Available via license: CC BY 4.0
Content may be subject to copyright.
RESEARCH ARTICLE
Sociocultural understanding of Tuberculosis
and implications for care-seeking among
adults in the province of Zambezia,
Mozambique: Qualitative research
Celso Give
1☯
, Chrissie Morris
2‡
, Joanna Murray
2‡
, Benedita Jose
´
3
, Raimundo Machava
3
,
Sonali WayalID
2☯
*
1Development Media International, Maputo, Mozambique, 2Development Media International, London,
United Kingdom, 3National Tuberculosis Control Programme, Ministry of Health, Maputo, Mozambique
☯These authors contributed equally to this work.
‡ CM and JM also contributed equally to this work.
*sonali.wayal@developmentmedia.net
Abstract
Introduction
Mozambique has a high burden of Tuberculosis (TB) with an incidence of 368 per 100,000
population in 2020, coupled with a low all-form TB detection rate. The COVID-19 pandemic
has exacerbated delays in timely diagnosis and treatment of new TB cases. Promoting
active TB case finding is a national priority in Mozambique. We conducted qualitative
research to explore factors influencing TB testing in Zambezia province in Mozambique.
Materials and methods
One-to-one, semi-structured, audio-recorded telephone interviews were conducted to
explore TB-related knowledge, and barriers and facilitators to TB testing. A sample of two
TB Program staff, two community providers of TB services, and 19 community members
(10 women and 9 men) was recruited, with support from provincial government TB staff,
from four districts in Zambezia with a high TB burden. Interviews were transcribed verbatim,
and thematic analysis was conducted. The Mozambican National Bioethics Committee for
Health approved the study protocol.
Results
Our study highlights that knowledge about TB symptoms and its causes is low, which could
delay timely TB testing. Sociocultural beliefs often implicate certain types of sexual activity
and women as causes of TB symptoms; for example, having sex with a widow who has not
been traditionally purified, or with a woman who has had an abortion. Therefore, people usu-
ally tend to first seek care from traditional healers instead of going to a health facility. Addi-
tionally, stigma associated with HIV and TB also delays care seeking. Gender-related
disparities in TB care seeking were also evident.
PLOS ONE
PLOS ONE | https://doi.org/10.1371/journal.pone.0289928 January 18, 2024 1 / 11
a1111111111
a1111111111
a1111111111
a1111111111
a1111111111
OPEN ACCESS
Citation: Give C, Morris C, Murray J, Jose
´B,
Machava R, Wayal S (2024) Sociocultural
understanding of Tuberculosis and implications for
care-seeking among adults in the province of
Zambezia, Mozambique: Qualitative research. PLoS
ONE 19(1): e0289928. https://doi.org/10.1371/
journal.pone.0289928
Editor: Nabeel Al-Yateem, University of Sharjah,
UNITED ARAB EMIRATES
Received: March 24, 2022
Accepted: July 29, 2023
Published: January 18, 2024
Copyright: ©2024 Give et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: Due to ethical
reasons, we will not be able to share the data
generated from this study. The data generated in
this qualitative study is interview transcripts, which
have been translated verbatim. It is a challenge to
completely deanonymize these transcripts and we
do not have the budget for it. Moreover, due to the
sensitive nature of the data, it cannot be deposited
in a public repository. Additionally, in the consent
form, we have ensured participants that their
responses will be kept confidential and only the
Conclusions
This study provides valuable insights into how healthcare seeking for TB is influenced by
sociocultural understanding of symptoms and gender dynamics. Therefore, interventions to
promote timely and appropriate care seeking for TB should be contextually tailored, cultur-
ally appropriate, and gender sensitive.
Introduction
Tuberculosis (TB) remains a significant global health concern. In 2020, an estimated 9.9 mil-
lion people developed TB for the first time and 1.5 million people died due to the disease [1].
The burden of TB in adult men (56%) was higher than among adult women (33%) and chil-
dren (11%) [1]. A modelling study has estimated that TB deaths in low- and middle-income
countries (LMICs) with a high burden of TB could increase by 20% between the years 2020–
2024, due to the negative impact of COVID-19 on timely diagnosis and treatment of new TB
cases [2]. Due to the COVID-19 pandemic, the number of people newly diagnosed and noti-
fied with TB fell from 7.1 million in 2019 to 5.8 million in 2020, and gaps in TB diagnosis and
reporting were higher among men than women [1]. Most TB transmissions occur between the
onset of cough and initiation of treatment. Reductions and delays in diagnosis and treatment
could have a significant impact on both disease prognosis at an individual level and transmis-
sion within the community. TB case finding, notification, and treatment therefore continue to
remain a global priority [3,4].
