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Knowledge of tuberculosis and associated health-seeking behaviour among rural Vietnamese adults with a cough for at least three weeks
Nguyen Phuong Hoa, Anna E. K. Thorson, Nguyen Hoang Long and Vinod K. Diwan Scand J Public Health 2003 31: 59 DOI: 10.1080/14034950310015121 The online version of this article can be found at: http://sjp.sagepub.com/content/31/62_suppl/59

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ORIGINAL ARTICLE

Knowledge of tuberculosis and associated health-seeking behaviour among rural Vietnamese adults with a cough for at least three weeks
Nguyen Phuong Hoa1,3, Anna E K Thorson3,4, Nguyen Hoang Long2,3 and Vinod K Diwan3,4
1 National Institute of Tuberculosis and Respiratory Diseases, Hanoi, Vietnam, 2Ministry of Health, Hanoi, Vietnam, 3Division of International Health (IHCAR), Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden, 4Nordic School of Public Health, Gothenburg, Sweden

Scand J Public Health 2003; 31(Suppl. 62): 5965 Aims: Good general lay knowledge of tuberculosis (TB), its cause and treatment is considered important for both prompt healthcare seeking and adherence to treatment. The main aim of this study was to describe the knowledge of TB among men and women with a cough for more than three weeks and to see how their health seeking related to TB knowledge. Methods: A population-based survey was carried out within a demographic surveillance site in Vietnam. The study population included 35,832 adults aged 15 years or over. Cough cases were identied at household level and structured interviews were carried out with all cases of cough in person. Results: A total of 559 people (1.6%) reported coughing with a duration of three weeks or longer (259 men and 300 women). A large proportion of individuals with a cough for more than three weeks had limited knowledge of the causes, transmission modes, symptoms, and curability of TB. Men had a signicantly higher knowledge score than women (3.04 vs 2.55). Better knowledge was signicantly related to seeking healthcare and seeking hospital care. More men than women did not take any health care action at all. Discussion: Health education for TB thus seems to be useful, but efforts must be made to ensure that both men and women in different socioeconomic contexts can access the information. Key words: cough, gender, health seeking, knowledge, population-based, tuberculosis, Vietnam. Nguyen Phuong Hoa, National Institute of Tuberculosis and Respiratory Diseases, Hanoi, Vietnam. e-mail: hoatuber@ yahoo.com

INTRODUCTION Tuberculosis (TB) is one of the greatest public health problems in the world. It accounts for about 2.5% of the global burden of disease and 26% of preventable deaths. About 95% of all TB cases and 99% of deaths due to TB occur in low-income countries (1). There are an estimated 8.4 million new TB cases every year (2). In most low-income countries, about two-thirds of the reported TB cases are among men, with only onethird among women (3). The reasons for this gender difference in case reporting are unclear. There are two hypotheses to explain such a difference: either a real difference in incidence, or under-diagnosis and underreporting of TB in females (4 6). Vietnam ranks thirteenth among the worlds nations in terms of numbers of TB cases (2). Gender-specic notication rates in Vietnam show similar ratios to
This paper has been independently peer-reviewed according to the usual SJPH practice and accepted as an original article. # Taylor & Francis 2003. ISSN 1403-4948

