Sociodemographic Determinants of Knowledge towards Tuberculosis Transmission among Women of 15–49 Years of Age in India

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Introduction
Tuberculosis (TB) is a contagious disease caused by the bacillus Mycobacterium tuberculosis (MTB). TB remains a major public health concern worldwide [1]. It is transmitted when an infected individual coughs or sneezes and releases infectious droplets into the air. TB is a highly contagious disease that can afect the lungs (pulmonary tuberculosis, PTB) as well as other parts of the body (extrapulmonary tuberculosis, EPTB). TB is a disease that manifests under poor economic conditions leading to improper nutrition, unhygienic living conditions, and so on.
About 90% of TB-related infections and deaths occur in underdeveloped countries with weak economies and inadequate healthcare infrastructure [1,2].
Globally, around 10 million people are infected with tuberculosis of which 1.2 million deaths occurred in 2019 alone. Amongst those infected, 56% were males (>15 years), 32% were females (>15 years), and 12% were children throughout the world in 2019. According to the World Health Organization (WHO), the regions of Southeast Asia are geographically most afected (44%) followed by Africa (25%), and the Western Pacifc (18%). Two-thirds of the global TB burden is developed in the eight countries where India shares the greatest burden (26%) followed by Indonesia (8.5%), China (8.4%), South Africa (8.4%), the Philippines (6.0%), Pakistan (5.7%), Nigeria (4.4%), Bangladesh (3.6%), and South Africa (3.6%). Globally, India accounts for more than a quarter of all the reported cases. Te proportion of TB cases is higher in India due to poor socioeconomic conditions, which are further aggravated by environmental pollution [3]. As per the National Family Health Survey-4 (NFHS-4) report, about 316 people are infected with TB per 100,000 people in India [4].
Tuberculosis is a curable disease that requires a combination of correct knowledge, attitude, and perception. Having the correct knowledge and understanding the mode of transmission of the disease is an essential prerequisite for prevention, screening, early detection, and health-seeking behaviour. Women in adult age group  year) bear a signifcant burden of TB in India and globally. TB among women can adversely afect the health of the mother, foetus, neonate, and their children with a wide spectrum of short and long-term implications [2]. Terefore, early diagnosis of TB among women can prevent further transmission thereby reducing the risk of deaths. In general, men have a higher prevalence of TB than women. However, women of reproductive age have a higher rate of disease progression and mortality than men due to less access to health care facilities and various socioeconomic factors [1]. Stigma is one of the important social factors that also create a hurdle among women seeking treatment for TB. Stigma has been referred to as negative social experiences such as discrimination, isolation, devaluing, and shaming of a person that exclude the individual from society due to the hazards they are facing. Few studies have suggested that social stigma and fear are strongly associated with the disease that may lead to TB at comparatively higher rate in women [5,6]. Te majority of people infected with tuberculosis can be efectively treated with drugs. However, early identifcation and detection among the suspects will help to cure the disease and prevent its further spread. Various studies have revealed that inaccurate and inadequate knowledge about TB, such as how it spreads, its cause, and symptoms, are the leading obstacles to the efective control of the disease [7][8][9]. Terefore, adequate knowledge and awareness, the right attitude, and approach to the disease are crucial for its efective control.
Te aim of this study was to examine the knowledge and attitudes towards TB among women in India. We have included various sociodemographic factors to evaluate the knowledge and attitude towards TB among the women. Several studies have reported that socioeconomic and demographic characteristics such as age, education, place of residence, wealth index, caste, religion, and geographic location play a role in TB transmission [10][11][12][13][14]. TB careseeking behaviour among people has been shown to be infuenced by their perceived knowledge about the signs and symptoms of TB. [15][16][17]. Using the population-based data, this study aimed to examine correct knowledge and perception about TB among adults' women in India. Te longterm objective of the study is to come up with fndings for stakeholders and policymakers to develop an efective intervention strategy for TB management.

Ethical Consideration.
Te present analysis utilizes a secondary dataset with no identifable information on the surveyed participants. Tis dataset is available in the public domain for research purposes; therefore, no approval is required from any institutional review board.

