Tuberculosis (TB), an airborne infectious disease that is caused by Mycobacterium tuberculosis (MTB), remains a global human health problem. The World Health Organization (WHO)’s 2018 global tuberculosis report states that there were approximately 10.0 million new cases of TB in 2017 [1
]. China, as well as 29 other countries in the WHO’s list of 30 high-TB-burden countries accounted for 87% of cases worldwide, of which China possessed 9% [1
TB, as an ancient disease, is a leading cause of death among people in the most economically productive age groups and those living with human immunodeficiency virus (HIV) [2
]. Though it is curable, patients who suffer from TB may be left with lifelong sequelae that lower their quality of life [3
]. Therefore, efficient assessment, robust monitoring, and practical strategies urgently need to be implemented. According to the Sustainable Development Goal (SDGs), an annual reduction in global TB incidence of 20% by 2020 has been set as one of the milestones to achieve the ambitious goal of eliminating TB by 2030, which requires a 90% reduction in the number of deaths due to TB and an 80% reduction in global TB incidence by 2030 compared with 2015 levels [1
]. In China, the Chinese Ministry of Health has launched a series of highly targeted plans to relieve the TB burden. The goal of the latest National Guideline aims to further reduce the incidence below 58/100,000 nationwide and improve the public’s awareness of key knowledge about TB prevention and control to 85% by 2020 [4
The development of TB is more easily affected by social and economic factors than any other disease [5
]. In addition to HIV infection, malnutrition, increased susceptibility of infants and the elderly, and poverty [1
], a lack of awareness about TB is also considered to be an essential factor that increases the risk of exposure to TB [8
Public awareness of TB plays a significant role in the prevention and control of this disease. A high level of TB knowledge is a crucial intervention that can influence the disease’s early detection in patients, reduce early transmissions, and increase a patient’s compliance with standard TB treatments in order to prevent multi-drug-resistant tuberculosis (MDR-TB) and extensive multi-drug-resistant tuberculosis (XDR-TB) [9
]. In contrast, poor awareness not only leads to a delay in diagnosis and suboptimal treatments, but also negatively influences the social relations and moral identity of those who are afflicted with this disease [10
]. Additionally, a previous study found that public awareness was tightly associated with several individual characteristics of the population, such as age, gender, education level, and occupation [11
]. For these reasons, there is an urgent need to raise the health literacy of the public with respect to TB information and to carry out prevention and control measures in different populations.
In 2015, China conducted a nationwide survey on the rate of awareness of TB, which suggested that the national TB awareness rate was well below the target of 85% [12
]. Since the degree of economic development, environment, and population varied wildly among different provinces, there were also large differences in the rate of awareness of TB among them. Hence, the national results cannot simply be used as the main indicators of practice at the provincial level. However, few provinces in China have recently conducted population-based investigations on TB awareness at the provincial level. Data on the lack of regional TB awareness may also affect local government public health decision-making. Zhejiang is one of the representative provinces in southeastern China. It is a relatively well developed province and, although the incidence of TB in this province was shown to have continuously declined over the last decade [13
], the rate of awareness of key knowledge about TB was 44.5% in 2014 [14
]. Consequently, special attention should to be paid to public awareness of knowledge about TB in Zhejiang Province, as it may provide evidence for the prevention and control of TB at the next stage of the plan.
This study aims to evaluate the knowledge and awareness that residents living in Zhejiang Province have about TB and to analyze the association of different characteristics of population with TB awareness. The findings may help to build a scientific foundation for TB awareness in Zhejiang Province and also assist public health practitioners to develop programs and strategies that more effectively serve people in southeast China.
For the general public, a lack of TB awareness can contribute to low TB detection rates and the interruption of treatments [19
], or even delays in early TB diagnosis [20
]. This population-based study showed that the overall rate of awareness of five key pieces of information about TB was only 48.0%, an increase of nearly 3.5% and 2.4% compared with findings from 2014 and 2010, respectively [14
]. However, there remains a long way to go to reach the 85% target of the national TB control plan by 2020, suggesting that there is an urgent need for the government and responsible agencies to further promote health and health education in relation to TB among communities.
In this survey, nearly 16% of respondents had never heard about TB; these respondents were mainly concentrated in the 12–20 year old group and the over 60 age group. This represents an increase of 3.8% and a decrease of 9.3% compared with the data on adolescents (22.8%) and the elderly (32.9%), respectively, in the National Tuberculosis Awareness Survey of 2015 [12
]. The proportion of young people under 21 years old who had heard about TB was higher than in Tianjin (58.9%) but lower than the rate found in Shenzhen (77.9%) [21
]. It is worth noting that gender did not seem to be a factor that affected the overall TB awareness rate in our study, which contrasts with the conclusion drawn in some studies that the overall rate of awareness about TB in women was generally lower than that in men [16
]. Regarding the place of residence, respondents living in urban areas were more likely to have a better awareness of TB than those residing in rural areas, which is similar to the results of other studies conducted in China [26
]. The focus of health education in the future should remain on the countryside.
