This document analyzes risk factors and treatment seeking behavior for tuberculosis (TB) in four Indian states using data from the National Family Health Survey 3 (NFHS-3). The key points are: 1. The prevalence of TB was highest in Tamil Nadu and among males, older age groups, and rural populations. 2. Risk factors for TB included poor housing conditions, cooking with biomass fuels, and behaviors like smoking and drinking. Wealth, education, and urban residence were protective. 3. Treatment seeking varied by state, with households in Andhra Pradesh least likely to use government facilities for TB care. Private providers remained the primary source of care overall.

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Risk factors and treatment seeking behavior of Tuberculosis in
Selected States: NFHS-3 Data Analysis
By
Prof. C.P.Prakasam
Former Professor, International Institute for Population Sciences, Mumbai
prakasamcp60@gmail.com

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Risk factors and treatment seeking behavior of Tuberculosis
In Selected States: NFHS-3 Data Analysis*
By
Dr. C.P.Prakasam
Former Professor,
International Institute for Population Sciences, Mumbai, India
prakasamcp60@gmail.com
ABSTRACT:
Tuberculosis has recently emerged as a major health problem in many parts of the developing
countries, leading to concomitant illness of HIV/AIDS. It is also known as “White Plague” spreads
through air when a person with the infection coughs talks or sneezes. TB is the leading cause of
death among people who are HIV positive. TB would be serious health problem where there is
poor sanitation, poverty and illiteracy.
In this paper an attempt is made to know 1.Prevalence of TB in four southern states, 2. Risk
factors associated with the infection (TB) and 3.Health seeking behavior among the infected
person with TB.
Data were collected from NFHS-3 for the four selected states viz: Andhra Pradesh, Karnataka,
Kerala and Tamil Nadu. Risk factors for the infection of TB have been identified as: 1.Houseld
factors viz: Persons per room used for sleeping, Cooking fuel, Place for cooking, Type of
fuel/stove, and 2.individual factors viz: Use of Tobacco, Use of Alcohol. Treatment seeking
behavior has been identified as: Source of health care and Health insurance coverage. By using the
NFHS-3 data for the four states, analysis has been done by considering risk factors, Health seeking
behavior for TB. These factors further analyzed with the background characters of the respondent.
Results revealed that number of persons suffering from TB per one lack population found to be
highest in Tamil Nadu (508) followed by Andhra Pradesh (449) and least in Karnataka (141).Risk
factor found to be high with poor housing condition, cooking arrangements with straw/shrubs/grass
and cow dung. TB found to be associates with Smoking and alcohol directly and poverty, illiteracy
indirectly. Analysis revealed that highest health insurance coverage found to be in urban
households and majority of households are covered under one scheem or other. The private
medical sector remains the primary source of health care for the majority of households in both
urban and rural areas. The results further revealed that majority of households in Andhra Pradesh
do not use Government health facilities followed by Karnataka for the treatment of TB.

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Risk factors and treatment seeking behavior of Tuberculosis in Selected States: NFHS-3 Data Analysis
By
Dr. C.P.Prakasam
Former Professor,
International Institute for Population Sciences, Mumbai, India
prakasamcp60@gmail.com
Introduction:
India has about 1.8 million new cases of tuberculosis annually with 0.8 million new smear positive
cases , accounting for a fifth of new cases in the world having highest number than in any other
country. Tuberculosis has recently emerged as a major health problem in many parts of the
developing countries including India, leading to concomitant illness of HIV/AIDS. It is also known
as “White Plague” spreads through air when a person with the infection coughs talks or sneezes.
Tuberculosis is the most common HIV-related opportunistic infection in India. TB is the leading
cause of death among people who are HIV positive. Taking Care of TB patients with both diseases
(TB and HIV) is a majorpublic health challenge. The influence of tuberculosis co-infection on the
progression of HIV disease is a research matter of debate and controversial issue (Reid A, Scano
F, Getahun H, et al., 2006). In 2004, about 330,000 people in India died from tuberculosis. (India
TB, 2006 RNTCP status report, 2007). Two of every five persons,more than 400 million , have
latent tuberculosis infection. Tuberculosis can be expected to develop in more than half of those
who are also infected with HIV. Between January and September 2006, a total of 15,000 people
with suspected tuberculosis that were HIV-positive and 16,420 who were HIV-negative were
referred to such facilities by centers in the six Indian states with the highest HIV prevalence
(Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland, and Tamil Nadu).
Estimated incidence rate by WHO (2009) of TB in Indian during 2007 was 168 per one lack
population of all forms and the prevalence rate was 238 per lack population. Estimated TB
mortality during 2007 among HIV –negative cases was 26 per lack per year and it was 2.5 per lack
among HIV positive population. Government of India introduced DOTS (Directly Observed
Treatment, Short-course strategy) in 1994 and adopted “Stop TB strategy” to reduce the TB burden
by 2015 in line with MDG. However TB prevalence and incidence are at static levels and cases
are identified as HIV in these current years. Keeping in view of the TB situation in India an attempt

