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Makonokaya L, Kapanda L, Woelk GB, Chauma-Mwale A, Kalitera LU, Nkhoma H, Zimba S, Chamanga R, Golowa C, Machekano R, Maphosa T. Safety of Janssen Ad26.COV.S and Astra Zeneca AZD1222 COVID-19 Vaccines among Mobile Phone Users in Malawi: Findings from a National Mobile-Based Syndromic Surveillance Survey, July 2021 to December 2021. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7123. [PMID: 38063553 PMCID: PMC10706488 DOI: 10.3390/ijerph20237123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/18/2023] [Accepted: 09/02/2023] [Indexed: 12/18/2023]
Abstract
The safety profiles of the Ad26.COV2.S and AZD1222 COVID-19 vaccines have not been described in the general population in Malawi. We present self-reported adverse events (AE) following the receipt of these vaccines in Malawi as part of a national syndromic surveillance survey. We conducted phone-based syndromic surveillance surveys among adults (≥18 years) with verbal consent. We used secure tablets through random digit dialing to select mobile phone numbers and collected data electronically. Survey questions included whether the respondent had received the COVID-19 vaccines, whether they had experienced any AE following vaccination, and the severity of the AE. We used multivariable analysis to identify factors associated with self-reported AE post-COVID-19 vaccination. A total of 11,924 (36.0%) out of 33,150 respondents reported receiving at least one dose of either Ad26.COV2.S or AZD1222 between July-December 2021; of those, 65.1% were female. About 49.2% of the vaccine recipients reported at least one AE, 90.6% of which were mild, and 2.6% were severe. Higher education level and concern about the safety of COVID-19 vaccines were associated with AE self-report (Adjusted Odds Ratio [AOR] 2.63 [95% CI 1.96-3.53] and 1.44, [95% CI 1.30-1.61], respectively), while male gender and older age were associated with reduced likelihood of AE self-report (AORs 0.81, [95% CI 0.75-0.88], 0.62 [95% CI 0.50-0.77], respectively). Ad26.COV2.S and AZD1222 vaccines are well-tolerated, with primarily mild and few severe AE among adults living in Malawi. Self-reporting of AE following COVID-19 vaccination is associated with gender, age, education, and concern about the safety of the vaccines. Recognizing these associations is key when designing and implementing COVID-19 vaccination communication messages to increase vaccination coverage.
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Affiliation(s)
- Lucky Makonokaya
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe P/Bag 2543, Malawi (R.C.); (C.G.); (T.M.)
| | - Lester Kapanda
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe P/Bag 2543, Malawi (R.C.); (C.G.); (T.M.)
| | - Godfrey B. Woelk
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC 20005, USA; (G.B.W.); (R.M.)
| | - Annie Chauma-Mwale
- Public Health Institute, Ministry of Health Malawi, Lilongwe P.O. Box 30377, Malawi
| | - Louiser Upile Kalitera
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe P/Bag 2543, Malawi (R.C.); (C.G.); (T.M.)
| | - Harrid Nkhoma
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe P/Bag 2543, Malawi (R.C.); (C.G.); (T.M.)
| | - Suzgo Zimba
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe P/Bag 2543, Malawi (R.C.); (C.G.); (T.M.)
| | - Rachel Chamanga
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe P/Bag 2543, Malawi (R.C.); (C.G.); (T.M.)
| | - Cathy Golowa
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe P/Bag 2543, Malawi (R.C.); (C.G.); (T.M.)
| | - Rhoderick Machekano
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC 20005, USA; (G.B.W.); (R.M.)
| | - Thulani Maphosa
- Elizabeth Glaser Pediatric AIDS Foundation, Lilongwe P/Bag 2543, Malawi (R.C.); (C.G.); (T.M.)
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Banti AB, Datiko DG, Hinderaker SG, Heldal E, Dangisso MH, Mitiku GA, White RA, Winje BA. How many of persistent coughers have pulmonary tuberculosis? Population-based cohort study in Ethiopia. BMJ Open 2022; 12:e058466. [PMID: 35613773 PMCID: PMC9125699 DOI: 10.1136/bmjopen-2021-058466] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 05/03/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Many individuals with persistent cough and smear microscopy-negative sputum test for tuberculosis (TB) remain at risk of developing the disease. This study estimates the incidence of pulmonary TB (PTB) among initially smear-negative persistent coughers and its risk factors. DESIGN A prospective population-based follow-up study. SETTING Health extension workers visited all households in Dale woreda three times at 4-month intervals in 2016-2017 to identify individuals with symptoms compatible with TB (presumptive TB) using pretested and semistructured questionnaires. PARTICIPANTS We followed 3484 presumptive TB cases (≥15 years) with an initial smear-negative TB (PTB) test. OUTCOME MEASURES Bacteriologically confirmed PTB (PTB b+) and clinically diagnosed PTB (PTB c+). RESULTS 3484 persons with initially smear-negative presumptive PTB were followed for 2155 person-years (median 0.8 years); 90 individuals had PTB b+ and 90 had PTB c+. The incidence rates for PTB b+ and PTB c+ were both 4176 (95% CI 3378 to 5109) per 100 000 person-years. We used penalised (lasso) and non-penalised proportional hazards Cox regression models containing all exposures and outcomes to explore associations between exposures and outcomes. In lasso regression, the risk of development of PTB b+ was 63% (HR 0.37) lower for people aged 35-64 years and 77% (HR 0.23) lower for those aged ≥65 years compared with 15-34 year-olds. Men had a 62% (HR 1.62) greater risk of PTB b+ development than women. The risk of PTB c+ was 39% (HR 0.61) lower for people aged 35-54 years than for those aged 15-34 years. Men had a 56% (HR 1.56) greater risk of PTB c+ development than women. CONCLUSIONS PTB incidence rate among persistent coughers was high, especially among men and young adults, the latter signifying sustained transmission. Awareness about this among healthcare workers may improve identification of more new TB cases.