In terms of each key piece of information about TB, the study participants had the highest level of correct knowledge about TB’s transmission route, which was much better than participants either in Vietnam (62.4%) or in Inner Mongolia (63.3%) [20
]. The fact that TB has been characterized as a curable disease was also well comprehended by respondents, whose level of awareness on this point was also much higher than that found in an American study (32.0%) and a Tanzanian study (72%) [28
]. Similarly, the awareness rate of TB’s designated diagnosis and treatment sites exceeded 60%. The rate of correct awareness on the question of for how long should a cough and expectoration persist in order to suspect TB, nevertheless, was far from satisfactory. It is widely known that coughing and sneezing, particularly coughing, are not only the transmission modes of some airborne infectious diseases, but also constitute typical symptoms of lung diseases such as asthma, chronic obstructive pulmonary disease (COPD), and TB. Individuals who have coughed for over two weeks and are well aware of TB would seek out a medical service and start anti-tuberculosis treatments more immediately, and thus would have a shorter duration of infection than those who take no notice of, or are not bothered by, coughing [30
]. However, people are not likely to identify the early symptoms of TB (cough, fever, etc.) unless serious symptoms appear (hemoptysis, weight loss) [30
]. Some people think that a persistent cough is normal, or even not a potential symptom of TB. This may be one of the reasons for the low awareness rate for this piece of key information. Similarly, the policy that the fees for a TB diagnosis and first-line therapeutic drugs are covered by the government was not well understood by our respondents. Moreover, some respondents, even if they were aware of the policy, still doubted its authenticity. In fact, the free items that the government provides cover less than 40% of the total TB diagnosis and treatment cost, which means that TB patients will still bear more than 50% of the total cost [31
]. The heavy economic burden on TB patients was found to be one of the primary reasons for poor compliance with TB treatments, as well as the major problem for TB control in China and other developing countries [32
]. With respect to the rates of correct answers to questions about key pieces of TB information among different groups, the results showed that access to knowledge about TB was not equal among subjects with a different socioeconomic status. We found that the amount of key knowledge about TB increased as the education level increased. This result was also confirmed in several studies [21
]. Most notable to us in this study was that, among the various walks of life, health care workers (HCWs) tended to have the highest accuracy rate with respect to TB knowledge, with teachers ranked second. Therefore, increased involvement of highly educated health practitioners in health education delivery may have an impact on raising the public’s awareness of TB in the area. Although the rate of awareness of farmers was very low, it also provided us with a positive sign: approximately a 2.3% increase compared with the latest investigation in 2014 (41.5%) [12
]. Students, however, accounted for the lowest overall accuracy with respect to key pieces of information about TB, which may be partly related to the higher proportion in the low- and middle-age groups among them in this survey. Meanwhile, the propaganda and education work on TB prevention and control was mainly allocated to TB patients and adults in society, which was also one of the reasons to explain the low awareness of students. We believed that the low awareness of TB may be one of the reasons for patients’ care-seeking delay, which may cause the cluster infection among congregate settings such as schools. As a high-risk group for clustered TB, once it breaks out, the incidence rate of students tends to exceed the average prevalence level of the local population [33
], as they may not seek out immediate medical help because of their low awareness of TB. This evidence indicates that students, especially primary and secondary school ones, should definitely be the focus of the main intervention in the next phase by more novel health educational methods.
Differences reflected by careers may partially result from the relativity between the high level of awareness and the educational state of each occupational group, or it may be that occupational differences lead to unequal opportunities to acquire information about TB [22
]. These two factors interacted with each other and jointly promote the improvement of the awareness rate. Generally, HCWs are considered to have a higher risk for TB infection because they are more frequently exposed to patients with active TB in the process of diagnosis, treatment, and other medical practices compared with individuals in other occupations, even with those of similar socioeconomic status, such as teachers [34
]. The TB control plan needs to strictly implement health education on TB in order to reduce TB infection in Chinese hospitals.
In Zhejiang Province, the medical insurance system for urban workers and the NCMS constitute the main foundation of the medical security system, which covers urban and rural employees and rural residents, respectively [36
]. Due to the differences in social-economic status, differences will also exist in the level of understanding of TB. A study conducted among Chinese adults suggested that medical insurance for urban workers had the greater impact on improving health-related behaviors than the NCMS [37
]. This may be the reason why people who were insured under the medical insurance for urban workers scheme had a higher rate of awareness of TB.
Our study has some limitations. Firstly, TB is a disease that is related to socioeconomic development; due to the geographical constraints and taking into account the economic conditions and low TB prevalence in Zhejiang Province, the results of our study could be taken to represent southeastern China but may not fully represent the rate of awareness of key knowledge about TB at the national level, especially in areas that are relatively poor and have a high incidence of this disease. Secondly, as this study was cross-sectional, we could not draw a causal relationship between factors and effects.