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is made to understand the current incidence and the risk factors associated with it in selected states
by analyzing the national wide survey data NFHS-3.
Objectives:
1. To know Prevalence of TB in four Southern states
2. To assess the Risk factors associated with the infection (TB)
3. To know the Health seeking behavior among the infected person with TB in the selected
states in India and
Data and Methodology:
To achieve the above objectives data were collected from NFHS-3 (National Family Health
Survey-3) conducted during 2005-06 (IIPS &MACRO International 2007). NFHS-3 collected the
information from the household interview was obtained by asking question as “Does any usual
resident of your household suffer from tuberculosis?” for each household member identified as
suffering from TB, further the respondent was asked: “Has the person suffer from TB received
medical treatment for the TB?. In all 522,027 numbers of usual residents responded to these
questions in India. For the present study information from the selected four states viz: Andhra
Pradesh (28755), Karnataka (25801), Kerala (12309) and Tamil Nadu (23107) were analyzed.
Among these four three states viz: Andhra Pradesh, Karnataka and Tamil Nadu are high HIV
prevalence states gives a clear understanding of TB and its association with HIV. From the derived
data, prevalence of TB has been calculated as the number of persons per 100,000 usual household
residents suffering from tuberculosis and the number of persons per 100,000 usual household
residents suffering from medically treated TB.
Research study carried out by Mishra, (2004), Mishra, V, R.D. Retherford and K.R.Smith (1999)
shows that exposure to indoor smoke can cause serious respiratory and other adverse health effects.
Study done in slums in Ahmedabad city (Khatri GR, Frieden TR. (2002), Khadri, A.M. et al, 2003)
and all India study by Chakraborty A.K. (2004) shows that the prevalence of tuberculosis varies
by age and sex. High prevalence was observed among male than female and in age group 60+.
Hence in this study the Risk factors for the infection of TB have been identified as: Household
factors viz: Persons per room used for sleeping, Cooking fuel, Place for cooking, Type of
fuel/stove. To understand the influence of these risk factors and persons with and without TB,
Logit regression analysis has been used. Further treatment seeking behavior of the TB persons has
been analyzed by their place of treatment.

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Prevalence of Tuberculosis in selected States:
Prevalence of TB who has been medically treated found to be high in Tamil Nadu (118,455 per
100,000) in the age group 15-59 and 60+ than other states followed by Andhra Pradesh and Kerala.
Least prevalence of TB for medically treated found to be in Karnataka (Table 1).Sex wise
prevalence of TB found to be high for Males (659,319 per 100,000) in Tamil Nadu followed by
Andhra Pradesh. Place of residences wise rural areas found to have high prevalence than Urban in
all districts. This clearly indicate that high prevalence was observed in Tamil Nadu and age wise
15-59, 60+, sex wise Male than female and place of residence wise rural population found to have
high prevalence of TB.
Table 1: Prevalence of Tuberculosis* in selected states by age, sex and Place of residence:
NFHS-3 Data Analysis:
Characteristics
Andhra Pradesh Karnataka Kerala Tamil Nadu
T.B Medically
Treated
TB
T.B Medically
Treated
TB
T.B Medically
Treated
TB
T.B Medically
Treated
TB
Age
<15 years
15-59 years
60+
121
447
1462
121
384
1462
54
138
465
54
131
465
60
276
783
60
255
783
118
480
1602
118
455
1519
Sex
Male
Female
570
330
532
289
168
114
168
105
340
217
340
203
699
329
659
319
Place of residence
Urban
Rural
283
530
268
479
120
154
109
154
245
291
245
279
292
697
271
669
Total 449 409 141 136 275 268 508 483
*Number of persons per 100,000 usual household suffering from any TB and medically treated TB.
Risk Factors Associated with TB:
To understand the risk factors associated with TB, following household factors has been
considered: Age of respondent who identified with TB, Persons per room used to sleeping, cooking
fuel used, Place of cooking, Type of fire used for cooking, Place of food cooked and wealth index
. These are all proxy variable to understand the risk factors of TB. The details of the category of
variables are given in Table 2. According to the influencing variable, percentage of usual resident
of the household suffers from TB or not has been cross classified for each state and given in Table
3. Results shows that in Andhra Pradesh all six variables showed significant

