BEHAVIOUR PATTERNS OF PERSONS WITH CHEST SYMPTOMS IN KARNATAKA STATE
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Original Article Ind. J. Tub., 2002,49,39
BEHAVIOUR PATTERNS OF PERSONS WITH CHEST
SYMPTOMS IN KARNATAKA STATE
S.S. Nair1, S. Radhakrishna2, M.A. Seetha3 and G.E. Rupert Samuel4
(Received on 2.1.2001; Revised version received on 3.10.2001; Accepted on 30.10.2001)
Summary
Setting: Urban and rural areas of Karnataka state in south India where the Revised Tuberculosis National Control
Programme based on Directly Observed Treatment, Short-course was not yet implemented.
Objectives: To ascertain the time taken in seeking care among persons found to have cough of three weeks or more in
the preceding 6 months and get details about the health care providers consulted, investigations undertaken, and costs
incurred.
Design: Interview with representative samples of 10,000 urban and 10,000 rural people from two districts in Karnataka,
one representing more extensive public health care provider availability and the other representing less extensive
facilities.
Results: Reported prevalence of cough of any duration in the preceding 6 months was nearly 6%. And 1.4% had cough
for 3 weeks or more {chest symptomatic persons [CS]); 6% of households had at least one CS. Cough increased with age.
and was more common in males and in the lower socio-economic groups. The vast majority (83-90%) of CS had sought
care, two thirds within 2 weeks and 81% within one month of symptom onset.
In the district with a more extensive public health care provider system, CS sought care more promptly, the
median interval between onset and reporting for care being 8.8 days compared with 12.8 days in the district with less
extensive care provider system (P=O.O1). Private medical practitioners were the first provider sought by 65% of CS.
Sputum examination was undertaken for only 35% of CS over an average of 8 encounters.
Conclusion; Chest symptoms are relatively common in the community. Most CS seek care promptly, even where the
public health care provider system is less extensive; most patients first seek care from private doctors. Only one third
of patients had only a single sputum sample examined despite multiple encounters with the health system. Improvement
in diagnostic and treatment services in the health system, rather than genera! health education, is the top priority.
Key Words.-Chest symptoms, Chest Symptomatics, Behaviour patterns in seeking health care, Public and private health
systems.
INTRODUCTION Commencement of treatment in active cases. While delays
in diagnosis and initiation of anti-tuberculosis treatment
The control of tuberculosis requires prompt among diagnosed cases have been widely reproted1-4,
diagnosis and effective treatment. Revised National information on the health-seeking behaviour (hereinafter as
Tuberculosis Control Programme (RNTCP) in India ‘behaviour’) of persons with chest symptoms (here in after
aims to achieve effective treatment of tuberculosis as a symptomatics) in the communith is limited 5,6
cases with good chemotherapy, using the DOTS
(Directly Observed Treatment,Shot-coures) strategy. Repeated evaluation of the National Tuberculosis
However,mere administration of good treatment to Programme (NTP) has endorsed the strategy for case
diagnosed cases may not control the disease unless detection based on sputum smear examintion of persons
accompanied by efficient case finding. Since active with chest symptoms who spontaneously attend a health
case finding is impracticable, it is important to facility .7,8 The same strategy has been adopted by the
diagnose promptly and correctly those who attend RNTCP more recently.9 It is important that those who
clinic spontaneously. Failure to do so could prolong attend on
their suffering andndelay the
1 Director, Institute of Communication, Operations Research and Community Involvement, Bangalore 2
(Formerly) Director, Institute for Research
in Medical Statistics, Chennai, 3 (Formerly) Health Education-cum-Trammg Officer, National Tuberculosis
Institute, Bangalore, 4 (Formerly)
Research Officer, Regional Office of Health & Family Welfare, Bangalore
Correspondence: Dr S. Radhakrishna, D 201, High Rise Apartments, Lower Tank Bund Road, Gandhmagar,
Hyderabad 500 080
Indian Journal of Tuberculosis
Indian Journal of Tuberculosis40 S.S.NAIRETAL
their own must be offered good quality sputum coverage in India 10, was studied in each ward.