In Mozambique, the absolute number of TB deaths between 2015 and 2020 reduced by
35%; however, in 2020, TB incidence (368/100,000) and TB-HIV co-infections (101/100,000)
continued to be high along with drug-resistant TB [1]. Moreover, the notification rate of TB in
all forms was 323/100,000 inhabitants (97,093 cases) [5]. Zambezia is the second largest prov-
ince in central Mozambique with more than 5.1 million inhabitants [6]. It has a TB notification
rate of 353/100,000 inhabitants (20,944 cases), with a high prevalence of drug-resistant TB [5].
Therefore, Zambezia is a high priority province for TB prevention and control, with an
emphasis on enhancing case detection [7].
Traditionally in Mozambique, TB case detection, diagnosis and notification has predomi-
nantly relied on passive case finding (waiting for individuals to present to a health facility with
TB-related symptoms), potentially leading to a significant gap between the actual number of
people with TB, and those who present to the health facilities and are diagnosed and notified
[8]. Thus, in recent years the Mozambican National Tuberculosis Program (NTP) has been
promoting active TB case finding as a national priority [7,9] in all health facilities via Finding
TB cases Actively, Separating safely, and Treating effectively (FAST) strategy, and at the com-
munity level via community health workers. However, timely TB case detection in Mozam-
bique is affected by various factors. A survey conducted among diagnosed TB patients
attending a health facility for treatment in Southern Mozambique has shown delays in patients
presenting to health facilities despite having symptoms, as well as health system delays (interval
between patient’s first contact with the health care system and initiation of TB treatment) of
approximately two months [10]. Factors such as farming responsibilities, visiting a traditional
healer first, low TB knowledge, and coexistence of a chronic disease, could lead to delays in
care-seeking among adult TB patients [10]. Literature reviews of studies performed in LMICs
have also highlighted that factors contributing to patient delays in TB care-seeking can vary by
sex [11,12].
PLOS ONE
Sociocultural factors influencing Tuberculosis care-seeking among adults in Mozambique
PLOS ONE | https://doi.org/10.1371/journal.pone.0289928 January 18, 2024 2 / 11
research team will have access to the data files.
The Mozambican National Bioethics Committee for
Health approved the study protocol (Ref:259/
CNBS/20). For further information, you can contact
researcher, Celso Give via email celso.
give@developmentmedia.net or contact the
National Bioethics Committee of the Ministry of
Health, via cell phone 82 4066350.
Funding: STOP TB PARTNERSHIP, STBP/
TBREACH/GSA/W7-7507.
Competing interests: The authors declare that they
have no competing interests.
The slow rate at which patients with TB report to health facilities is a major limiting factor
in global efforts to control TB [13]. Understanding what causes delays in TB care seeking and
why, is important to develop effective interventions to promote timely TB testing and treat-
ment seeking. Despite the high prevalence of TB in Zambezia province, no studies have been
conducted to understand TB-related care-seeking behaviours there. Moreover, existing litera-
ture from Mozambique does not provide insights into if and why TB-care seeking behaviour
varies by sex. Therefore, the aim of this study is to explore the contextual understanding of TB
and care-seeking patterns for TB symptoms, and to explore if these vary by sex among adults
in Zambezia.
Materials and methods
Study setting
Active case detection strategy has been implemented in all districts in Zambezia in all hospitals
and health centers via FAST strategy and in the community it is implemented by the commu-
nity health workers who are trained to offer TB testing and treatment services. This study was
conducted between June-July 2020 in the districts of Milange, Mocuba, Ile, and the City of
Quelimane in Zambezia province. These districts were chosen because they have a high preva-
lence of risk factors associated with TB such as mining areas (Milange), poverty, and people
living with HIV (Milange, Mocuba, Ile and City of Quelimane) [14]. They have therefore been
identified as priority districts for promoting TB case detection by the Ministry of Health in
Mozambique (personal communication with Zambezia’s Provincial Health Directorate
(DPS)).
Study design and sampling approach
A qualitative study was conducted, comprising of semi-structured interviews with (i) commu-
nity members, and (ii) key informants, namely health professionals working in the field of TB
with the National TB Program and TB program in Zambezia, and community health workers
(CHWs) who work with a non-governmental organization (NGO) named Ajuda Do Povo
para Povo (ADPP) in Zambezia to provide TB testing services and health promotion in the
community. Due to their experience of working with the communities for TB prevention and
service provision, the key informants and CHWs were interviewed to understand their per-
spectives regarding the attitudes of community members towards TB and the barriers and
facilitators for TB testing. Insights from these interviews helped us to refine the topic guide we
used for data collection with the community members. Topic guides were piloted with two
participants and minor changes were made to enhance clarity.
