Correct knowledge of tuberculosis as a determinant of risk perception among patients with type 2 diabetes mellitus in rural Karnataka

Abstract

Background

The prevalence of type 2 diabetes mellitus (T2DM) varies significantly among Tuberculosis (TB) patients from 25.3 to 44% in India. Correct knowledge regarding TB symptoms is a determinant for health-seeking behaviour among T2DM patients. However, there is limited literature regarding TB knowledge and risk perception among patients with T2DM in rural communities of coastal Karnataka, India.

Objectives

To determine the association of correct knowledge regarding TB among patients with T2DM and their TB risk perception in a rural community in coastal Karnataka.

Methodology

A cross-sectional study was conducted over 18 months in the rural villages under the rural health training centre of a tertiary care private medical college at Dakshina Kannada District, Karnataka, involving 202 T2DM patients. Data were collected via pretested semi-structured questionnaires administered through interviews. Descriptive statistics and chi-square tests were used to analyse demographic variables, TB knowledge and TB risk perception.

Results

Among the 202 participants, 116 (57.4%) demonstrated overall correct knowledge regarding TB. Participants with high risk perception showed significantly better recognition of specific TB knowledge components, including airborne transmission (p = 0.013), key symptoms such as cough (p = 0.029), fever (p = 0.049), and weight loss (p = 0.019), as well as awareness of asymptomatic disease (p = 0.003) and extrapulmonary involvement (p = 0.046). They were also more likely to correctly reject misconceptions related to TB transmission.However, overall correct TB knowledge was not significantly associated with perceived risk (χ² = 0.008, p = 0.927). High risk perception was significantly associated with being single/widowed (p = 0.003), higher education (p < 0.001), higher socio-economic status (p < 0.001), skilled occupation (p < 0.001), and a family history of DM (p = 0.008). Age, sex, and duration of DM were not significantly associated with risk perception.

Conclusion

Although more than half of the participants demonstrated correct TB knowledge, this did not translate into higher perceived risk, highlighting a critical knowledge-perception gap among patients with T2DM. While specific and clinically relevant knowledge components were associated with higher risk perception, general awareness alone was insufficient to evoke a sense of personal vulnerability. Educational strategies should therefore move beyond general information dissemination and focus on personalised risk communication that explicitly links DM with increased susceptibility to TB. Such interventions should emphasise the possibility of asymptomatic disease and promote timely screening and care-seeking behaviour.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28340-x.

Introduction

The Global TB burden in 2024 was estimated to be 10.8 million new TB cases and 1.25 million TB deaths [1]. Many of the new cases of TB were attributed to T2DM among other health conditions like HIV, undernutrition, harmful use of smoked form of tobacco, and harmful use of alcohol [1]. India had reported 2.607 million cases of TB and 0.323 million TB-related deaths in 2024 [2]. The India TB Report 2024, based on 2022 surveillance data, reported that out of 2.607 million reported TB cases, 0.102 million individuals were co-infected with T2DM, warranting the significant burden of TB-DM comorbidity in India [2].

The dual burden of TB and DM is a significant global public health concern and challenge [3].The prevalence of T2DM among TB patients ranges from 12.39 to 44% in India, with the highest prevalence among southern states of India, where it was estimated to be 25.3 to 44% [4].

In India, the combination of TB and T2DM is a serious public health concern, especially in rural regions where there is inadequate access to healthcare [2, 5] Screening for TB among individuals with T2DM thus is the need of the hour in a high burden country like India [6]. However, perceived risk of TB among patients with T2DM is an important determinant of health-seeking behaviour, as it can influence symptom recognition, care-seeking, willingness to undergo screening, and timely diagnosis, which may ultimately contribute to improved treatment outcomes in this vulnerable population [7]. The health belief model often describes perceived susceptibility and severity as a definition of risk perception that influences preventive health behaviour. [8] Studies conducted in India have shown that the risk perception of TB is low among rural T2DM patients [9]. While studies conducted in India have shown that both patients and healthcare providers consider that screening for TB among patients with non communicable diseases such as T2DM was relevant and acceptable, the assessment of correct knowledge regarding TB with respect to their perceived susceptibility and severity has not been assessed [9]. Although previous studies have assessed general awareness of TB or DM separately, limited evidence exists on whether individuals with T2DM who possess TB-related knowledge also perceive themselves to be at increased risk of developing TB. Understanding this knowledge perception gap is important because awareness alone may not translate into preventive behaviour, timely screening, or early care seeking [8]. With this background, the present study aimed to assess the correct TB knowledge and the proportion of high and low TB risk perception among patients with T2DM in a rural community of coastal Karnataka.

