Introduction

Tuberculosis (TB) remains a major global health challenge. An estimated of 8.6 million people developed TB and 1.3 million died from the disease in 2012 [1]. As a matter of fact, the emergence of totally drug resistant Mycobacterium tuberculosis (M. tb) strains and absence of new effective vaccine made tuberculosis a threatening disease of the world [2].

Household contacts of active TB cases are at high risk of getting TB disease. TB detection rate among contacts of household members and neighbors is high especially among people exposed to case with high-grade sputum smears [3]. It is estimated that, over one year, a single pulmonary TB patient in a community can infect, on the average, 10 to 15 people she/he has contact with [4].

Patients with smear positive TB are responsible for up to 90% of the transmission occurring in the community [5]. Thus, early detection of active tuberculosis and provision of preventive therapy is essential to reduce the death rate and interrupt transmission of TB [6, 7].

Many people don't know how someone could acquire tuberculosis and also they don’t know any sign and symptom of TB [8]. This reduces effectiveness of passive case finding. So, an extensive contact investigation is essential to enhance efforts of TB control.

The Ethiopian comprehensive training manual for clinical and programmatic management of TB, Leprosy and TB/Human Immunodeficiency Virus (HIV) reiterates the need to trace and examine all close contacts of TB patients. Household contacts are screened for signs & symptoms of TB with particular attention to cough of two weeks or more duration. Other symptoms that help to identify TB suspects include fever, night sweating and weight loss. Isoniazid preventive therapy (IPT) is given for all young children (<5 years) that are household contacts of sputum smear-positive TB if they are free of TB disease [9].

Household contacts screening is not well operational zed in Amhara region. Hence, the present study was developed to investigate the adherence to household contact screening and associated factors among pulmonary tuberculosis patients in Amhara region, Ethiopia.

Methods

Result

Socio-demographic characteristics

A total of 418 pulmonary TB patients were interviewed. Of these, 164 (39.2%) were sputum smear positive and more than half of the respondents, 220 (54.5%), were males. About 337 (80.6%) respondents were from public health facilities. The median age of the respondents was 28 years; with inter quartile range of 13 years.

Majority, 331 (79.2%), of the respondents were Christians. The mean household contact size of the patients was 4 (inter quartile range = 3) and the median monthly income of respondents was 800 ET birr (43.01USD) with inter quartile range of 1100 ET birr (59.14 USD); (Table 1).

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Table 1. Socio demographic characteristics of respondents, Amhara region, July 2013, (N = 418).

https://doi.org/10.1371/journal.pone.0125767.t001

Health care system related characteristics

Only one third (34.2%) of the patients were very satisfied with service delivered at TB clinic. Likewise, half (51.2%) of the participants reported that it took them more than half an hour to reach the TB clinic and most of them (80.4%) travelled to and from the clinic on foot. In all the health facilities, 155 (37.1%) study subjects did not take health education from health care worker(HCW)providing them the anti-TB drugs (Table 2).

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Table 2. Health care system related characteristics of respondents, Amhara region, July 2013(N = 418).

https://doi.org/10.1371/journal.pone.0125767.t002

Factors associated with household contact screening adherence

In the bivariate logistic regression analysis, contact screening adherence was significantly associated with religion, family income, relationship with contact, family support, type of tuberculosis, health education by HCW and knowledge on tuberculosis.

However, in multivariate logistic regression (adjusted analysis), religion, family income, relationship with contact, health education by HCW, type of PTB and knowledge on TB were significantly and independently associated with adherence. Thus, Muslims were two times more likely to adhere to contact screening as compared to Christians (AOR = 2.4, 95%CI: (1.4, 4.2).Patients who took health education from HCW were three times (AOR = 3.2(95% CI: 1.9, 5.5) more likely to adhere to contact screening as compared to patients who did not take health education. Patients with sufficient knowledge were two times (AOR = 2.2, 95%CI: 1.3, 3.7) more likely to adhere to contact screening during the interview (Table 3).

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Table 3. Factors associated with household contact screening adherence among TB patients using bivariate and multivariate logistic regression, Amhara region, July 2013, (N = 418).

https://doi.org/10.1371/journal.pone.0125767.t003

Discussion

Investigation of contacts of tuberculosis patients is a priority for TB control [10]. Hence, this study investigated the level and factors affecting adherence to household contact screening. Accordingly, the household contact screening adherence in this study was 33.7%. This finding is lower than the adherence level reported in Bangkok, Thailand: 52% [3]. However, it exceeds the finding from India, 14% [11].The possible explanations could be: low socio-economic status of the index cases and lack follow up to contact screening in low income countries.

As previously reported from other studies [3, 12, 13], adherence to screening of household members is affected by individual, social- cultural, accessibility and health system factors.

In this study, family income of a patient plays crucial role in adherence to household contact screening as patients with higher family income were more likely to be adherent. Similarly, in Vietnam, low income was positively associated with longer delays in tuberculosis diagnosis among women [14] and in Philippines, family income had determined intended health-seeking behavior of TB patients [15]. In Ethiopia, although TB diagnosis and treatment is being provided freely at the community level (in health centers and health posts); nevertheless 51.2% patients in this study reported the inaccessibility of tuberculosis service centers. Thus, lower income people might not afford cost of transportation to bring household contacts.

Health education by HCW was an important determinant of adherence to household contact screening as patients who took health education were three times more likely to adhere to contact screening. In our setting, the health education focuses on signs and symptoms of TB, advantage of early screening, TB infection prevention techniques and the type of person they should bring. Okuonghae in 2010[8]reported that patients who lacked information on tuberculosis cannot say much on the symptoms and signs of TB; they cannot use chronic cough as a marker for identifying a potential TB case which may lead to failure in notify the TB case to the relevant health worker.

Household contact screening was significantly lower among Christians. The belief on use of holy water (16%) and herbal medicine (1.5%) for treatment of tuberculosis among Christians, in this study, could contribute to the lower adherence. In support of this, TB patients who used holy water from orthodox churches in Tigray, Ethiopia [16] were delayed to seek modern health care. Additionally the Christians TB patients might belong to a lower socio-economic status family. As the proportion of Muslim participants in this study were small (20%), the assumption needs further investigation.

In the present study, the adherence level among HIV infected and HIV uninfected patients had no significance difference. This was consistent with previous study [16] where HIV status had no association with delayed consultation among pulmonary tuberculosis patients. However many of the HIV infected patients were expected to adhere as they have regular visits to health facility for anti retro viral therapy follows up.

Knowledge of tuberculosis patients had significant association with adherence to household contact screening. Understanding the benefit of bringing household contact to TB clinic might contribute to their adherence. Other study, in Zambia, had reported that low knowledge was preventive to treatment adherence [17]. The study sample could be possible reason of disparity.

This study has several limitations. Firstly, the study was cross-sectional and therefore no causal inferences can be made. Second, there might be social desirability bias from participants towards which they assumed good response. Thirdly, the setting was only limited to urban districts.

Conclusion

Household contact screening adherence among tuberculosis patients was low in Amhara region. Religion, family income and relationship with contacts, type of TB, health education by HCW and knowledge on tuberculosis were significantly associated with adherence. Hence, promotion of universal knowledge of TB in the community and continuous health education to tuberculosis patients are recommended. The association between religion and adherence needs to be further investigated.

Acknowledgments

The authors are grateful to Amhara National Regional State Bureau of Health and all of the TB clinic staff for their unreserved help during data collection. Finally we would like to appreciate the study participants for their willingness and participation in the study.