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Affiliation(s)
- Abiot Bezabeh Banti
- USAID Urban TB LON project, REACH Ethiopia, Addis Ababa, Ethiopia
- Centre for International Health, University of Bergen, Bergen, Norway
| | - Daniel Gemechu Datiko
- USAID Eliminate TB Project, Management Sciences for Health Ethiopia, Addis Ababa, Ethiopia
| | | | - Einar Heldal
- Department of Infection Control and Vaccine, Norwegian Institute of Public Health, Oslo, Norway
| | | | | | - Richard Aubrey White
- Department of Methods Development and Analytics, Norwegian Institute of Public Health, Oslo, Norway
| | - Brita Askeland Winje
- Department of Infection Control and Vaccine, Norwegian Institute of Public Health, Oslo, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
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Mmolawa L, Siwelana T, Hanrahan CF, Lebina L, Martinson NA, Dowdy D, Nonyane BAS. Time to care-seeking for TB symptoms. Int J Tuberc Lung Dis 2022; 26:268-275. [PMID: 35197167 PMCID: PMC9636494 DOI: 10.5588/ijtld.21.0447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: Early presentation to healthcare facilities is critical for early diagnosis and treatment of TB. We studied self-reported time to care-seeking from the onset of TB symptoms among primary healthcare clinic (PHC) attendees in Limpopo Province, South Africa.METHODS: We used data from participants enrolled in a cluster-randomized trial of TB case finding in 56 PHC clinics across two health districts. We fitted log-normal accelerated failure time regression models and we present time ratios (TRs) for potential risk factors.RESULTS: We included 2,160 participants. Among the 1,757 (81%) diagnosed with active TB, the median time to care-seeking was 30 days (IQR 14-60); adults sought care later than children/adolescents (adjusted TR aTR 1.47, 95% CI 1.10-1.96). Among those not diagnosed with TB, the median was 14 days (IQR 7-60); being HIV-positive (aTR 1.57, 95% CI 1.03-2.40); having less than grade 8 education and currently smoking were associated with longer time to care-seeking. In the combined analysis, living with HIV and having underlying active TB was associated with faster care-seeking (TB status x HIV interaction: TR 0.68, 95% CI 0.48-0.96).CONCLUSION: Delay in care-seeking was associated with age, lower education and being a current smoker. TB awareness campaigns targeting these population groups may improve care-seeking behavior and reduce community TB transmission.
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Affiliation(s)
- L Mmolawa
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - T Siwelana
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - C F Hanrahan
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - L Lebina
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
| | - N A Martinson
- Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa, Johns Hopkins University, Center for TB Research, Baltimore, MD, USA
| | - D Dowdy
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Johns Hopkins University, Center for TB Research, Baltimore, MD, USA
| | - B A S Nonyane
- Departments of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, Perinatal HIV Research Unit, South Africa Medical Research Council Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg, South Africa
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Makgopa S, Madiba S. Tuberculosis Knowledge and Delayed Health Care Seeking Among New Diagnosed Tuberculosis Patients in Primary Health Facilities in an Urban District, South Africa. Health Serv Insights 2021; 14:11786329211054035. [PMID: 34720588 PMCID: PMC8554548 DOI: 10.1177/11786329211054035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022] Open
Abstract
Patients' delay in seeking health care is a major problem in the control of tuberculosis (TB) and increases the risk of TB transmission. This study determined health-seeking practices and delays that occurred from the onset of TB symptoms until diagnosis and assessed the patients' TB-related knowledge. This was a cross-sectional study involving 391 new TB patients recruited from health facilities at an urban sub-district in South Africa from December 2016 to March 2017. Descriptive statistics and logistic regression analyses were performed using Stata 14. Over half (56.3%) of the patients delayed seeking health care for more than 30 days after the onset of their symptoms, 32% sought treatment from informal providers, and 13.3% self-medicated. Lack of suspicion of a TB diagnosis, which was prevalent in 45% of respondents, was statistically associated with delay in seeking healthcare (AOR = 0.53, CI: 0.32-1.87). Overall TB knowledge was high, correct knowledge about TB transmission was 92.6%. TB knowledge was significantly associated with educational status (AOR = 3.96, CI: 1.69-9.28) and seeking treatment from informal sectors (AOR = 0.17, CI: 0.03-0.95). High overall TB knowledge was not statistically associated with seeking health care for TB diagnosis and treatment. We found a substantial delay between the onset of TB symptoms and seeking healthcare from a public health facility providing TB screening services. Promoting early screening and diagnosis through increasing awareness of TB is key in the elimination of TB in communities with a high TB burden.