examination and those who do not must be studied
to find the reasons for neglect of their health. Studies Trained study personnel used structured
on behaviour and actions taken by symptomatics are, questionnaires to collect information regarding
therefore, important. A community survey was, morbidity in the preceding six months and health-
accordingly, conducted in representative rural and seeking behaviour of chest symptomatics in each
urban populations in Karnataka state, to study the ward.
interval between onset of symptoms and action-
taking/diagnosis, the type of health provider initially MATERIAL AND METHODS
contacted, multiple consultations availed of, the
pattern of provider utilization, the frequency and The study was undertaken between August
nature of investigations undertaken, and the costs 1997 and January 1998. The study population
incurred. consisted of 10,151 persons in rural Mysore, 10,495
in urban Mysore, 10,058 in rural Raichur and 10,265
in urban Raichur. In Mysore, 29% of the study
DESIGN population was aged under 15 years, compared with
38% in Raichur. Information on the entire study
After excluding Bangalore district (Urban) population was collected from 3935 respondents in
because of the metropolitan city of Bangalore, the Mysore and 3462 in Raichur district; most
other 19 districts of Karnataka State were ranked respondents were females aged 25-54 years. Proxy
according to the number of hospital beds, TB interviews were not allowed for collection of detailed
sanatorium beds, tuberculosis clinics and general information about symptomatics. A chest
clinics available per thousand population (indicating symptomatic (CS) was defined (as under RNTCP)
curative services), and the percentage of couples as a person with productive cough for 3 weeks or
protected by surgical contraception (indicating health more, with or without haemoptysis, fever, chest pain,
and family welfare services). Considering the sum weight loss and/or night sweat. Detailed information
of these five ranks as indicator of the extent of the was collected from nearly all the identified
public health care provider system, three districts symptomatics (97% rural Mysore, 92% urban
with the lowest rank totals and three districts with Mysore, 85% rural Raichur and 87% urban Raichur).
the highest rank totals were identified and one district Neither of these districts had implemented the
was selected at random from each set. Mysore RNTCP at the time.
(representative of a more extensive public health care
provider system) and Raichur (representative of a Statistical significance was assessed using
2
less extensive public health care provider system) X tests, t-tests and ANOVA techniques.
districts were thus chosen.
RESULTS
Within each selected district, a representative
sample of 10,000 rural and 10,000 urban population Prevalence of cough and chest symptomatics
was identified. For the rural sample, two primary
health centre areas were selected by probability Cough in the preceding six months was
proportional to size (PPS) of population, and from reported by nearly 6%: 657 (6.5%) rural and 632
each, a population of 5,000 was identified by total (6.0%) urban subjects in Mysore district and 526
coverage of a random sample of villages. For urban (5.2%) rural and 515 (5.0%) urban subjects in
areas, two urban agglomerations (as per 1991 Raichur district. Of these, 169 (1.7%) and 86
census) were selected by PPS. From each, five (0.82%) in rural and urban Mysore, and 106 (1.1%)
wards were selected by simple random sampling, and 120 (1.2%) in rural and urban Raichur were chest
and a representative sample of 1000 persons, symptomatics (CS)
identified by a method similar to the WHO 30-cluster
survey technique used for estimating immunizations The weighted prevalence of CS in the
Indian Journal of TuberculosisBEHAVIOUR PATTERNS OF PERSONS WITH CHEST SYMPTOMS 41
Table I: Characteristics of population surveyed and prevalence of CS in Karnataka state
