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Present day public knowledge of and attitudes to tuberculosis
218
PUBLIC HEALTH VOL. 84 NO. 5
problem, due to the fact that they or those who have infected them have had inadequate treatment in their c o u n t r y of origin with isoniazid. TABLE llI
Drug resistance~Birmingham Year
Primary no. per yr.
Acquired no. per yr.
Chronic excreters, no.
1956-60 1961 1962 1963 1964 1965 1966 1967 1968
9 12 (4) 9 (2) 6 (2) 11 (8) 9 (3) t8 (12) 18 (12) 18 (13)
53 29 (3) 15 (6) 16 (3) 19 (4) 16 (4) 12 (2) 1i (3) 10 (t)
60 47 45 41 31 34 25 27 (1) 21 (.9)
Numbers in parentheses, figures for those born outside the British Isles included in the total. The acquisition of" resistance during the course o f treatment is normally associated with inadequate co-operation in taking the drugs. Chronic excreters tend to be a "dying race". They are in the main the survivors of those who were i n a d e q u a t ~ y treated during the early 1950's before it had been determined what constitutes an adequate therapeutic course, and during the time that, because of inadequate hospital a c c o m m o d a t i o n , numerous patients were being treated at home where insufficient supervision could be attained.
References BRITISHTur~rtCULOSlSASSOCIATION(1966). Tubercle, Lond. 47, No. 2, 145. SVrUNGETT,U. H. (1969). Tubrcle, Lond. 50, 159. STEVENSON,D. K. (1962). Br. reed. J. i, 382.
Present Day Public Knowledge of and Attitudes to Tuberculosis M. B R A Y
Department of Social Medicine, University of DmTdee, Scotland Introduction IT tS GENERALLY accepted that one o f the most effective methods o f reducing the incidence of tuberculosis in this country is the early detection o f people suffering from the disease. Over the past 10 years, the rate o f decline in the incidence o f tuberculosis has slowed down, and is now almost stationary, with a high prevalence o f the disease in elderly males. H a w t h o r n e (1968) emphasized the need to accelerate the present detection rate, a n d also the need to concentrate o n the elderly p o p u l a t i o n . C o h e n (1969) stressed the importance of public attitudes to disease. He suggested that what people know,
TUBERCULOSIS TODAY
219
think and do about a disease is necessary knowledge prior to any preventive action. A survey was therefore carried out to discover what people know, think, and do about tuberculosis today. Method A multiple-choice questionnaire was presented verbally to all participants in the survey. A r a n d o m sample of the population of D u n d e e was c h o s e n from the Electoral Roll of the city. O f the 240 people selecte& 152 answered the questionnaire, 12 refused, and the remaining 76 could not be traced. This
represents a 63 o,~ success rate. A second sample consisted of work people from Tullis Russell's paper mill in Fife, where 112 people were interviewed. There was lao significant difference between the results from the two samples~ and they have been analysed together as one population. There were no immigrants from developing countries in the samples. The age and sex distribution of the combined population is shown ill Table 1. TABLE 1 Population structure Sex Males Females Total
Under 45
45-64
63 80 143
33 46 79
Age groups 65 and over
All ages
15 27 42
11 l 153 264
Results Knowledge o f the aetiology and epidemiolog)' o f tuberculosis The first question was: " W h a t d o you think is the cause of tuberculosis?'" (Table II). Only 37.9% of all ages, and only 19 ~o o f people aged over 65 think that tuberculosis is an infectious disease. TABLE I1 What do you think is the cause of tuberculosis ? Cause A growth A disease a person is born with An infectious disease A result of injury Due to some other cause Don't know
Age groups 65 and over
Under 45
45-64
14 (9.8)
3 (3.8)
23 (16-0)
t8 (22-8)
11 (26-2)
52 (t9-7)
64 (44-8)
28 (35.4)
8 (19.0)
100 (37.9)
8 (5-6)
7 (8-9)
2 (4.8)
17 (6.4.)
20 (14.0)
21 (26-6)
13 (31-0)
54 (20-5)
8 (19.0) 42 (100-0)
24 (9.1) 264 (100.0)
14 (9"8) 143 (100.0)
2 (2-5) 79 (100.0)
--
(0)
All ages 17 (6"4)
220
PUBLIC HEALTH VOL. 84 NO. 5
When asked about the variation in incidence of tuberculosis over the last 10 years, 69').,, thought that the incidence of tuberculosis had decreased, 17,% thought that it had increased, 6 °~i thought that it had remained the same, and 8 did not know.