Methodology

Setting and design

A cross-sectional descriptive design was conducted among villages under the rural health training centre of a tertiary care private medical college situated in the Dakshina Kannada District of Mangalore, Karnataka. The study was carried out for 18 months, from June 1, 2023, to November 30, 2024.The extended study duration reflected the community-based census approach, which involved household visits across multiple rural wards, repeated contact attempts to minimise non-response, and the consecutive enrolment of newly diagnosed eligible participants identified during the study period.

Sample size calculation

The details on the known cases of T2DM residing in the study setting were collected from the nearby PHC. The total population of the villages attached to the PHC was 8638, and there were 6 wards with 177 known patients of T2DM as per the NCD register in the Primary Health Centre (PHC). Given the limited Indian data on TB knowledge and symptoms among DM patients, sample size calculations were based on study done in from Indonesia where 29.2% of DM patients had good knowledge regarding TB [10], given 5% absolute precision at 95% Confidence level assuming a population correction factor of 177 known DM cases in the study settings, a minimum of 114 patients with T2DM were required using Cochran’s formula for sample size estimation using a single proportion [10].

A community-based census approach was adopted within the selected rural field practice area. All eligible T2DM patients listed in the PHC NCD register were approached for participation rather than selecting a random sample. Of the 177 registered patients, 172 consented and were enrolled, while five did not provide consent. To achieve the required sample size and maximise coverage of eligible participants, newly diagnosed T2DM patients who were added to the NCD register during the study period and fulfilled the inclusion criteria were consecutively recruited, resulting in an additional 30 participants and a final sample of 202. The non-response rate among the originally registered patients was 2.8% (5/177), which was within acceptable limits.

Study tool

A pretested semi-structured questionnaire designed specifically for this study was made, and content validity was ascertained. After attaining the face and content validity, the final tool was finalised [11]. To calculate the correct knowledge of TB, the authors utilised the questions from the validated questionnaire, as shown in Table 1. To compute the risk perception, 1 question each in perceived susceptibility and perceived severity, which was self-reported by the T2DM patients, was used and categorised as high and low levels of risk perception for TB. Risk perception was operationally assessed using two context-specific self-reported items selected to reflect key dimensions relevant to TB prevention among patients with T2DM: perceived seriousness/curability of TB and perceived susceptibility related to DM. Responses were used to classify participants into high and low risk perception categories. This brief measure was chosen to facilitate administration during community-based household interviews in a rural population with varying literacy levels. The detailed computation of risk perception is also described in Table 1.

Table 1.

Operational definition of risk perception toward TB

Category	Operational Definition
T2DM patients with TB knowledge.	Correct knowledge of TB
	If questions, – have you heard about TB(Yes/No), Source of TB infection was through the air when coughing or sneezing by a TB patient (Yes/No), and that TB disease was curable(Yes/No), were all answered as yes.
	Incorrect knowledge of TB
	If the questions were answered with “no” or “don’t know” responses to the above-mentioned questions.
High Risk Perception	Participants who answered “Yes” to both Question 3 A (“TB is curable”) and Question 3B (“DM increases the risk of TB”) under Part B of the questionnaire.
Low Risk Perception	Participants who answered “No” or “Don’t know” to either one or both of the items (Questions 3 A and 3B, Part B).

Method of data collection

All consenting adults (age ≥ 18 years), known cases of DM patients for at least 6 months who may or may not be included in the NCD register at the PHC residing at the village, Dakshina Kannada District, Mangalore, Karnataka, were included in this study. T2DM patients who were not available for the interview after three consecutive informed visits by the investigator and community health workers, Accredited Social Health Activist (ASHA) workers were excluded. Data collection was carried out by the principal investigator, assisted by trained ASHA workers who facilitated access to participants during home visits. The semi-structured questionnaire was administered through face-to-face interviews conducted at the participants’ homes. The study tool was administered after obtaining consent from the participants. Of the 202 participants, 172 were known T2DM patients from the NCD register, all of whom had a confirmed diagnosis of at least 6 months duration. The remaining 30 were newly diagnosed T2DM patients identified during the study period; upon verification, all 30 had received their diagnosis at least 6 months before data collection and met the inclusion.

