1. Background
Tuberculosis (TB) remains one of the most serious public health challenges globally, especially in developing countries. Tuberculosis is an airborne disease, typically transmitted when individuals with active infections cough, sneeze, speak, or spit, releasing tuberculosis bacilli into the air. Transmission is therefore particularly high in crowded and poorly ventilated environments (1, 2). More than 95% of deaths from tuberculosis occur in low - and middle - income countries, making it one of the five leading causes of death (3).
In 2017, Nigeria ranked as the second most affected country by tuberculosis in Africa, after South Africa. The disease continues to pose a significant public health challenge in Nigeria, a country of more than 200 million people. The country currently ranks 10th among the 22 high TB burden countries of the world and is the highest in Africa. As of 2018, the prevalence of the tuberculosis scourge in Nigeria is between 400,000 and 450,000 cases, the highest in Africa and sixth globally (4). Due to the COVID -19 pandemic, Lagos State has emerged as the epicenter of tuberculosis in Nigeria (4, 5).
Socio-demographic characteristics are believed to shape individuals’ behaviour by influencing their perception of symptoms and treatment. It also has a wide range of effects on health by influencing opportunities, individual beliefs, attitudes, and values when making life-course decisions. As such, socio-demographic characteristics may be a surrogate for exposure to TB and its management-living conditions and lifestyle (6).
This study is hinged on the Andersen behavioural model, which provides a framework for examining socio-demographic and behavioural factors that influence patients’ health-seeking. The model suggests a sequence of three factors that predict health care use: Predisposing factors, enabling factors, and health care need (7). The predisposing component explains an individual's disposition to utilise health services prior to their sickness. Thus, predisposing factors contribute to the fact that certain individuals seek and use health care services more often than others due to their personal characteristics. This group of factors includes gender, age, marital status, ethnicity, and attitudes. Enabling factors are the conditions and resources that facilitate or act as barriers to health-seeking and the use of healthcare services. They include income, availability and access to service, and access to free service. Need factors are the physical conditions or symptoms that necessitate healthcare seeking and service (8).
The socio-demographic characteristics of patients with tuberculosis differ in different parts of the world due to variations in custom, beliefs, attitude, and quality of health-care delivery services, among other factors. Different studies have documented the socio-demographic characteristics of patients with tuberculosis in many countries (9-11). However, the available literature predominantly focuses on clinical outcomes such as diagnosis, treatment success, and drug resistance, with comparatively limited attention given to the socio-demographic circumstances in which TB patients live and seek care. This gap is particularly evident in Lagos State, where there is a paucity of studies examining socio-demographic characteristics of TB patients attending public health facilities, despite the State having the highest burden of tuberculosis in Nigeria and consistently accounting for approximately 11% of the country’s registered TB cases each year (12, 13). There is a need to understand the characteristics of tuberculosis patients receiving treatment, as this may aid the modification of the strategies to fight the scourge (14).
2. Objectives
Therefore, this study aimed at identifying the socio-demographic characteristics prevalent among tuberculosis patients in some selected public health facilities in Lagos State, Nigeria.
3. Methods
The research adopted a cross-sectional survey design, and a multi-stage sampling technique was used to select the primary sample unit.
3.1. Study Population
The population of the study were 918 TB patients accessing treatment during the study in some selected public DOTS Centres in Lagos State, Nigeria. The study sites were DOTS Centres - six secondary/tertiary hospitals and six Primary Health Care (PHC) facilities that cut across the three senatorial districts of the State.
3.2. Sampling and Sample Size
The study employed a multi-stage sampling technique to select the study participants. In the first stage, all the three Senatorial Districts in Lagos State were included (Lagos East, Lagos Central, and Lagos West). In the second stage, a simple random sampling technique using balloting was used to select two Local Government Areas (LGAs) from each Senatorial District. In the third stage, purposive sampling was used to select two DOTS Centres with the highest TB patient load in each of the selected LGAs. This approach was adopted because several DOTS Centres had relatively few TB patients. Subsequently, a total of twelve DOTS Centres were included in the study. In the fourth stage, stratified proportionate sampling was applied to distribute the sample across the twelve DOTS Centres based on the population of TB patients in each Centre. To ensure an adequate representation of the study population, a total of 310 TB patients were determined using the Taro Yamane formula.
3.3. Study Variables
To operationalize the variables based on Andersen’s behavioral model, predisposing factors were categorized as gender, age, marital status, and family size. Enabling factors include occupation, education attainment, and income level, while need factors are symptoms, illness, and health status, which is TB.