To recruit community members, convenience sampling, a method commonly used in qual-
itative studies, was used [15,16]. Community members were identified with the help of experts
working with DPS and three community-based radio stations in Zambezia because they have
frequent contact with community members and local leaders. Participants aged between 20 to
50 years, an age group at greater risk of TB [17], were eligible for recruitment. From the above-
mentioned districts, names, telephone numbers and preferred contact times were collected by
the experts from all potential participants who were interested in participating in the study.
They were informed that a researcher would contact them regarding study participation. Addi-
tionally, a snowball method was used to ensure recruitment of community members from
remote rural areas. To this end, at the end of each interview, the researcher asked the partici-
pant about their willingness to refer people from their social network (i.e., friends, neighbours,
family etc.) located in remote areas of the study districts, to participate in the study. If a partici-
pant was willing to refer someone, they were asked to provide that person’s contact details and
PLOS ONE
Sociocultural factors influencing Tuberculosis care-seeking among adults in Mozambique
PLOS ONE | https://doi.org/10.1371/journal.pone.0289928 January 18, 2024 3 / 11
inform them that they will be contacted by a researcher regarding study participation. There
was no obligation for participants to make a referral. To minimize recruitment bias, each par-
ticipant was asked to provide details of only two contacts who were willing to be interviewed.
Eight participants were recruited via snowball method. A purposive sample across age groups,
by sex, and districts was planned to enable us to detect differences across these. We recruited
community members until there were no new themes emerging from the data being collected.
To recruit the key informants, a study co-author (BJ), who is a member of staff at the NTP,
was contacted directly by a researcher and interviewed in person. She introduced the
researcher to a staff member from the DPS in Zambezia who was also interviewed in person. A
coordinator of an NGO asked the CHWs, who work with them, about their interest in partici-
pating in the study prior to sharing their name and telephone details with a researcher. Subse-
quently, the researcher directly contacted the CHWs via phone.
Due to the risk of COVID-19 transmission, there were travel restrictions in place in Mozam-
bique during the time of this study. Therefore, all the data collection with CHWs and community
members was conducted via telephone by an experienced qualitative researcher (CG) who is an
anthropologist and contacted all the potential participants and confirmed their eligibility to partic-
ipate. Prior to data collection, the researcher read the consent form to all the potential participants
to explain the study objectives and procedures, voluntary participation in the study, and their
right to decline to participate in the study without facing any negative consequences. Subse-
quently, oral consent for study participation as well as for audio recording from each participant
was obtained via telephone and audio-recorded as proof of consent to study participation. In-per-
son as well as the phone interviews lasted for approximately 35 to 50 minutes. The Mozambican
National Bioethics Committee for Health approved the study protocol (Ref:259/CNBS/20).
Participants were given the choice to be interviewed in local languages spoken in Zambezia
or in Portuguese. All the participants (23) who were approached to participate in the study
agreed to participate and opted to be interviewed in Portuguese. A topic guide was used to
explore attitudes and perceptions of key informants towards people’s knowledge and care
seeking behaviors for TB, especially TB testing, and any differences in these by sex. A separate
topic guide, informed by data collected from the key informants, was used to explore commu-
nity members’ perceptions about the causes of TB, its symptoms, and modes of transmission;
awareness, barriers, and facilitators for TB testing and treatment; and attitudes towards people
diagnosed with TB.
Analysis
All interviews were transcribed in Portuguese and a thematic analysis was conducted [18]. Ini-
tially a researcher (CG) read the transcripts verbatim, thoroughly, and repeatedly to familiarize
with the data. Initially six transcripts were coded inductively by CG manually. Excel spread-
sheet (S1 Data) was used to identify and extract data for the broad themes of interest explored
during the interviews. Subsequently, data under each theme was analysed and codes were
developed (See Fig 1). These codes were then discussed by the research team (SW and CG)
and revised if necessary to develop a codebook. Subsequently, all the transcripts were coded
(CG) using the codebook while being mindful of new emerging codes. Data under each code
was grouped together to identify emerging patterns and themes in an iterative manner. Tran-
scripts were re-read to verify the accuracy of themes and sub-themes identified. To ensure con-
fidentiality of the study participants and to account for the potential risk of stigma associated
with sharing personal perspectives/experiences about TB, anonymised quotations illustrating
participants’ own, or their perception of others’ knowledge, beliefs, experiences, and behav-
iours have been used. No interviewees participated in the discussions related to data analysis.