those globally, with a total of 88,879 TB cases detected in 1999, with a male to female ratio of 2:1 (7). Vietnam is one of only a few countries with a high TB burden that have reached the WHO targets on case nding and treatment success (2). High political commitment in Vietnam is translated into high priority on TB control. Major obstacles to sustain effective TB control in Vietnam include the increasingly active but poorly regulated private health sector (8), the growing threat from HIV/AIDS (9) and the emergence of multi-drug resistant TB (7). Vietnam has developed a vast infrastructure of health facilities, achieving a good density of service provision at all levels, including hospitals and health centres (10). Since 1986 an economic reform movement from planned to market-oriented economy, Doi Moi, has been implemented in Vietnam. Major healthcare reforms have included the introduction of hospital user fees and legalisation of private healthcare practices. The large amount of out-of-pocket expenditure on healthcare shows that families pay signicant user costs even
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NP Hoa et al. so, the individual was interviewed in person using a structured questionnaire. A structured questionnaire was developed and administered for all identied cough cases to collect socioeconomic and demographic variables (age, gender, marital status, education, health insurance, means of transportation, smoking, etc.), symptoms other than cough, healthcare-seeking behaviour from the onset of the cough symptoms, and knowledge of TB. To classify education, skills in reading and writing were rst elicited. If literate, then the level of schooling was used to classify education; otherwise the individual was categorized as illiterate. The knowledge questions were based on the medical perspective on TB promoted by the National Tuberculosis Control Programme (NTP). The cough cases were asked about the causes of TB, whether TB was contagious, the mode of TB transmission, whether TB was curable and symptoms suggestive of TB. The questions asked were open-ended and several alternatives were allowed in the responses. Answers were categorized into correct (if matching the medically correct answer) or else incorrect and then in turn sorted into categories inspired by the qualitative studies by Long et al. in 1996 in Vietnam (13). One point was given for each of the correct answers. If several alternatives were given and at least one was dened as correct, one point was given. The interviewees were also asked how and from which sources they had received information about TB. The questionnaire was pre-tested in the eld to ensure that all questions were clear and understandable. No person refused to take part in the interview study. A local authority classication was used to dene socioeconomic status. This classication is based on the amount of rice produced per capita. Healthcare actions and providers were classied as: (a) selftreatment, (b) private practitioners, (c) pharmacies, (d) traditional healers, (e) communal health centres (CHCs), (f) hospitals, and (g) others. Qualied health providers were dened as those operating within the government healthcare system. Less qualied providers were dened as those less regulated by the government, whose quality of care has proved to be low (20, 21). To minimize recall bias, the interviewers used calendars or individual events. A medical record crosscheck was done in cases who had used healthcare at CHCs or hospitals. One medical doctor supervised the data collection, including rechecking all questionnaires submitted by eld supervisors. Some 15% of all cases were randomly selected to be re-interviewed by the study supervisor or by one of the investigators within a week of the original interview. Data were processed and analysed using Epi-Info 6.04 and SPSS version 10.0. Means and proportions

to use subsidized public facilities. Expenditures on fees and drugs average US$2 visit to a commune health centre, despite the fact that there are no ofcial fees, and about US$5 for a hospital outpatient visit (11). Some evidence indicates that economic reforms have affected the public healthcare system, making it less accessible and less affordable, particularly for the poor (11). In Vietnam, as recommended by the WHO, case detection is based on passive case nding using sputum smear microscopy. The patients should themselves seek an adequate health facility. However, factors such as the stigma attached to TB (12, 13), perceptions of TB as a dirty and incurable disease (14) and popular misconceptions are likely to have negative effects on the health-seeking behaviour of undiagnosed TB patients. Considerable delays in healthcare seeking and TB diagnosis have been reported (15). TB control could improve signicantly if more consideration were given to knowledge and attitudes towards TB and related healthcare seeking among the population (16 18). The main aim of this study was to describe the knowledge of TB among men and women with a cough for more than three weeks and how that knowledge affected their health-seeking behaviour. METHODS The study was conducted within a longitudinal population-based demographic surveillance site called FilaBavi, in Bavi District, in a northern rural area of Vietnam. The population of Bavi District in 2000 was 242,780. The public healthcare system in this district included a district hospital with 150 beds, three intercommunal polyclinics and 32 commune health centres. In addition, there were more than one hundred private practitioners and some private pharmacies and drug outlets in the district. However, most of them practised illegally, without licences. The sample size for FilaBavi included 67 randomly selected clusters comprising 11,547 households with 49,893 inhabitants, about one-fth of the total districts population (19). A population-based cross-sectional survey was carried out during April June 2000. All people aged 15 years or older in all 67 clusters of the FilaBavi were included in the study. During the survey, all households were visited by specially trained interviewers. Potential cough cases were identied by a screening question. The denition of a cough case was an individual who had had a cough for three or more weeks at the point of interview. Female interviewers asked the household representative (most often the senior female head of the family) whether anyone in the family had a prolonged cough, and, if
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Knowledge of TB and associated health-seeking behaviour were calculated as appropriate. Chi-squared tests and 95% condence intervals for means or proportions were used to describe differences between groups. Non-parametric methods were used for some comparisons. Logistic regression analyses were performed to study associations between background variables and healthcare action or hospital treatment. The following variables were included as independent variables: gender, age, education, economic status, cough duration, number of symptoms, health insurance, means of transportation, and TB knowledge score. Ethical permission for the study was obtained from the Ministry of Health, local authorities of the Bavi District, Vietnam, and Karolinska Institutet, Sweden. The Research Ethics Committee at Umea University has given ethical approval for the FilaBavi household surveillance system, including data collection on vital statistics (reference number 02 420). RESULTS Prevalence of cough and background data A screening question was put to a total of 11,547 households (covering 35,832 people aged 15 or over;
Table I. Socioeconomic and demographic characteristics of 300 women and 259 men in Vietnam with a cough for more than three weeks Characteristics Occupation: Farmer Student & Government staff Other Women n (%) Men n (%) 199 (66.3) 21 (7.0) 80 (26.7) 147 (56.7) 45 (17.4) 67(25.9) 10 214 23 12 25 51 134 46 3 (3.9) (82.6) (8.9) (4.6) (9.7) (19.7) (51.7) (17.8) (1.1)