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Affiliation(s)
- Sylvia Makgopa
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Sphiwe Madiba
- Department of Public Health, School of Health Care Sciences, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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Govender K, Girdwood S, Letswalo D, Long L, Meyer-Rath G, Miot J. Primary healthcare seeking behaviour of low-income patients across the public and private health sectors in South Africa. BMC Public Health 2021; 21:1649. [PMID: 34503478 PMCID: PMC8431853 DOI: 10.1186/s12889-021-11678-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 08/29/2021] [Indexed: 01/21/2023] Open
Abstract
Background The proposed National Health Insurance (NHI) system aims to re-engineer primary healthcare (PHC) in South Africa, envisioning both private sector providers and public sector clinics as independent contracting units to the NHI Fund. In 2017, 16% of the South African population had private medical insurance and predominately utilised private providers. However, it is estimated that up to 28% of the population access private PHC services, with a meaningful segment of the low-income, uninsured population paying for these services out-of-pocket. The study objective was to characterise the health seeking behaviour of low-income, patients accessing PHC services in both the public and private sectors, patient movement between sectors, and factors influencing their facility choice. Methods We conducted once-off patient interviews on a random sample of 153 patients at 7 private PHC providers (primarily providing services to the low-income mostly uninsured patient population) and their matched public PHC clinic (7 facilities). Results The majority of participants were economically active (96/153, 63%), 139/153 (91%) did not have health insurance, and 104/153 (68%) earned up to $621/month. A multiple response question found affordability (67%) and convenience (60%) were ranked as the most important reasons for choosing to usually access care at public clinics (48%); whilst convenience (71%) and quality of care (59%) were key reasons for choosing the private sector (32%). There is movement between sectors: 23/76 (30%) of those interviewed at a private facility and 8/77 (10%) of those interviewed at a public facility indicated usually accessing PHC services at a mix of private and public facilities. Results indicate cycling between the private and public sectors with different factors influencing facility choice. Conclusions It is imperative to understand the potential impact on where PHC services are accessed once affordability is mitigated through the NHI as this has implications on planning and contracting of services under the NHI.
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Affiliation(s)
- Kerensa Govender
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. .,Health Economics and Epidemiology Research Office (HE2RO), Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sarah Girdwood
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Health Economics and Epidemiology Research Office (HE2RO), Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniel Letswalo
- Health Economics and Epidemiology Research Office (HE2RO), Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Health Economics and Epidemiology Research Office (HE2RO), Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, Mass, USA
| | - G Meyer-Rath
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Health Economics and Epidemiology Research Office (HE2RO), Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, Mass, USA
| | - J Miot
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Health Economics and Epidemiology Research Office (HE2RO), Wits Health Consortium, University of the Witwatersrand, Johannesburg, South Africa
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Potty RS, Kumarasamy K, Adepu R, Reddy RC, Singarajipura A, Siddappa PB, Sreenivasa PB, Thalinja R, Lakkappa MH, Swamickan R, Shah A, Panibatla V, Dasari R, Washington R. Community health workers augment the cascade of TB detection to care in urban slums of two metro cities in India. J Glob Health 2021; 11:04042. [PMID: 34326992 PMCID: PMC8285758 DOI: 10.7189/jogh.11.04042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Tuberculosis Health Action Learning Initiative (THALI) funded by USAID is a person-centered initiative, supporting vulnerable urban populations to gain access to TB services. THALI trained and placed 112 Community health workers (CHWs) to detect and support individuals with TB symptoms or disease within urban slums in two cities, Hyderabad and Bengaluru, covering a population of about 3 million. Methods CHWs visited the slums once in a fortnight. They conducted TB awareness activities. They referred individuals with TB symptoms for sputum testing to nearest public sector laboratories. They visited those testing TB positive, once a fortnight in the intensive phase, and once a month thereafter. They supported TB patients and families with counselling, contact screening and social scheme linkages. They complemented the shortfall in urban TB government field staff numbers and their capacity to engage with TB patients. Data on CHWs’ patient referral for TB diagnosis and treatment support activities was entered into a database and analyzed to examine CHWs’ role in the cascade of TB care. We compared achievements of six monthly referral cohorts from September 2016 to February 2019. Results Overall, 31 617 (approximately 1%) of slum population were identified as TB symptomatic and referred for diagnosis. Among the referred persons, 23 976 (76%) underwent testing of which 3841 (16%) were TB positive. Overall, 3812 (99%) were initiated on treatment and 2760 (72%) agreed for regular follow up by the CHWs. Fifty-seven percent of 2952 referred were tested in the first cohort, against 86% of 8315 in the last cohort. The annualized case detection rate through CHW referrals in Bengaluru increased from 5.5 to 52.0 per 100 000 during the period, while in Hyderabad it was 35.4 initially and increased up to 118.9 per 100 000 persons. The treatment success rate was 87.1% among 193 in the first cohort vs 91.3% among 677 in the last cohort. Conclusions CHWs in urban slums augment TB detection to care cascade. Their performance and TB treatment outcomes improve over time. It would be important to examine the cost per TB case detected and successfully treated.