Data management and statistical analysis

The investigator converted the questionnaire into an Epicollect version 5 form to capture the responses from the interviews with T2DM patients. Continuous data were expressed in mean, standard deviation, median or interquartile range, and categorical data were expressed in percentages and proportions. The responses from the Epicollect form spreadsheet were analysed using SPSS software version 29.

Results

Table 2 shows the association between selected sociodemographic and self-perceived risk of TB among patients with T2DM. Marital status (χ² = 8.66, p = 0.003), educational status (χ² = 29.94, p < 0.001), socio-economic status as per the Modified BG Prasad classification (χ² = 29.66, p < 0.001), occupation (χ² = 53.49, p < 0.001) and family history (χ² = 7.10, p 0.008) were significantly associated with TB risk perception. Higher perceived risk was observed among participants who were single/divorced/widowed, had an education above the primary level, belonged to higher socio-economic groups (Class II and above), were engaged in skilled occupations and had a family history of DM. Participants belonging to higher socio-economic groups (Class II and above) demonstrated greater perceived risk compared with those in lower socio-economic groups. This may reflect better health awareness, greater access to health information, and improved engagement with healthcare services among higher-income participants. Age (χ² = 3.64, p = 0.162), sex (χ² = 0.99, p = 0.320), and duration of DM (χ² = 2.93, p = 0.087) did not show a significant association with perceived TB risk.

Table 2.

Self-perceived risk of TB among T2DM patients (N=202)

Demographic characteristics and variables		Risk perception		Chi-square value	P value
		High n(%)	Low n(%)
Age (in years)	20–40	10(5.0)	24(11.9)	3.64	0.162
	41–60	18(8.9)	86 (42.6)
	≥ 61	9 (4.5)	55(27.2)
Sex	Male	16(7.9)	89 (44.1)	0.99	0.320
	Female	21(10.4)	76(37.6)
Marital Status	Married	22(10.9)	137(67.8)	8.66	0.003
	Others*	15(7.4)	28(13.9)
Education	Not literate	7(3.5)	83(41.1)	29.94	< 0.001
	Up to primary	8(4.0)	54(26.7)
	Above Primary	22(10.9)	28(13.9)
Socio- economic status as per BG prasad classification [12]	Class II and above	19(9.4)	75(37.1)	29.66	< 0.001
	Class III	15(7.4)	16(7.9)
	Class IV and below	3(1.5)	74(36.6)
Occupation	Unskilled	6(3.0)	125(61.9)	53.49	< 0.001
	Semi-skilled	9(4.5)	21(10.4)
	Skilled	22(10.9)	19(9.4)
Duration of T2DM in years	≤ 5 years	20(9.9)	116(57.4)	2.93	0.087
	≥ 6 years	17(8.4)	49(24.3)
Family history of DM	Yes	28 (14)	85 (42.5)	7.10	0.008
	No	9 (4.5)	80 (40)

Others – single, divorced, widowed

Bold represents the highest percentage/frequency

Table 3 shows the distribution of correct TB knowledge according to participants’ perceived TB risk status. Participants were classified into high-risk perception (n = 37) and low-risk perception (n = 165) groups. Table 3 compares correct responses to individual TB knowledge items between these groups. Participants classified as having high risk perception demonstrated significantly better recognition of several specific TB knowledge items, including airborne transmission, common symptoms such as cough, fever, and weight loss, asymptomatic disease, and extrapulmonary involvement (p < 0.05). They were also more likely to correctly reject certain misconceptions regarding TB transmission. Table 3 shows the distribution of individual TB knowledge items according to participants’ perceived TB risk status. Participants were classified into high-risk perception (n = 37) and low-risk perception (n = 165) groups. Participants with high risk perception demonstrated significantly better recognition of several specific TB knowledge items, including airborne transmission, common symptoms such as cough, fever, and weight loss, asymptomatic disease, and extrapulmonary involvement (p < 0.05). They were also more likely to correctly reject certain misconceptions regarding TB transmission. These findings suggest that awareness of specific and clinically relevant aspects of TB may influence perceived risk among patients with T2DM.

Table 3.

