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ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue XI November 2025
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Factors and Impact of Access to Primary Health Care Services on
Tuberculosis Awareness among Women in Rural Communities in
Orlu, Imo State
Okeke, Miracle Chidiebere
1
, Udum, Henry Chinonso
2
, Amazu, Chidiebube Sonia
3
, Oluka, Chinwuba
Benedict
4
, Okeke, Chibuzor Sochima
5
, Agbo, Obinna Chijindu
6
, Onuwa, Frankline Chidiebere
7
1
Department of Internal Medicine, Enugu State University Teaching Hospital.
2,3
Federal Medical Center Asaba, Delta state.
4
Enugu State University of Science and Technology Teaching Hospital, Parklane.
5
University of Nigeria Teaching Hospital Enugu.
6
Enugu State University of Science and Technology Teaching Hospital, Parklane.
7
St Raphael Divine Mercy Specialist Hospital Ikorodu, Lagos Nigeria.
DOI: https://doi.org/10.51244/IJRSI.2025.12110107
Received: 24 November 2025; Accepted: 30 November 2025; Published: 15 December 2025
ABSTRACT
Background: Equitable access to healthcare is a core principle of national health systems globally. However,
individuals living in rural communities continue to face substantial informational, geographical, and financial
barriers to primary health care (PHC) services. These barriers contribute to poorer health outcomes and widen
rural–urban health disparities.
Aim: This study assessed factors associated with access to PHC services and examined the influence of PHC
access on tuberculosis (TB) awareness among adult women residing in rural communities in Orlu, Imo State.
Methods: A community-based descriptive cross-sectional study was conducted using a convenience sampling
approach to select the study area based on proximity, security, and accessibility. A simple random sampling
technique was then used to recruit 430 women. Data were collected using a semi-structured questionnaire
administered through self-report and interviewer assistance, encoded using Open Data Kit (ODK), and analysed
with SPSS version 28. Descriptive statistics (frequencies and percentages) and chi-square tests were used, with
significance set at p < 0.05.
Results: Most respondents (60%) demonstrated poor knowledge or awareness of pulmonary TB. More than half
(51%) reported poor to moderate health status, and 47% had poor access to PHC services. TB
awareness/knowledge was significantly associated with educational level (p = 0.002), occupation (p = 0.020),
and household room density (p = 0.002). However, TB awareness was not significantly associated with access
to PHC services (p = 0.119).
Conclusion: Despite limited TB awareness and restricted access to PHC services, women in these rural
communities reported generally good perceived health status, suggesting notable resilience. The findings
highlight the need for holistic, strengthened PHC systems that ensure equitable, accessible, and high-quality care
for rural women, alongside targeted interventions to improve TB knowledge.
Keywords: Tuberculosis, Awareness, Knowledge, Primary Health Care Access, Rural Communities.
INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)
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INTRODUCTION
Primary health care (PHC) represents the foundation of effective health systems globally and remains central to
achieving equitable and accessible health services. Defined at the International Conference on Primary Health
Care, PHC encompasses essential health services delivered through scientifically sound, socially acceptable, and
affordable methods that communities can readily access and sustain through active participation.¹ Despite this
universal mandate, access to PHC remains uneven, particularly between urban and rural populations. Evidence
consistently shows that rural residents face more pronounced informational, geographic, and financial barriers
than their urban counterparts, which contributes to poorer health outcomes and entrenched health disparities.³–⁵
PHC services operate at both individual and population levels, delivering preventive, promotive, and curative
interventions such as health education, environmental health, nutrition, family planning, immunization, disease
control, treatment of minor ailments, and provision of essential drugs.⁶–⁹ Tuberculosis (TB) remains a major
global health threat and is strongly intertwined with social and economic inequities. It disproportionately affects
impoverished populations—particularly rural dwellers who often face food insecurity, substandard housing, and
limited health care access.¹⁰ TB morbidity and mortality, especially in low- and middle-income countries, are
concentrated among men and individuals of working age.¹¹ The World Health Organization’s End TB Strategy
emphasizes universal health coverage (UHC) as one of the most effective pathways to reducing TB burden by
2025.¹² The Declaration of Astana further reinforces PHC as the cornerstone of UHC, highlighting its potential
to reduce TB incidence and mortality among vulnerable populations in resource-limited settings.¹³ Strengthening
community-based PHC therefore holds significant promise for mitigating TB burden in rural communities.
