Tuberculosis (TB) is an airborne, infectious disease caused by organisms of the Mycobacterium tuberculosis complex [1]. It mostly affects the lungs, and its symptoms include a persistent cough lasting for more than 3 weeks, chills, fever, night sweats, loss of appetite and fatigue. In the worst cases, blood is also found in the sputum, and patients complain of chest pain [1, 2]. Tuberculosis is among the top ten causes of death globally [3-5]. Tuberculosis remains a major health problem in South Africa, even though its rate of spread has declined over the years, after reaching a peak in 2009 [3]. The Directly Observed Treatment Short-course (DOTS) is one of the principle programmes initiated by the World Health Organization (WHO) for the management and treatment of TB [6]. The DOTS is effective in escalating successful treatment results and lowering drug resistance by treating patients with a conglomerate of drugs for at least six months [7]. Many countries worldwide have adopted the DOTS programme, including South Africa.

Another strategy initiated by WHO in the fight against TB is the ‘End TB’ with its proposed milestones for 2020 and 2025 plus targets for 2030 and 2035 to reduce TB cases and deaths [5]. This strategy is focused on integrated person-centred care at all levels, expanded access to preventive treatment, maximal use of limited resources and roll out plus uptake of innovations [4]. The targets for 2030 are a 90% drop in TB deaths and an 80% decrease in the TB incidence rate (new cases per 100 000 population per year) compared with levels in 2015; 35% reduction in the number of TB deaths and a 20% reduction in the TB incidence rate [5]. Accordingly, the South African National Department of Health adopted the DOTS programme with strict guidelines and the `End TB’ strategy to combat the TB scourge in the country. In addition to the TB guidelines, the National Strategic Plan for HIV/Sexually transmitted infections /TB initiated measures aimed at addressing the societal norms and behaviours that fuel, amplify and trigger TB and HIV spread in South Africa, especially in the marginalised, poor and informal settlements [8]. Notwithstanding this, South Africa is among the eight countries accounting for two-thirds of TB prevalence globally [5, 8-10]. In addition, TB is the leading cause of death in South Africa; the incidence rate for active TB was estimated at 322,000 in 2017, with 60% co-infected with HIV [11]. Worryingly, the Eastern Cape is one of the highly TB burdened provinces [11], and Nelson Mandela Bay Health District has one of the highest TB caseloads in the Eastern Cape Province [12]. The province also ranks third with the TB treatment defaulters and forms part of the ten worst regions in South Africa with TB-related deaths, poor TB cure and treatment success rates [13].

The high incidence of active TB infection, high proportion of latent infection and Human Immunodeficiency Virus (HIV) comorbidity, poor or high-risk infection control practices or non-adherence to treatment by patients has greatly thwarted effective TB control in South Africa [14]. Although DOTS is the most effective global TB programme, its effectiveness is related to the patients’ knowledge of TB, their ability to identify symptoms, as well as their attitudes and health-seeking behaviour, and timely accessibility to health services [6, 8, 15]. Moreover, the effectiveness of DOTS depends on the willingness of the patient to accept and comply with its principles [10]. Studies conducted in the low- and upper-middle-income countries have shown that patients with TB have a significant deficit in the levels of knowledge of causal agents of TB, transmission, poor attitudes and health-seeking behaviour [6, 15]. In the Pacific island nation of Vanuatu, TB was attributed to the smoking of cigarettes; the consumption of kava; a mildly intoxicating drink found across the Pacific made from the roots of a certain plant; alcohol consumption; eating of contaminated food; the sharing of eating utensils and witchcraft [16]. In rural Uganda, smoking, an inherited consumptive tendency, witchcraft, heavy manual work, and sharing of food and eating utensils with a TB patient were factors associated with the cause of TB [17].

Anecdotal evidence has shown that patients with TB recognise symptoms of TB when they experience them; they find them worrisome, so they feel compelled to seek medical help. Studies conducted in the low- and upper-middle-income countries revealed that all patients with TB have good knowledge of TB symptoms, such as loss of appetite, weight loss, night sweats, fever, tiredness and a productive cough endured for more than a few weeks, where at times it is accompanied by blood in the sputum [6, 15, 16, 18].

