Gender specific epidemiology of tuberculosis in Vietnam

Abstract

Background: Globally, about two-thirds of notified tuberculosis (TB) cases are men, only one third are women. Whether this gender difference in notification rates reflects a true difference in TB incidence, or an under-notification of the disease among women is a subject to speculation.

Objective: To describe the epidemiology of TB in Vietnam with special reference to differences between men and women of relevance for TB control.

Methods: The study was conducted during 1996-1999 in 23 districts randomly selected in four provinces in different regions of Vietnam, and in Bavi district, Ha Tay province. Both qualitative and quantitative methods were applied: (i) a hospital-based structured questionnaire study of 1027 new smear-positive pulmonary TB patients; (ii) a population-based survey of 34,127 persons aged 15 or more; (iii) follow-up of 540 new smear-positive pulmonary TB patients during their treatment course; (iv) sixteen focus group discussions (FGDs) with men/women, TB patients/non-TB participants.

Main findings: (i) In general, people had fairly good knowledge about TB. However, knowledge and practice were not closely related and misconception of TB still existed; (ii) Women had poorer access to health care than men; (iii) Health care seeking patterns were similar among men and women: practising self-medication, buying drugs, followed by visiting private practitioners, and then visiting hospitals; (iv) Women did not start seeking health care later than men, however, they sought health care from less-qualified providers and visited more providers than men; (v) Total delay to TB diagnosis was significantly longer among women (13.3 wks) compared to men (11.4 wks). This difference was mainly due to a longer doctor's delay among women (5.4 wks) than among men (3.8 wks), p=0.003; (vi) Among persons with a prolonged cough, delay to hospital was significantly longer among women compared to men; (vii) Prevalence of cough and sputum expectoration was significantly lower in female smear-positive PTB patients than in male patients. The absence of these symptoms was significantly associated with increased doctor's delay; (viii) Fewer women were reportedly given sputum test than men were (13.6% vs. 35.5%) among those who came to hospitals with the same symptom of prolonged cough; (ix) Recovery rates of cough and expectoration after two months of treatment were higher among women compared to men; (x) Women were perceived as more compliant with TB treatment than men. The main obstacles to compliance among men were insufficient understanding of TB treatment, and individual costs, while among women attitudes of health staff, social isolation and stigma played important roles; (xi) Social isolation of TB was perceived to happen both within the patient's family and outside community, and to be more severe among women than among men.

Suggestions for TB control: Some intervention areas are suggested: (i) Improving practice of general population toward TB and TB patients; (ii) Reducing misconceptions and unnecessary social isolation and stigma of TB; (iii) Prioritising the interventions to reduce diagnostic delays on doctors; (iv) Increasing suspicion of TB, especially for women, in the general health care; (v) Diversifying TB control activities, increasing involvement of other health providers (e.g. private health sectors) in TB case-detection; (vi) Decentralising and strengthening TB case-detection at grass-root level; (vii) Better understanding of the TB patients.