Access to health services is often assessed through health service coverage (HSC), which reflects the capacity
of facilities to meet the needs of their target populations. Availability, accessibility, accommodation,
affordability, and acceptability constitute key dimensions of access, yet the presence of a facility alone does not
guarantee optimal utilization.¹⁴–¹⁶ Geographic accessibility—specifically proximity to health facilities—
significantly shapes patterns of PHC utilization.¹⁸ Spatial analysis using residential locations and geographic
information systems (GIS) provides valuable insights into inequities in service availability and helps guide
resource allocation and facility placement.¹⁶–²⁴ In Nigeria, healthcare delivery is organized across primary,
secondary, and tertiary levels, with PHC facilities serving as the first point of contact for most citizens.²⁵
Although Nigeria has implemented the Directly Observed Treatment Short-Course (DOTS) strategy for nearly
three decades and continues to expand PHC infrastructure, significant challenges remain, particularly regarding
TB control. Long distances to treatment facilities and inconsistent drug availability have been shown to
undermine treatment adherence, reduce treatment success, and increase the likelihood of loss to follow-up.²⁶–²⁷
TB exerts a disproportionate burden on the poorest populations, and equitable health requires that all individuals,
regardless of socioeconomic status, can access quality services tailored to their needs.²⁸–³² Achieving equity
demands a combination of broad public health interventions and targeted efforts aimed at vulnerable
populations.³³ Understanding the lived experiences of rural residents is therefore crucial to identifying barriers
to TB services and improving both quality and uptake of care. Poverty compounds these barriers, limiting health-
seeking behavior, diminishing ability to adhere to long and complex treatment regimens, and reducing
understanding of clinical instructions. Cultural beliefs further influence health decisions, sometimes conflicting
with biomedical knowledge and affecting treatment outcomes.³⁴–³⁵ The global agenda to eradicate TB by 2030,
articulated under Sustainable Development Goal 3.3, therefore requires prioritizing infection control and early
diagnosis at PHC facilities.³⁶ Poor implementation of TB infection control—including delays in identifying
symptomatic individuals, inadequate patient flow, and facility overcrowding—continues to drive TB
transmission in healthcare settings.³⁷–³⁹ Because nurses are key implementers of infection control at the PHC
level, their practices, competencies, and work environments are critical determinants of TB outcomes; however,
studies indicate persistent gaps in infection control practices across PHC facilities.⁴⁰–⁴² Despite Nigeria’s
commitment to PHC strengthening, significant underutilization persists, including within TB services. Recent
studies document challenges such as overcrowding, long waiting times, inadequate infrastructure, insufficient
funding, and unreliable power supply—all of which undermine the functionality of PHC facilities and limit
access to essential services such as immunization and antenatal care.³³–³⁴,⁴⁶ These systemic weaknesses
contribute to gaps in TB case detection and management, particularly in rural settings. Nigeria’s high TB/HIV
co-infection burden and the large proportion of undetected TB cases underscore the urgency of addressing these
challenges.⁴⁴–⁴⁵ The compounded effects of poverty, inadequate healthcare delivery, infrastructural deficits, and
socio-cultural influences make it essential to investigate how rural women perceive and access PHC services
and how these factors shape their awareness of TB. Given this context, the present study focuses on women in
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rural communities in Orlu, Imo State, examining the interplay between PHC access, socio-demographic
characteristics, health status, and TB awareness. Because women frequently serve as caregivers and primary
decision-makers in family health matters, understanding their experiences provides critical insights for
improving community TB control. This work aims to generate evidence that will support local governments and
health service providers in designing targeted interventions, strengthening PHC delivery, enhancing TB
awareness, and ultimately improving health outcomes in rural Nigeria.
LITERATURE REVIEW
Literature consistently demonstrates that access to primary health care (PHC) remains deeply unequal in rural
settings, largely due to geographic isolation, poor transportation networks, limited facility distribution,
workforce shortages, and financial constraints.