Study
Design and Sample. TB in adults' women as well as pregnancy could have serial and sequential efects: repeated reproductive failure, foetal ill-health, preterm delivery, and TB of the newborns and infants, leading to high maternal and perinatal morbidity and mortality concern. A quantitative analysis was performed to explore the knowledge and attitude towards TB among women in India. Tis study utilized a large dataset from the United States Agency for International Development Demographic and Health Survey (USAID-DHS) program. Te current study utilized data from the fourth round of NFHS-4 (2015-16) in India. NFHS-4 provides sociodemographic and health perspective data of each state and union territory in India. Te survey included data on 699,686 women in the age group of 15-49 years across the nation.
A cross-sectional study was conducted at regular intervals for NFHS-4 data. Each round of the NFHS has the following two specifc goals: (a) to provide essential data on health and family welfare needed by the Ministry of Health and Family Welfare (MoHFW) for health policy program purposes, and (b) to provide important information on emerging health and family welfare issues. Te Government of India designated the International Institute for Population Sciences (IIPS) as a nodal agency responsible for providing technical guidance for the survey. A specifc questionnaire directed towards the women regarding their TB knowledge and attitude was developed by the surveyor, such as "Have you ever heard of an illness called tuberculosis or TB? ." Te resulting response defned the knowledge of TB among women. Te study participants were women (N � 699,686) recruited through a stratifed sampling described elsewhere [18].

Outcome Variables.
In this study, the outcome variables considered the respondent's knowledge and attitudes toward the mode of TB transmission. In this regard, the variables were created with the help of a set of nine questionnaires. For instance, the questionnaire "Q1. Have you ever heard of an illness called TB?" was designed to identify the comprehensive knowledge about TB among women. In addition, there are several questionnaires designed to evaluate the correct knowledge about TB. Te questionnaire from Q2 to Q7 was used to evaluate the mode of transmission, while the questionnaire, Q8 and Q9, was used to evaluate the idea about the curability of disease and secrecy owing to the stigma related with the disease, respectively.
Q2. Does TB spread from one person to another through the air when coughing or sneezing?
Q3. Can TB be transmitted through sharing utensils? Q4. Can TB be transmitted by touching a person with tuberculosis? Q5. Can TB be transmitted through food? Q6. Can TB be transmitted through sexual contact? Q7. Can TB be transmitted through mosquito bites? Q8. Can tuberculosis be cured? Q9. If a member of your family has tuberculosis, would you want it to remain a secret or not?
Te aforementioned set of questions revealed the outcome of respondent knowledge, attitude, and perception of tuberculosis. However, response to Q2 was used for measuring the mode of TB transmission, whereas Q3 to Q7 was a misconception. If the women responded "yes" to Q1, Q2, and Q8 and answered "no" to Q3 to Q7 and Q9 was recorded as adequate knowledge about TB. Terefore, getting the correct answer from the respondents showed the quality and quantum of knowledge about tuberculosis.

Exposure Variables.
In this study, the exposure variable is considered an independent variable such as age group; place of residence; education level; wealth index; religious afliation; and caste or tribe. All these exposure variables were selected based on the literature reviewed. Tese variables were further categorized into covariates such as, age group (15-19, 20-24, 25-29, 30-34, 35-39, 40-44, and 45-49), place of residence (urban, rural), education level (secondary and above, primary, or no education), wealth index (rich, middle-class, poor), and religion (Hindu, Muslim, Christian, Sikh, Buddhist, Jain, Jewish, Parsi, and other). All these variables were used to determine the association between knowledge and attitude towards TB with exposure variables.

Statistical Analysis.
We performed our analysis on NFHS-4 data for women respondents. First, we applied basic statistics to all the categories of exposure variables and outcome variables to check the frequency or percentage of the study participants. Second, we applied bivariate analysis to both the variables (exposure and outcome) of women participants. We used the chi-square test to check the association between all the categorized variables of the exposure and outcome variables and the mode of TB transmission among adult women. Finally, we conducted multivariate logistic regression to recheck the strength of association between both the variables and knowledge about TB transmission among women. We have also considered the adjusted odds ratio (aOR), 95% confdence interval (95% CI), and the P value (P ≤ 0.001) for assessing the association between sociodemographic factors and knowledge about TB transmission among the women participants. Te P value (P ≤ 0.001) was considered statistically signifcant. All analyses were performed with STATA version 16.0 (Stata Corp., College Station, Texas, USA).

