Background. Tuberculosis (TB) prevention and control remains a major global public health challenge. Ecuador has among the highest estimated population prevalence rates for TB, TB-mortality, and multidrug resistant TB in the Americas (WHO, 2007; PAHO, 2004). However, with the exception of one prior study of a high-risk group of suspected cases and household contacts referred for TB testing (Armijos et al., 2008), very little is known about the disease and treatment knowledge, beliefs, attitudes, and practices of Ecuadorian groups and the various socio-cultural and other factors (e.g., rurality, education, gender, disease experience) that shape these. The improved understanding of such factors that may influence health-seeking behavior is of potential value to the Ecuadorian National TB Control Program. This information can be used to shape culturally appropriate messages regarding TB prevention, diagnosis, treatment and follow-up which can make the program and its services more relevant to the competing needs, demands, and priorities of the population.

Study Aims. The study investigated the ethnomedical context of TB in two predominantly mestizo rural and peri-urban groups residing in the same Ecuadorian province (Pichincha). It specifically examined reported subject knowledge, beliefs, and perceptions about TB symptoms, severity, causation, transmissibility, and treatment. It also investigated their reported beliefs, attitudes, and perceptions about the impact of TB on usual lifestyle and role functioning. In addition, it examined reported subject perceptions regarding TB-associated stigma. The study explored the perspectives and priorities of subjects regarding the Ecuadorian national TB control program and its services. It was hypothesized was that rural residents would have less knowledge and more misperceptions about the disease and its treatment compared to those living in a peri-urban setting due to their reduced access to health care, lower education, and reduced experience with the disease. It was also hypothesized that these factors would make rural residents more likely to associate a higher degree of stigma with TB.

Methods. The data were collected during a 6-month period (1999-2000) in two rural Ecuadorian (Malchingui; n=150) and peri-urban (Chillogallo; n=126) communities. Potential subjects were included in the data analysis if they were ≥ 15 years, had no conditions that would impede their ability to adequately understand and respond to questions, and did not have another household member participating in the study. The data were collected by structured questionnaire during face-to-face interviews with subjects. Subjects first answered a closed-ended question (yes/no) followed by an open-ended question on the same topic. This strategy allowed subjects to explain their answers in their own words and permitted further probing by interviewers. Subject qualitative responses to open-ended questions were subsequently grouped into categories using content analysis which produced general categories or "themes". Quantitive data were analyzed using descriptive, bivariate, and multivariate statistical techniques.

Results. Although many subjects reported being acquainted with the disease and some of its characteristics, they also held a number of common misconceptions and/or lacked key pieces of knowledge which could adversely affect early diagnosis, prompt treatment, and treatment adherence. Education, age, gender, and prior disease experience were the most consistent predictors of reported subject knowledge, beliefs, perceptions, and attitudes. The influence of residence site (rural vs. peri-urban) was less evident. The subjects also associated TB with a number of adverse consequences for the lifestyle, role functioning, and social relationships of the TB sufferer. In addition to internal stigma, most subjects linked TB with significant social stigma, regardless of the degree of kinship.

Conclusions and Recommendations. The results underscore the need for improving TB education and promotion efforts in rural and peri-urban communities. They confirm that TB is a highly stigmatized disease. Many persons are afraid of contracting TB and strongly desire formal educational opportunities to learn more about its prevention and control. The study findings can be used by the Ecuadorian National TB Control Program to develop population-specific health promotion and education interventions aimed at decreasing stigma, improving disease prevention, and faciliating early diagnosis, prompt treatment, and treatment adherence.