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Affiliation(s)
| | | | - Rajesham Adepu
- Office of the Joint Director (TB), Commissionerate of Health and Family Welfare, Hyderabad, Telangana, India
| | - Ramesh Chandra Reddy
- Office of the Joint Director (TB), Lady Willingdon State TB Centre, Bengaluru, Karnataka, India
| | - Anil Singarajipura
- Office of the Joint Director (TB), Lady Willingdon State TB Centre, Bengaluru, Karnataka, India
| | | | | | | | | | - Reuben Swamickan
- Tuberculosis and Infectious Diseases Division, USAID/India, New Delhi, India
| | - Amar Shah
- Tuberculosis and Infectious Diseases Division, USAID/India, New Delhi, India
| | | | | | - Reynold Washington
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,St John's Research Institute, Bengaluru, India
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7
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Sun X, Luo S, Lou L, Cheng H, Ye Z, Jia J, Wei Y, Tao J, He H. Health seeking behavior and associated factors among individuals with cough in Yiwu, China: a population-based study. BMC Public Health 2021; 21:1157. [PMID: 34134671 PMCID: PMC8207678 DOI: 10.1186/s12889-021-11250-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 06/10/2021] [Indexed: 01/14/2023] Open
Abstract
Background Previous studies have shown that a certain proportion of the population did not seek medical treatment after coughing, and understanding the potential reasons is crucial for disease prevention and control. Method A population-based study was conducted with the probability proportional to population size sampling in Yiwu, Zhejiang, China. A total of 5855 individuals aged ≥15 years lived in Yiwu for more than 6 months were included. All participants completed a laptop-based questionnaire to collect detailed information by a face-to-face interview. Characteristics of individuals were described by categories of health seeking behavior using frequency and percentage. Univariate and multivariate logistic regression analyses were performed to estimate the associations of social-demographic and cough characteristics with health seeking behavior. Results 19.3% (1129/5855) of participants had a cough in the past month, 40% (452/1129) had sought medical treatment. Of these, 26.5% (120/452) chose hospitals at county level or above. Individuals aged ≥65 years old (OR = 2.25, 95% CI: 1.23, 4.12), female (OR = 1.57, 95% CI: 1.21, 2.06), living in rural areas (OR = 1.30, 95% CI: 1.003, 1.69), persistent cough for 3–8 weeks (OR = 2.91, 95% CI: 1.72, 4.92) and with more accompanying symptoms (P trend < 0.001) were more likely to seek medical treatment, but those coughed for > 8 weeks were not (p > 0.5). Female (OR = 0.33, 95% CI: 0.21, 0.54) and people living in rural areas (OR = 0.57, 95% CI: 0.36, 0.92) were less likely to choose hospitals at county level or above while the higher educated were more likely to (OR = 3.29, 95% CI: 1.35, 8.02). Those who coughed for more than 2 weeks were more likely to choose hospitals at or above the county level. But the number of accompanying symptoms does not show any significant relationship with the choice of medical facility. Conclusion The present study found that age, sex, living areas and features of cough were associated with health seeking behavior. It is worth noting that those who coughed for too long (e.g. > 8 weeks) were less likely to seek medical treatment. Targeted measures should be developed based on the key factors found in this study to guide persons to seek medical treatment more scientifically. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11250-5.
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Affiliation(s)
- Xiaoyan Sun
- Yiwu Center for Disease Control and Prevention, Yiwu, 322000, P.R. China
| | - Shuying Luo
- Yiwu Center for Disease Control and Prevention, Yiwu, 322000, P.R. China
| | - Lingqiao Lou
- Yiwu Center for Disease Control and Prevention, Yiwu, 322000, P.R. China
| | - Hang Cheng
- Yiwu Center for Disease Control and Prevention, Yiwu, 322000, P.R. China
| | - Zhen Ye
- Yiwu Center for Disease Control and Prevention, Yiwu, 322000, P.R. China
| | - Jianwei Jia
- Yiwu Center for Disease Control and Prevention, Yiwu, 322000, P.R. China
| | - Yina Wei
- Yiwu Center for Disease Control and Prevention, Yiwu, 322000, P.R. China
| | - Jingbo Tao
- Yiwu Center for Disease Control and Prevention, Yiwu, 322000, P.R. China
| | - Hanqing He
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, 310051, P.R. China.