Characteristic Number studied Mysore Raichur Both Relative
(both districts) district* district* districts@ Riskb
Age (years)
15-24 7991 0.5 0.3 0.4 1.0
25-34 6644 1.2 0.7 0.9 2.3
35-44 5177 2.4 1.0 1.8 4,4
45-54 3405 3.4 3.6 3.5 8.7
55-64 2055 4.4 5.8 5.0 12.6
65+ 1630 5.7 6.5 6.1 15.2
Total 26902 2.1 1.8 1.9 —
All ages 40969 1.4 1.1 1.3 __
Sex
Male 20659 1.8 1.3 1.6 1.7
Female 20310 1,0 0.8 0.9 1.0
c
Social class
Scheduled caste/tribe 12673 1.5 1.4 1.4 1.5
Other disadvantaged classes 17233 1.5 1.0 1.3 1.3
Others 10711 1.0 0.9 1.0 1.0
c
Occupation
Housewife 8632 1.5 1.1 1.3 1.0
Student 7995 0.I 0.0 0.1 0.I
Agriculture 6661 1.1 1.8 1.8 1.4
Skilled labour or business 5078 2.6 1,7 2.2 1.6
Unskilled labour 2186 4.3 1.3 2.9 2.2
Unemployed 1876 5.2 6.8 5.9 4.5
* Weighted average of rural and urban prevalences in the district, weights being the corresponding population sizes
@ Weighted average of the two district prevalences, weights being the district population sizes
b The group with a Relative Risk of I 0 is the Reference class
C Information tor some not available
Figure 1 : Percentage of CS by age and sex, 1997
Indian Journal of Tuberculosis42 S.S.NAIR ETAL
preceding 6 months was 1.4% in Mysore district primary level health facility. The proportion who
and 1.1% in Raichur district. In both the districts, remained with the same health facility was 51% of
the prevalence increased steadily with age and was rural and 54% of urban in Mysore district and 80%
significantly higher in males than in females (Table 1 and 64% in Raichur district. Contact with specialized
and Figure 1); it was higher in rural than in urban health facility such as district tuberculosis centre or
areas in Mysore district (1.7% vs 0.8%, PO.05), TB sanatorium was made by very small proportions,
but similar in Raichur district (1.1% vs 1.2%); it namely 14% and 24% in rural and urban Mysore
was highest in scheduled castes/tribes (1.4%), and 4% and 9% in rural and urban Raichur.
followed by other disadvantaged groups (1.3%) and
was least in others (1.0%). In unemployed persons, Private medical practitioners (PMPs) were
the prevalence was 5.9%, followed by 2.9% in the providers of choice for all three actions in rural
unskilled labourers. About 6% of the households and urban areas of both the districts (Table 2),
had at least one CS in the family. particularly for the first contact, with more than two-
thirds (69%-93%) preferring PMPs except in rural
Health-seeking behaviour Mysore (44%). The overall proportion who sought
PMPs declined steadily from 65% for the first action
Most CS took some action for alleviation of to 59% for the second action and 44% for the third
their symptoms: 83% and 85% in rural and urban action (P=0.01). This decline was not due to increase
Mysore and 90% and 85% in rural and urban Raichur in visits to primary health centres or district
district. About 40% took such an action within 7 tuberculosis centre, contact with the latter being
days, 67% within 15 days and 81% within 30 days. negligible even for subsequest actions.
CS in Mysore were quicker to take action than were
those in Raichur (76% vs. 57% within 2 weeks, In rural areas, very few visited the primary
PO.001). This difference was particularly prominent health centres in Mysore, namely, 36% for the first
in urban areas (85% vs 55%, PBEHAVIOUR PATTERNS OF PERSONS WITH CHEST SYMPTOMS 43
diagnosis and treatment (14%). In Raichur district, distance to the health facility was about 10 km,
however, there were significant differences between understandably, only 24% walked and 75% took a
rural and urban CS in the proportions giving the bus. Walking to the health facility was much less
reason as proximity to residence (73% vs. 54%, P < common for the second and third actions, the average
0.05), and expectation of free or correct diagnosis being 9% in rural Mysore, 34% in urban Mysore,
and treatment (10% vs 31%, P < 0.01 ). 37% tn rural Raichur, and 55% in urban Raichur.
