Abstract
Background
Tuberculosis (TB) remains a major global health challenge, particularly in low-income settings where structural inequities hinder early diagnosis and care. Ethiopia, one of the 30 high TB-burden countries, continues to experience marked geographic disparities. Understanding knowledge, attitudes, and practices (KAP) among affected populations is essential to inform context-specific interventions supporting the End TB Strategy.
Methods
A cross-sectional KAP survey was conducted in Woliso District (Oromia Region, Ethiopia) between April 2023 and December 2024, including 152 TB index cases and 326 household contacts. A structured, interviewer-administered questionnaire assessed knowledge of TB symptoms, transmission, diagnosis, and perceived barriers to care. Categorical variables were compared using Chi-square or Fisher's exact test, and continuous variables with Mann–Whitney test.
Results
Among 478 participants (median age 28 years [IQR 19–40]; 44.1% female), 69.5% lived in rural areas. The main barriers to timely diagnosis were absence of nearby TB diagnostic facilities (13.4%), poor road conditions (6.3%), health system delays (5.9%), and financial constraints for transportation (3.8%). Poor roads and transport costs were reported more often by rural residents (p < 0.05), while absence of nearby TB diagnostic facilities was reported most often by index cases and older subjects (p < 0.05). Recognition of cough lasting >2 weeks (84.3%) and night sweats (65.7%) was common, while hemoptysis (49.6%) and fever (16.1%) were less recognized. Awareness of sputum and X-ray diagnostics was 87.2%, higher among index cases (95.4% vs. 83.4%, p = 0.0005). Although 77.0% considered TB life-threatening, 52.2% believed it was transmissible only through close or bed-sharing contact (p < 0.0001 for rural vs. urban). Older age correlated with better knowledge across most domains (all p < 0.01). Overall, subjects living in rural area had higher scores about barriers for accessing TB care (p = 0.0004) and attitude on TB (p = 0.01), and lower score about knowledge on TB (p = 0.002).
Conclusions
While TB knowledge and attitudes were generally high, misconceptions about transmission and persistent structural barriers hinder access to timely diagnosis and care. Expanding community-based diagnostic capacity, improving rural infrastructure, and integrating social protection strategies are key to advancing Ethiopia's progress toward End TB targets.
1. Introduction
Despite being preventable and curable, tuberculosis (TB) still causes over 10 million new cases and 1.3 million deaths each year. Its burden is strongly shaped by poverty and social inequities, underscoring that biomedical interventions alone are insufficient without complementary socio-economic and health system–strengthening measures [1], [2].
Ethiopia remains one of the 30 high TB-burden countries identified by WHO. Although national incidence has gradually declined, TB continues to pose major challenges, with an estimated incidence of 182 per 100,000 population and 8% TB/HIV co-infection in 2023 (1). Through its Health Sector Transformation Plan, Ethiopia has prioritized TB, TB/HIV, and MDR-TB control, yet marked geographic disparities persist, particularly in rural “hotspot” districts where poverty, stigma, and limited infrastructure converge [3], [4].
To improve healthcare access in remote areas, the country launched the Health Extension Program in 2003, deploying salaried female Health Extension Workers (HEWs) who deliver community-based services and support TB case detection at the household level in collaboration with community health promoters (5).
Understanding how people perceive TB and respond to it is crucial. Knowledge, attitudes, and practices (KAP) studies provide insights into behavioral and contextual barriers that can undermine national strategies. While previous research in Africa has documented limited knowledge of TB transmission, stigma, and diagnostic delays [6], [7], data focusing specifically on TB patients and their household contacts in Ethiopia remain scarce.
This study aims to assess TB-related knowledge, attitudes, and practices among Ethiopian TB patients and their household contacts in Woliso District, Oromia Region, with particular attention to perceived barriers to timely diagnosis and care. The findings are expected to inform targeted, community-based interventions aligned with the WHO End TB Strategy (8) and Ethiopia's national elimination goals.