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Iwaki Y, Rauniyar SK, Nomura S, Huang MC. Assessing Factors Associated with TB Awareness in Nepal: A National and Subnational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105124. [PMID: 34066015 PMCID: PMC8151409 DOI: 10.3390/ijerph18105124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022]
Abstract
Tuberculosis (TB) has still remained a serious global health threat in low- and middle-income countries in recent years. As of 2021, Nepal is one of the high TB burden countries, with an increasing prevalence of cases. This study evaluates factors associated with TB awareness in Nepal. This study uses data from the Nepal Demographic and Health Survey, a cross-sectional survey carried out from June 2016 to January 2017. Multilevel logistic regression is performed to examine the association of demographic and socioeconomic factors with TB awareness. Our findings show a high level of TB awareness in all seven provinces of Nepal. Province 5 has the highest level of awareness (98.1%) among all provinces, followed by provinces 3 and 4, while province 6 has the lowest awareness level (93.2%) compared to others. Socioeconomic factors such as wealth, education and owning a mobile phone are significantly associated with TB awareness. Socioeconomic determinants are influential factors associated with TB awareness in Nepal. The wide variation in the proportion of awareness at a regional level emphasizes the importance of formulating tailored strategies to increase TB awareness. For instance, the use of mobile phones could be an effective strategy to promote TB awareness at a regional level. This study provides valuable evidence to support further research on the contribution of information and communication technology (ICT) usage to improving TB awareness in Nepal.
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Affiliation(s)
- Yoko Iwaki
- Science, Technology and Innovation Policy Program, National Graduate Institute for Policy Studies (GRIPS), 7-22-1 Roppongi, Minato-ku, Tokyo 106-8677, Japan
- Correspondence: ; Tel.: +81-3-6439-6000
| | - Santosh Kumar Rauniyar
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (S.K.R.); (S.N.)
| | - Shuhei Nomura
- Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (S.K.R.); (S.N.)
- Department of Health Policy and Management, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Michael C. Huang
- SciREX Center, National Graduate Institute for Policy Studies (GRIPS), 7-22-1 Roppongi, Minato-ku, Tokyo 106-8677, Japan;
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Medina-Marino A, de Vos L, Bezuidenhout D, Denkinger CM, Schumacher SG, Shin SS, Stevens W, Theron G, van der Walt M, Daniels J. "I got tested at home, the help came to me": acceptability and feasibility of home-based TB testing of household contacts using portable molecular diagnostics in South Africa. Trop Med Int Health 2021; 26:343-354. [PMID: 33289194 DOI: 10.1111/tmi.13533] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The effectiveness of household contact investigations is limited by low referral uptake for clinic-based TB testing by symptomatic household contacts. We qualitatively investigated the acceptability and perceived benefits of home-based TB testing using a portable GeneXpert-I instrument (GX-I) in an urban South African township. METHODS In-depth interviews were conducted with household contacts tested and those that observed testing. Semi-structured interviews explored household contact's understanding of TB, perceptions of the GX-I device and testing procedures, confidentiality, willingness to refer others, and views on home- vs. clinic-based testing. Focus group discussions with home-based TB testing implementing staff assessed operational considerations for scale-up. Data were analysed using a constant comparison approach to qualitatively evaluate the acceptability and feasibility of home-based TB testing. RESULTS Thirty in-depth interviews and two focus group discussions were conducted. Observing one's own sputum being tested resulted in an emergent trust in home-based TB testing, the GX-I device and one's test results. Home-based TB testing was considered convenient, helped to overcome apathy towards testing and mitigated barriers to clinic-based testing. Perceptions that home-based TB testing contributes to improved household and community health resulted in an emergent theme of alleviation of health insecurities. Operational concerns regarding inadvertent disclosure of one's diagnosis to household members and time spent in people's homes were identified. CONCLUSIONS Home-based TB testing was acceptable and feasible. Individuals expressed belief in the machine by being able to witness the testing process. Though most themes mirrored qualitative studies of home-based HIV testing, the alleviation of health insecurities theme is unique to home-based TB testing. Future research must evaluate the impact of home-based TB testing on case finding yield, time-to-treatment initiation and household outcomes.