PLOS ONE
Sociocultural factors influencing Tuberculosis care-seeking among adults in Mozambique
PLOS ONE | https://doi.org/10.1371/journal.pone.0289928 January 18, 2024 4 / 11
Results
Twenty-three semi-structured interviews (4 with key informants and 19 with community
members) were conducted. As shown in Table 1, more interviews were conducted with com-
munity members from Cidade de Quelimane because it has the highest TB prevalence in Zam-
bezia. Similar numbers of men and women participated in the interviews. Overall, eleven and
eight participants were recruited from urban and rural areas respectively. The results focus on
the community members beliefs and perceptions about TB and healthcare seeking behaviors.
Socio-cultural understanding of Tuberculosis
Very few participants associated symptoms such as coughing, blood in sputum, loss of weight/
appetite, etc with TB. Participants recruited from urban areas were more aware of TB
Fig 1. Factors influencing Tuberculosis testing.
https://doi.org/10.1371/journal.pone.0289928.g001
Table 1. Site of recruitment and socio-demographic characteristics of participants.
Characteristics Health professionals/ community health workers (n = 4) Community members (n = 19)
Districts
Cidade de Quelimane 2 8
Mocuba 1 4
Milange 1 4
Ile - 3
Gender
Female 1 10
Male 3 9
Age
20–30 - 7
31–40 4 9
41–50 - 3
https://doi.org/10.1371/journal.pone.0289928.t001
PLOS ONE
Sociocultural factors influencing Tuberculosis care-seeking among adults in Mozambique
PLOS ONE | https://doi.org/10.1371/journal.pone.0289928 January 18, 2024 5 / 11
symptoms than those from rural areas. This was reported to be due to greater exposure to TB-
related information on the radio, via pamphlets in health centres, and relatively easy access to
health centres in urban areas. Both male and female in rural areas lacked awareness about TB
symptoms.
I think we have a lot of information about tuberculosis,on the radio people talk about TB,
some lectures are given about TB and if you go to the health units you will see that all the
places have pamphlets about TB which promote TB testing if anyone had a cough and spu-
tum. (Male, 27 years old)
In principle,when a person has a cough,they should go to the hospital.And there at the hospi-
tal,they do an analysis.They will see if the cough is persistent or not,give the medication.
Now if you continue to cough,go back and do the analysis and that analysis decides whether
you have it or not. (Female, 35 years old)
However, most of the participants, both male and female, from urban as well as rural areas,
perceived symptoms such as persistent cough, weight loss, etc., were caused by witchcraft,
adultery, or sexual involvement with “impure women”. Women who had lost their husband
and had not yet performed purification rituals or women who had had an abortion were per-
ceived to be “impure women”.
Many people in my community think that tuberculosis results from sexual involvement with
another person’s wife or with impure women.When a woman loses her husband,she has to go
to the traditional healer to perform purifications rituals,if she does not perform this ritual,
she is perceived as impure. (Male, 46 years old)
I know a person who had tuberculosis and thought it was witchcraft because he had a good
life and people were jealous of his life,so they cast a spell for him.There are a lot of people in
the communities who think like that about tuberculosis. (Female, 42 years old)
Health care-seeking behaviours
Several factors influence healthcare seeking behaviour among people with TB symptoms.
Social norms and beliefs. Due to the above-mentioned perceptions and beliefs about the
causes of TB symptoms, most of the participants mentioned that people usually seek help from
traditional healers first, especially if the symptoms are perceived to be caused due to witchcraft
or lack of performing purification rituals. Some participants felt that in general in Mozam-
bique people usually seek help from traditional healers first. However, if their health condition
does not improve, then people go to health facilities.
If you grew up in a society where everything is treated on a traditional (healer) level,and even
if you know that it can be cured in two days if you go to a health center,the person still goes to
a traditional healer. (Male, 41 years old)
Some participants felt that people seek care from traditional healers because they are per-
ceived to be caring towards their clients and provide better health services compared to the
health professionals in the health facilities. Some participants also felt that people seek care
from traditional healers because healthcare provided at the medical health facilities is expen-
sive, and health professionals do not offer timely TB testing.
PLOS ONE
Sociocultural factors influencing Tuberculosis care-seeking among adults in Mozambique
PLOS ONE | https://doi.org/10.1371/journal.pone.0289928 January 18, 2024 6 / 11
Traditional healers serve better than hospitals.When you go to the traditional healer you are
welcomed,they talk with you and try to understand what is going on.At the hospital,they yell
at you. (Female, 37 years old)
I was sick for a long time,then I went to the hospital,and they didn’t know what I had.For
some time,I couldn’t even walk,I had to take other people’s help to be able to walk.I was get-
ting frustrated,and I didn’t know what to do anymore.I was desperate and then they tested
me at the hospital where they found out I had tuberculosis.This happens to many people,get-
ting sick and not knowing what they have,a lot of people don’t know much about tuberculosis.