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16,737 men and 19,095 women). Among those, 559 people (1.6%) reported a cough with duration of three weeks or longer (prolonged cough) at the point of interview (259 men and 300 women). The prolonged cough prevalence was similar among men and women in the age groups 15 54 years, but signicantly higher among men compared with women in the older age groups (54 years or over). The illiteracy rate was signicantly higher among women (15%) than men (4%) (pv0.001). More men (22%) than women (13%) reported having health insurance (pv0.01). More men than women reported being smokers (48% compared with 12%, pv0.001) (Table I). Knowledge and sources of information about TB Among the 559 people who reported a prolonged cough, 41% of the women and 57% of the men thought that TB was caused by hard work and 31% of the women and 36% of the men that it was hereditary (Table II). Only 22% of the people reported that bacteria caused TB. Signicantly more men than women gave the answer of a bacterial cause (pv0.05); 86% of the men and 79% of the women (pv0.05) reported that TB is contagious. Knowledge about the mode of TB transmission (droplet spread) was lower among women (63%) than among men (73%), pv0.05. Signicantly more men than women thought that TB was curable if correct treatment were given (73% of men vs 59% of women, pv0.001). The mean knowledge score was 2.78 (95% CI 2.66 2.90). Men had a signicantly higher score than women (3.04 and 2.55 respectively, pv0.001). A higher knowledge score was signicantly associated with higher education, age less than 65 years, being married, being government staff, and being a student (Table III). Commonly reported sources of information included television and radio (54% of men, 46% of women, pv0.001), friends and relatives (50% of men and 49% of women). People who reported television and radio as sources of information had higher knowledge scores compared with those who reported receiving information from friends or relatives (mean score: 3.39 vs 2.05 respectively, pv0.001). Health-seeking behaviour More women (94.6%) than men (78.8%) reported that they took healthcare action for their symptom of cough (pv0.001). The most common reason for not taking action was that the disease symptoms were not considered serious (42%). The general healthcareseeking pattern was quite similar among men and women with a preference for private health providers. However, signicantly more women than men chose self-medication or a visit to the pharmacy as their rst
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Education: Illiterate 45 (15.0) Primary and secondary school 232 (77.3) High school 17 (5.7) University or higher 6 (2.0) Economic classication: Very poor Poor Average Upper average Rich Religion: Non-religious Buddhists and others Marital status: Married Single Separated, divorced, widowed 26 55 159 57 3 (8.7) (18.3) (53.0) (19.0) (1.0)

282 (94) 18 (6) 166 (55.3) 37 (12.3) 97 (32.4)

244 (94.2) 15 (5.8) 210 (81.1) 31 (12.0) 18 (6.9) 66 (25.5) 125 (48.3) 68 (26.2)

Number of persons in household: 13 95 (31.7) 45 117 (39.0) 6 or more 88 (29.3)

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Table II. Responses to questions on causes, communicable nature, modes of transmission, possibility of cure, and knowledge of TB symptoms among Vietnamese adults with a cough for more than three weeks Response to questions 1. Cause of TB Germ/bacillusa Hard work Hereditary TB Other Do not know 2. Is TB transmissible? Yesa No Do not know 3. Mode of transmission Infectious droplet spreada Other (sharing eating, smoking) Do not know 4. Possible to cure TB? Yesa No Do not know 5. Knowledge of TB symptoms Yesa No Women (n~300) n (%) 55 124 92 19 115 (18.3) (41.3) (30.7) (6.3) (38.3) Men (n~259) n (%) 67 148 93 35 66 (25.9) (57.1) (35.9) (13.5) (25.5) Pb 0.03