2. Methods
2.1. Study design and setting
This was a cross-sectional survey conducted in the Wolisso District, Oromia Region, Ethiopia, between April 2023 and December 2024. The study aimed to evaluate tuberculosis (TB) knowledge, attitudes, and perceived barriers to care among TB index cases and their household contacts. Wolisso District is a predominantly rural area where healthcare delivery relies heavily on health centers, peripheral health posts, and the Ethiopian Health Extension Program. The questionnaire was adapted from the WHO Advocacy, Communication and Social Mobilization for TB Control: A Guide to Developing KAP Surveys (9) and from previously validated Ethiopian KAP tools [3], [4]. Additional items exploring perceived structural barriers to TB care were developed by the CADOOL study team based on formative field discussions with local health workers.
The questionnaire covered four domains: Socio-demographic characteristics, Knowledge (symptoms, transmission, diagnosis, and risk factors of TB), Attitudes (perceived severity, stigma, and willingness to seek care), Perceived barriers (economic, geographic, and health system–related). responses were checked daily for completeness and consistency by the local study coordinator.
2.2. Bias mitigation and ethical considerations
To reduce social desirability bias, interviews were conducted in a private area by staff not involved in clinical care; neutral, non-judgmental wording and ‘don't know’ options were used. Written informed consent (and parental consent with child assent when applicable) was obtained. Approval to carry out this study was received from the Oromia Health Bureau Research Ethics Committee (reference number BFO/MBTFH/1–16/100023). as previously approved for the CADOOL study. (10)
2.3. Statistical analysis
Categorical data were summarized as absolute and relative frequencies, while numerical data as median and interquartile range (IQR). Three scores about barriers for accessing TB care (range 0–11 points), knowledge on TB (range 0–18 points) and attitude on TB (range 0–10 points) were calculated by assigning 1 point to a correct answer and 0 point to a wrong answer, then summing the points obtained. We refrained from arbitrary dichotomization of the scores as this would provide unreliable information to the reader. The scoring system is summarized in Supplementary Table 1. Categorical data were compared between groups using Chi-Square test or Fisher's exact test. Numerical data were compared between two groups using Mann-Whitney test. The correlation between numerical data was evaluated using Spearman's rank correlation coefficient. All tests were 2-sided and statistical significance was set at 5%. The statistical analysis was performed using R 4.4 (11).
3. Results
Overall, the study included 152 index cases and 326 household contacts between 27 April 2023 and 13 Decembre 2024. There were 211 females (44.1%) and 267 males (55.9%), with median age of 28 years (IQR 19–40). Of them, 332 (69.5%) lived in rural areas and 146 in urban areas (30.5%).
The most frequently reported barriers included absence of nearby health facilities providing TB diagnostic services (13.4%), inadequate roads and transportation (6.3%), health system delays in the diagnostic process (5.9%) and economic constraints for transportation (3.8%) (Fig. 1 and Supplementary Table 2). Of note, the absence of nearby health facilities providing TB diagnostic services was reported more frequently by index cases (21.7% vs. 9.5% in household contacts, p = 0.0004) and older subjects (median 34 vs. 27 years, p = 0.009). In addition, participants living in rural area reported more frequently inadequate roads and transportation (8.4% vs. 1.4% in those living in urban areas, p = 0.006) and economic constraints for transportation (5.4% vs. 0.0% in those living in urban areas, p = 0.009) (Supplementary Tables 3–6).
Fig. 1.
Participants' opinions on barriers for accessing to TB care.
Overall, median score about barriers for accessing TB care was 0 (IQR 0–1) and was higher in index cases (p = 0.003), older subjects (p = 0.009) and those living in rural area (p = 0.0004), while it was statistically different in males vs. females (p = 0.79) (Supplementary Tables 3–6).