47–50
These structural barriers reduce service availability and
utilization, leading to unmet health needs and widening disparities between rural and urban populations. Studies
from diverse settings—including China, Australia, Ghana, Nigeria, and South Africa—show that rural women
face unique challenges such as long travel distances, low household income, limited health literacy, and cultural
influences that hinder their ability to seek care, comply with treatment, or access TB-related services.
51–61
Evidence on tuberculosis (TB) awareness reveals significant knowledge gaps globally, particularly in rural and
low-income settings where myths, stigma, and misconceptions persist.
62–75
Awareness of TB symptoms, routes
of transmission, and availability of free treatment is often low, causing delays in diagnosis, increased community
transmission, and reduced treatment adherence. Studies across Africa and Asia consistently report that TB
knowledge is strongly associated with education level, exposure to health workers, media messaging, cultural
beliefs, and household socioeconomic status.
65–73,75
Research assessing health status among TB patients shows
that TB substantially impairs quality of life and is associated with both physical and psychological burdens.
76–83
Even after treatment, many patients continue to experience long-term sequelae, reduced well-being, and
persistent social stigma. Quality-of-life studies demonstrate worse health outcomes among individuals with
active TB, HIV–TB co-infection, multidrug-resistant TB (MDR-TB), and extra-pulmonary disease.
84–104
Consequently, impaired health status influences health-seeking behaviour and reinforces barriers to PHC
utilization. Factors influencing PHC access are multidimensional, including predisposing characteristics (age,
gender, education, cultural beliefs), enabling factors (income, insurance, facility location, transportation), and
need factors (perceived illness severity, chronic conditions).
106–175
Socioeconomic disparities, poor facility
quality, drug stock-outs, long waiting times, and negative attitudes of health workers consistently deter rural
populations from using PHC services. Financial barriers, hidden costs, and user fees—despite policies promoting
free PHC—further limit access.
216–231
Improved access to PHC is strongly associated with higher TB awareness.
Studies show that communities with closer, better-equipped facilities or stronger PHC coverage report better
knowledge of TB symptoms, prevention, and treatment.
187–192
PHC systems also play a central role in raising
awareness through health education, counseling, routine consultations, and community outreach.
193–200
Educational interventions delivered through PHC significantly improve TB knowledge and positively influence
health behaviour. Government initiatives and TB control policies influence health service accessibility and
awareness levels. Weak governance, inadequate funding, limited integration of TB services, and inconsistent
policy implementation remain major barriers in many low- and middle-income countries, including Nigeria.
201–
202
Strengthening governance, ensuring uninterrupted drug supply, improving accountability, and integrating TB
into PHC frameworks are crucial to improving awareness and early detection. Community engagement and
empowerment are also essential components of PHC delivery. Active community participation enhances health
promotion, improves uptake of TB services, reduces stigma, and supports sustainable health interventions.
199–200
When communities are mobilized and empowered, TB awareness improves, and preventive behaviours become
more widely adopted. Overall, the literature highlights a clear relationship between improved PHC access and
higher tuberculosis awareness. Addressing structural, socioeconomic, and cultural barriers—alongside
strengthening governance and promoting community participation—is essential to improving TB awareness and
overall health outcomes in rural settings.
METHODS
The study was conducted in four rural communities in Orlu—Umuna, Owerre Ebeiri, Eziachi, and
Umuokwara—an agrarian region in Imo State, Nigeria, characterized by warm climatic conditions, seasonal
rainfall, erosion-prone topography, and limited social amenities. The population is predominantly engaged in
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farming and palm oil production, with health services delivered primarily through local primary health care
(PHC) facilities.
189,190
Against this backdrop, a community-based descriptive cross-sectional design was
employed to assess factors influencing access to PHC services and their impact on tuberculosis (TB) awareness
among women. The study population comprised adult women aged 20 years and above who were permanent
residents of the selected communities. Eligibility required informed consent, while women with severe illness,
mental incapacity, those who withdrew consent, or were absent during data collection were excluded. Using
Cochrane’s sample size formula and assuming a 50% prevalence estimate, a minimum sample of 384 was
calculated, which was increased to 430 to account for non-response.