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Affiliation(s)
- Andrew Medina-Marino
- Research Unit, Foundation for Professional Development, East London, South Africa.,Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lindsey de Vos
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Dana Bezuidenhout
- Research Unit, Foundation for Professional Development, East London, South Africa
| | - Claudia M Denkinger
- Foundation for Innovative New Diagnostics, Geneva, Switzerland.,Division of Tropical Medicine, Center for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Sanghyuk S Shin
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, CA, USA
| | - Wendy Stevens
- Department of Molecular Medicine and Haematology, University of the Witwatersrand, Johannesburg, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Stellenbosch University, Cape Town, South Africa
| | | | - Joseph Daniels
- Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
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10
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Alene M, Assemie MA, Yismaw L, Gedif G, Ketema DB, Gietaneh W, Chekol TD. Patient delay in the diagnosis of tuberculosis in Ethiopia: a systematic review and meta-analysis. BMC Infect Dis 2020; 20:797. [PMID: 33109110 PMCID: PMC7590610 DOI: 10.1186/s12879-020-05524-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 10/16/2020] [Indexed: 12/17/2022] Open
Abstract
Background Delay in the diagnosis of Tuberculosis (TB) remains a major challenge against achieving effective TB prevention and control. Though a number of studies with inconsistent findings were conducted in Ethiopia; unavailability of a nationwide study determining the median time of patient delays to TB diagnosis is an important research gap. Therefore, this study aimed to determine the pooled median time of the patient delay to TB diagnosis and its determinants in Ethiopia. Methods We followed PRISMA checklist to present this study. We searched from Google Scholar, PubMed, Science Direct, Web of Science, CINAHL, and Cochrane Library databases for studies. The comprehensive search for relevant studies was done by two of the authors (MA and LY) up to the 10th of October 2019. Risk of bias was assessed using the Newcastle-Ottawa scale adapted for observational studies. Data were pooled and a random effect meta-analysis model was fitted to provide the overall median time of patient delay and its determinants in Ethiopia. Furthermore, subgroup analyses were conducted to investigate how the median time of patient delay varies across different groups of studies. Results Twenty-four studies that satisfied the eligibility criteria were included. Our meta-analysis showed that the median time of the patient delay was 24.6 (95%CI: 20.8–28.4) days. Living in rural area (OR: 2.19, 95%CI: 1.51–3.18), and poor knowledge about TB (OR: 2.85, 95%CI: 1.49–5.47) were more likely to lead to prolonged delay. Patients who consult non-formal health providers (OR: 5.08, 95%CI: 1.56–16.59) had a prolonged delay in the diagnosis of TB. Moreover, the narrative review of this study showed that age, educational level, financial burden and distance travel to reach the nearest health facility were significantly associated with a patient delay in the diagnosis of TB. Conclusions In conclusion, patients are delayed more-than three weeks in the diagnosis of TB. Lack of awareness about TB, consulting non-formal health provider, and being in the rural area had increased patient delay to TB diagnosis. Increasing public awareness about TB, particularly in rural and disadvantaged areas could help to early diagnosis of TB. Supplementary information Supplementary information accompanies this paper at 10.1186/s12879-020-05524-3.
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Affiliation(s)
- Muluneh Alene
- Department of Public Health, Debre Markos University, Debre Markos, Ethiopia.
| | | | - Leltework Yismaw
- Department of Public Health, Debre Markos University, Debre Markos, Ethiopia
| | - Getnet Gedif
- Department of Public Health, Debre Markos University, Debre Markos, Ethiopia
| | | | - Wodaje Gietaneh
- Department of Public Health, Debre Markos University, Debre Markos, Ethiopia
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11
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Lakoh S, Jiba DF, Adekanmbi O, Poveda E, Sahr F, Deen GF, Foray LM, Gashau W, Hoffmann CJ, Salata RA, Yendewa GA. Diagnosis and treatment outcomes of adult tuberculosis in an urban setting with high HIV prevalence in Sierra Leone: A retrospective study. Int J Infect Dis 2020; 96:112-118. [PMID: 32339724 DOI: 10.1016/j.ijid.2020.04.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To assess the diagnosis, treatment outcomes, and predictors of mortality in adult tuberculosis (TB) patients in an urban setting with a high HIV prevalence. METHODS A retrospective study was conducted of adult TB patients aged ≥15 years who were treated at Connaught Hospital in Freetown, Sierra Leone from January through December 2017. Multivariate logistic regression was used to identify predictors of mortality. RESULTS Of 1127 TB cases notified in 2017, 1105 (98%) were tested for HIV, yielding a TB/HIV co-infection rate of 32.0%. Only HIV-tested cases (n=1105) were included in the final analysis. The majority were male (69.3%), aged 25-34 years (29.2%), and had pulmonary TB (96.3%). Treatment outcomes were as follows: 29.0% cured, 29.0% completed, 0.5% treatment failure, 24.2% lost to follow-up, 12.8% transferred/not evaluated, and 4.5% died. The majority of deaths (80.0%, 40/50) occurred within 2 months of TB treatment initiation. Age 65 years or older (adjusted odds ratio 3.48, 95% confidence interval 1.15-10.56; p=0.027) and HIV-positive status (adjusted odds ratio 3.50, 95% confidence interval 1.72-7.12; p=0.001) were independent predictors of mortality. CONCLUSIONS Suboptimal TB treatment outcomes were observed in Sierra Leone in 2017. More local and international action is warranted to help achieve the 2035 global TB elimination targets.
