Review of Literature

The review of literature will depict what is already known about the variables of

the study based on facts and results of previous researches.

Tuberculosis

Tuberculosis (TB) is an ancient enemy. Koehler (2002) reports that human bones from
the Near East dating back five millennia show the telltale pitting of TB. Mummies from Egypt
2400 BCE show tubercular decay in their spines. The ancient Greeks described it, too. Around
460 BCE, Hippocrates identified phthisis, or consumption, as the most widespread disease of his
age. It was almost always fatal. Because of that, he advised his followers and students against
treating late-stage consumption to avoid damage to their reputations. In medieval Europe it was
called the kings evil because newly crowned kings and queens in England were alleged to
cure scrofula, glandular swellings in the neck associated with TB, with their touch. Pulmonary
TB was romanticized in the arts and music of the 19th century. The deaths of Mimi in Puccinis
La Boheme and Satine in Moulin Rouge are portrayed as romantic, tragic events, but end-stage
pulmonary TB is anything but glamorous, and Mimi and Satine exposed everyone around them
to danger with each cough. The afflicted person faced night sweats and chills, paroxysmal cough,
spread of the disease to other organs of the body, and of course, the wasting away that led
helpless bystanders to name the disease consumption.

Tuberculosis is a mycobacterial disease that is a major cause of disability and death in

most of the world, especially developing countries. Pulmonary TB is transmitted via exposure to
tubercle bacilli in airborne droplet nuclei, 1 to 5 microns in diameter, produced by people with
pulmonary or respiratory tract tuberculosis during expiratory efforts (coughing, singing or
sneezing), and inhaled by a vulnerable contact into the pulmonary alveolae, where they are taken
up by alveolar macrophages, initiating a new infection. One bout of coughing or laughing would
release up to 3500 bacilli in air, in the form of droplets, and stay suspended for up to 4-6 hours
thus making the people an easy prey of this highly contagious disease. Prolonged or repeated
close exposure to an infectious case may lead to infection of contacts. Overall, one-third of the
world's population is currently infected with the TB bacillus and 5-10% of people who are
infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some
time during their life, prompting the World Health Organization (WHO) to now call tuberculosis
a fire raging out of control in developing nations, among the poor, in prisons and in people
with AIDS. People with HIV and TB infection are much more likely to develop TB (World
Health Organization, 2010). In 2006, WHO launched the new Stop TB Strategy. The core of this
strategy is DOTS or Directly-Observed Treatment Short-course program, the TB control
approach launched by WHO in 1995. Since its launch, 36 million patients have been treated
under DOTS-based services. It responds to access, equity and quality constraints, and adopts
evidence-based innovations in engaging with private health-care providers, empowering affected
people and communities, to help strengthen health systems and promote research.
Knowledge of tuberculosis, its cause and treatment is considered important for both
prompt healthcare seeking and adherence to treatment. However, despite the worldwide efforts to
stop TB, it still seems to be relentless in wreaking havoc. According to WHO as of March 2010,

someone in the world is newly infected with TB bacilli every second. Gaps in health-care
delivery system such as shortage of logistics for proper diagnosis and lack of information
dissemination contribute to this difficult situation. A study done by Mboera, Rumisha, Senkoro,
Mayala, Shayo, & Kisinza (2007) has shown that major constraints in adopting health education
messages included poverty, inappropriate health education, ignorance and local beliefs.
Moreover, although the information gets to the community, most of them are not able to utilize it
properly because they lack the necessary background knowledge. In Norway, participants
experienced that the diagnostic process in the health services could endure for months, even
years. The diagnosis could be difficult to confirm, and health professionals appeared to have
difficulties with associating their symptoms with TB. This resulted in delays in initiating
diagnostic tests for TB (Sagbakken, M., Frich, J. & Bjune, G, 2010). In Canada, analysis among
Aborigines revealed a high level of experiential knowledge among participants, although gaps in
biomedical knowledge about the disease and available resources were apparent even among
those who had been ill. Negative memories and experiences relating to the colonial history of TB
treatment emerged as significant for many participants, helping to explain a silence around the
topic of TB in the community. Barriers to TB testing were identified, including the fear of
positive test results, the burden of long-term treatment for either latent or active disease, and
systemic barriers within and mistrust of the health system (Macdonald, Rigillo, & Brassard,
2010). In Vietnam, a study conducted by Phuong Hoa, Thorson, Hoang Long, & Diwan, (2010)
regarding the knowledge of tuberculosis and associated health-seeking behaviour among rural
Vietnamese adults with a cough for at least three weeks revealed that in a total of 559 people, a
large proportion of individuals with a cough for more than three weeks had limited knowledge of
the causes, transmission modes, symptoms, and curability of TB. Better knowledge was