The mean distance travelled was greater for the
second action, i.e. 23 and 19 km in rural and urban
The sequence of provider utilization and the
Mysore and 17 and 12 km in rural and urban Raichur.
reasons for change of provider are illustrated in
It became even greater for the third action, the
Figure 2 for rural and Figure 3 for urban CS, for the
corresponding averages being 28 and 15 km in
two districts combined. Figure 4 shows that while Mysore and 24 and 23 km in Raichur.
convenience became less important for second and
third actions, (13-14%) compared to first action Diagnosis
(63%), advice by lay persons became steadily more
important (from 20% to 34% and then 42%). The proportion of CS who had sputum
Expectation of better service increased from 17% at examination at the first action was 13% while 16%
first action to 44% at second action. Remarkably, had a radiograph taken (Table 3). After multiple
advice by doctors which increased for second and actions, these proportions increased to 35% and 48%,
third actions, was still not of much consequence respectively. The findings were similar in Mysore
even for the third action (14%). and Raichur districts for the first action. However,
after multiple actions, the proportion with sputum
For the first action, about 70% of CS walked examination became significantly higher in Mysore
to the health facility in urban Mysore and rural and district (which had more extensive public health care
urban Raichur, the average distance covered being provider services ) than in Raichur district, both in
3-4 km. However, in rural Mysore where the average rural areas (38% vs 24%, P44 S.S.NA1RETAL
TOTAL RURAL CS
Figure 2 : Health facilities used by rural CS (Mysore and Raichur districts combined)
TOTAL URBAN CS
Figure 3 : Health facilities used by urban CS (Mysore and Raichur districts combined)
Indian Journal of TuberculosisBEHAVIOUR PATTERNS OF PERSONS WITH CHEST SYMPTOMS 45 areas (51% vs 31%, P
46 SS. NAIRET AL
Mysore district and 75% in Raichur district. Although 1.2%, being 1.4% in Mysore district and 1.1% in
government provided health care by policy is free of Raichur district. Among persons aged 15 years or
charge, some chest symptomatics reported that they more, the corresponding prevalence rates were 2.1 %
incurred a direct cost for services provided at and 1.8%. The prevalence was 1.6% among males
government health facilities; the extent of this cost and 0.9% among females and increased with age
was not quantified. from 0.6% in 15-34 years group to 2.5% in 35-54
years group and to 5.5% in those 55 years or older.
DISCUSSION
The vast majority of CS (81% in
The NTP, initiated in 1962, emphasizes Mysore, 93% in Raichur) approached general
diagnosing and treating tuberculosis in patients who health facilities for symptom relief and most of
spontaneously attend health institutions. More than them (64% in Mysore, 77% in Raichur)
half of the bacterioiogically positive cases identified restricted themselves to attending only one
by a 1961 community epidemiological survey were facility. Private doctors (PMPs) were the most
found to have attended a health facility on their own common first choice (average 65%, range 44-
for relief of symptoms. 1 1 This finding was 93%), the reasons being proximity to home,
12
reconfirmed in 1973 in the same area. Such studies convenient working hours and a perception of
are, however, expensive and difficult to undertake good quality care. For subsequent actions also,
repeatedly. A less expensive alternative is to monitor the PMP continued to be preferred, the averages being
the pattern of health-seeking behaviour of persons 59% and 44% for the second and third actions. These
with chest symptoms. By taking steps to ensure that findings indicate the importance of ensuring that
all persons with prolonged cough seek attention early, PMPs participate in and collaborate with the control
the efficiency of case-detection can be increased. programme. Strategies must be evolved to ensure
Thus, the behaviour of CS is of crucial importance that PMPs either refer all symptomatic persons to
to the tuberculosis programme. government facilities or they diagnose accurately
(using sputum smear examination) and ensure
The prevalence of CS in the community in regular, observed, short-course treatment for the
the preceding 6 months in the present study was appropriate duration. PMPs also need to be informed
Table 3 : Radiographic and sputum examinations done for CS taking action
Radiograph taken (%) Sputum examinations undertaken (%)
Number of First Multiple (b-a) First Multiple (d-c)
CS taking action action(a) actions(b) action(c) actions(d)
Mysore rural 135 10.4 48.1 37.7 8.9 37.8 28.9
Raichur rural 81 111 32.1 21.0 9.9 23.5 13.6
Total rural 216 10.6 42.1 31.5 9.3 32.4 23.1
Mysore urban 67 19.4 642 44.8 19.4 50.7 31.3
Raichur urban 88 25.0 50.0 25.0 19.3 30.7 11.4
Total urban 155 22.6 56.1 33.5 19.4 39.4 20.0
Grand Total 371 15.6 48.0 32.4 13.5 35.3 21.8
Indian Journal of TuberculosisBEHAVIOUR PATTERNS OF PERSONS WITH CHEST SYMPTOMS 47
that overdiagnosis can cause patient trauma, and result The perception that females in developing
in avoidable expenditure and drug toxicity, and that countries are less likely to utilize health services
improper treatment leads to drug resistance. compared with males may not be correct because
the proportions of CS who attended a health facility
On an average, about 30% of chest were similar for the two sexes in this study, as well
symptomatics went to government health facilities as in two other studies undertaken at about the same
such as primary health centres (PHCs), district time in rural and urban Tamil Nadu (Tuberculosis
tuberculosis centre (DTC), government hospital and Research Centre, personal communication) and in
sanatoria. Only 16% contacted PHCs at first action, urban Delhi (New Delhi Tuberculosis Centre,
7% at second action and 11% at third action. Even personal communication).