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Affiliation(s)
- Sulaiman Lakoh
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone; Department of Medicine, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone.
| | - Darlinda F Jiba
- Department of Medicine, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone
| | - Olukemi Adekanmbi
- College of Medicine, University of Ibadan, Ibadan, Nigeria; Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Eva Poveda
- Group of Virology and Pathogenesis, Galicia Sur Health Research Institute, Complexo Hospitalario Universitario de Vigo, SERGAS-Vigo, Vigo, Spain
| | - Foday Sahr
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Gibrilla F Deen
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone; Department of Medicine, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone
| | - Lynda M Foray
- National TB and Leprosy Control Programme, Ministry of Health and Sanitation, Government of Sierra Leone, Freetown, Sierra Leone
| | - Wadzani Gashau
- College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria
| | | | - Robert A Salata
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - George A Yendewa
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Division of Infectious Diseases and HIV Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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12
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Shewade HD, Gupta V, Satyanarayana S, Kumar S, Pandey P, Bajpai UN, Tripathy JP, Kathirvel S, Pandurangan S, Mohanty S, Ghule VH, Sagili KD, Prasad BM, Singh P, Singh K, Jayaraman G, Rajeswaran P, Biswas M, Mallick G, Naqvi AJ, Bharadwaj AK, Sathiyanarayanan K, Pathak A, Mohan N, Rao R, Kumar AMV, Chadha SS. Active versus passive case finding for tuberculosis in marginalised and vulnerable populations in India: comparison of treatment outcomes. Glob Health Action 2020; 12:1656451. [PMID: 31475635 PMCID: PMC6735288 DOI: 10.1080/16549716.2019.1656451] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Community-based active case finding (ACF) for tuberculosis (TB) implemented among marginalised and vulnerable populations in 285 districts of India resulted in reduction of diagnosis delay and prevalence of catastrophic costs due to TB diagnosis. We were interested to know whether this translated into improved treatment outcomes. Globally, there is limited published literature from marginalised and vulnerable populations on the independent effect of community-based ACF on treatment outcomes when compared to passive case finding (PCF). Objectives: To determine the relative differences in unfavourable treatment outcomes (death, loss-to-follow-up, failure, not evaluated) of ACF and PCF-diagnosed people. Methods: Cohort study involving record reviews and interviews in 18 randomly selected districts. We enrolled all ACF-diagnosed people with new smear-positive pulmonary TB, registered under the national TB programme between March 2016 and February 2017, and an equal number of randomly selected PCF-diagnosed people in the same settings. We used log binomial models to adjust for confounders. Results: Of 572 enrolled, 275 belonged to the ACF and 297 to the PCF group. The proportion of unfavourable outcomes were 10.2% (95% CI: 7.1%, 14.3%) in the ACF and 12.5% (95% CI: 9.2%, 16.7%) in the PCF group (p = 0.468). The association between ACF and unfavourable outcomes remained non-significant after adjusting for confounders available from records [aRR: 0.83 (95% CI: 0.56, 1.21)]. Due to patient non-availability at their residence, interviews were conducted for 465 (81.3%). In the 465 cohort too, there was no association after adjusting for confounders from records and interviews [aRR: 1.05 (95% CI: 0.62, 1.77)]. Conclusion: We did not find significant differences in the treatment outcomes. Due to the wide CIs, studies with larger sample sizes are urgently required. Studies are required to understand how to translate the benefits of ACF to improved treatment outcomes.