significantly related to seeking healthcare and seeking hospital care. In Tamil Nadu of South
India, 80% of 310 urban residents and 63% of 339 rural people had sought care within 1 month
of onset of symptoms. Symptomatics who did not seek care attributed their inaction to
insufficient severity of symptoms (51%), unaffordability (46%) and lack of time due to work
pressures (25%). Socio-economic factors such as literacy and family income significantly
influenced care-seeking behaviour. Fifty per cent of the participants who did not seek care felt
that their symptoms were not severe (Sudha, et al, 2003). In Shandong Province, China, a study
by Chenga, Tolhurstb, Lic, Menga, & Tangb (2004) on the factors affecting delays in
tuberculosis diagnosis in rural China appealed to improve case detection of TB as it is a serious
challenge in controlling the disease. Multivariate analysis using Cox Regression showed that old
age, lack of education and distance from home to a township health centre were significantly
associated with delay in seeking care from service providers.
The Philippines ranks ninth on the list of 22 high-burden TB countries in the world,
according to the WHOs Global TB Report in 2009. After China, Philippines had the second
highest number of cases in the WHO Western Pacific Region in 2007. It is estimated that
approximately 100 Filipinos die each day from the disease in 2007. TB remains to be the sixth
greatest cause of morbidity and mortality in the country.
According to United States Agency for International Development or USAIDs Trainer
Manual, important findings in the 2007 National Prevalence Survey that were identified with
implications to communication include: a) knowledge about the cause, transmission, and
available services on TB was substantially inadequate; b) only 32% of the subjects with TB
symptoms consulted a health care provider, 43.4% self-medicated, and 25.1% did nothing; c)
54.8% consulted public health facilities, 26.7% consulted DOTS centers, and 26.4% consulted

hospitals; only 49.5% are able to complete six months of treatment or longer; and e) default rate
is 21.2% among females and 18.8% among males. The survey also noted that DOTS utilization
has not reached the desired level.

Auer, Sarol Jr, Tanner, Weiss (2000) conducted a study regarding the health seeking
behavior and perceived causes of tuberculosis among patients in Manila. The results of the study
reveal that inefficient case finding is a big stumbling block to successful control of tuberculosis.
Multiple health seeking may account for delayed case finding. The patients were treated in 22
governmental health centres of Malabon, a municipality of Metro Manila, Philippines. Only 29%
of the respondents had gone first to a health centre after onset of TB-related symptoms, and more
than half (53%) had initially consulted a private doctor. A chest X-ray was obtained for nearly
everyone (97%). Two thirds of the patients (66%) had received a prescription for drugs, and 29%
had purchased and taken anti-TB drugs for at least three weeks before they came to a
governmental health centre. Concerning community interactions, 36% said they knew at least
one person who had been treated for TB without success. The health seeking delay after
symptom onset was relatively short 64% of the respondents said they went to a health facility
within 1 month. Case studies illustrate the rationale for health seeking and explain delayed
initiation of appropriate treatment for many patients. Findings underscore the need for and
indicate approaches to health communication for improved control of TB. Furthermore, their
findings from interview narratives also suggest that improved interpersonal skills of health centre
staff and co-ordination between the private doctors and the health centers may substantially
improve services for TB patients.

Another study was done by Tupasi, Sistla, Co, Villa, Quelapio, & Mangubat, in 2000 on
bacillary disease and health seeking behavior among Filipinos with symptoms of tuberculosis:
implications for control. It was done among urban and rural communities and urban poor
settlements in the Philippines wherein the subjects aged 20 years and older were interviewed.
Sputum acid-fast smears and cultures were done in subjects with abnormal screening chest
radiographs. The results are that individuals with TB symptoms comprised 18.1% of the
population studied. The prevalence of bacillary disease was 39/1000 in symptomatic subjects
compared to 13/1000 in asymptomatic subjects.. Significantly more symptomatic than
asymptomatic subjects attended chest radiographic screening during the survey. However, in
response to their symptoms, the majority took no action or self medicated while 11.8% consulted
a private practitioner, 7.5% a public health center, 4.4% a hospital, and 1.7% a traditional healer.
The study concludes that sputum smear examination after symptom screening was acceptable for
case finding, but that the health seeking behavior of subjects with TB symptoms was
inappropriate. A health education program and public-private collaboration in DOTS are
essential for TB control.
In Davao Region of the Philippines, TB of all forms ranked number 7 in morbidity and
Respiratory TB ranked number 10 in mortality in 2008 (Center for Health Development-Davao
Region, 2008). Former Regional Health Director Paulyn Jean B. Rosell-Ubial (2006) explained
during the commemoration of the World TB Day in Region XI that there is enough drugs and
trained health workers for TB program, but the problem lies in finding TB cases. She further said
that TB stigma still exists as people are ashamed and afraid to seek health assistance once they
have the symptoms. Ubial stated that in the 2003 survey, the results showed that respondents
have very high knowledge on the cure of TB, but with a very low knowledge on how the disease

is being transmitted. People still believe that smoking causes TB or that one becomes infected
through the use of utensils of persons with TB. She stressed that TB is caused by a bacteria
known as Mycobacterium tuberculosis and is transmitted by droplet infection through coughing,
sneezing, and spitting. Ubial emphasized the need to change our culture or habit of spitting
anywhere, and the importance of practicing healthy lifestyle in order to avoid the disease.