Distribution of correct knowledge on TB among patients with Type 2 DM in rural Karnataka (N = 202)

TB Knowledge Item		High risk perception N=37 (n / %)	Low risk perception N-165 (n / %)	Chi-square valueφ	P value
A. Knowledge of TB Transmission-TB spreads through-
Air when a TB patient coughs/sneeze	Yes	30(14.9)	95(47)	6.12	0.013
	No	7(3.5)	70(34.7)
Sharing utensils with an infected TB patient	Yes (misconception)	8(4)	75(37.1)	6.14	0.013
	No (correct)	29(14.4)	90(44.6)
Touching a person with TB	Yes (misconception)	6(3)	68(33.7)	7.09	0.0077
	No (correct)	31(15.3)	97(48)
Sharing food and water with an infected TB patient	Yes (misconception)	7(3.5)	45(22.3)	0.71	0.40
	No (correct)	30(15)	120(59.4)
Sexual contact with an infected TB patient	Yes (misconception)	2(1)	32(15.8)	3.28	0.070
	No (correct)	35(17.3)	133(65.8)
Infected mosquito bites	Yes (misconception)	4(2)	88(43.6)	20.35	<0.001
	No (correct)	33(16.3)	77(38.1)
B. Knowledge of TB Symptoms- Identification of cardinal symptoms as a possible symptom of TB
Cough	Yes	32(15.8)	110(54.5)	4.78	0.029
	No	5(2.5)	55(27.2)
Fever	Yes	29(14.4)	98(48.5)	3.89	0.049
	No	8(4)	67(33.2)
Weight loss	Yes	31(15.3)	102(50.5)	5.54	0.019
	No	6(3)	63(31.2)
C. Knowledge of Disease Characteristics
Asymptomatic	Yes	20(9.9)	45(22.3)	8.74	0.003
	No	17(8.4)	120(59.4)
Affects organs beyond lungs	Yes	27(13.4)	88(43.6)	3.99	0.046
	No	10(5)	77(38.1)

To calculate the correct knowledge of TB, the authors utilised the questions from the validated questionnaire, as shown in Table 1 and added in this table

φChi-square Table value

P value <0.05 is considered significant

Bold indicates statistical significance

Table 4 presents the relationship between overall knowledge of TB and risk perception among patients with DM; however, no statistically significant association was observed (χ² = 0.008, p = 0.927). The proportion of participants with correct TB knowledge was similar in both the high-risk perception group (56.8%) and the low-risk perception group (57.6%). No statistically significant association was observed between overall TB knowledge and risk perception (χ² = 0.008, p = 0.927), indicating that correct TB knowledge alone did not differ by perceived risk status.

Table 4.

Association between knowledge and risk perception

Knowledge of TB among DM	High Risk Perception	Low Risk perception	Table value of Chi-squareφ	p-value
Correct Knowledge of TB (Yes)	21 (10.3%)	95(47%)	0.008	0.927
Incorrect Knowledge of TB (No)	16(7.9%)	70(34.7%)

φChi-square Table value

P-value < 0.05 is considered significant

Discussion

This study explored the relationship between TB knowledge and perceived TB risk among patients with T2DM in a rural community of coastal Karnataka. Although more than half of the participants demonstrated overall correct TB knowledge, only a small proportion perceived themselves to be at high risk of developing TB. This highlights an important knowledge–perception gap, suggesting that factual awareness alone may not be sufficient to generate a sense of personal vulnerability among individuals with DM.

Sociodemographic factors and risk perception

Selected sociodemographic factors were significantly associated with perceived TB risk, whereas overall TB knowledge was not significantly associated with risk perception. This suggests that perceived vulnerability may be influenced not only by factual awareness but also by broader social and contextual factors. Marital status, education, and monthly family income, occupation and family history of DM showed significant associations with perceived risk in the present study. Participants with education above primary level and those in skilled occupations demonstrated higher perceived risk, possibly due to better health literacy, greater access to health information, and increased awareness of TB-related vulnerability among individuals with DM. Individuals with prior family exposure to chronic illness may have greater engagement with healthcare services and health-related discussions, which could influence their appraisal of disease risk. Similarly, socioeconomic circumstances may shape living conditions, access to care, and opportunities to receive health information, all of which can affect perceptions of susceptibility. Evidence from India has demonstrated substantial socioeconomic inequalities in TB burden, with lower household wealth and disadvantaged living conditions associated with higher TB risk [13–15]. Previous studies have also highlighted the importance of sociodemographic characteristics in shaping TB awareness, healthcare-seeking behaviour, and treatment-related outcomes [13, 14]. These findings support the need for risk communication strategies that are focused on the social context of patients with T2DM [15].