Results
Te study included 699,686 women participants with their sociodemographic factors such as, age group, education level, place of residence, wealth index, religion, caste, or tribe.  Figure 1 show the level of knowledge and attitude towards TB transmission among the study participants in absolute numbers and percentage. About 618,274 (88.36%) participants out of a total (699,686) knew about TB. Overall, 418,449 (59.81%) of the participants correctly knew that TB spreads from one person to another via infectious airborne droplets when the infected person coughs or sneezes, while 113,061 (16.16%) of the women participants did not know about the mode of TB transmission. As shown in Table 2 and Figure 1, there is a relatively high level of misconception about the mode of TB transmission among women such as, TB spreads from one person to another through sharing utensils 128,710 (18.40%), touching a person with TB 106,346 (15.20%), sharing food 233,081 (33.31%), sexual contact 52,777 (7.54%), mosquito bite 14,659 (2.10%), and others 4,260 (0.61%), respectively. A relatively large number of participants 549,671 (78.53%) knew that TB is a curable disease while 36,132 (5.16%) knew that TB is noncurable. Majority of the study participants 592,612 (75.69%) preferred to disclose the infection status of their family members, and relatively a few 79,397 (11.35%) participants preferred to keep it a secret. Te women participants who answered "yes" about the questionnaire of "heard of TB," "TB can be cured," and "TB spreads by air when coughing or sneezing" while those women participants who answered "no" about the questionnaire "hide the infection status of their family members which was considered as adequate knowledge about the TB. Table 3 shows the bivariate association between knowledge regarding the transmission of TB and the sociodemographic characteristics of study participants. Tese associations are age groups of the respondents (P ≤ 0.001), place of residence of the respondents (P ≤ 0.001), education level (P ≤ 0.001), wealth index (P ≤ 0.001), religion (P ≤ 0.001), and caste or tribe of the respondents (P ≤ 0.001). Results show that all of these sociodemographic variables Advances in Public Health were signifcantly associated with respondents' knowledge and attitudes towards TB. Table 4 shows the multiple logistic regression analysis, which was performed to determine the association between the sociodemographic characteristics of the study participants and knowledge of TB transmission among women. Multivariable logistic regression analysis show that parameters such as age group 30