Knowledge of the symptoms and treatntent of tuberculosis 78 o/o/ o f people knew that tuberculosis is a disease which affects the lungs, 23 ~o mentioned a wide variety of other sites in the body, and 11.4~ had no idea which part of the body is affected (Table Ill). TABLE III Which part or parts o f the body are affected by tuberculosis?
Chest Chest Some Don't
173 (65-5) 33 (12.5)
or lungs mentioned or lungs + some other site mentioned other site only mentioned know
e8 (10.6)
3o (11.4) 264 000.0)
Total
When asked what a person suffering from tuberculosis complains of. 39.4~ could not suggest any symptoms at all. Shortness of breath, cough, chest pain, tiredness and weakness were mentioned in that order of frequency by the others. Only six people out of the 264 (2.3 ~/,) specifically mentioned that tuberculosis can be asymptomatic. Eightyseven per cent of people knew that tuberculosis can be cured, 6 ~ thought that it could not, and 7 ~/o were not sure. Ideas a b o u t p r o t e c t i o n agahlst tubm'culosis
The next question: "Is there any way that you can protect yourself against tuberculosis ?" 33.3 ~ of people did not know of any specific protective measures that they could take. Of the remainder, the younger people mentioned immunization, while the older people tended to favour care of one's general health as a protective measure (Table IV). "FABLE IV Is there arty way that you can protect yourself against luberculosis ? Under 45 Immunization, vaccination, or injection Care of one's general health X-ray Obscure methods No or don't know
49 (34-3)
45~64 4
Age groups 65 and over
(5.1)
1
All ages
(2-4)
54 (20.5)
32 (22-4)
42 (53.2)
25 (59-4)
99 ( 3 7 . 5 )
8 (5-6) 1 (13"6) 53 (37-1)
7 (8.8) 3 (3-8) 23 (29'1)
2 (4 "8) 2 (4-8) 12 (2"86)
17
(6.4)
6
(2.3)
88 (33"3)
79 (I00.0)
42 (100.0)
264 (1t30.0)
143 (100-0)
TUBERCULOSIS TODAY
221
Attitudes to chest X-ray Ninety two per cent of the people in the survey had had their chest X-rayed at least once in their lives. Most of those who had aot been X-rayed claimed that they had never been given the opportunity; they were mainly either people who had just left school, or were aged over 65. Those who had had their chest X-rayed were then asked how long ago their last X-ray had been. It was found that in men aged under 65, 70 ~,o / had had their chests X-rayed within the last two years, while in men aged over 65, over 50 ~/o had gone at least five years without a chest X-ray. In women, the frequency with which they have their chests X-rayed decreases steadily with age (Table V). TABLE V Time since last chest X-ray In last 2 ye,~s
2-5 years ago
More than 5 years ago
68 ~ 72 ~ 20~/o
21% 22 ~ 27 ~
11 6 ,°/o 53 ~'£
71% 41 ~/o 11 ~o
15 % 23 ~/o 39 ~
I4% 36 /oo/ 50,0/0
Males under 45 45-64 65 and over Females under 45 45-64 65 and over
Finally, everybody was asked the reason for their last chest X-ray, whether it had been voluntary, compulsory for their job, or because they had been sent by their doctor. It was found that the majority of people aged under 65 went for their last X-ray.voluntarily, while in the over 65 age group, 4 2 ~ went for their last chest X-ray on the advice of their doctors (Table VI). TABLE VI Reason for last chest X-ray
Voluntary Medical referral Compulsory for job Total
Age groups 65 and over
Under 45
45-64
All ages
101 (74.8) 14 (10-4)
67 (88-2) 8 (t0.5)
18 (54-5) t4 (42.5)
186 (76.2) 36 (14.8)
20 (t4-8) 135 (100.0)
1 (1.3) 76 (100.0)
I (3-0) 33 (100-0)
22 (9-0) 244 (100-0)
Conclusion In conclusion, these results show a marked difference between the knowledge and attitudes of the under and over 65's. The older people know little and do
222
PUBLIC HEALTH VOL. 84 NO. 5
little about tuberculosis and its early detection, and their ignorance and complacency may well be a factor in the perpetuation of the disease in this age group. This survey was done under a Wellcome Vacation Scholarship. I would like to thank Professor Mair and members of the staff of the Department of Social Medicine at the University of Dundee for their guidance and many helpful suggestions. This survey would not have been possible without the co-operation of the people of Dundee and the management and employees of Tullis Russell and Company Limited, Markinch, Fife. References COHEN (1969). Jr. Inst. Itlth Ed. 7, 3. HAWTHORNE, J. M. (1968). Scot. M e d . J. 14, 222.
