- Research article
- Open Access
- Open Peer Review
Health care providers’ knowledge, attitude and perceived stigma regarding tuberculosis in a pastoralist community in Ethiopia: a cross-sectional study
© The Author(s). 2019
- Received: 28 February 2018
- Accepted: 13 December 2018
- Published: 8 January 2019
Tuberculosis (TB) remains the prime killer disease among infectious diseases. TB control depends on early case detection and treatment in a directly observed treatment short course (DOTS) programme. The success of DOTS depends on the ability of the health care system to identify and properly manage TB cases. The present study aims to assess healthcare provider (HCP) knowledge, attitude and perceived stigma regarding TB and perception about traditional healers.
A descriptive cross sectional study was conducted among 108 HCPs using a semi-structured, self-administered questionnaire from September 2014 to January 2015. The study district has a high TB burden area with one district hospital, 4 health centres, and 18 health posts. All health facilities and HCPs available during the study period in the district were included in the study. Statistical software for social science (SPSS) version 22 and STATA version 14 were used to enter and analyse data, respectively.
The majority (64%) of the HCPs had poor overall knowledge regarding TB, and 67.6 and 57.6% had poor knowledge regarding TB diagnosis and nature of the disease, respectively. Moreover, most 66.7 and 55.6% of the HCPs had an unfavourable attitude towards TB and TB control systems, respectively. Slightly under half (49.1%) of the HCPs had a favourable attitude towards TB patients, and the majority (88.9%) had low perceived stigma. The majority (87.0%) of the HCPs indicated the importance of community involvement in TB control activity. Moreover, most (60.2%) of the HCPs showed willingness to collaborate with traditional healers (THs) on TB control activity.
Healthcare workers’ knowledge gap and unfavourable attitude towards TB control systems reported in this study may cause poor TB care delivery. HCPs’ perception of the importance of community involvement in TB control and willingness to collaborate with THs on TB management could be an opportunity to strengthen the World Health Organization’s (WHO’s) component of End TB strategy through community engagement. Training and workshops could be used to address the knowledge gap and the unfavourable attitude regarding TB among HCPs.
- Health care workers
- Stigma tuberculosis
Tuberculosis (TB) is the leading cause of death and results in ill health for approximately 10 million people each year from a single infectious agent, ranking above human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) . Ethiopia ranks among the 30 highest TB burden countries, with estimated incidence of 200,000 TB per 100,000 populations in 2015. It has fully integrated the World Health Organization (WHO) End TB strategy into the national TB prevention and care plan . The WHO reported that more than 3 million people with TB are not accurately diagnosed by the health care system every year , and healthcare workers (HCWs) have been reported to play a major role contributing to the success of TB treatment and management .
In Ethiopia, TB treatment is provided free of charge at primary, secondary and tertiary levels of public health facilities. Primary health care is the main mode of health care delivery, and the first point of medical contact for most rural residents in the country and is delivered through health centres and health posts. The success of directly observed treatment short course (DOTS) depends on the ability of the health care system to identify and properly manage TB cases. This requires active involvement of the HCPs in TB diagnosis and management [5, 6]. TB treatment should include counselling regarding disease progress and the importance of adherence to treatment. Failure to do so may result in the spread of TB and development of multi-drug resistant bacteria .
However, some studies reported misconceptions and lack of knowledge about TB among HCWs. For instance, a study in Iraq showed that only 12.6% of HCWs believe that TB is caused by bacteria, and another study in South Africa showed 21% of HCWs believe in prayer as treatment for TB [8, 9].
In pastoralist communities in Ethiopia, in addition to poor knowledge and poor healthcare-seeking behaviour [10–12], poor access to modern health care facility and quality of care has been a great challenge in the TB control activity [13–15]. Delays in the diagnosis and treatment of TB have also been reported [16–18]. Moreover, the Ethiopian national health care system has identified health extension workers (HEWs) as the first contact point in rural settings, which is difficult to implement in pastoralist communities due to their different lifestyle compared to non-pastoralists .