238 (79.3) 12 (4.0) 50 (16.7) 150 (63.0) 56 (23.5) 32 (13.4) 177 (59.0) 20 (6.7) 103 (34.3) 145 (48.3) 154 (51.3)

222 (85.7) 9 (3.5) 28 (10.8) 163 (73.4) 47 (21.2) 12 (5.4) 190 (73.4) 15 (5.8) 54 (20.8) 145 (56.0) 114 (44.0)

0.04

0.04

0.001

0.08

Notes: Correct answers according to the National Tuberculosis Programme health education guidelines; bp-values were calculated for the comparison of the proportions of men and women giving the correct answer.

Table III. TB knowledge scores by gender, age group, level of education, occupation, and marital status among Vietnamese adults with a cough for more than three weeks Characteristics Gender: Male Female Age group: 15 24 25 44 45 64 65z Education: Illiterate Primary and secondary school High school or higher Occupation: Farmer Student, Government staff Other n Knowledge score Mean SD pa 0.001

259 3.04 1.59 300 2.55 1.48 51 156 157 195 2.69 2.96 2.99 2.48 1.59 1.39 1.34 1.52

0.003

55 1.91 1.34 446 2.77 1.44 58 3.64 1.21 346 2.75 1.38 66 3.30 1.54 147 2.62 1.56

0.001

0.001

Marital status: Married 376 2.99 1.34 Other (single, divorced, etc.) 183 2.34 1.59

0.001

Notes: ap-values based on comparisons of two or several means using analysis of variance.
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healthcare action (33% vs 20%, pv0.02), and signicantly more men (26%) than women (16%) sought care at a hospital at any point during their disease period (pv0.005). Factors that could inuence healthcare seeking among men and women were also investigated. The mean duration of cough was signicantly longer among men (21.1 weeks) than among women (16.2 weeks) (pv0.001). Sputum production was more common among men than among women (61% vs 50%, pv0.01). The mean numbers of symptoms other than cough were not signicantly different between genders (3.1 among men and 3.0 among women). Knowledge score mean values did not differ signicantly between those who took any healthcare action and those who did not (2.81 vs 2.55), but more people who knew TB symptoms than those who did not reported taking healthcare action (Table IV). However, in a logistic regression model taking healthcare action as the dependent variable and age, gender, education, economic status, cough duration, number of symptoms, means of transportation, and TB knowledge score as independent variables, being a woman (pv0.001) and having a higher knowledge score (pv0.05) were signicantly associated with taking healthcare action.

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Knowledge of TB and associated health-seeking behaviour

Table IV. Knowledge of TB among potential TB cases in Vietnam and subsequent healthcare actions Healthcare action (n~559) Yes (%) pa 48 (88.9) 136 (85.5) 0.716 304 (87.9) 265 (91.4) 0.002 223 (82.9) 116 (95.1) 0.004 372 (85.1) 400 (87.0) 0.600 88 (88.9) Seeking hospital care (n~559) Yes (%) pa 7 (13.0) 25(15.7) 0.024 85 (24.6) 80 (27.7) 0.001 37 (13.8) 33 (27.2) 0.05 84 (19.2) 102 (22.2) 0.13 15 (15.3) 70 (22.3) 0.35 47 (19.1) 84 (22.9) 0.12 33 (17.2)

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Knowledge Score: 0 12 35 TB symptoms: Yes No Cause of TB: Bacteria Others TB transmission: Yes No/unknown

Mode of transmission: Droplet spread 268 (85.6) 0.180 Others 20 (89.4) Curable disease: Yes No/unknown 322 (87.7) 0.666 166 (86.5)

Notes: ap-values are based on chi-squared tests.