Clinical Practice in Tuberculosis P. D. B. DAVIES M.A., M.D., F.R.C.P.
.Physician, Whittington Hospital, London N. 19 I SHALL consider the work of the chest physician; what he does and why he thinks he does it. I shall start simply by thinking of the chest physician as a diagnostician. Diagnosis You may think a clinician has little or no part to play in the diagnosis of pulmonary tuberculosis. It is perhaps fair to comment that in the field of miniature radiography the yield of new cases of tuberculosis is 8-10 times higher in cases referred from general practitioners because of symptoms than in routine mass radiography. I should like to discuss three clinical diagnostic problems. First, the recognition of atypical mycobacteriaI infections particularly in cervical adenitis and superimposed on pre-existing lung disease such as pneumoconiosis. Atypical mycobacterial disease of the glands of the neck is very difficult to distinguish from tuberculous adenitis. One may get a clue if the gland is solitary and in the anterior triangle, but there are no other clinical distinguishing features and there is often great difficulty in culturing mycobacteria from cervical glands. Quite apart from the difficulty of persuading surgeons not to put glands straight into formalin, even when glands are properly handled the yield of positive cultures is low. In the Children's Hospital in Manchester, 9I cases clinically and histologically resembling tuberculous glands of neck yielded mycobacteria in only 11 cases and only one of these proved to be Mycobacterium tuberculosis (Marsden & Hyde, 1962). Another difficulty is that in this country we do not
PUBLIC HEALTH VOL. 84 NO. 5
problem, due to the fact that they or those who have infected them have had inadequate treatment in their c o u n t r y of origin with isoniazid. TABLE llI
Drug resistance~Birmingham Year
Primary no. per yr.
Acquired no. per yr.
Chronic excreters, no.
1956-60 1961 1962 1963 1964 1965 1966 1967 1968
9 12 (4) 9 (2) 6 (2) 11 (8) 9 (3) t8 (12) 18 (12) 18 (13)
53 29 (3) 15 (6) 16 (3) 19 (4) 16 (4) 12 (2) 1i (3) 10 (t)
60 47 45 41 31 34 25 27 (1) 21 (.9)
Numbers in parentheses, figures for those born outside the British Isles included in the total. The acquisition of" resistance during the course o f treatment is normally associated with inadequate co-operation in taking the drugs. Chronic excreters tend to be a "dying race". They are in the main the survivors of those who were i n a d e q u a t ~ y treated during the early 1950's before it had been determined what constitutes an adequate therapeutic course, and during the time that, because of inadequate hospital a c c o m m o d a t i o n , numerous patients were being treated at home where insufficient supervision could be attained.
References BRITISHTur~rtCULOSlSASSOCIATION(1966). Tubercle, Lond. 47, No. 2, 145. SVrUNGETT,U. H. (1969). Tubrcle, Lond. 50, 159. STEVENSON,D. K. (1962). Br. reed. J. i, 382.