However, to our knowledge, there are no published reports on the knowledge, attitude and practice, and stigma towards TB among HCPs of pastoralist communities in Ethiopia, where access to health care is limited  and cultural differences between HCPs and the community are reported to be a challenge in the primary health care delivery system . Therefore, this study aims to assess HCPs’ knowledge, attitude and perceived stigma regarding TB and perception regarding collaboration with traditional healers (THs) on TB control in the Kereyu pastoralist community in Ethiopia.
Study area and population
This study was conducted in Fentalle (Kereyu pastoralist) Wereda (equivalent to district), located in the east Shoa zone of Oromia, in the southern part of the northern rift valley of Ethiopia. The area falls within an altitude range of 800–1100 masl. The total land area is 1170 km2 with a total population of 76,367; it is located 200 km east of the capital city, Addis Ababa. Metehara is the capital and administrative centre of the district. A detailed description of the study area is given elsewhere .
There are four health centres and 18 health posts for the entire population of the Kereyu District. There is one referral hospital in Metehara Sugar Corporation called Merti Hospital. There was a total of 65 HEWs and 46 other health professionals (clinical nurses, midwifes, environmental health workers and pharmacy technicians and laboratory technicians) in the district, excluding the HCPs working at Merti Hospital, which is not the administrative unit of the district health office but does provide services to the pastoralist community. The number of HEWs reported at the district health office includes those training for upskilling, travelling for workshops, not available due to maternity or sick leave as well as those in the process of transfer to other districts. We included all available HEWs at the health posts during the study period.
Study design and sampling
We conducted a facility-based cross sectional study from September 2014 to January 2015.
Before the actual data collection, we identified all the health facilities in the district with the help of HEWs and identified the TB focal person responsible for coordinating the district’s TB prevention and care activities. We included all HCPs and HEWs in the district in the study. Those who were available during the study period were given a self-administered questionnaire to complete and return. If the HCPs reported insufficient time to return the questionnaire the same day, they were allowed to return it the next day.
Data were collected using semi-structured and self-administered questionnaires prepared in English as in previous similar studies [20, 21, 25] and translated to Amharic (the federal working language). We gave training to three experienced local coordinators and involved them in the facilitation of the data collection process with the principal investigator.
The survey contained 71 questions, with sections on sociodemographic characteristics, TB knowledge, attitude, perceived stigma regarding TB and perception of collaboration with traditional healers. The tools were pre-tested before the actual data collection to assess the comprehensibility of the questionnaire.
Knowledge is defined as the fact or condition of knowing something with familiarity gained through experience or association . The knowledge section had 24 questions and was divided into three sections: TB diagnosis (10 questions about signs and symptoms of susceptive TB, active TB and relapse TB), nature of the disease (12 questions about transmission, cause, factors in the spread of TB) and treatment duration (2 questions, one for intensive phase and one for the whole duration of TB treatment required). The correct (yes) response to each question was scored as one for a positive response, and incorrect (no/I don’t know) response was scored as zero for a negative response. The scores were added together to generate a knowledge score from 0 to 24 (including each sign and symptom mentioned and factors for the exposure of TB), and the overall score was dichotomized using a median of 18 as a cut-off value. Those who scored 18 and above were coded “1” for good overall TB knowledge, and those below 18 coded “0” for poor overall TB knowledge. Likewise, scores were generated for the two sub-scales of knowledge regarding TB (TB diagnosis and nature of the disease), and the sub-scale of knowledge was categorized as poor and good levels of knowledge.
The term ‘nature of the disease’ is used to summarize the response of the HCPs about the organ affected most by TB, transmission, cause, factors for the spread of TB and the public importance of TB in the community.