Hospital care seeking was signicantly related to mean knowledge score (Table IV). In the group who had visited a hospital, the mean knowledge score was 3.15 compared with 2.70 among those who did not visit a hospital (pv0.005). Individuals who did not know any symptoms suggestive of TB more commonly (80.0%) used less-qualied healthcare providers (such as self-medication, private practitioners, and pharmacies) for their rst healthcare action than people who knew TB symptoms (68.3%) (pv0.01). In total, 30% among those who knew TB symptoms compared with 17% of those who did not visited a hospital. In a logistic regression model with visiting a hospital as the dependent variable, seeking hospital care was signicantly associated with having a higher knowledge score, (pv0.05), longer cough duration (pv0.001), more disease symptoms (pv0.002), and having health insurance (pv0.001). Other variables (gender, age, economic status, means of transportation) were not signicantly associated with going to hospital. DISCUSSION Most countries in the world nowadays apply passive case-nding approaches for TB detection, as recommended by the WHO. This means that individuals who suspect TB infection have to initiate the

rst patient-health provider contact. In this context, knowledge of causes, symptoms, modes of transmission, and curability of TB plays a critical role. Several studies have reported long delays in TB diagnosis, differences between men and women in TB diagnosis and health-seeking delays, and factors inuencing these delays (12, 15, 17, 21). However, studies that have assessed health seeking in relation to knowledge are less common. We found that knowledge of causes, transmission routes, symptoms, and curability of TB was low: 82% of the women and 74% of the men did not know that TB is caused by bacteria. A large proportion reported that TB is caused by hard work or that it is a hereditary disease. Our ndings indicate an association between knowledge levels and education, media access, and gender, and highlight the complexity of successful health communication. Promoting health education through radio and television may not be enough if the wish is to reach and inuence potential TB cases. TB globally is most common among the socioeconomically disadvantaged, and if equal opportunities to education and media access are not forthcoming, health communication may fail despite good intentions. To understand traditionally held beliefs in causes and characteristics of TB is important for facilitating communication about the disease to the population. The NTP in Vietnam considers modern (biomedical) actual knowledge in the population important for TB control. A generally good knowledge level is wished for in order to minimize patients delay in receiving healthcare and to reduce TB-related stigma. The concept of knowledge has many aspects and the denition of what is right or wrong is not self-evident. Peoples expressed traditional beliefs may in some respects relate to correct perceptions of the disease. However, since the Vietnamese NTP has used health education and communication campaigns specically to educate the population in medical knowledge of TB, we chose to study this aspect. Despite these campaigns knowledge levels were low. One reason for this could be that the NTPs message about TB is not contextualized in traditionally held beliefs. To be successful, any educational programme must begin with an understanding of the knowledge base of participants and relate traditional beliefs to modern medical knowledge. Traditional beliefs in the causes and transmission patterns of TB have been reported from many parts of the world (17, 22, 23). A qualitative study from Vietnam reported beliefs in four types of TB: hereditary TB congenital transmission, mental TB caused by too much thinking, physical TB caused by hard work, and lung TB caused by a germ (13). Our study reports similar ndings. Hard work or
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2. World Health Organization Western Pacic Region Cases notied in 1999, WHO WPR Report 2000. WHO-WPR/TB/00.5. Manila: WHO-WPR, 2000. 3. World Health Organization 2002. Global tuberculosis control: surveillance, planning, nancing. Report 2002, WHO/CDS/TB/2002.295. Geneva: WHO. 4. Holmes CB, Hausler H, Nunn P. A review of sex differences in the epidemiology of tuberculosis. Int J Tuberc Lung Dis 1998; 2: 96 104. 5. Thorson A, Diwan VK. Gender inequalities in tuberculosis: aspects of infection, notication rate, and compliance. Curr Opin Pulm Med 2001; 7: 165 9. 6. Borgdorff WM, Nagelkerke NJD, Dye C, Nunn P. Gender and tuberculosis: a comparison of prevalence surveys with notication data to explore sex differences in case detection. Int J Tuberc Lung Dis 2000; 4: 123 32. 7. National Tuberculosis Programme, Vietnam. Review of the National Tuberculosis Programme for the period 1996 2000. Ho Chi Minh City: Author, 2001. 8. Lonnroth K, Thuong LM, Linh PD, Diwan V. Delay and discontinuity a survey of TB patients search of a diagnosis in a diversied health care system. Int J Tuberc Lung Dis 1999; 3: 992 1000. 9. Bosman MCJ. National TB Control Programme, Vietnam. MCNV-KNCV mission, report no 23. Hanoi: MCNV/KNCV, 2001. 10. Ministry of Health, Vietnam. Health Statistics Yearbook 1997. Hanoi: Ministry of Health, 1997. 11. World Bank. Vietnam: poverty assessment and strategy. Washington, DC: World Bank, 1995. 12. Johansson E, Long NH, Divan VK, Winkvist A. Gender and tuberculosis control: perspectives on health seeking behaviour among men and women in Vietnam. Health Policy 2000; 1: 33 51. 13. Long NH, Johansson E, Diwan VK, Winkvist A. Different tuberculosis in men and women: beliefs from focus groups in Vietnam. Soc Sci Med 1999; 49: 815 22. 14. Johansson E, Diwan VK, Huong ND, Ahlberg BM. Staff and patient attitudes to tuberculosis and compliance with treatment: an exploratory study in a district in Vietnam. Tuber Lung Dis 1996; 77: 178 83. 15. Long NH, Johansson E, Lonnroth K, Eriksson B, Winkvist A, Diwan V. Longer delays in tuberculosis diagnosis among women in Vietnam. Int J Tuberc Lung Dis 1999; 3: 388 93. 16. Westaway MS. Knowledge, beliefs and feeling about tuberculosis. Health Educ Res 1989; 4: 205 11. 17. Steen TW, Mazonde GN. Ngaka ya setswana, ngaka ya sekgoa or both? Health seeking behaviour in Botswana with pulmonary tuberculosis. Soc Sci Med 1999; 48: 163 72. 18. Alvarez-Gordillo GC, Alvarez-Gordillo JF, DorantesJimenez JE, Halperin-Frisch D. Perception and practices related with tuberculosis and treatment compliance in Chiapas, Mexico. Salud publica Mex 2000; 42: 520 8. 19. Chuc NTK, Diwan VK. FilaBavi, a demographic surveillance site, an epidemiological eld laboratory in Vietnam. Scand J Public Health 2003; 31(Suppl. 62): 3 7. 20. Van Duong D, Binns CW, Van Le T. Availability of antibiotics as over-the-counter drugs in pharmacies: a threat to public health in Vietnam. Trop Med Int Health 1997; 2: 1133 9. 21. Thorson A, Hoa NP, Long NH. Health-seeking

