South Africa is burdened by one of the worst tuberculosis epidemics in the world, with disease rates more than double those observed in other developing countries and up to 60 times higher than those currently observed in the USA or Western Europe. The Medical Research Council (MRC) estimated that the country had about 180,507 cases (55% reported) in 1997, or 419 per 100,000 of the total population. Of these, 32.8% (73,679 cases) were probably infected with HIV (1). The tuberculosis problem in South Africa is largely a result of historical neglect and poor management systems, compounded by the legacy of fragmented health services. Prior to the introduction of the Tuberculosis Register in 1995, cure rates were unknown, and consequently control efforts could not challenge the poor performance. The implication of this failure is evident from the fact that, in 1997, a cure rate of only 54% could be recorded, with the consequence of continued high rates of transmission in the country (1). Data on self-reported tuberculosis among men and women related more frequently to older people (e.g. age less than 35 years was 1.5% and age more than 35 was 4.6%) and people living in non-urban areas (e.g. men: urban 2.6%, non-urban 3.3%, women: urban 1.6%, non-urban 2.6%) (2).
The Department of Health in November 1996 declared tuberculosis a top health priority, and National Health Minister Zuma committed her Department to implementing a new control programme based on the directly-observed therapy (DOT) strategy of the World Health Organization that includes: (a) Government commitment to a national tuberculosis programme as a specific health-system activity, integrated into comprehensive primary care, and supported technically at a national level; (b) Standardized, directly observed, short-course treatment, prioritizing sputum smear-positive patients; (c) Case detection by means of a patient-friendly and clinically-efficient service based primarily on smear microscopy (passive case-finding); (d) An ensured supply of essential anti-tuberculosis drugs; and (e) Effective monitoring (3).
The pace and extent of implementation of the programme is, however, slow in most provinces. Since 1996, a system of case registration based on strict criteria for case definition was implemented in South Africa. These registrations, based on standardized criteria, are now beginning to present a clearer picture of disease rates in the country than what was available before (4). Some progress has been made in DOTS population coverage in South Africa (70% in 2001), but the implementation of the DOT strategy in the Limpopo province has been slow (1).
Early case identification and adherence to treatment regimens are the remaining barriers to successful control of tuberculosis. Two twin problems of delay in seeking treatment and abandonment of prescribed regimens derive from complex factors. One reason for the patient's delay in seeking treatment may be poor understanding of tuberculosis among people as a disease and its risk factors (5). Westaway reported from a study in South Africa that tuberculosis was perceived as a threat, and sufferers of the disease were thought to be dirty and to eat bad food (6).
In South Africa, the conventional strategies to combat tuberculosis focused on the treatment of individual patients within the framework of the control programme (7). This approach emphasizes the role of education and behaviour adjustment on the part of patients, particularly with regard to compliance with medical regimens (8). Causation and treatment of the disease, including problematic area, must be understood by taking into account the social environment of patients, including living arrangements, belief systems, and nature of community health services (9). Insights into social and cultural factors could possibly help reduce delays in diagnosis, improve treatment compliance, and provide suggestions …