Attitude is defined as how people feel about certain subjects or issues . The attitude section contained 10 questions addressing two sub sections: attitude towards TB patients (3 questions) and attitude towards TB control (7 questions). A 5-point Likert scale was used to obtain responses to these questions and was treated as a continuous interval variable for analysis. The overall score for attitude regarding TB, attitude towards TB patients and TB control system was obtained by computing the included items using the SPSS syntax Compute by summing included items and multiplying the sum by 5 (number of Likert points). The attitude score was not normally distributed, therefore, overall attitude score was dichotomized using the median score of 37 as a cut-off value; those who had a mean score of 37 and above were coded “1” for a favourable attitude regarding TB and below 37 coded “0”, indicating an unfavourable attitude regarding TB.
Perceived stigma refers to the fear of discrimination or, in general, to the awareness of negative attitude and/or practices related to a particular condition . The perceived stigma section had three sections: feeling about a person with TB, perceived community feelings towards TB patients and feelings about being near a person with TB. The first section had five items and was summed to create a perceived stigma score towards TB patients for analysis. Each item was coded as a “yes” or “no” response where ‘yes’ indicated the absence of perceived stigma and ‘no’ indicated the presence of perceived stigma. Negatively stated questions were reverse coded to obtain the correct scoring. The responses consistent with “lack of stigma” were scored one and the rest scored zero. The sum of the responses to (1) I feel compassion and desire to help; (2) I feel compassion but tend to stay away from TB patients; (3) It is their problem, and I cannot get TB; (4) I feel fear because they might infect me; and (5) I have no particular feelings were used to generate stigma score from 0 to 5. The overall score was dichotomized using the median as a cut-off point. Since the stigma scores were not normally distributed, the median score (median 1, IQR = 1) was used to classify the HCPs as having high or low perceived stigma towards TB patients. Those who have a score above 1 were coded as one, showing high perceived stigma towards TB patients, and those who scored 1 or lower were coded as zero, showing low perceived stigma towards TB patients (Additional file 1).
Perception about THs
Perception is man’s primary form of cognitive contact with the world around him . In this study, we assessed the HCPs’ perception for possible future collaboration of the conventional health system with THs on TB control. Perception of the HCPs regarding collaboration with THs and their willingness to collaborate on TB prevention and care was assessed using 17 items. The questions had multiple choice and ‘yes’ or ‘no’ responses. The proportion of responses to some of the items used and relationship to the conclusion of this paper is reported.
The data were entered and analysed using statistical software for social science (SPSS) version 22 and STATA version 14. We applied descriptive statistics to summarize the socio-demographic status of the HCPs, describe their knowledge and attitude and perceived stigma regarding TB and their perception about collaboration with THs on TB diagnosis and treatment. A Chi-square test was used in bivariate analysis to determine the association between the outcome variables and selected covariates. Univariate logistic regression was used to assess the strength of the association. The statistical significance of the differences was evaluated using p value < 0.05 and a 95% confidence interval.
Socio-demographic characteristics of HCPs in the Kereyu pastoralist district, Ethiopia
Frequency (n = 108)
< 2 years
6 to 10 years
> 10 years
Work at the DOTS unit
< 6 months
> 6 months
Attended DOTS/TB training
Provide health education on TB
Knowledge regarding TB
Knowledge level and factors associated with knowledge regarding TB among HCPs in Kereyu pastoralist district, Ethiopia
Towards nature of the disease
Towards TB diagnosis
Overall TB knowledge
Knowledge about TB diagnosis
Attending TB training
Poor NO. (%)
Good NO. (%)
Knowledge about the nature of TB
Duration of work at DOTS unit
Poor NO. (%)
Good NO. (%)
< 6 months
> 6 months
Overall Knowledge regarding TB
Duration of work at the health facility
Poor NO. (%)
Good NO. (%)
< 2 years
> 10 years
Attending TB training was associated with a 2.45-point increase in knowledge score about TB diagnosis compared with those who had never attended TB training (p = 0.03). Working at the DOTS units increased knowledge about the nature of TB (for less than 6 months yielded a 5.39-point increase and greater than 6 months with a 3.05-point increase, respectively) compared with those who had never worked at the DOTS unit (p = 0.02 and p = 0.047, respectively) (Table 2).