The most recognized TB symptoms were long-lasting cough (84.3%) and night sweats (65.7%), while the least recognized TB symptoms were blood sputum (49.6%) and fever (16.1%) (Fig. 2 and Supplementary Table 7). Long-lasting cough was recognized more frequently by index cases (96.0% vs. 78.8% in household contacts, p < 0.0001) and older subjects (median 30 vs. 16 years, p < 0.0001). Similarly, night sweats were recognized more frequently by index cases (72.4% vs. 62.6% in household contacts, p = 0.04) and older subjects (median 30 vs. 25 years, p = 0.03). In addition, shortness of breath was recognized more frequently by index cases (63.8% vs. 53.7% in household contacts, p = 0.04). (Supplementary Tables 3–6).
Fig. 2.
Participants' knowledge on TB.
Most participants (87.2%) identified sputum analysis and chest X-ray as TB diagnostic tools, while some (11.7%) could not indicate any TB diagnostics tools (Fig. 2 and Supplementary Table 7). The identification of sputum analysis and chest X-ray was more common in index cases (95.4% vs. 83.4% in household contacts, p = 0.0005) and older subjects (median 30 vs. 14 years, p < 0.0001) (Supplementary Tables 3–6).
Most participants (77.0%) recognized that TB could be life-threatening, but the others (23.0%) considered TB as not very serious or had no opinion on the matter (Fig. 2 and Supplementary Table 7). The awareness of TB seriousness was more common in index cases (85.5% vs. 73.0% in household contacts, p = 0.004) and older subjects (median 30 vs. 20 years, p < 0.0001) (Supplementary Tables 3–6).
Almost all participants (98.4%) were aware of the risk of TB transmission among people living with a TB case, but half participants (52.2%) restricted the risk to those sleeping together or being in close contact (Fig. 2 and Supplementary Table 7). Such belief was more common in participants living in rural areas (59.4% vs. 35.6% in those living in urban areas, p < 0.0001) (Supplementary Tables 3–6).
The most common population strata that were considered at higher TB risk included HIV-positive subjects (78.9%), children (74.7%), smokers (72.8%) and undernourished subjects (64.6%) (Fig. 2 and Supplementary Table 7). The inclusion of HIV-positive subjects among those at higher TB risk was more common in index cases (87.5% vs. 74.8% in household contacts, p = 0.002) and older subjects (median 29 vs. 22 years, p = 0.003) (Supplementary Tables 3–6). The inclusion of children among those at higher TB risk was more common in index cases (80.9% vs. 71.8% in household contacts, p = 0.04), older subjects (median 30 vs. 22 years, p = 0.002) and males (78.7% vs. 69.7% in females, p = 0.03) (Supplementary Tables 3–6). The inclusion of smokers among those at higher TB risk was more common in index cases (79.6% vs. 69.6% in household contacts, p = 0.03) and older subjects (median 30 vs. 23 years, p = 0.0003) (Supplementary Tables 3–6). The inclusion of undernourished subjects among those at higher TB risk was more common in index cases (73.0% vs. 60.7% in household contacts, p = 0.01) and older subjects (median 30 vs. 22 years, p = 0.0004) (Supplementary Tables 2–5).
Overall, median score about knowledge on TB was 12 (IQR 11–14) and was lower in subjects living in rural area (p = 0.002), while it was statistically different in index cases vs. household contacts (p = 0.34), older subjects (p = 0.08) and males vs. females (p = 0.46) (Supplementary Tables 3–6).
Almost all participants (>98%) would encourage people in their house to screen for TB if they had TB, or would seek medical attention in case of TB symptoms or a close friend/relative with TB (Fig. 3 and Supplementary Table 8). In addition, they believe that TB can be treated (98.4%) and would take part to an awareness session about TB prevention (96.6%).
Fig. 3.
Participants' attitude on TB.