inherited TB were both more often stated as causes of TB than bacteria. Healthcare seeking is a complex process, inuenced by many external and internal factors. It seems that the level of medical knowledge is the common denominator steering health-seeking behaviour among potential TB cases in this community. We found knowledge to be associated with taking healthcare action as well as with the quality and type of provider sought. However, level of knowledge was also associated with education and gender. Women sought less qualied care than men, had a lower knowledge level, and less often reported having health insurance. An obvious limitation of the study is that the information depended on self-reported data from the respondents and the survey on health-seeking behaviour was based on recall history. To minimize bias, questionnaires were pre-tested to make sure that all questions were understandable. Cross-checked and repeated questions in the different sections of the questionnaire were used in order to check the internal consistency. Professional surveyors and supervisors were carefully trained. With the multiple-stage supervisory system in FilaBavi and direct interviewing of the cases, recall bias is considered to have been minimized. In conclusion, a large proportion of individuals with a cough for more than three weeks had limited knowledge of TB. Only 24% of the potential TB cases in this district had gone to hospital, which was related to lack of knowledge of TB. In general, women had a poorer knowledge of TB and sought healthcare from less qualied providers. The study results were derived from a Vietnamese rural population, but could be discussed also in relation to other populations with a similar gender structure and educational situation. It seems that medical knowledge of TB is positively related to health seeking. This area needs to be further explored and informative interventions within different societal levels need to be studied. ACKNOWLEDGEMENTS This study was conducted within the epidemiological eld laboratory for Health Systems Research (FilaBavi) in Vietnam. The study was nancially supported by Sida/SAREC, Stockholm. The authors are grateful for valuable advice and comments given by Prof. Peter Allebeck. REFERENCES
1. World Health Organization. 2001. Progress in TB control in high-burden countries, 2001. WHO Report 2001, WHO/TB/01.4. Geneva: WHO.
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behaviour of individuals with a cough of more than 3 weeks. Lancet 2000; 356: 1823 4. 22. Corona Aguilera AE, Morales Casas G, Chalgub Moreno AM, Armas Perez L, Acosta Cabrera OS, Gonzalez Ochoa E. The knowledge, attitudes and practice of population groups with respect to tuberculosis.

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1994 1996. Rev Cubana Med Trop 2000; 52: 110 14. 23. Gelaw M, Genebo T, Dejene A, Lemma E, Eyob G. Attitude and social consequences of tuberculosis in Addis Ababa, Ethiopia. East Afr Med J 2001; 7: 382 8.

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