(Female, 33 years old)
Distance to health facilities. Participants also mentioned that people usually seek help
from traditional healers first, especially in rural areas, because health facilities are far away.
This makes accessing care expensive due to travel costs as well as opportunity costs (taking
time away from work, especially for men; household chores and childcare for women).
It is a long way from the communities to the hospital,if you do not have transportation to go
there,you have no way to resolve it.Imagine that sometimes you have to walk more than 25
kilometers when you are sick.How can you do that?People end up going to the healer,it is
closer and some like to go there. (Female, 27 years)
Stigma associated with Tuberculosis and HIV. Some community members as well as
key informants felt that the perceived association between TB and HIV/AIDS in the commu-
nity is common. This negatively affects people’s healthcare seeking behaviour if they have
symptoms of TB. People who live with others, fear being discriminated against due to the fear
of TB transmission to other people.
Currently,because of what is happening in society,TB is one of the diseases,the one most asso-
ciated with HIV-AIDS.So,when people start to have these symptoms,they are a little more
afraid of approaching hospitals.That ends up generating some fear due to the stigma that is
still associated with HIV-AIDS.So,I think that when there are these kinds of symptoms,there
are people who tend to hide their symptoms. (Male, 38 years)
Unfortunately,in the community,discrimination against people with TB persists.During our
mobilization meetings and working in the communities,we can see that people are discrimi-
nated against due to the association of TB with HIV. (Male CHW, 36 years)
Gender dynamics. Some female participants mentioned that women have limited access
to health care, including if they have TB symptoms, because they lack decision-making power
about where and when to seek health care. These decisions are usually made by spouses or
senior male members of the family. Their financial dependence on men for transport and asso-
ciated costs to go to the health facilities, further affects their decision-making capacity with
regards to healthcare seeking.
I met a lady who was sick in the hospital.She told me that she had told her husband that she
did not feel well and that she should go to the hospital.Her husband denied it,but she went to
the hospital and told him that she had tuberculosis and that she was going to start treatment
and she would have to stay away from him for 6 months.The husband told her that if she
wants to take the treatment,he will not be waiting for her until the treatment is over.She had
to decide whether to lose her husband or undergo treatment,that is,to choose between her life
PLOS ONE
Sociocultural factors influencing Tuberculosis care-seeking among adults in Mozambique
PLOS ONE | https://doi.org/10.1371/journal.pone.0289928 January 18, 2024 7 / 11
and her husband.She decided to undergo the treatment and her husband left her.Now she is
fine.Imagine if she had not had the treatment. (Female, 38 years old)
Some male participants felt that health services are more targeted at women and so men
have limited access to health care and feel excluded from services:
I think that women have more advantages because they are the first to benefit from any type
of hospital intervention compared to men.Not only that,even in the health system itself,there
is now more attention focused on maternal and child health.So,men feel left out.So,they
may be one of the last to be seen at the health center. (Male, 36 years old)
Discussion
This study explored factors influencing health care seeking behaviours for TB in Central
Mozambique. Our study findings highlight that sociocultural beliefs and understanding of the
causes and symptoms of TB contribute to delays in seeking timely and appropriate testing and
treatment for TB. Similar to findings from studies conducted in other African countries, TB
symptoms were perceived to be a manifestation of witchcraft [19,20]. As reported in a study
conducted in Southern Mozambique [21], TB symptoms were also perceived to be caused due
to transgression of sexual or social norms and customs, and were associated with stigma. For
example: sexual engagement with people perceived to be impure, or not performing a purifica-
tion ceremony following a death in the family. Sex was perceived to be a mode of TB transmis-
sion [16]. This probably led to community members sharing their experiences and beliefs in
third person. Women were often perceived to be impure, either due to the death of their hus-
band or undergoing an abortion. Such rationalization of TB symptoms leads to women being
blamed for the illness. Anthropological studies have shown that such notions of impurity as a
cause of illness are embedded in the broader belief system in Mozambique and other African
countries, and such illnesses are perceived to be contagious [22]. Nevertheless, sometimes the
sociocultural interpretations of causes of TB co-existed with bio-medical understanding of the
illness, usually in the urban areas [23].
Our findings suggest that such sociocultural interpretations of the causes of TB typically
encourages people to consult traditional healers in times of distress and ill-health to identify
the source of the problem, to eliminate the source of the evil, and to avoid it in the future [24].