TB Knowledge findings in context

In the present study, more than half of the participants demonstrated overall correct TB knowledge, although important gaps persisted in specific domains. Despite this, overall TB knowledge was not significantly associated with perceived risk. The findings of the present study are consistent with earlier research reporting suboptimal TB awareness and low perceived risk among individuals with DM. A study from Tamil Nadu found that while most patients with DM had heard of TB, only a minority perceived themselves to be at risk [16]. Similarly, research from Indonesia reported limited TB knowledge among patients with T2DM [10]. These findings indicate that awareness of TB as a disease does not necessarily translate into meaningful understanding of personal susceptibility.

Why knowledge did not translate into risk perception

Analysis of individual knowledge components provided further insight. Participants with higher perceived risk were more likely to correctly identify airborne transmission, recognise key symptoms such as cough, fever, and weight loss, and reject common misconceptions regarding transmission through food, utensils, sexual contact, or mosquito bites. Knowledge that TB can be asymptomatic and affect organs beyond the lungs was also associated with higher perceived risk. This suggests that specific and clinically relevant knowledge may be more influential in shaping perceived vulnerability than composite knowledge scores alone. From the perspective of the Health Belief Model, perceived susceptibility and perceived severity are key determinants of preventive health behaviour.8 Individuals may therefore possess general knowledge about TB without applying that knowledge to their own DM related risk.

Programmatic implications

The low level of awareness regarding the TB–DM link may further explain the observed gap between knowledge and risk perception. Unless individuals understand that DM increases the risk of developing TB and may worsen TB outcomes, they may continue to perceive TB as a disease affecting others rather than themselves. Previous evidence has shown that DM approximately doubles the risk of active TB and supports the importance of integrated TB–DM care [17]. Bidirectional screening studies from India and Indonesia have demonstrated feasibility under routine programme conditions but highlighted gaps due to low patient awareness, limited healthcare provider training, and systemic barriers [18–20]. Community health workers, DM educators, and primary care providers can play an important role in improving perceived susceptibility through personalised counselling. The use of locally adapted visual IEC materials, culturally relevant messaging, and digital reminders within NCD registers may further strengthen screening uptake and timely care-seeking among patients with T2DM [21, 22].

Nearly half of the participants in the present study were not literate, which aligns with existing evidence suggesting that limited education hampers comprehension of DM causation, risk, and preventive behaviour [6]. Although Dakshina Kannada district has a high overall literacy rate [23], the literacy profile observed in this study reflects the characteristics of the sampled population rather than district-level estimates. Participants were adults with T2DM recruited from a rural community setting, with a substantial proportion of older individuals, among whom educational attainment may be lower than that of the general population. This may partly explain why general awareness of TB did not translate into heightened perceived susceptibility.

The findings of this study have important programmatic implications. The lack of association between overall TB knowledge and risk perception suggests that existing health education approaches may be overly informational and insufficiently personalised. Educational strategies that focus only on symptoms and modes of transmission may fail to evoke perceived susceptibility among T2DM patients. Integrating messaging that explicitly links DM to increased TB risk, emphasises the possibility of asymptomatic disease, and highlights the consequences of delayed diagnosis may be more effective in improving risk perception and encouraging timely screening.

Given the low level of TB risk perception despite moderate knowledge, there is a need to integrate targeted TB risk communication within existing DM care services. While the National Tuberculosis Elimination Programme (NTEP) advocates bidirectional screening for TB and DM, components addressing risk perception should also be incorporated into Advocacy Communication and Social Mobilisation (ACSM) strategies. Counselling by community health workers and DM educators should focus on illustrating personal vulnerability among individuals with DM rather than merely imparting information. The use of locally adapted, visual-based IEC materials and incorporation of TB screening prompts into digital NCD registers may further enhance awareness, promote proactive health-seeking behaviour, and strengthen TB–DM collaborative efforts at the primary healthcare level.

Strengths and limitations

This study addresses an important relationship between TB knowledge and risk perception among patients with T2DM in a rural Indian setting. The community-based approach allowed inclusion of participants beyond facility-based attendees, improving the relevance of findings to real-world rural populations. The use of a pretested, semi-structured questionnaire with established face and content validity strengthened the reliability of data collection. In addition, assessment of both overall TB knowledge and individual knowledge components provided insights into how specific aspects of knowledge relate to risk perception. The study also incorporated sociodemographic and clinical variables, enabling an analysis of factors influencing TB risk perception among T2DM patients.