HCPs’ Knowledge regarding TB in Kereyu pastoralist district, Ethiopia
Frequency (n = 108)
Cause of TB
Organs most affected
Routes of TB transmission
Droplets from coughing and sneezing of a person with active TB
Factors for the spread of TB
People at high risk of developing TB
People in contact with TB patient
People with chronic disease
Infectious type of TB
Active pulmonary TB
TB in other organs/body parts
Symptoms suspicious for TB
Cough for more than three weeks
Loss of appetite
Loss of weight
Diagnosis of Active PTB
Two or three positive smear tests
One positive smear and positive X-ray
Completed treatment. Cured and returned with positive smear
Under treatment & sputum remains positive after 5 months
Interrupted treatment for 3 months and returned with positive smear
Duration of active PTB treatment
Do not know
Duration of intensive TB treatment phase
When the bacilli is resistant to all currently available drugs of TB
When the bacilli is resistant to at least isoniazid and pyrazinamide
When the bacilli is very aggressive and you need at least 8 to 12 months of treatment
Attitude towards TB
Attitude Score towards TB and factors associated with overall attitude towards TB
Median score (Q1, Q3)
Unfavourable NO. (%)
Towards TB control
Towards TB patient
Overall Attitude towards TB
People with HIV are most affected by TB
No. % No. %
3 (21.4) *
HCPs’ attitude towards TB in Kereyu pastoralist district in Ethiopia
Variables Frequency (n = 108)
New cases of TB are major challenges for TB control
Community involvement is important in TB prevention and control
TB patients do not understand why they should take the medication after starting to feel better
MDR-TB is a major public health problem in your community
Using DOTS makes a difference in treatment compliance
A person with TB faces stigma and shame in your community
DOTS implementation should take individual circumstances in to consideration
Poor knowledge about TB makes it difficult to follow DOTS
TB treatment we provide is accepted by the clients
Most HCWs at this facility have adequate training for TB control activities
Perceived stigma towards TB patients
Factors associated with perceived stigma towards TB patients in Kereyu pastoralist district, Ethiopia
Perceived stigma level
Overall knowledge towards TB
Low perceived stigma
High perceived stigma
HCPs’ Perceived stigma towards TB in Kereyu pastoralist district, Ethiopia
Frequency (n = 108)
Feeling about a person with TB
I feel compassion and a desire to help
I feel compassion but I tend to stay away from these people
I am afraid of them because they might infect me
I have no particular feeling
TB is a shameful disease
How TB patients are regarded/treated in the community
Most people reject him or her
Most people are friendly but they generally avoid him/her
The community mostly supports her/him
Feeling around a person having TB
I feel like I would get infected so I will make my conversation short
I feel like I have to keep my distance
I feel like I have to be supportive
Others (no particular feeling)
Perception of HCPs towards collaboration with THs
HCPs’ perception of collaboration with THs for TB control in Keryu pastoralists District, Ethiopia
Frequency (n = 108)
Traditional medicine exist
People in this community go to TH for TB treatment
Most preferred treatment option
Reason for traditional medicine preference
Less time taking
Most Preferred to consult for health problems
Know a patient who visited healthcare facility soon after visiting THs for TB
Treated a person with TB referred by THs
Why TH do not refer TB patients
TH can treat TB
THs fear losing patient trust
No collaboration mechanisms
THs fear losing money
No referral system
No trust in modern medicine
THs fear critics
Do not know
Accept THs practice
TH learning about TB
THs refer patients to healthcare facility
Joint research programme
The current study assessed the knowledge, attitude and perceived stigma of HCPs regarding TB and perception of THs. The results show that the majority of the HCPs had poor overall knowledge regarding TB, with particularly poor knowledge about the nature of the disease and aspects of diagnosis. In addition, most of the HCPs had an unfavourable attitude towards TB and TB patients as well as the TB control system. Interestingly, most HCPs in this study had low perceived stigma towards TB patients.