3.4. Inclusion and Exclusion Criteria
The main inclusion criteria comprised registered patients with pulmonary tuberculosis who had been on treatment for more than two months, were aged 18 years and above, and mentally capable of giving informed consent. The exclusion criteria included pregnant women, patients with extrapulmonary tuberculosis, severely ill patients, and TB patients who did not provide consent.
3.5. Study Instrument
A questionnaire developed through a review of related literature was used to collect the data. To ensure the validity of the research instrument, face, content, and construct validity were used. The questionnaire was scrutinised by three experts (a public health consultant, a medical sociologist, and a statistician).
3.6. Data Analysis
Data were obtained through copies of the questionnaire, which was administered to the respondents at the DOTS Centers after obtaining necessary approvals and informed consent. The data collected was coded and analysed using the Statistical Package for Social Sciences (SPSS) - version 23. Descriptive statistical methods such as frequency distribution, percentages, mean, and standard deviation were employed to analyse the data. Finally, the information obtained was summarized and presented in tables for better understanding.
4. Results
Out of the 310 questionnaires distributed to the TB patients, only 298 were correctly completed and validated for analysis. The demographic information of the respondent includes gender, age, marital status, family type, family size, type of residence, highest educational attainment, occupational status, person al income per month and mode of transportation to the DOTS Centre. The socio-demographic characteristics analyses are presented in Table 1.
Table 1.Participants’ Socio-demographic Characteristics
| Predisposing Factors | Frequency (%) |
|---|---|
| Demographic Variables | |
| Gender | |
| Male | 199 (66.8) |
| Female | 99 (33.2) |
| Total | 298 (100) |
| Age (y) | |
| 18 - 29 | 102 (35.1) |
| 30 - 41 | 109 (37.5) |
| 42 - 53 | 53 (18.2) |
| 54 - 65 | 21 (7.2) |
| > 66 | 6 (2.1) |
| Mean age in years (SD) | 35.87 (± 11.95) |
| Marital status | |
| Single | 125 (41.9) |
| Married | 152 (51.0) |
| Divorced | 05 (1.7) |
| Widow/widower | 13 (4.4) |
| Separated | 03 (1.0) |
| Total | 298 (100) |
| Family type | |
| Monogamous | 224 (75.8) |
| Polygamous | 74 (24.2) |
| Total | 298 (100) |
| No. of children/family size | |
| None | 97 (32.6) |
| 1 - 2 | 80 (26.8) |
| 3 - 5 | 101 (33.9) |
| > 6 | 18 (6.0) |
| Missing value | 2 (0.7) |
| Mean of family size | 2.17 |
| Total | 298 (100) |
| Type of residence | |
| One room | 119 (39.9) |
| A Room and Parlour | 74 (24.8) |
| Self-contained flat | 39 (13.1) |
| Two/three rooms | 56 (18.8) |
| Duplex | 2 (0.7) |
| Others (on the street / homeless, on the water, slum areas) | 8 (2.7) |
| Total | 298 (100) |
| Enabling factors | |
| Highest educational qualification | |
| No formal education | 28 (9.4) |
| Primary | 41 (13.8) |
| Secondary | 140 (47.0) |
| University/tertiary | 89 (29.9) |
| Total | 298 (100) |
| Occupation status | |
| Self-employed | 148 (49.7) |
| Civil servant | 19 (6.4) |
| Private organization worker | 51 (17.1) |
| Retired | 09 (3.0) |
| Student | 40 (13.4) |
| Unemployed | 2 (0.7) |
| Others (pastor, clergy, corpers, drivers, housewives) | 29 (9.7) |
| Total | 298 (100) |
| Personal Income per month [N444 ($1)] | |
| < N30,000 | 129 (43.3) |
| N 30,001 - N 59,999 | 70 (23.5) |
| N 60,000 – N 89,999 | 25 (8.4) |
| More than N 90,000 | 11 (3.7) |
| No income | 63 (21.1) |
| Total | 298 (100) |
| Mode of transportation to DOTs | |
| Private vehicle | 19 (6.4) |
| Commercial bus | 194 (65.1) |
| Commercial vehicle | 23 (7.7) |
| Motorcycle | 38 (12.8) |
| Bicycle | 11 (3.6) |
| Others (trekking, tricycle, boat) | 13 (4.4) |
| Total | 298 (100) |
The results of the study, as shown in Table 1, indicate that 199 (66.8%) were male, and 99 (33.2%) were female. This suggests that tuberculosis is more common among males than females in Lagos State, Nigeria. Hence, the DOTS Centers in Lagos State are male-dominated with tuberculosis. Furthermore, most of the patients, 109 (37.5%), were aged 30 - 40 years, whereas the least (2.1%) were older than 66 years. The overall mean age was 35.87 years (SD 11.95). From the result, this outcome suggested that most tuberculosis patients under study are still in their prime age, young and energetic.