191
A convenience sampling technique was
used to select both study sites and participants, primarily due to security concerns, accessibility issues, and
practical considerations; women were recruited in public spaces, workplaces, and residential areas without
predetermined selection patterns. Data collection utilized a semi-structured questionnaire adapted from prior
studies and modified for contextual relevance.
192
The tool contained 36 items covering socio-demographic
characteristics, TB awareness and knowledge, health status, and access to PHC services. Data were collected
using the Open Data Kit (ODK), with instruments uploaded onto Kobo Toolbox and administered through self-
response and interviewer assistance. For participants with limited English proficiency, explanations were
provided in Igbo to ensure comprehension and accurate responses. Completed questionnaires were uploaded
electronically following informed consent procedures. Data management involved exporting responses from
Kobo Toolbox to Microsoft Excel for cleaning and subsequently analyzing the dataset using SPSS version 28.
193
Descriptive statistics, including frequencies and percentages, summarized respondent characteristics and key
variables. Analytical procedures included chi-square tests and cross-tabulations to examine associations, with
statistical significance set at p < 0.05. Scoring systems were developed for key constructs. TB awareness was
quantified on a 31-point scale and categorized as poor (0–15), moderate (16–21), or good (22–31). Health status
was assessed using four items with scores classified as poor (0–1), moderate (2), or good (3–4). Access to PHC
services was rated on a 9-point scale and categorized as poor (0–4), moderate (5–6), or good (7–9). These
structured scoring frameworks facilitated consistent interpretation of participants’ knowledge, experiences, and
health-seeking behaviours. Written informed consent was secured from each participant, with provisions for
reading the text aloud to non-literate respondents and using thumbprints as signatures. Confidentiality, voluntary
participation, and the right to withdraw at any point were emphasized.
194
RESULTS
Table I: Socio-demographic Characteristics of Women in Rural Communities in Orlu
Variables
Frequency (N=430)
Percentage
Age (years)
Young Adult Women
212
49.3
Middle Aged Women
123
28.6
Older Adult Women
95
22.1
Total
430
100.0
Marital status
Divorced/Separated/Widowed
14
3.3
Married
300
69.8
Single
116
27.0
Total
430
100.0
Family/marriage type
Monogamy
296
68.8
No husband/partner
118
27.4
Polygamy
16
3.7
Total
430
100.0
Religion
Anglican
50
11.6
Catholic
241
56.0
Muslim
2
.5
Others
8
1.9
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Pentecostal
115
26.7
Traditional
14
3.3
Total
430
100.0
Highest educational level
Primary
58
13.5
Secondary
281
65.3
Tertiary
91
21.2
Total
430
100.0
Table I (cont’d): Socio-demographic Characteristics of Women in Rural Communities in Orlu
Variables
Percentage
Occupation
Civil servant
5.6
Farmer
0.5
None
0.7
Others
6
Students
4.9
Trading/Business
82.3
Total
100
Monthly Income
Above ₦50,000
16.5
Less ₦10,000
20.5
₦10,000 -20,000
36
₦21,000-50,000
27
Total
100
Type of residence
Communal
16.5
Owned
39.8
Rented
43.7
Total
100
Number of rooms
1-3 rooms
56.3
4-6 rooms
35.1
More than 6 rooms
8.6
Total
100
Number of persons
0-2 persons
17
3-5 persons
41.9
More than 5 persons
41.2
Total
100
Number of children
0-2 children
50.7
3-5 children
39.8
More than 5 children
9.5
Total
100
Table I presents the socio-demographic characteristics of the respondents. Almost half (49.3%) were young adult
women, and most were married, with 68.9% in monogamous unions. The respondents were predominantly
Christian, with more than half identifying as Catholic (56.0%). Educational attainment was relatively high, as
approximately two-thirds (65.3%) had completed secondary school. A large proportion (82.3%) were engaged
in trading or business activities as their main occupation. More than one-third (36.0%) reported a monthly
income between ₦10,000 and ₦20,000. In terms of housing conditions, 43.7% lived in rented apartments, and
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56.3% resided in households comprising 1–3 rooms. These households typically accommodated 3–5 persons
(41.9%), and more than half (50.7%) had between 0 and 2 children.