Present Day Public Knowledge of and Attitudes to Tuberculosis M. B R A Y
Department of Social Medicine, University of DmTdee, Scotland Introduction IT tS GENERALLY accepted that one o f the most effective methods o f reducing the incidence of tuberculosis in this country is the early detection o f people suffering from the disease. Over the past 10 years, the rate o f decline in the incidence o f tuberculosis has slowed down, and is now almost stationary, with a high prevalence o f the disease in elderly males. H a w t h o r n e (1968) emphasized the need to accelerate the present detection rate, a n d also the need to concentrate o n the elderly p o p u l a t i o n . C o h e n (1969) stressed the importance of public attitudes to disease. He suggested that what people know,
TUBERCULOSIS TODAY
219
think and do about a disease is necessary knowledge prior to any preventive action. A survey was therefore carried out to discover what people know, think, and do about tuberculosis today. Method A multiple-choice questionnaire was presented verbally to all participants in the survey. A r a n d o m sample of the population of D u n d e e was c h o s e n from the Electoral Roll of the city. O f the 240 people selecte& 152 answered the questionnaire, 12 refused, and the remaining 76 could not be traced. This
represents a 63 o,~ success rate. A second sample consisted of work people from Tullis Russell's paper mill in Fife, where 112 people were interviewed. There was lao significant difference between the results from the two samples~ and they have been analysed together as one population. There were no immigrants from developing countries in the samples. The age and sex distribution of the combined population is shown ill Table 1. TABLE 1 Population structure Sex Males Females Total
Under 45
45-64
63 80 143
33 46 79
Age groups 65 and over
All ages
15 27 42
11 l 153 264
Results Knowledge o f the aetiology and epidemiolog)' o f tuberculosis The first question was: " W h a t d o you think is the cause of tuberculosis?'" (Table II). Only 37.9% of all ages, and only 19 ~o o f people aged over 65 think that tuberculosis is an infectious disease. TABLE I1 What do you think is the cause of tuberculosis ? Cause A growth A disease a person is born with An infectious disease A result of injury Due to some other cause Don't know
Age groups 65 and over
Under 45
45-64
14 (9.8)
3 (3.8)
23 (16-0)
t8 (22-8)
11 (26-2)
52 (t9-7)
64 (44-8)
28 (35.4)
8 (19.0)
100 (37.9)
8 (5-6)
7 (8-9)
2 (4.8)
17 (6.4.)
20 (14.0)
21 (26-6)
13 (31-0)
54 (20-5)
8 (19.0) 42 (100-0)
24 (9.1) 264 (100.0)
14 (9"8) 143 (100.0)
2 (2-5) 79 (100.0)
--
(0)
All ages 17 (6"4)
220
PUBLIC HEALTH VOL. 84 NO. 5
When asked about the variation in incidence of tuberculosis over the last 10 years, 69').,, thought that the incidence of tuberculosis had decreased, 17,% thought that it had increased, 6 °~i thought that it had remained the same, and 8 did not know.
Knowledge of the symptoms and treatntent of tuberculosis 78 o/o/ o f people knew that tuberculosis is a disease which affects the lungs, 23 ~o mentioned a wide variety of other sites in the body, and 11.4~ had no idea which part of the body is affected (Table Ill). TABLE III Which part or parts o f the body are affected by tuberculosis?
Chest Chest Some Don't
173 (65-5) 33 (12.5)
or lungs mentioned or lungs + some other site mentioned other site only mentioned know
e8 (10.6)
3o (11.4) 264 000.0)
Total
When asked what a person suffering from tuberculosis complains of. 39.4~ could not suggest any symptoms at all. Shortness of breath, cough, chest pain, tiredness and weakness were mentioned in that order of frequency by the others. Only six people out of the 264 (2.3 ~/,) specifically mentioned that tuberculosis can be asymptomatic. Eightyseven per cent of people knew that tuberculosis can be cured, 6 ~ thought that it could not, and 7 ~/o were not sure. Ideas a b o u t p r o t e c t i o n agahlst tubm'culosis
The next question: "Is there any way that you can protect yourself against tuberculosis ?" 33.3 ~ of people did not know of any specific protective measures that they could take. Of the remainder, the younger people mentioned immunization, while the older people tended to favour care of one's general health as a protective measure (Table IV). "FABLE IV Is there arty way that you can protect yourself against luberculosis ? Under 45 Immunization, vaccination, or injection Care of one's general health X-ray Obscure methods No or don't know