Table 1 also revealed that 152 (51.0%) of the TB patients were married, 1.0% were separated, and 1.7% were divorced. The large number of married people accessing treatment in the DOTS Centres in Lagos State, may imply that tuberculosis is highly prevalent among married persons in Lagos State but less noticeable among the separated and divorced people.
The result on family type revealed that 224 (75.8%) of the participants were monogamous, while 24.2% (74) were in polygamous families. The result also shows that a majority of the participants, 101 (33.9%), have about 3-5 children, while those with more than six children, 18 (6.0%), were the least. On average, tuberculosis patients in the DOTS Centers in Lagos State, Nigeria, had a family size of 2.17. The results also revealed that those living in one room constitute a greater percentage, 119 (39.9%), while the least, 2 (0.7%), lived in a duplex. This implies that tuberculosis is prevalent among those that live in a single-room apartment.
Table 1 also shows that a majority of the patients, 140 (47.0%), had secondary education, while only a few, 28 (9.4%), had no formal education. This result shows that a small number of tuberculosis patients at the DOTS Centers lacked formal education. The result could also indicate that the tuberculosis patients in the study area have basic educational qualifications. The occupational distribution shows that the majority of the patients, 148 (49.7%,) were self-employed, with the smallest group, 2 (0.7%) being unemployed. This result showed that many of the participants in the study are engaged in one form of business or the other.
The results on monthly personal income show that 129 (43.3%) of the tuberculosis patients earned less than ₦30,000, whereas 11 (3.7%) earned between ₦60,000 - ₦89,999. The large number of low-income earners in the DOTS Centers in Lagos State, Nigeria, may imply that tuberculosis is highly prevalent among low-income persons in Lagos State but less obvious among high-income persons. Hence, this outcome may reflect the difficult financial situation of TB patients receiving treatment in the DOTS Centers in Lagos State, Nigeria. Six out of every ten persons (65.1%) indicated commercial bus as the means of transportation to the DOTS Centers, while those who boarded bicycles and commercial vehicles to the DOTS Centers were 3.6% and 7.7%, respectively. This finding suggests that many of the participants in the study area incur some expenses during their visit to DOTS Centers.
5. Discussion
In view of the communicable nature of tuberculosis, examining the socio-demographic characteristics is critical for interpreting the observed patterns of TB occurrence and the factors influencing exposure, health-seeking behavior, and access to care. The socio-demographic characteristics of the gender distribution revealed that a majority of the participants were male. This finding indicates a higher rate of tuberculosis infection among males than females. Similar trends have been reported globally, suggesting that males are disproportionately affected by TB. This could also mean that the males report for diagnosis and treatment at a greater rate than females. Quick response to TB or any ailment outside the immediate household is usually poor among females when compared to males, especially in a culture where the former need to seek permission or financial assistance before seeking treatment. Another probable explanation for this male predominance could be that men are more engaged in social and labour activities than women in many countries, resulting in increased tuberculosis transmission and infection. This is due to the fact that males are more likely to engage in risk behaviors such as smoking, alcohol consumption, and drug addiction, which have been identified to often trigger tuberculosis. This finding is similar to a study conducted by Hendrik et al. (15) and Ochonma et al. (16) done in Indonesia and Nigeria, respectively, who reported that more males than females were being infected with tuberculosis. However, this contradicts the findings of Omotowo, Ekwueme and Omotowo et al. (17) and Osahon and Okolo (18), who reported that females were the most infected with TB in Nnewi and South East, Nigeria, respectively.
The study further showed that the participants had a mean age of 35.87 years, indicating that tuberculosis is more prevalent among young adults attending the DOTS Centers. This result supported the findings of Onazi et al. (19), Ochonma et al. (16), Kastien-Hilka et al. (20) that most TB patients were in the productive years of their lives in Nigeria and South Africa, respectively. Hutahaean (21) buttressed that those who are young are at a higher risk of contracting tuberculosis and may easily transmit the disease due to mobility, resulting in an increase in TB prevalence. Meanwhile, the high proportion of TB cases in this age group poses profound and far-reaching consequences that extend beyond individual health, including reduced work capacity and lower productivity. This outcome underscores the importance of targeting TB prevention, early detection, and treatment adherence programmes on young adults in order to minimize transmission and socio-economic impacts.