Similar to findings from a study conducted in Uganda, our study found that traditional healers
were preferred to healthcare providers because they were perceived to be respectful and sup-
portive compared to the health professionals, indicating that healthcare users value the impor-
tance of interpersonal interactions and trustworthiness of healers [25]. Moreover, as reported
in studies done in other African countries, perceived stigma associated with TB and the associ-
ation of TB with HIV negatively affects timely care seeking [19,26]. Poor knowledge and
stigma associated with TB could lead to diagnostic delays [27], delays in appropriate care seek-
ing [11,21] and influence where people seek care in Mozambique. Health literacy is an impor-
tant predictor of health status [28], thus improving TB related knowledge in Mozambique is
vital. However, these data highlight that interventions promoting TB-related health literacy
should be contextually tailored and culturally appropriate.
However, unlike a survey conducted in Ethiopia [19], our study did not find differences in
knowledge about TB among men and women. Nevertheless, gender norms influenced TB care
seeking. Delayed healthcare seeking among men was due to work pressures, and feelings of
alienation from health care facilities which were perceived to be places for women and
PLOS ONE
Sociocultural factors influencing Tuberculosis care-seeking among adults in Mozambique
PLOS ONE | https://doi.org/10.1371/journal.pone.0289928 January 18, 2024 8 / 11
children, and as being insensitive towards men’s healthcare needs [29]. Whereas among
women, access to TB health care services was affected by the demands of childcare and house-
hold chores made on women, as well as by their limited decision-making power and financial
dependence on their spouse or other family members. Therefore interventions promoting
knowledge and awareness of TB in Mozambique should be gender-sensitive, and should be
accompanied by TB services which are tailored to the gender-specific barriers to accessing ser-
vices [12].
Ending the TB epidemic by 2030 is a Sustainable Development Goal [28]. However, to
address the threat of TB, innovative approaches that extend beyond clinics and hospitals are
needed [13]. A study conducted among women in India has shown that participants who had
seen TB campaigns on any mass media had better knowledge about TB than those who had
not [30]. A mass media health education campaign in Cali, Colombia showed that providing
basic information about TB symptoms and the procedures for diagnosis can increase diagnos-
tic coverage [30]. Increasing public awareness of TB disease could potentially promote volun-
tary reporting to health facilities for TB care and reduce stigma towards TB patients [16,29].
Therefore, we used data from this research to develop a mass media campaign to promote
awareness of TB symptoms and promote testing for TB in Zambezia.
Our study has contributed to the limited existing literature on factors influencing care
seeking for TB symptoms in Mozambique. However, the study findings should be inter-
preted considering its limitations. This study was conducted during the state of emergency
declared by the President of Mozambique in March 2020 due to Covid-19, which led to the
research being conducted remotely via telephone. This meant that there was no observation
of nonverbal cues of the participants during the interviews which may have affected the
nuances of the data collected. The recruitment of study participants was done by staff of
community radio stations and the DPS which may have introduced some selection bias.
However, we tried to minimize this bias by using a snowball approach to recruit community
members from participants’ social networks from remote areas in Zambezia. Lastly, the
study was conducted in the province of Zambezia, limiting the generalizability of the study
findings to the whole country. However, the significant overlap between our study findings
and those of a study conducted in Southern Mozambique [19] indicates that some percep-
tions about symptoms and causes of TB, and barriers to TB care seeking are likely to be gen-
eralizable beyond the study area. Further studies should explore TB related care seeking
behaviors and knowledge in other parts of Mozambique, which continue to have high TB
prevalence.
Conclusions
Our study provides valuable insights into how healthcare seeking for TB is influenced by socio-
cultural understanding of symptoms and gender dynamics. Therefore, interventions to pro-
mote timely and appropriate care seeking for TB should be contextually tailored, culturally
appropriate and gender sensitive.
Supporting information
S1 Data. Example of coding raw data by theme.
(DOCX)
S1 File. Topic guides.
(DOCX)
PLOS ONE
Sociocultural factors influencing Tuberculosis care-seeking among adults in Mozambique
PLOS ONE | https://doi.org/10.1371/journal.pone.0289928 January 18, 2024 9 / 11
Acknowledgments
We thank all the study participants for their time and engagement with our study, and the
DPS and community radio stations for helping with recruitment of the participants. We would
like to thank Khatia Munguambe from Centro de Investigacão em Saúde de Manhiça, Maputo,
Mozambique for sharing her insights from a previous study conducted by her on TB in South-
ern Mozambique. We would also like to thank Dr. Ulisses Jantar for sharing his experience of
working with the TB program in Zambezia, and Ajuda de Desenvolvimento de Povo para Povo
staff for their help with the study.