Regarding transmission, patients with TB have misconceptions. In India, people perceive TB to be transmitted through droplets, food sharing utensils and by touching a person with TB [15]; in Ethiopia, inhaled droplets, exposure to dust and cold and drinking of raw milk are blamed [19]; and in Brazil, inhaled droplets; wearing the same clothes; sharing eating utensils; having sexual intercourse with the infected person and drinking contaminated water are deemed the common modes of transmission [20].

Concerning attitudes, few patients with TB disclose their TB status freely to family and friends. Most of them believe that there are many treatments available, and one can stop TB treatment if one feels better [17-19]. The reasons for patients with TB not disclosing freely is the fear of being isolated by the family because of the fear of airborne infection, the fear of being labelled as having HIV and subsequent stigmatization of the whole family [17]. Lack of knowledge of a causal agent, the transmission of TB and an attitude of unwillingness to disclose TB delay and affect proper health care. In such instances, TB patients would first seek care from a traditional healer with the belief that traditional medicine is the ideal treatment for TB; medical consultation will be the last option when patients are presenting the worst TB symptoms [15, 16, 18, 19]. The delay in seeking health care by TB patients might negatively impact the management of TB.

Recognising that there are several international studies exploring the Knowledge, Attitudes and Practices (KAP) regarding TB [21-23], and in the socio-economic perspective; and TB awareness has been explored in South Africa, little information exists on community-based context. Whether late uptake of treatment, poor cure rate and treatment success rates are responsible for the prevalence and death rate from TB or not is speculative; our research is responding to the high defaulter and death rates in Nelson Mandela Bay Health, Eastern Cape, South Africa. The study seeks to ascertain whether TB control and management are influenced by 1) a lack of knowledge and an inability to identify symptoms, 2) negative attitudes and unwillingness to accept, disclose, and comply with DOTS principles and 3) a delay in health-seeking behaviour among patients with TB. Such information may be useful for designing health facility interventions for TB control and management in this setting with high TB rates.

This present study was designed to assess the knowledge, attitude and treatment of TB, and to further examine the health-seeking behaviour of TB patients attending community health centres in the Eastern Cape, South Africa. The regression analysis exhibited no difference in knowledge, attitude and health-seeking behaviour in relation to age, gender, literacy level, employment status and marital status. This suggests that people in the Nelson Mandela Bay Sub-District C share the same TB knowledge, attitude and health-seeking behaviour. This is similar to a South African study where regression analysis of TB knowledge and attitude toward TB showed no significant difference in age, gender and education [24]. However, a Nigerian study showed that males have a higher level of TB knowledge than females, and the knowledge of TB was higher among participants who were single, married, aged 16-29 years and had tertiary education [25].

Tuberculosis knowledge was generally high among TB patients. While most of the participants knew that bacteria causes TB, there was also a high misconception that cold air and dust cause TB. These findings are similar to an Ethiopian study where 79.9% of the respondents knew the source of TB, yet 62.2% still mentioned exposure to cold air as a cause and 65.4% indicated exposure to dust [19]. In contrast, a study from Vanuatu reported that 96% of the TB patients did not know that TB was caused by bacteria in the air [16]. A misunderstanding of TB causation and a knowledge barrier can influence patients’ health-seeking behaviour, adherence to a prescribed treatment regimen and treatment outcome [16]. This calls for concerted efforts to dispel the misconceptions people have on TB causes and treatment; they also need to be enlightened about the wisdom of repositioning their TB health-seeking behaviour. Participants in this present study misrepresented some facts about TB and HIV, respectively: in fact, 77.4% indicated that TB could change into HIV; and HIV infects TB patients. A previous study done in South Africa revealed that 89% of the respondents agreed that only people who are HIV positive have TB and 60% agreed that all people with TB would develop HIV. This notion can be explained by the fact that South Africa has a high prevalence of HIV and TB is the major source of mortality in people who are co-infected with HIV and TB [11, 25]. The belief that having TB automatically translates to HIV positive provides a potential explanation of why some TB patients hide symptoms, resulting in a delay to seek medical advice and get a diagnosis of the disease [26]. In addition, the threat of HIV stigma and fear or denial also affect early diagnosis and treatment of TB [27]. As such, there is a need to scale up TB programmes focusing on stigma-related perceptions and attitudes, especially regarding patient support and family sensitisation, irrespective of HIV status [27].