With respect to marital status, the results show that a majority of the TB patients receiving treatment in DOTS Centers in Lagos State were married. Married adults often live in shared households, which can increase TB transmission. This outcome suggests that most of these individuals likely have family support, which can provide both emotional and logistical assistance for treatment adherence, potentially enhancing their motivation and ability to attend regular treatment sessions. However, they may also face additional social and economic pressures, particularly if they are the primary “breadwinners” with caregiving responsibilities or financial burdens, which could complicate their focus on treatment and recovery. The result supported the findings of Duyan et al. (22), conducted in Turkey, and Patel et al. (23), conducted in India, which found that the majority of their participants were married.
On the family type, the findings showed that a majority of the participants were monogamous, and a majority of the participants have approximately 3 - 5 children, while the average number of family members among tuberculosis patients in the DOTS Centers in Lagos State, Nigeria, is 2.17. While the large size and presence of children may provide social support and help to mediate psychological stress that tends to overwhelm coping capability for TB patients, TB burden can, however, increase the workload on family breadwinners, thereby inhibiting their ability to work and generate income to care for other family members. In addition, when one member of a household is a carrier or infected with TB, all other members are at risk because the disease is contagious in nature.
The study outcome indicated that the majority of the participants lived in a single room. In urban settings, limited affordable housing options often force low-income individuals into small, shared spaces, demonstrating how socio-economic and environmental factors contribute to TB prevalence. This finding suggests that the chances of infecting other people living in a single room may be high. This is because many TB patients shared the same beds, ate together, and even shared house utensils, which can aid in the spread of the disease. Tuberculosis patients who live in a small house with a large family member tend to have less space and privacy; thus, they aid transmission of the disease (24). It is generally known that the risk of tuberculosis infection rises with proximity to an index case. As a result, the risk of TB infection among contacts of TB cases is anticipated to be higher than in the general population. This finding is inconsistent with the result of the study done by Odone et al. (25) that TB was more prevalent in those who lived in better-built houses at the household level in Malawi. Similarly, this outcome is inconsistent with the result of Vange et al. (26), who conducted a study in Nigeria and reported that the majority of the study participants (TB patients) lived in flats and bungalows. This finding could be attributed to the fact that the majority of their study participants were civil servants, implying that they have a steady source of income that afford them to live in luxury houses.
The outcome of this study shows that a large proportion of the participants were educated up to the secondary educational level. This indicates that the level of education among the study participants is quite high; thus, it is expected that it will be easy for them to comprehend or receive health information that can lead to behavioral changes and improve their health-related quality of life. It is widely assumed that people with a reasonable level of education have a lower risk of TB infection, while those with no formal education have a higher risk of TB. Meanwhile, individuals with secondary education may work in occupations that expose them to crowded environments, increasing their vulnerability to TB. Level of educational attainment has been identified as a significant predictor of symptom identification and treatment. This finding is similar to a study conducted in Nigeria by Omotowo et al. (14, 17), and Onazi et al. (19), who all reported that those infected with tuberculosis patients as their study participants were educated up to the secondary educational level. However, this outcome contradicts the findings of Kisaka et al. (27), who reported that the majority of their respondents (TB patients) had no formal education in Uganda.
The study also found that the majority of the participants assessing treatment in the DOTS Centers were self-employed in one occupation or the other. This may be alluded to by the fact that self-employed individuals (business people) are often exposed to a larger number of people and tend to move around more frequently, which predisposes them to a higher risk of tuberculosis infection. Moreover, the nature of work and responsibilities may contribute to delayed healthcare-seeking, increasing the likelihood of TB detection at treatment Centers. This finding contradicts the results of Ochonma et al. (16), who conducted a study in Nigeria and discovered that the majority of their participants (TB patients) do not have paid employment.
