereas smear-positive PTB (SPPTB) cases were estimated to be 46,634 among adults aged above 15 years [2]. To reverse the impact of TB situation, TB control strategies including decentralizing/expansion of TB diagnosis and treatment services to peripheral units like health posts, private clinics, expanding health extension program (HEP) and engagement of communities through health extension workers (HEWs) have been the focus of Federal Ministry of Health [10]. One study in the southern part of Ethiopia indicated that engagement of the HEWs has improved TB case detection rate (CDR), treatment success rate (TSR), community’s awareness in TB suspect identification/contact tracing activities and screening of TB patients for HIV infection [11].

Gambella Regional State (GRS) is one of the high TB burden regional sates within Ethiopia [3]. In the year 2010, 953 TB cases were detected and treated in this Regional State and among these cases 621 patients were PTB cases [12]. Even though assessment of communities’ knowledge, attitude and practice (KAP) are key elements in prevention and control of TB parallel to other control strategies [3], there is no/little information on communities’ KAP towards the control of TB in GRS. The objective of this study was to assess communities’ KAP regarding TB in Itang Special District of the GRS, South Western Ethiopia.

The results of this community-based cross-sectional study showed that most of the community’s members of Itang Special District have information about TB. The finding is similar to the results of studies from Afar Region [16], South West Ethiopia [17] and North Ethiopia [15, 18], Malaysia [19] and rural China [20]. The main sources of information mentioned by the study participants are also similar to the findings of study conducted in other part of Ethiopia [15]. In the current study, very few participants mentioned mass media as a source of information about TB which is inconsistent with studies done in Lahore [21], Iraq [22] and Pakistan [23] in which most of the study participants’ mentioned mass media as a major source of information about TB.

Despite a higher proportion of the study participants have heard about TB, the majority had no/little knowledge about the cause of the disease. Only 3.3% of the participants correctly answered the cause of TB as being germ/bacteria which is in agreement with the findings of study from other part of Ethiopia [16]. Cold air, alcohol consumption, smoking and shortage of food were frequently mentioned as the cause of PTB by the present study participants which is similar to the findings of studies in Tigray, Afar and North Ethiopia [15, 16, 18], but differ from the findings of previous study on TB suspects in a rural community of southwest Ethiopia, in which sizeable number of the study participants mentioned bacteria as the cause of TB [17]. The difference might be due to early deployment of HEWs in the previous study area as compared to the present study area [9]. In addition to this, a rural community of South West Ethiopia has been exposed to students’ practicum program from Medical school of the Jimma University. Hence, relatively information on TB might be easily disseminated among that community as compared to the present studied community [24].

In previous studies conducted in varies parts of Ethiopia [15–18], the majority of the study participants identified persistent productive cough as the major signs and symptoms of PTB. In the present study, persistent productive cough was mentioned as signs and symptoms of PTB by very few study participants. The discrepancies might be due to socio-cultural factors such as smoking of Gaya by most of the indigenous in the present study area [12].

Gaya is a local name given to instrument used to prepare and suck after tobacco, few drops of water is added and roasted with fire gently until evaporation starts to make it comfortable for sucking. It causes addiction like any other addiction causative substances such as cigarette. It causes productive cough among smokers. This situation misleads perception of the communities in that, productive cough is caused by smoking of Gaya rather than due to PTB and delay them from early diagnosis and treatment of PTB. Results of the present study regarding the signs and symptoms of PTB are also inconsistent with the findings of other studies conducted elsewhere [20, 21] in which majority of the participants mentioned persistent productive cough as major signs and symptoms of PTB.

In this study, the study participants reported that PTB is treatable and curable with modern drug which is consistence with the findings of previous studies in other parts of Ethiopia [15, 16], in Iraq [22], in South Africa [25] and in Tajikistan [26]. However, the finding of the current study is different from the results of previous studies conducted in south part of Ethiopia [27] and in Tanzania in which greater than half of the study participants reported roots bark from trees, oil from meat, blood, and fat as the effective treatment for TB [28]. High level of awareness of the communities about the appropriate treatment of the disease could have significant implications in reducing diagnosis and treatment delay, as well as the spread of the disease.

The present study showed that a considerable proportion of the study participants had unfavorable attitude towards TB patients which could potentially create ground for stigmatization of TB patients in the communities [18, 25, 29]. On the other hand, the participants recognized that specific groups of population/individuals such as poor, people living with HIV/AIDS, alcohol consumption and smokers are at high risk of getting TB which corroborates the findings of previous studies conducted in Ethiopia [15–17], in India [29], Vietnam [30] and Tajikistan [26]. More than half of the study participants thought that TB is killer even after treatment in patients who have low socio economic status, which is similar to the finding of study conducted in West Bengal in which the majority of the study participants including community leaders felt that poor people cannot be cured completely from TB by treatment [31].

The study participants indicated that the communities in the present study area are engaged in different practices such as cultural and modern facility based mixed approaches of treatments for TBL. A considerable proportion (45%) of the study participants said that they consult traditional healers for the treatment of TBL, and the traditional healers treat the site of swelling by burning with metal materials. Study in other part of Ethiopia indicated that patients with TBL are treated with herbal medicine by traditional healers [16]. The discrepancies in traditional ways of treatment of TBL might be aroused from several factors like cultural and environmental differences of the studied communities.

About half of the study participants’ consult HEWs for the treatment of PTB at health post levels which disagrees with findings of previous study in North part of Ethiopia [18] in which majority of the PTB suspects visited medical health providers at health centers and hospitals levels, where there are trained man power, diagnostic facilities and anti TB regimens relatively available. This difference might be due to early deployment of community’s HEWs in the previous study area [9]. In addition to this, majority of the present study communities are highly mobile as compared to the previous study which make difficult to provide health education on the medical importance of TB [14].

In this study, it was noted that, majority of the participants from the Nuer site had low level of overall knowledge; attitude and practices of TB compared to participants from Opwo and Anywa sites. This difference might be linked to mobility of the community as most of the inhabitants of Nuer are pastoralists which make it difficult to provide health education on the importance of medical care for TB by HEWs. The results of the study conducted in Malaysia showed absence of significant association between score on general knowledge and attitude towards TB with age, gender and educational levels of the study participants [19]. In the present study, it was found that female participants had low level of favorable attitude and poor practices towards the prevention of TB as compared to male participants. The finding is in agreement with previous study done in Ethiopia [15] and studies done elsewhere [29, 32–34]. Hence, community based health education which focuses on pastoral community and females’ inhabitants could be important to improve their knowledge, attitude and practices of TB in the present study area.

The results of this study revealed a low level of knowledge about the causative agent as well as about the main symptom of TB in the present study communities. In addition, the study showed low level of overall knowledge, unfavorable attitude and poor practices towards TB especially in participants from Nuer site and females. Hence, public health education on the cause, symptoms and mode of transmission of TB would be important towards the prevention and control of TB in the present study area.