Author Contributions
Conceptualization: Joanna Murray, Sonali Wayal.
Formal analysis: Celso Give.
Funding acquisition: Joanna Murray.
Investigation: Celso Give, Chrissie Morris, Joanna Murray, Benedita Jose
´, Sonali Wayal.
Methodology: Celso Give, Joanna Murray, Sonali Wayal.
Supervision: Joanna Murray, Sonali Wayal.
Writing – original draft: Celso Give, Sonali Wayal.
Writing – review & editing: Celso Give, Chrissie Morris, Joanna Murray, Benedita Jose
´, Rai-
mundo Machava, Sonali Wayal.
References
1. World Health Organisation. Global tuberculosis report 2021. 2021 [cited 19 Oct 2021]. Available:
https://www.who.int/publications-detail-redirect/9789240037021
2. Hogan AB, Jewell BL, Sherrard-Smith E, Vesga JF, Watson OJ, Whittaker C, et al. Potential impact of
the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries:
a modelling study. The Lancet Global Health. 2020; 8: e1132–e1141. https://doi.org/10.1016/S2214-
109X(20)30288-6 PMID: 32673577
3. Goosby E, Jamison D, Swaminathan S, Reid M, Zuccala E. The Lancet Commission on tuberculosis:
building a tuberculosis-free world. The Lancet. 2018; 391: 1132–1133. https://doi.org/10.1016/S0140-
6736(18)30666-4 PMID: 29595482
4. Reid MJA, Arinaminpathy N, Bloom A, Bloom BR, Boehme C, Chaisson R, et al. Building a tuberculo-
sis-free world: The Lancet Commission on tuberculosis. The Lancet. 2019; 393: 1331–1384. https://doi.
org/10.1016/S0140-6736(19)30024-8 PMID: 30904263
5. Ministe
´rio Da Sau´de. Relato
´rio Anual do Programa: 2020. 2020 [cited 27 Oct 2021]. Available: https://
www.misau.gov.mz/index.php/relatorios-anuais-pnct
6. Instituto Nacional de Estatistica. Recenseamento Geral da Populac¸ão e Habitac¸ão. 2017 [cited 27 Oct
2021]. Available: http://www.ine.gov.mz/operacoes-estatisticas/censos/censo-2007/censo-2017
7. Ministe
´rio de Sau
´de, Direcc¸ão Nacional de Sau
´de Publica, Programa Nacional de Controlo da Tubercu-
lose. PLANO ESTRATE
´GICO E OPERACIONAL: 2014–2018. 2018.
8. Jose
´B, Manhic¸a I, Jones J, Mutaquiha C, Zindoga P, Eduardo I, et al. Using community health workers
for facility and community based TB case finding: An evaluation in central Mozambique. PLOS ONE.
2020; 15: e0236262. https://doi.org/10.1371/journal.pone.0236262 PMID: 32702073
9. Ministe
´rio Da Sau
´de. Polı
´tica e Plano Nacional de Controlo da Infecc¸ão para a Tuberculose em Uni-
dades Sanita
´rias e ambientes conglomerados de Moc¸ambique. 2010. Available: https://www.who.int/
hiv/pub/guidelines/mozambique.pdf
10. Saifodine A, Gudo PS, Sidat M, Black J. Patient and health system delay among patients with pulmo-
nary tuberculosis in Beira city, Mozambique. BMC Public Health. 2013; 13: 559. https://doi.org/10.1186/
1471-2458-13-559 PMID: 24499197
11. Waisbord S. Behavioral barriers in tuberculosis control: A literature review. 2005. Available: https://pdfs.
semanticscholar.org/fb37/40d21e6744fd19eef2c002a36f4ee083191d.pdf
PLOS ONE
Sociocultural factors influencing Tuberculosis care-seeking among adults in Mozambique
PLOS ONE | https://doi.org/10.1371/journal.pone.0289928 January 18, 2024 10 / 11
12. Krishnan L, Akande T, Shankar AV, McIntire KN, Gounder CR, Gupta A, et al. Gender-Related Barriers
and Delays in Accessing Tuberculosis Diagnostic and Treatment Services: A Systematic Review of
Qualitative Studies. Tuberculosis Research and Treatment. 2014; 2014: e215059. https://doi.org/10.