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Table 2: Risk factors influencing Tuberculosis selected for the data analysis
Influencing Variable Classification
1 Age <15 years
15-59 years
60+
2 Person per room used
for sleeping
One room house
Two and more rooms house
3 Cooking fuel Solid fuel:
Wood,
Straw/Shrubs/grass
Agricultural Crop residue
Dung Cakes
Other
Other fuel:
Electricity or Gas
Kerosene
Coal/lignite/charcoal
4 Type of fire used Stove other:
Stove with a chimney
Stove used kerosene or electricity
Open fire:
Open file/Chullah ,other
5 Place of food cooked In house with in the room
With no window
Other: in other room
In Other building
6 Wealth Index Poor
Middle
Rich
influence on usual household suffering from TB (Table 3).In Tamil Nadu except “type of file used”
all other variables showed significant influences, in Karnataka except age and type of fire used
and in Kerala cooking fuel, Place of cooking shows significant influence on usual household
suffering from TB (Table 3). This analysis showed that better housing condition and place of
cooking are important variables influencing the prevalence of TB.
Above analysis showed that influence of each variable independently on usual resident suffering
TB. To identify the influence variable controlling for the influence of other variable, this will give
assessment of significant variables, hence Logit regression analysis applied by considering usual
resident suffer from TB or not as dependent variable and others six risk factors given in Table 2
as independent variables. The results of Logit regression analysis is given in Table 4.

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Table: 3: Percent usual resident of the household suffer from TB by Risk Factors associated with it in
Tamil Nadu Andhra Pradesh Karnataka and Kerala: NFHS-3 Data
Risk Factors
TAMIL
NADU
Andhra
Pradesh Karnataka
KERALA
usual resident
of the
household
suffers from TB
usual resident
of the
household
suffers from
TB
usual resident
of the
household
suffers from
TB
usual resident
of the
household
suffers from
TB
Yes Yes Yes Yes
AGE GROUP
<15 years 120(24.6) 104(29.9) 58(31.9) 39(22.8)
15-59 years 293(60.0) 201(57.8) 108(59.3) 110(64.3)
60+ 75(15.4) 43(12.4) 16(8.8) 22(12.9)
Ψ2
= 14.278 ** 9.901 * N.S NS
Person per room used for sleeping
one room 406(83.2) 250(71.8) 122(67.0) 34(19.9)
Two rooms 82(16.8) 98(28.2) 60(33.0) 137(80.0)
Ψ2
= 51.880 ** 24.455 ** 16.039 ** NS
Cooking fuel
Solid fuel 304(62.3) 223(64.1) 147(80.8) 154(90.1)
Other fuel 1849(37.7) 125(35.9) 35(19.2) 17(9.9)
Ψ2
= 35.387 ** 86.006 ** 12.135 ** 23.803 **
Type of fire used
Stove other 94(23.6) 222(90.2) 147(94.2) 154(100.0)
Open fire 304(76.4) 24(9.8) 9(5.8) 0(0)
Ψ2
= N.S 25.251 ** N.S NS
Place of food cooked
In house 339(69.5) 215(61.8) 156(85.7) 138(80.7)
Other 149(30.5) 133(38.2) 26(14.3) 33(19.3)
Ψ2
= 15.419 ** 30.756 ** 3.170 * 13.995 **
Wealth index
Poor 206(42.2) 97(27.9) 96(52.7) 14(8.2)
Middle 118(24.2) 104(29.9) 46(25.3) 40(23.4)
Rich 164(33.6) 147(42.2) 40(22.0) 117(68.4)
Ψ2
= 126.578 ** 67.861 ** 37.424 ** NS
Total 488(100.0) 348(100.0) 182(100.0)
Logit regression analysis results shows (Table 4) that in Andhra Pradesh, Household with no
separate room used for kitchen, middle aged persons, persons per room used for sleeping (one
room), solid fuel used for cooking , stove with kerosene and poor household were at high risk of
suffering with TB than others . In Karnataka, Kerala wealth index showed significant influence.
In Tamil Nadu persons sleeping in one room, type of fire used for cooking and wealth index