Discussion
Te aim of this study was to examine the association of sociodemographic factors with TB transmission knowledge among women subjects in India. Te study shows a signifcant association of sociodemographic factors with the respondent's knowledge and attitude towards TB (88.76%). Similar fndings were also reported in Brazil, and Lesotho [9,19]. Our study reported that younger women in the age groups of 15-19 years (18.29%), 20-24 years (18.49%), and 25-29 years (16.77%) had relatively better knowledge about TB transmission compared to the age group of 45-49 years (9.53%). Similarly, women subjects with secondary or higher education (68.81%) had better knowledge compared to the women respondents with no education (20.321%). Our results are consistently similar to the previous studies in this regard [7,20,21]. Women with higher education have relatively better access to and understanding of TB transmission through diferent sources.  Tis study shows most of the women respondents knew that TB is a curable disease (78.55%) as well as its route of transmission (59.81%). Terefore, most of the women correctly answered the questionnaire "TB can be cured" and "TB spreads from person to person through the air when an infected person coughs or sneezes." A similar study was conducted in Lesotho, and Brazil reported that 83.3% and 96.1% of women in these countries knew that tuberculosis is a curable disease which is almost similar to our fndings [9,19].
Te educational level and age group of women were strongly associated with knowledge and awareness about tuberculosis. A study reported that women with secondary education or higher education were at a lower risk of getting TB as compared to those who had no education [8]. Te fndings from the study also revealed a possible causal relationship between the age group and correct knowledge about TB transmission. Another study also revealed that the correct knowledge about tuberculosis among Indian females was signifcantly associated with their age group and the knowledge increased with age [8]. Te adult female individuals (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29) years and above had better knowledge about TB transmission. Tis is consistent with the fndings of previous studies [22,23]. Consistent with our fndings, previous studies have also reported that female respondents with secondary or higher education had relatively better knowledge about TB transmission [7,20,21]. Tis may suggest that education is important to improve the knowledge among women about TB and its mode of transmission [21]. A study by Jadgal and Nakhaei-Moghadam [24] also suggested that the implementation of educational intervention programs can increase the level of knowledge and awareness about TB. Tese educational intervention training programs enhances the correct health behaviour practices such as self-care, and personal hygiene. Te wealth index of women respondents was also signifcantly associated with their knowledge and awareness about TB. Tis study also revealed that rich women respondents had higher knowledge compared to the poor women respondents.
TB scenario in tribes is particularly intriguing as most of the tribes lead insular life in the inaccessible deep pockets of the jungle. Te insularity and seclusion make them averse to the treatment by modern medicine, sometimes even leading to side efects. Additionally, tribes largely depend on the tribal healers, herbs, and other forest products for most of their treatment, which may not work efectively all the time [25]. TB is more common in countries with poor human development index (HDI). Terefore, it could aptly be dubbed as a poor man's disease that manifests in poor socioeconomic conditions [26]. Tis was refected in our fndings also, i.e., with increased income level (wealth index) the chances of getting access to education, better living conditions, exposure to mass media (television, radio, and Internet), and medicare increases. Numerous studies have shown that mass media infuences people's behaviour [27][28][29].
Place of residence is one of the important sociodemographic factor, which is signifcantly associated with TB [12]. People living in urban areas have better cure rates due to the availability of medical facilities than those living in rural areas. However, the cost of living is relatively higher in the urban areas forcing people with a lower or intermediate income to live in the unliveable dark, dingy, claustrophobic urban slums/ghettos leading to the rapid transmission of TB. Tis, coupled with air pollution and poor nutrition, makes urban slum dwellers vulnerable to TB infection. In rural areas, the biggest limiting factor is the lack of medicare facilities leading to delayed diagnosis thus complicating the overall treatment outcome [30]. Most of the time gets aggravated by drug-resistant TBs (MDR, XDR). Additionally, lower education level, lack of awareness, and lower income are other major driving forces. However, more comparative analyses of the knowledge of TB in rural and urban communities are required so as to arrive at a concrete conclusion.

Limitations.
Tis study has few limitations frstly, our analysis is confned to the information available in the NFHS-4 dataset. Secondly, some variables that can afect people's knowledge and attitudes about tuberculosis, such as the distance to a medical facility, the time required to fnd a medical service, and the regional category were not analyzed in our study. Te questionnaire related to the knowledge of TB in the primary dataset did not contain  Advances in Public Health 5  Advances in Public Health some important questions. For example, "whether drinking unpasteurized milk causes tuberculosis?" Tirdly, identifying the causal relationship behind the association is not possible in our study. Despite the above limitations, our study demonstrated that the risk factors for TB transmission are infuenced by age group, educational status, wealth index, and place of residence. An understanding of such knowledge will help policymakers and stakeholders make efective TB control programs and awareness campaigns in TB hotspot regions such as rural areas and urban slums or ghettos. Additional messages can be spread through print and social media, primary and community health centers and district hospitals. Tere is a need to bring in NGOs working at the grassroot level with all the stakeholders to launch a nation-wide campaign covering every nook and corners of the country in a mission mode to eradicate TB completely out of India.

Conclusions
Te results of this study showed that women in India have moderately good knowledge and the correct attitude towards tuberculosis. However, the level of information varies with the various demographic factors such as age group, education, religion, caste/tribe, place of residence, and wealth index, bearing positive causal relationship between the knowledge and TB transmission and hence the resulting attitude. Te management of current TB infections and eradicating the future infections requires the alignment of all the stakeholders to devise a strategy where appropriate solutions and interventions are provided to address the causative sociodemographic factors, the foremost being the spread of knowledge "faster than the spread of TB."

Data Availability
Data are available from the corresponding author upon reasonable request to the National Family Health Survey (NFHS) of India for providing us with the population-based tuberculosis data.

Ethical Approval
Te present analysis utilizes a secondary data set with no identifable information on the survey participants. Tis dataset is available in the public domain for research purposes therefore, no approval is required from any institutional review board.