Overall, around half of participants would be supportive (64.2%) or would feel compassion (56.3%) toward someone in family or neighborhood with TB (Fig. 3 and Supplementary Table 8). Being supportive was reported by older subjects (median 38 vs. 26 years, p = 0.04), while feeling compassion was more common in in participants living in rural areas (69.9% vs. 50.3% in those living in urban areas, p = 0.0001) (Supplementary Tables 3–6).
Overall, median score about attitude on TB was 9 (IQR 8–10), and was higher in subjects living in rural area (p = 0.01), while it was statistically different in index cases vs. household contacts (p = 0.28), older subjects (p = 0.81) and males vs. females (p = 0.55) (Supplementary Tables 3–6).
4. Discussion
This KAP study explored tuberculosis (TB) preparedness among Ethiopian patients and their household contacts. Overall, awareness of TB symptoms, risk factors, and preventive actions was higher among older participants and index cases, likely reflecting their greater exposure to health information and prior disease experience. Participants most often identified cough lasting more than two weeks and night sweats as typical symptoms, while fever and hemoptysis were less frequently recognized.
To our knowledge, this is one of the few studies conducted in Ethiopia that concurrently assessed TB knowledge, attitudes, and perceived barriers among both patients and their household contacts. By including these two complementary groups, our study provides a more comprehensive understanding of community-level determinants of TB awareness and health-seeking behavior.
The most frequently reported barriers to timely diagnosis were the absence of nearby diagnostic facilities, poor road conditions, health system delays, and limited financial means to travel. These findings highlight the persistence of structural constraints that hinder early case detection, especially in rural areas, where transport difficulties and inadequate infrastructure remain major obstacles. Similar associations between awareness, service availability, and TB outcomes were reported by Wolde et al., who showed that better-informed and better-resourced districts made greater progress toward End TB targets [8], [12].
In our context, economic constraints, transportation difficulties, and long distances to health facilities were the most commonly reported barriers. These findings are consistent with national surveys and underscore the need to strengthen decentralized diagnostic services and the role of Health Extension Workers (HEWs) in case detection and referral. Evidence shows that decentralizing TB services and empowering HEWs in sputum collection and referral can substantially improve case detection and outcomes, as demonstrated in other infectious disease programs across Ethiopia and sub-Saharan Africa [5], [13], [18].
Knowledge of TB transmission and risk factors was generally good, with many participants identifying HIV infection, smoking, malnutrition, and childhood as major risk factors consistent with well-established scientific evidence [13], [14], [15]. However, misconceptions persisted: one in four underestimated the severity of TB, and nearly half restricted the risk of transmission to close or bed-sharing contact, suggesting that the concept of airborne spread remains only partially internalized. Awareness of diagnostic tools such as sputum microscopy and chest X-ray was common, yet 12% of respondents could not identify any diagnostic method. This knowledge–practice gap, observed in several African KAP studies, confirms that awareness alone does not necessarily translate into preventive behavior or timely care-seeking [6], [7].
However, important misconceptions persisted, particularly regarding airborne transmission and curability, highlighting the need for continuous community education. This pattern is consistent with findings from other Ethiopian settings and reinforces the importance of sustained health communication at both household and community levels.
Consistent with findings from the HEAL TB project, our data revealed that rural participants reported the most significant barriers to accessing care, particularly related to transport and distance. These results echo earlier studies from southern Ethiopia linking geographic inaccessibility and costs to delayed diagnosis and treatment [16], [17]. Overcoming these barriers requires system-level interventions that bring diagnostic capacity closer to communities. Growing evidence indicates that decentralizing diagnostic services and empowering Health Extension Workers (HEWs) in sputum collection and referral processes can significantly enhance TB case detection and treatment outcomes [5], [18], echoing similar successes reported in decentralized models for other infectious diseases (19). Complementary approaches, such as mobile clinics in pastoralist areas, may extend reach but require stable funding and logistical coordination (20).