The low level of knowledge regarding TB among HCPs in this study is in line with other studies examining communities with similar high TB burden and rural settings in African countries [28, 29] and other settings . These results also indicated that attending TB training increased HCPs’ knowledge regarding TB diagnosis more than two-fold compared with those who did not have TB training. In addition, a longer duration of work and working for less than 2 years at the healthcare facility and experience working at the DOTS unit are significantly associated with increased knowledge regarding TB. This might indicate a lack of training and updating the HCPs with new and current national TB control guidelines in the district. HCPs’ knowledge regarding diagnosis and management of TB is crucial for TB control through proper case management, and it has a direct impact on the effectiveness and quality of the health care provided [7, 31, 32].
The majority of the HCPs in this study knew that bacteria cause TB. This is in contrast to studies in Iraq and South Africa, where misconceptions about TB among health care workers were more frequent. For instance, a study in Iraq  showed that only 12.6% of HCWs believed TB is caused by bacteria, and another study in south Africa showed 21% of HCWs believe in prayer as a treatment for TB .
In the present study, most HCPs had an unfavourable attitude towards TB, and most also demonstrated an unfavourable attitude towards TB patents and TB control system. Studies reported that the negative attitude of providers towards TB patients and the existing treatment system has led to a high treatment dropout rate, while home visits by providers and supportive and caring staff resulted in high treatment compliance and positive experience with DOTS [4, 30].
In the present study, the majority of the HCPs acknowledged the importance of community involvement in TB control activities and expressed their willingness to collaborate with THs on TB control activities. In this regard, many studies have reported positive contributions by THs to TB management through collaboration with modern medicine in resource-poor settings [25, 33].
Knowledge, attitude and perceived stigma of the HCPs regarding TB were not significantly associated with age, sex or profession of the HCPs. The low scores might also be because the questionnaires were administered to all HCPs in spite of their engagement at the DOTS clinic during the study period.
HCPs’ knowledge, attitude and perceived stigma regarding TB and their perception about THs in kereyu pastoralist district were assessed. To the best of our knowledge, no similar study has been conducted in kereyu pastoralist communities in Ethiopia. This could help to strengthen TB prevention and care activities in the district. However, this study has limitations because the report does not include TB case management/diagnosis and treatment practice of the HCPs at the TB unit. In addition, the self-reporting nature of the study and the fact that HCPs were allowed to return the completed questionnaire the next day might allow the respondents to receive external assistance in responding to the questions, affecting the results. Moreover, we were not able to include all HCPs reported to be working at the target healthcare facilities because of absence for training, workshops, leave of absence, transfer process, etc. Furthermore, the stigma questionnaire was not validated.
This study provides relevant information about the HCPs’ knowledge gap regarding TB, unfavourable attitude towards TB and TB prevention and care system. Our results showed that the HCPs had an unfavourable attitude towards the TB control system and had low perceived stigma towards TB patients. Training and workshops could help to fill in the knowledge gap of the HCPs’ and change their attitude towards TB control system and TB patients. The HCPs interest in involving the community and THs in TB prevention and care activity is an opportunity to implement or strengthen the WHO’s End TB strategy through community engagement.
The study was financially supported by the University of Oslo. We would like to thank Oromia regional health office for the permission to conduct the study and Fentalle district health office for facilitating the fieldwork. Last but not least, we would like to thank our respondents for their participation in the study.
This study was not funded by a grant. It is a PhD project and is supported by single student support programme at the University of Oslo.
Availability of data and materials
All data sets generated or analysed during the current study were included in this manuscript.
BTS developed the study, prepared the questionnaire, collected and analysed and interpreted the data and wrote the manuscript. FA developed the study and critically reviewed the manuscript. TB critically revised the manuscript. All authors have read and approved the final manuscript.
Ethics approval and consent to participate
The Norwegian Social Science Data Service (NSD) and Ethical Review Committee of Jimma University, Jimma Ethiopia and Oromia Regional Health Office Ethical Review Committee, Addis Ababa, Ethiopia approved this study. The HCPs provided written consent to participate after receiving information about the study. We used codes instead of personal identifiers to maintain confidentiality and the anonymity of the interviewees.
Consent for publication
The authors declare no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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