49 (34-3)
45~64 4
Age groups 65 and over
(5.1)
1
All ages
(2-4)
54 (20.5)
32 (22-4)
42 (53.2)
25 (59-4)
99 ( 3 7 . 5 )
8 (5-6) 1 (13"6) 53 (37-1)
7 (8.8) 3 (3-8) 23 (29'1)
2 (4 "8) 2 (4-8) 12 (2"86)
17
(6.4)
6
(2.3)
88 (33"3)
79 (I00.0)
42 (100.0)
264 (1t30.0)
143 (100-0)
TUBERCULOSIS TODAY
221
Attitudes to chest X-ray Ninety two per cent of the people in the survey had had their chest X-rayed at least once in their lives. Most of those who had aot been X-rayed claimed that they had never been given the opportunity; they were mainly either people who had just left school, or were aged over 65. Those who had had their chest X-rayed were then asked how long ago their last X-ray had been. It was found that in men aged under 65, 70 ~,o / had had their chests X-rayed within the last two years, while in men aged over 65, over 50 ~/o had gone at least five years without a chest X-ray. In women, the frequency with which they have their chests X-rayed decreases steadily with age (Table V). TABLE V Time since last chest X-ray In last 2 ye,~s
2-5 years ago
More than 5 years ago
68 ~ 72 ~ 20~/o
21% 22 ~ 27 ~
11 6 ,°/o 53 ~'£
71% 41 ~/o 11 ~o
15 % 23 ~/o 39 ~
I4% 36 /oo/ 50,0/0
Males under 45 45-64 65 and over Females under 45 45-64 65 and over
Finally, everybody was asked the reason for their last chest X-ray, whether it had been voluntary, compulsory for their job, or because they had been sent by their doctor. It was found that the majority of people aged under 65 went for their last X-ray.voluntarily, while in the over 65 age group, 4 2 ~ went for their last chest X-ray on the advice of their doctors (Table VI). TABLE VI Reason for last chest X-ray
Voluntary Medical referral Compulsory for job Total
Age groups 65 and over
Under 45
45-64
All ages
101 (74.8) 14 (10-4)
67 (88-2) 8 (t0.5)
18 (54-5) t4 (42.5)
186 (76.2) 36 (14.8)
20 (t4-8) 135 (100.0)
1 (1.3) 76 (100.0)
I (3-0) 33 (100-0)
22 (9-0) 244 (100-0)
Conclusion In conclusion, these results show a marked difference between the knowledge and attitudes of the under and over 65's. The older people know little and do
222
PUBLIC HEALTH VOL. 84 NO. 5
little about tuberculosis and its early detection, and their ignorance and complacency may well be a factor in the perpetuation of the disease in this age group. This survey was done under a Wellcome Vacation Scholarship. I would like to thank Professor Mair and members of the staff of the Department of Social Medicine at the University of Dundee for their guidance and many helpful suggestions. This survey would not have been possible without the co-operation of the people of Dundee and the management and employees of Tullis Russell and Company Limited, Markinch, Fife. References COHEN (1969). Jr. Inst. Itlth Ed. 7, 3. HAWTHORNE, J. M. (1968). Scot. M e d . J. 14, 222.
Clinical Practice in Tuberculosis P. D. B. DAVIES M.A., M.D., F.R.C.P.
.Physician, Whittington Hospital, London N. 19 I SHALL consider the work of the chest physician; what he does and why he thinks he does it. I shall start simply by thinking of the chest physician as a diagnostician. Diagnosis You may think a clinician has little or no part to play in the diagnosis of pulmonary tuberculosis. It is perhaps fair to comment that in the field of miniature radiography the yield of new cases of tuberculosis is 8-10 times higher in cases referred from general practitioners because of symptoms than in routine mass radiography. I should like to discuss three clinical diagnostic problems. First, the recognition of atypical mycobacteriaI infections particularly in cervical adenitis and superimposed on pre-existing lung disease such as pneumoconiosis. Atypical mycobacterial disease of the glands of the neck is very difficult to distinguish from tuberculous adenitis. One may get a clue if the gland is solitary and in the anterior triangle, but there are no other clinical distinguishing features and there is often great difficulty in culturing mycobacteria from cervical glands. Quite apart from the difficulty of persuading surgeons not to put glands straight into formalin, even when glands are properly handled the yield of positive cultures is low. In the Children's Hospital in Manchester, 9I cases clinically and histologically resembling tuberculous glands of neck yielded mycobacteria in only 11 cases and only one of these proved to be Mycobacterium tuberculosis (Marsden & Hyde, 1962). Another difficulty is that in this country we do not