in Mysore district, which had more extensive public
health care provider services, the proportions were Sputum smear examination, an essential
low, i.e. 25%, 11% and 14% for the three actions component of diagnosis of tuberculosis, was
respectively. Among reportedly diagnosed cases, only undertaken at the time of first action in only 9% of
3% were diagnosed at primary health centres. rural and 19% of urban CS. Even after multiple
Neither did PHCs refer CS to a DTC. There was a actions, the proportions thus examined rose to 32%
40% reduction in sputum examination at pei Spheral and 39%, a strikingly low performance especially as
health institutions (mostly PHCs) from 1988 to 1996
each CS had, on average, 8 encounters with the
in Mysore district and 15% reduction from the
health services. And, 40% of the CS in Mysore and
already low level in Raichur district (National
Tuberculosis Institute, unpublished data). Further, 26% in Raichur were reportedly not even told the
the study noted that some CS had incurred cost for sputum smear result. In both the districts, more CS
the services provided to them at governmental health underwent radiography than sputum examination,
facilities. Clearly, there is a need for improved even in rural areas. Moreover, following multiple
tuberculosis diagnosis and treatment in primary actions, the increase in radiographic coverage was
health care centres. significantly greater than for sputum coverage.
Provision of more extensive public health Tn the present study, about 85% of CS
care provider services (as in Mysore district) was sought relief from symptoms from a health care
associated with quicker action by CS and greater provider. About 40% did so within 7 days, 67%
likelihood of sputum smear examination (38% vs within 15 days, and 81% within one month of
24%, P=0.01). Perception of better quality service symptoms with a median interval of only 12 days.
had apparently motivated 75% of the rural CS in Thus, there is apparently little urgency for health
Mysore district to travel by bus, even for the first education of CS about the need to seek care early.
action. Instead, it is the health sector, rather than the
general public, which requires strengthening by
Judging purely from CS behaviour in way of microscopy services, information and
respect of action taken, the contribution of DTC case- education. Selected groups, such as non-literates
finding was negligible even in urban areas because and elderly persons of lower socio-economic status
DTC had existed in two of the four towns studied. may require targetted outreach, for example through
Even the number of persons X-rayed at the DTC peers or community structures.
decreased by 40% from 1989 to 1996 in Mysore
district and by 60% in Raichur district (National
The prevalence of CS in the community in
Tuberculosis Institute, unpublished data). The 13-17
meager contacts made with primary health centres various studies has varied from l%to 14% . Such
too reflects the low utilization of primary health a large variability could be due to lack of uniformity
centres highlighting the need to improve tuberculosis in (a) definition of CS (cough for I, 2 or 3 weeks or
diagnosis and treatment services in all urban and rural of any duration), (b) quality of interviewers (social
areas and ensure effective coordination among or epidemiological investigator, health worker, young
various health care providers. graduate etc.), (c) population covered (all ages or
Indian Journal of Tuberculosis48 S.S. NAIRETAL
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