Although direct comparison of composite scores is not possible because different scoring systems were adopted across studies, the observed patterns are broadly consistent with previous KAP studies. Similar to reports from Pakistan and Afghanistan, participants living in rural areas showed lower TB knowledge and greater barriers to healthcare access, suggesting that geographic inequities remain major determinants of TB awareness and access to care [21], [22]. Studies from China have likewise emphasized the need for targeted health education strategies to address persistent knowledge gaps [23], [24]. Unlike many previous KAP studies, which evaluated either patients or the general population, our study simultaneously assessed TB index cases and their household contacts, allowing a broader evaluation of knowledge and perceived barriers within the same transmission setting.
These findings support the implementation of community-based TB control strategies that combine health education, social protection, and early referral through the existing Health Extension Program. Integrating awareness campaigns with community screening initiatives could accelerate progress toward the End TB Strategy targets in Ethiopia.
Beyond health system strengthening, addressing the social and economic determinants of TB remains essential (25). Poverty, malnutrition, and economic vulnerability continue to limit access to timely diagnosis and adherence [26], [27]. Social protection interventions—such as cash transfers, subsidized healthcare, and food support—can help mitigate these barriers when integrated with broader health and educational programs (28).
This study has some limitations. It was carried out in a single site with a moderate sample size, hence the generalizability of the findings should be limited to similar settings and may not be generalized to the entire country. The interviewer-administered questionnaire could have introduced social desirability bias, potentially inflating knowledge scores. However, the use of a standardized, WHO-aligned tool enhances the validity and comparability of the results across high-burden settings.
In conclusion, while knowledge among patients and household contacts was relatively high, persistent gaps in practice and access remain. Bridging these gaps will require reinforcing rural diagnostic capacity through HEWs, improving transport and infrastructure, and embedding social protection measures within TB control programs. Aligning community education with health system readiness will be essential to accelerate progress toward Ethiopia's End TB targets.
Addressing knowledge gaps, strengthening decentralized TB services, and enhancing the capacity of community health workers are essential steps to improve case detection and treatment outcomes, particularly in rural and resource-limited settings.
CRediT authorship contribution statement
Giacomo Guido: Writing – original draft. Berhanu Gulo: Writing – original draft. Sergio Cotugno: Writing – original draft. Birhanu Kenate Sori: Writing – original draft. Flavio Antonio Bobbio: Writing – original draft. Tilahun Melaku: Writing – original draft. Alemseged Abdissa: Writing – original draft. Rosa Buonamassa: Writing – original draft. Yoseph Tafesse: Writing – original draft. Francesco Vladimiro Segala: Writing – original draft. Alessandro Cornelli: Writing – original draft. Worku Nigussa: Writing – original draft. Fabio Manenti: Writing – original draft. Mulugeta Miressa: Writing – original draft. Francesco Cavallin: Writing – original draft. Surra Abata: Writing – original draft. Abdi Reta: Writing – original draft. Bobosha Kidist: Writing – original draft. Giovanni Putoto: Writing – original draft. Annalisa Saracino: Writing – original draft. Francesco Di Gennaro: Writing – original draft.
Funding
This research was partially supported by the 2022 call of the Italian Agency for Development Cooperation (AICS – Agenzia Italiana per la Cooperazione allo Sviluppo). This research was partially supported by EU funding within the NextGenerationEU-MUR PNRR Extended Partnership initiative on Emerging Infectious Diseases (Project no. PE00000007, INF-ACT).
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jctube.2026.100634.
Appendix A. Supplementary data
Supplementary Tables S1–S8 provide details of the scoring system; participants’ perceived barriers, knowledge, and attitudes regarding tuberculosis; and subgroup analyses according to participant status (index cases vs household contacts), age, sex, and rural or urban residence.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Tables S1–S8 provide details of the scoring system; participants’ perceived barriers, knowledge, and attitudes regarding tuberculosis; and subgroup analyses according to participant status (index cases vs household contacts), age, sex, and rural or urban residence.