Original Article                                                                          Ind. J. Tub., 2002,49,39

                           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)

        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
        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
        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

        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 Tuberculosis
40                                                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
less extensive public health care provider system)       X   tests, t-tests and ANOVA techniques.
districts were thus chosen.
          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 Tuberculosis
BEHAVIOUR 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                       __
Male                                         20659                   1.8              1.3               1.6                      1.7
Female                                       20310                   1,0              0.8               0.9                      1.0
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

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 Tuberculosis
42                                              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%, P
BEHAVIOUR 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%, P
44                                          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 Tuberculosis
BEHAVIOUR 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.
                                                                        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,
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 Tuberculosis
BEHAVIOUR 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 Tuberculosis
48                                              S.S. NAIRETAL

age 15 years or more), and (d) time frame of                   2. Lawn SD, Affut B, Acheampong JW. Pulmonary
                                                                   tuberculosis: diagnostic delay in Ghanaian adults. Int J Tuberc
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                                                               3   Asch S, Leake B, Anderson R, Gelberg L. Why do
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symptoms and health-seeking behaviour, particularly            4.    Long NH, Johansson E, Lonnroth K, Eriksson B, Winkvist
of duration of cough prior to seeking care, and of                   A. Diwan VK. Longer delays in tuberculosis diagnosis among
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persons. To have a proper understanding of the                 5.    Narayan R, Thomas S, Pramilakumari S. et al. Prevalence
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                                                                     in a rural community. IndJ Tub I976;23;60
which cover all of the above aspects would be
                                                               6.    Subramanian T. Sample survey of awareness of symptoms
                                                                     and utilization of health facilities by chest symptomatics.
                                                                     IndJ Tub !990;37:69
          The present study has some limitations.The           7.    Institute of Communication, Operations Research and
reference period was long (6 months) and memory                      Community Involvement, Bangalore— In depth study on
lapses could have occurred. Further, the entire study                National Tuberculosis Programme of India. 1988
was completed in 6 months, and, consequently, not              8.    WHO/SEARO—Tuberculosis Programme Review. 1992
all the seasons were included. Not all individuals             9.    Directorate-General of Health Services. New Delhi—
were directly questioned about chest symptoms. A                     Technical guidelines for Tuberculosis control, Revised
priori, this could lead to underestimation of the                    National Tuberculosis Control Programmel 1997
prevalence of chest symptoms. However, because                 10.   Henderson RH, Sundaresan T. Cluster sampling to assess
                                                                     immunization coverage: a review of experience with a
cough for more than three weeks will be noticed by
                                                                     simplified sampling method. Bull WHO 1982:60:253
members of the family, and because all household
                                                               11.   Banerji D, Andersen S. Sociological study of awareness of
members present at the time of interview furnished                   symptoms among persons with pulmonary tuberculosis.
information, non-identification of CS in the present                 Bull WHO 1963;29:665
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                                                                     tuberculosis in a primitive tribe in Madhya Pradesh. Ind J
                                                                     Tub 1996:43:85
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                                                               14.   Gopi PG, Vallishayee RS, Appe Gowda BN, et al. A
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and time were not sufficient to determine which of                   1997:44:171
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differs systematically from the health-seeking                       sputum in a district of south India. IndJ Tub 1968:15:130
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