Our study has certain limitations. The cross-sectional design of the study limits the ability to establish causal relationships between TB knowledge and risk perception. Risk perception was assessed using self-reported measures, which may be subject to recall bias and social desirability bias. In addition, risk perception was measured using a brief two-item operational definition rather than a validated multidimensional scale. Although this approach was practical for field-based data collection, it may not have fully captured the broader cognitive, emotional, and behavioural dimensions of perceived risk. The study was conducted in a single rural field practice area of a tertiary care medical college, which may limit the generalisability of the findings to other rural or urban settings.

Additionally, risk perception was measured using a limited number of items, which may not have fully captured the multidimensional nature of perceived susceptibility and severity. The study did not assess actual health-seeking behaviour or TB screening uptake, which would have provided further insight into how risk perception translates into preventive action. Additionally, the sample was drawn from the NCD register of the Primary Health Centre, which recorded 177 known T2DM patients out of a total village population of 8,638, reflecting an apparent prevalence of approximately 2%, which is considerably lower than the estimated prevalence of T2DM in rural India. This suggests that the NCD register may not have captured all individuals with T2DM in the study area, potentially due to underdiagnosis, incomplete registration, or limited healthcare utilisation among certain segments of the population. Consequently, the findings may not be fully representative of all T2DM patients in the community, and this should be considered when interpreting the results.

Conclusion

This study found that among patients with T2DM in a rural community of coastal Karnataka, overall correct knowledge of TB was not significantly associated with perceived risk of developing TB. Although participants with high risk perception demonstrated better recognition of several specific TB symptoms and transmission-related facts, most participants did not perceive themselves to be personally vulnerable to TB. These findings highlight a gap between factual awareness and personal risk appraisal among individuals with DM. Health education strategies should therefore move beyond general information dissemination and emphasise the increased susceptibility to TB among patients with T2DM, the possibility of asymptomatic disease, and the importance of timely screening and early care seeking.

Recommendations

Health education strategies for TB prevention among patients with DM should move beyond general information dissemination and explicitly address perceived susceptibility. TB–DM integrated education should emphasise the bidirectional relationship between TB and DM, the possibility of asymptomatic disease, and the increased risk of poor TB outcomes among individuals with DM.

Strengthening the implementation of routine bidirectional TB–DM screening, as recommended under the National Tuberculosis Elimination Programme (NTEP), within NCD clinics and primary healthcare services may improve risk perception, promote timely health-seeking behaviour, and facilitate early identification of both conditions. Counselling by healthcare providers and community health workers should focus on personalised risk communication that explicitly links DM with increased susceptibility to TB.

Further longitudinal and qualitative studies are recommended to explore how risk perception influences screening uptake and care-seeking behaviour among this high-risk population. Future studies should consider using validated multi-item instruments to provide a more comprehensive assessment of TB risk perception among individuals with DM.

Abbreviations

TB

Tuberculosis

DM

Diabetes Mellitus

T2DM

Type 2 Diabetes Mellitus

NTEP

National Tuberculosis Elimination Programme

NCD

Non–communicable diseases

ACSM

Advocacy Communication and Social Mobilisation

PHC

Primary Health Centre

Authors’ contributions

Conceptualization- AMJ, AS Data curation- AMJ, MM. Formal analysis- AMJ, MMSoftware- AMJ, MM Supervision- AMJ, AS Visualization- AMJ, AS, MM Writing original draft- AMJ, MM, AS. Writing e-review & editing- AMJ, AS, MMMonisha Mary P(MM)- Conceptualization, Validation, formal analysis, writing (Original draft, review and editing, visualization.Ankeeta Menona Jacob(AMJ)- Conceptualization, investigation, data curation, writing (Original draft), review and editing, visualization, and supervision.Avinash Shetty (AS) - Conceptualization, investigation, data curation, writing (Original draft), review and editing, visualization, supervision.

Funding

This research received no external funding and was supported by the authors.

Data availability

The dataset for this study is not publicly accessible due to ethical constraints but may be available upon request from the corresponding author.

Declarations

Ethics approval and consent to participate

Ethical approval for the study was obtained from the Institutional Ethics Committee (IEC) of KS Hegde Medical Academy, Nitte University, under clearance certificate number KSNH/IEC/2023/1372, dated 17 November 2023. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and the Indian Council of Medical Research (ICMR) guidelines for biomedical research involving human participants. Necessary administrative permissions were obtained from the District Tuberculosis Officer (DTO), the State Tuberculosis Officer (STO), and the local Panchayat prior to recruitment of study participants. Oral and/or written informed consent was obtained from all participants before data collection. Confidentiality and anonymity were ensured by de-identifying participant data during analysis. Privacy and participants’ status were strictly maintained throughout the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.