1155/2014/215059 PMID: 24900921
13. World Health Organization. Global tuberculosis report 2019. 2019.
14. Instituto Nacional de Estatı
´stica. Estatistica de Territoriais (Distritais). 2013 [cited 28 Oct 2021]. Avail-
able: http://www.ine.gov.mz/estatisticas/estatisticas-territorias-distritais/zambezia/novembro-de-2013
15. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;
3: 77–101. https://doi.org/10.1191/1478088706qp063oa
16. Abebe G, Deribew A, Apers L, Woldemichael K, Shiffa J, Tesfaye M, et al. Knowledge, Health Seeking
Behavior and Perceived Stigma towards Tuberculosis among Tuberculosis Suspects in a Rural Com-
munity in Southwest Ethiopia. PLOS ONE. 2010; 5: e13339. https://doi.org/10.1371/journal.pone.
0013339 PMID: 20948963
17. Stop TB Partnership, and Mozambique Ministry of Health. Tuberculosis situation in Mozambique in
2019. 2019 [cited 28 Oct 2021]. Available: http://www.stoptb.org/resources/cd/MOZ_Dashboard.html
18. Mangesho PE, Shayo E, Makunde WH, Keto GBS, Mandara CI, Kamugisha ML, et al. Community
knowledge, attitudes and practices towards tuberculosis and its treatment in Mpwapwa district, central
Tanzania. Tanzan Health Res Bull. 2007; 9: 38–43. PMID: 17547099
19. Mindu C, Lo
´pez-Varela E, Alonso-Menendez Y, Mausse Y, Augusto OJ, Gondo K, et al. Caretakers’
perspectives of paediatric TB and implications for care-seeking behaviours in Southern Mozambique.
PLoS One. 2017; 12: e0182213. https://doi.org/10.1371/journal.pone.0182213 PMID: 28910284
20. Green EC. Purity, pollution and the invisible snake in southern Africa. Med Anthropol. 1996; 17: 83–
100. https://doi.org/10.1080/01459740.1996.9966129 PMID: 8757714
21. Boah M, Kpordoxah MR, Adokiya MN. Self-reported gender differentials in the knowledge of tuberculo-
sis transmission and curative possibility using national representative data in Ghana. PLOS ONE. 2021;
16: e0254499. https://doi.org/10.1371/journal.pone.0254499 PMID: 34252131
22. Granjo P. Sau
´de e doenc¸a em Moc¸ambique. Saude soc. 2009; 18: 567–581. https://doi.org/10.1590/
S0104-12902009000400002
23. Sundararajan R, Mwanga-Amumpaire J, King R, Ware NC. Conceptual model for pluralistic healthcare
behaviour: results from a qualitative study in southwestern Uganda. BMJ Open. 2020; 10: e033410.
https://doi.org/10.1136/bmjopen-2019-033410 PMID: 32317259
24. Musuka G, Teveredzi V, Mutenherwa F, Chingombe I, Mapingure M. Tuberculosis knowledge, miscon-
ceptions/myths in adults: findings from Lesotho, Malawi, Namibia and Zambia Demographic Health Sur-
veys (2013–2016). BMC Research Notes. 2018; 11: 778. https://doi.org/10.1186/s13104-018-3884-6
PMID: 30382927
25. Storla DG, Yimer S, Bjune GA. A systematic review of delay in the diagnosis and treatment of tuberculo-
sis. BMC Public Health. 2008; 8: 15. https://doi.org/10.1186/1471-2458-8-15 PMID: 18194573
26. Kickbusch IS. Health literacy: addressing the health and education divide. Health Promotion Interna-
tional. 2001; 16: 289–297. https://doi.org/10.1093/heapro/16.3.289 PMID: 11509466
27. Chikovore J, Pai M, Horton KC, Daftary A, Kumwenda MK, Hart G, et al. Missing men with tuberculosis:
the need to address structural influences and implement targeted and multidimensional interventions.
BMJ Global Health. 2020; 5: e002255. https://doi.org/10.1136/bmjgh-2019-002255 PMID: 32371568
28. World Health Organisation. The End TB Strategy: Global strategy and targets for tuberculosis preven-
tion, care and control after 2015. 2014 [cited 7 Sep 2020]. Available: https://www.who.int/tb/End_TB_
brochure.pdf?ua=1
29. Sharma AK, Sharma R. Impact of mass media on knowledge about tuberculosis control among home-
makers in Delhi. Int J Tuberc Lung Dis. 2007; 11: 893–897. PMID: 17705956
30. Jaramillo E. The impact of media-based health education on tuberculosis diagnosis in Cali, Colombia.
Health Policy Plan. 2001; 16: 68–73. https://doi.org/10.1093/heapol/16.1.68 PMID: 11238433
PLOS ONE
Sociocultural factors influencing Tuberculosis care-seeking among adults in Mozambique
PLOS ONE | https://doi.org/10.1371/journal.pone.0289928 January 18, 2024 11 / 11