The findings revealed that a large number of the participants were low-income earners. Tuberculosis is often linked to poverty, and the additional expenditures incurred during treatment often create significant impediments to patients' capacity to access and receive complete TB care. Additionally, poor living conditions and inadequate nutrition weaken immunity, making individuals more susceptible to TB. Patients' decisions to seek healthcare services may be influenced by factors such as proximity to health-care Centres and their income. Reis’ (6) study outcome in the Democratic Republic of Timor-Leste indicated that sufficient income is a key component of TB treatment, because those with enough money are more likely to have enough means to pay for transportation and other treatment-related expenses, thereby increasing the likelihood of completing treatment. This outcome is inconsistent with the findings of Boccia et al. (28), who found that TB infection was most prevalent in the wealthiest individuals in Zambia. This outcome is also inconsistent with the result of Onazi et al. (19), conducted in Nigeria, who found out that a little less than half (48.4%) of their study participants were not earning income. Furthermore, the outcome also contradicted the finding of Atif et al. (29) in Malaysia, who reported that the majority of patients with pulmonary TB have sufficient income.
The result of this study showed that many of the participants relied on public transportation as a means of transportation to DOTS Centres. It is possible that patients may be receiving treatment at facilities distant from their place of residence. Perhaps, one of the reasons many TB patients prefer to receive treatment away from their communities is the stigma and discrimination commonly associated with TB, particularly for individuals co-infected with HIV/AIDS, as treatment elsewhere offers greater anonymity. The risk associated with using commercial buses is that many TB patients hardly used their face masks while in public, probably due to the fear of stigmatization. As a result, many end up infecting more people. Findings of Feske et al. (30), carried out in Houston, Harris County, United States of America, revealed that weekly bus usage of public transportation was linked to a higher incidence of tuberculosis. Hassan et al. (2) asserted that TB thrives more in an overcrowded and poorly ventilated environment, which has been identified to characterise some of the present study area. This result also suggested that most of the study participants incurred some expenses towards their transportation to DOTS Centers. TB patients’ visits to health facilities may vary depending on the distance covered; as such, lack of financial resources for transportation could lead to treatment defaults. Transportation cost is a real cost, which most times is the only cost which tuberculosis patients could not avoid. The financial burden of such cost during treatment may impair health-related quality of life among low-income earners. Apart from disrupting their daily activities/job during clinic visits/appointment day(s), it is likely to have an impact on their income/earnings, particularly for those with lower income. In many low- and middle-income countries, many people depend on daily income to survive. In resource-limited settings, where income is mostly generated solely based on daily effort, the demand may affect patients’ chances of attending the clinic and adhering to treatment regimens accordingly. This outcome corroborates the findings of Yahaya et al. (31) study in Nigeria, which reported that a majority of the patients incurred cost during treatment as a result of transportation. Given the length of time required to treat tuberculosis, this could be a significant obstacle. As a result, patients who do not complete their treatment run the danger of infecting people in their environment and relapsing with tuberculosis.
5.1. Limitations
While the findings offer valuable insights, the outcome of this study should be interpreted with caution due to several inherent limitations. This study was limited to tuberculosis patients receiving treatment at government-designated DOTS Centers in Lagos State, Nigeria. Consequently, the findings may not be generalizable to DOTS Centers in other parts of the country. Finally, the study used only descriptive statistics because it focused only on socio-demographic factors of the patients; hence, the causal relationship could not be ascertained. Despite its limitations, the outcomes of this study draw policymakers’ attention to the prevalent socio-demographic characteristics observed among TB patients in selected public health facilities in Lagos State, Nigeria.
5.2. Conclusions
Tuberculosis remains a major threat that has a negative impact on patients’ health-related quality of life around the world. There is still a paucity of studies regarding the underlying mechanisms linking socio-economic characteristics of TB patients with the rising cases of infection reported in the country. Investigating the relationship between various socio-demographic factors and health is becoming increasingly important, particularly among patients with chronic illnesses and long-term treatments like tuberculosis. The study findings revealed that pulmonary TB was prevalent among males, married people and those educated up to secondary school level. The findings also revealed that most of the study participants were young adults in their economically productive age and self-employed. Furthermore, a high proportion of the participants belong to low-income earners, who are more vulnerable to tuberculosis infection due to poverty, ignorance, and a lack of healthcare services. This study's findings reinforce Andersen’s behavioral model by demonstrating how social and economic factors can profoundly shape health-seeking behavior. It emphasizes the role of individual perceptions and cues to action, and underscore the need for targeted interventions that could enhance accessibility, affordability, and awareness of TB services for high-risk populations. The findings of this study emphasize the need for TB control strategies that go beyond clinical management to address underlying social determinants. Furthermore, increasing community outreach, enhancing equitable access to TB services, and incorporating social protection measures into national and state TB programmes are essential for reducing disease burden and transmission. This study highlights the prevalent characteristics/profile of TB patients and should guide further research and identify the target group when intervention is needed.