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Affiliation(s)
- Hemant Deepak Shewade
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France.,Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India.,Karuna Trust , Bengaluru , India
| | - Vivek Gupta
- Dr RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS) , New Delhi , India
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France
| | - Sunil Kumar
- State TB Cell , Department of Health & Family Welfare, Government of Kerala, Thiruvananthapuram , India
| | - Prabhat Pandey
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - U N Bajpai
- Voluntary Health Association of India (VHAI) , New Delhi , India
| | - Jaya Prasad Tripathy
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France.,Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India
| | - Soundappan Kathirvel
- Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India.,Department of Community Medicine and School of Public Health , Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh , India
| | - Sripriya Pandurangan
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Subrat Mohanty
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Vaibhav Haribhau Ghule
- Joint Efforts for Elimination of TB (JEET) Project , Foundation for Innovate New Diagnostics (FIND), New Delhi , India
| | - Karuna D Sagili
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | | | - Priyanka Singh
- MAMTA Health Institute for Mother and Child , New Delhi , India
| | - Kamlesh Singh
- Catholic Health Association of India (CHAI) , Telangana , India
| | - Gurukartick Jayaraman
- Resource Group for Education & Advocacy for Community Health (REACH) , Chennai , India
| | - P Rajeswaran
- Resource Group for Education & Advocacy for Community Health (REACH) , Chennai , India
| | - Moumita Biswas
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Gayadhar Mallick
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Ali Jafar Naqvi
- MAMTA Health Institute for Mother and Child , New Delhi , India
| | | | - K Sathiyanarayanan
- Resource Group for Education & Advocacy for Community Health (REACH) , Chennai , India
| | - Aniruddha Pathak
- Department of TB and Communicable Diseases , The Union South-East Asia (USEA), New Delhi , India
| | - Nisha Mohan
- Karuna Trust , Bengaluru , India.,IIHMR University, Jaipur , India
| | - Raghuram Rao
- Central TB Division, Revised National Tuberculosis Control Programme, Ministry of Health and Family Welfare , Government of India , New Delhi, India
| | - Ajay M V Kumar
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) , Paris , France.,Department of Operational Research , The Union South-East Asia (USEA) , New Delhi, India.,Yenepoya Medical College, Yenepoya (Deemed to be University), Mangaluru , India
| | - Sarabjit Singh Chadha
- Infectious Diseases, Foundation for Innovate New Diagnostics (FIND), New Delhi , India
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13
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Wang W, Wang F, Peng Y, Liu K, Chen X, Chai C, Wang X, Chen B. Factors Associated with Health-Seeking Preference Among People Who Were Supposed to Cough for More Than 2 Weeks: A Cross-Sectional Study in Southeast China. Patient Prefer Adherence 2020; 14:1173-1183. [PMID: 32764890 PMCID: PMC7372003 DOI: 10.2147/ppa.s257722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/19/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The health-seeking preference of people with a cough >2 weeks had not been extensively researched in southeast China. The study aimed to explore factors associated with health-seeking preference, which could provide more evidence to improve individuals' appropriate health-seeking behavior. MATERIALS AND METHODS From October 2018 to December 2018, this cross-sectional study was conducted in Zhejiang, China. A questionnaire was used to collect information on sociodemographic characteristics, knowledge of tuberculosis (TB), and health-seeking preference. The chi-square test and multivariable logistic regression were performed to evaluate factors associated with health-seeking preference. RESULTS Of the 7174 participants, 3321 (46.3%) were men, 6148 (85.7%) were married, and 6013 (83.8%) knew about TB. Appropriate health-seeking preference was reported by 6229 (86.8%) participants. Respondents knowing about TB were more likely to seek appropriate care than those did not (89.6% vs 72.4%, p<0.001). Of the 6013 participants knowing about TB, respondents with higher scores on five key items of TB knowledge were more likely to get appropriate health-seeking preference. About 805 (96.6%) participants with 5 scores on TB knowledge had appropriate care preference. Only 97 (72.4%) participants with a score of 0 reported an appropriate preference. Multivariable logistic regression showed residence, marital status, education level, occupation, and awareness of TB knowledge were predictors of appropriate health-seeking preference. Compared to participants with a score of 0 on five TB key knowledge, participants with a score of 5 were 8.57 times more likely to have appropriate health-seeking preference (95% confidence interval [CI]: 4.97-14.78), followed by a score of 4 (odds ratio [OR]=5.99, 95% CI, 3.23-8.03); 3 (OR=3.74, 95% CI, 2.44-5.74); 2 (OR=1.99, 95% CI, 1.30-3.02) and 1 (OR=1.17, 95% CI, 0.76-1.80). CONCLUSION Participants with little knowledge of TB had a low level of appropriate health-seeking preference. Appropriate health-seeking preference of the participants improved with increased key knowledge level of TB.
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Affiliation(s)
- Wei Wang
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou310051, People’s Republic of China
| | - Fei Wang
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou310051, People’s Republic of China
| | - Ying Peng
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou310051, People’s Republic of China
| | - Kui Liu
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou310051, People’s Republic of China
| | - Xinyi Chen
- Department of Preventive Medicine, Epidemiology and Health Statistics, School of Medicine, Ningbo University, Ningbo315211, People’s Republic of China
| | - Chengliang Chai
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou310051, People’s Republic of China
| | - Xiaomeng Wang
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou310051, People’s Republic of China
| | - Bin Chen
- Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou310051, People’s Republic of China
- Key Laboratory of Vaccine, Prevention and Control of Infectious Disease of Zhejiang Province, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou310051, People’s Republic of China
- Correspondence: Bin Chen; Xiaomeng Wang Department of Tuberculosis Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, 3399, Binsheng Road, Binjiang District, Hangzhzou, Zhejiang Province310051, People’s Republic of China Tel/Fax +86 571 8711 5183; Tel +86 571 8711 5181Fax +86 571 8711 5189 Email ;
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