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showed significant influence in determining the usual household resident suffering with TB. This
Logit analysis also showed that household environment and cooking arrangements play a major
role in determining the prevalence of TB.
Table: 4 Logit regression analyses to understand the influencing risk factors on usual household resident
suffer from any TB in Selected States in India: NFHS-3 Data Analysis.
Andhra Pradesh Karnataka Kerala Tamil Nadu
RISK FACTORS Exp(B)
95.0% C.I. for
EXP(B) Exp(B)
95.0% C.I. for
EXP(B) Exp(B)
95.0% C.I. for
EXP(B) Exp(B)
95.0% C.I. for
EXP(B)
Lower Upper Lower Upper Lower Upper Lower Upper
Household Separate room
used for kitchen
Yes ref
No
1.000
1.133 .736 1.742
1.000
.801 .546 1.173
1.000
1.062 .550 2.050
1.000
1.102 .550
1.000
2.050
AGEGROUP
<15 years ref
1.000 1.000 1.000 1.000
15-59 years 1.107 .548 2.235 .819 .437 1.537 .674 .371 1.225 .619 .371 1.225
60+ .974 .496 1.912 .983 .546 1.769 .933 .561 1.552 .766 .561 1.552
Persons per room used for
sleeping
One ref
Two and More
1.000
.920 .874 2.219
1.000
.858 .588 1.253
1.000
1.352 .884 2.068
1.000
.378** .884 2.068
Cooking fuel:
Solid fuel ref
Other fuel
1.000
.812 .098 6.760 ---- --- ---- --- --- --- -- -- --
Type of fire used for cooking
Open fire, Chullah ref
Stove and other
1.000
3.568 .431 29.576
1.000
1.696 .604 4.765 ---- --- ---
1.000
.580*
WEALTH index
Poor ref
Rich
1.000
.825 .766 1.372
1.000
.631** .480 .830
1.000
.603** .458 .795
1.000
.638** .458 .795
Constant .005 .013** .048** .021
-2 Log likelihood
100 x R2
1150.31
2.60
1551.20
1.20
1491.00
1.60
2192.157
4.70
Health seeking behavior:
To understand the health seeking behavior, questions were asked about place of treatment of the
usual resident of the household suffering from TB. The results are given in Table 5. The analysis
shows that more than 40 percent of household who are suffers from TB visit Private hospital,
Private doctor/clinic for treatment in Andhra Pradesh and Karnataka (Table 5), where as in Kerala
and Tamil Nadu majority of persons suffering with TB visits Government/Municipal /CHC/Rural
hospital. This analysis reveals that the success of Government program through DOTS in Tamil
Nadu and Kerala than the other two states.

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Table: 5 Place for treatment by the usual resident of the house hold suffer from TB
In Selected States: NFHS-3 Data
HH member go for
treatment when sick
Any usual resident of the household suffers from TB
Andhra Pradesh Karnataka Kerala Tamil Nadu
Govt./Municipal
hospital
103(29.6) 59(32.4) 82(48.0) 241(49.4)
Govt. dispensary 37(10.6) 8(4.4) 33(19.3)
CHC/Rural
Hospital/PHC
4(1.1) 19(10.4) 35(20.5) 57(11.7)
NGO or trust
hospital/clinic
3(.90) 5(2.7) - 32(6.6)
Private hospital 147(42.2) 48(26.4) 17(9.9) 117(23.9)
Private doctor/clinic 14(4.0) 43(23.6) 4(2.3) -
Other private health
facility
40(11.5) -- - 41(8.4)
Total 348(100.0) 182(100.0) 171(100.0) 488(100.0)
Information about the reasons for not visiting Government health facilities by the usual household
suffering from TB has been collected and given in Table 6. Results revealed that 29 percent in
Andhra Pradesh, 17.5 percent in Karnataka, 10.5 percent in Tamil Nadu expressed that there is no
nearby health facilities to seek TB treatment. Further highest percent household suffering TB
revealed that Poor quality care in Andhra Pradesh, Karnataka and Tamil Nadu (Table 6). In
Karnataka nearly 31 percent household expressed that “Waiting time too long” as one of the major
reason for not utilizing healthcare facilities.
Table: 6: Reason for Household members suffering from TB not using Government facilities
in Selected States: NFHS-3 data
Reason for HH
members don't use
Government facility
Any usual resident of the household suffers from TB
Andhra
Pradesh
Karnataka Kerala Tamil Nadu
No nearby facility 101(29.0) 31(17.5) 7(4.1) 51(10.5)
Facility timing not
convenient
50(14.4) 21(11.9) 2(1.2) 41(8.4)
Health personnel often
absent
23(6.6) 29(16.4) 9(1.8)
Waiting time too long 42(12.1) 54(30.5) 3(1.8) 61(12.5)
Poor quality of care 100(28.7) 72(40.7) 12(7.0) 109(22.3)
Payment required 6(1.7) 5(2.7) 4(2.3) 4(0.8)
Total Respondents 348 182 171 488