Most (70.6%) of the respondents were aware that follow-up sputum tests are important. This perceived benefit is suggestive of good communication of treatment guidelines between health workers and patients. In contrast, a Zambian study revealed that only 57% of the participants knew the importance of follow-up sputum tests [28]. The sputum test results are important to determine the level of treatment required in the future and the outcome.

This study revealed negative attitudes towards the TB disease, treatment and adherence measures. More than half of the respondents felt that TB treatment is difficult and takes a long time. A study in Malawi found that the majority of the participants echoed that TB disease treatment is not easy [27]. The Moroccan study found that 34.1% of the non-adherent TB clients cited that TB treatment took long [29]. In addition, 58.7% of the respondents indicated that TB treatment interferes with work or marriage. Similar findings were noted in Zambia, where 35% of the TB patients reported dismissal from work and divorce [28].

The findings of the study indicated that 53.8% of the participants felt embarrassed taking TB treatment, and felt that the community did not respect people with TB. Similar findings were reported in an Indonesian study where 30% of the TB and ex-TB patients kept their illness a secret because of embarrassment and fear of discrimination [30]. Similarly, 64.2% of participants in a Moroccan study believed that society does not respect patients with TB [31].

The majority of the respondents (84.7%) concurred that smoking can cause TB. Smoking is a predisposing factor for TB [32]. This result is suggestive of high awareness of perceived susceptibility to tuberculosis if one is a smoker. In the Moroccan and Vanuatuan studies, only 15.7% and 26% of the respondents respectively, knew that smoking predisposes one to TB [16, 30]. More than half of the population (52.9%) of respondents voiced that people who acquire TB through smoking and drinking were getting what they deserved. A similar study in South Africa revealed that 74% of the respondents agreed that people who smoke and get TB deserve their punishment [30]. This notion can create fear of judgement by the community that can hinder health-seeking TB treatment and compliance. Most of the respondents (60.6%) in this present study acknowledged that reckless people who drink and smoke are to blame for the spread of TB. Similarly, 90% of the study respondents in a South African study agreed that irresponsible drinkers and smokers are to blame for the spread of TB [24].

Almost half (47.7%) of the respondents in this study did not initially take their symptoms seriously and more than half of the respondents were of the opinion that only people with a severe cough should seek medical attention. This is consistent with a Zambian study where (66%) did not associate their symptoms with TB beforehand [28]. This implies distorted personal susceptibility and that disease severity is the major cue to seeking health care. Patients waiting until a cough is severe leads to a delayed diagnosis and treatment commencement. This implies that there is a need for community sensitisation programmes to emphasise that any cough could indicate TB infection, not only a severe one.

The present study focused only on three community health centres in Nelson Mandela Bay Health District, Sub-District C. Therefore, the results cannot be generalised to the entire province or country. A structured questionnaire was used for data collection; consequently, no in-depth information could be obtained about the TB patients’ lived experiences while suffering from TB in Nelson Mandela Bay Sub-District C. Notwithstanding these limitations, the study provides insights into the knowledge, attitudes and health-seeking behaviour among patients suffering from TB in an understudied region with a high TB prevalence rate. Such information may be useful to inform health policy interventions on TB management.

The patients showed good comprehension of the causes of TB, duration of treatment and importance of treatment completion. Nevertheless, some patients had misconceptions about TB being caused by cold air and dust; untreated TB may convert to HIV and that having TB translates to HIV infection. As for attitudes towards TB, most patients regarded TB treatment as unpleasant, difficult, being a disease that interferes with work/marriage and endures too long. In addition, the patients expressed sentiments of community disrespect. With respect to health-seeking, it was revealed that patients had a low regard for the follow-up of TB test results and treatment. Disease severity was also the main driver for seeking medical assistance. There was no significant influence between socio-demographic variables (except for formal housing) and knowledge, attitude and health-seeking behaviour. These findings prompt the need for primary health care facilities in Nelson Mandela Bay and similar settings to strengthen health education solidarity in fighting stigmatisation; it would be advisable to build strong TB patient support groups in order to address prevailing difficulty experienced by patients while on treatment. Additionally, health education in these facilities should put more focus on tackling prevailing misconceptions about TB and to correct misinformation that might encourage social isolation of TB patients together with promoting health-seeking behaviour.