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Summary and Conclusions:
India is the world's TB capital recording an estimated 1.9 million new cases every year. However
only 70 percent of these are actually detected and put on the highly effective DOTS programme.
Each of these active TB patients left undetected goes on to infect 10-15 people on an average every
year. Programs have been planned in achieving “Stop TB” by 2015 keeping Millennium
Development Goals (MDGs). However the prevalence of TB is at static stage.
The present analysis is based on large household survey conducted in India (NFHS-3) by asking
questions on “Does any usual resident of household suffer from tuberculosis?” and “Has named
received medical treatment for the tuberculosis?” Data were collected for the four states viz:
Andhra Pradesh, Karnataka, Kerala and Tamil Nadu.
Results revealed that number of persons suffering from TB per one lack population found to be
highest in Tamil Nadu (508) followed by Andhra Pradesh (449) and least in Karnataka (141).Age
wise prevalence was high at 60+ years. Prevalence of TB found to be more among males and rural
population. Age group wise it has been observed that elderly population (60+) has been affected
nearly three times more than young age group and males are affected more than females.
Among the risk factors at the household level it has been observed that cooking environment and
number of rooms used for sleeping found to be the contributory risk factors in assessing TB
prevalence. These factors show significant impact in Tamil Nadu and Andhra Pradesh and
Karnataka. In Kerala state “cooking fuel” and “place of food cooked showed significant impact in
understanding TB prevalence. Among the household suffering from TB majority of them
expressed that they are not utilizing Government facilities with the reason for “Poor quality of
care”, “Waiting time too long”, and “No nearby facilities”.
It is suggested that DOTS program should be strengthened and awareness program related to using
better cooking facilities, better housing environment along with effective DOTS program will lead
to decline in prevalence of Tuberculosis in India.
References:
Chakraborty A.K. (2004): Epidemiology of tuberculosis: Current Status in India, Indian Journal
of Medical Research 120, pp: 248-276
Directorate General of Health Services (2007):” India TB 2006, RNTCP status report, New
Delhi, India” Central TB Division, Directorate General of Health Services, Ministry of Health
and Family Welfare (http://www.tbcindia.org.)
International Institute for Population Sciences and Macro International (2007): “National Family
Health Survey (NFHS-3), 2005-06, India”, Mumbai

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Kadri A.M., A. Bhagyalaxmi, M.K. Lala, Parimal Jivrajini, Madhu Vidhani, Tushar Patel (2003):
“An Epidemiological Study of Prevalence of Tuberculosis in the Urban Slum Area of
Ahmedabad City” Indian Journal of Community Medicine Vol. 28, No. 3
Khatri GR, Frieden TR. (2002): “Controlling tuberculosis in India. N Engl J Med ; 347: 1420-
1425.
Mishra, V (2004): “What do we know about health effects of smoke from solid fuel
combustion?” East-West Centre Working papers, Population and Health Series, No.117,
Honolulu: East-West Centre
Mishra, V, R.D. Retherford and K.R.Smith (1999): “Biomass cooking fuels and prevalence of
tuberculosis in India”, International Journal of Infectious Diseases 3 (3):119-129
Reid A, Scano F, Getahun H, et al. Towards universal access to HIV prevention, treatment, care,
and support: the role of tuberculosis/HIV collaboration. Lancet Infect Disease 2006;6: 483-495.
WHO (2009): “WHO Report 2009: Global Tuberculosis Control 2009 Epidemiological Strategy
Financing” WHO/HTM/TB/2009.411, WHO
This is revised version of paper presented in Thirty First National Conference of
Indian Association for Study of Population, held at Department of Population Studies,
Sri Venkateswara University, Tirupati, AP, India, During 3-5, November 2009