Figure I: Level of Awareness and Knowledge of Pulmonary TB among Women in Rural Communities in Orlu.
Figure I show that the majority of respondents (60%) demonstrated a poor level of knowledge and awareness
regarding pulmonary tuberculosis.
Table II: Health Status of Women in Rural Communities in Orlu
Variables
Frequency (N=430)
Percentage
Have you or any family member suffered from tuberculosis?
Yes
60
14.0
No
370
86.0
Total
430
100.0
What is your HIV Status?
Positive/Unknown
176
40.9
Negative
254
59.1
Total
430
100.0
Do you or any family member within your household have any
chronic health condition?
Yes/Not sure
292
67.9
No
138
32.1
Total
430
100.0
Have you ever received BCG?
No / I don't know
138
32.1
Yes
292
67.9
Total
430
100.0
Table II shows that most respondents or their family members (86.0%) had never been diagnosed with
pulmonary tuberculosis (PTB). More than half (59.1%) of the respondents reported being HIV-negative.
Additionally, approximately two-thirds (67.9%) indicated that they or their family members had chronic health
conditions and had received the BCG vaccine.
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Figure II Health Status Levels of Women in Rural Communities in Orlu
Figure II shows that more than half of the respondents (51%) had poor to moderate health status.
Table III: Association between Health Status and Awareness of PTB among Women in Rural Communities in
Orlu
Variable
Level of
Awareness/knowledge
of PTB
Total % N=430
Health Status Level
Poor level of
awareness/knowledge
Moderate-Good level of
awareness/knowledge
Total (%)
df
χ
2
/p-value
Poor Health Status
57(76.0)
18(24.0)
75(100.0)
2
13.435/0.001*
Moderate Health Status
91(63.2)
53(36.8)
144(100.0)
Good Health Status
111(52.6)
100(47.4)
211(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
*significant
Table III shows a significant association between respondents’ level of awareness/knowledge of pulmonary
tuberculosis (PTB) and their health status (p < 0.001).
Table IV: Association between Socio-demographic Factors and Awareness of PTB among Women in Rural
Communities in Orlu
Level of Awareness/knowledge
of PTB
Total %
N=430
Socio-demographic
Factors
Poor level of
awareness/knowledge
Moderate-Good level of
awareness/knowledge
Total (%)
df
χ
2
/p-value
Age group
Young Adult Women
128(60.4)
84(39.6)
212(100.0)
2
0.096/0.953
Middle Aged Women
75(61.0)
48(39.0)
123(100.0)
Older Adult Women
56(58.9)
39(41.1)
95(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
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Marital status
Married
168(56.0)
132(44.0)
300(100.0)
1
7.422/0.006
Single
91(70.0)
39(30.0)
130(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
Family/marriage
type
Monogamy
163(55.1)
133(44.9)
296(100.0)
2
10.664/0.005
No husband/partner
84(71.2)
34(28.8)
118(100.0)
Polygamy
12(75.0)
4(25.0)
16(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
Regrouped Religion
Anglican
30(60.0)
20(40.0)
50(100.0)
3
5.253/0.154
Catholic
137(56.8)
104(43.2)
241(100.0)
Others
19(79.2)
5(20.8)
24(100.0)
Pentecostal
73(63.5)
42(36.5)
115(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
*significant
Table IV (cont’d): Relationship between Socio-demographic Factors and Awareness of PTB among Women in
Rural Communities in Orlu
Variable
Level of Awareness/knowledge
of PTB
Total % N=430
Socio-
demographic
Factors
Poor level of
awareness/knowledge
Moderate-Good level of
awareness/knowledge
Total (%)
df
χ
2
/p-value
Educational level
Primary
39(67.2)
19(32.8)
58(100.0)
2
12.970/0.002*
Secondary
180(64.1)
101(35.9)
281(100.0)
Tertiary
40(44.0)
51(56.0)
91(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
Occupation
Civil servant
8(33.3)
16(66.7)
24(100.0)
3
9.852/0.020*
Others
16(51.6)
15(48.4)
31(100.0)
Students
15(71.4)
6(28.6)
21(100.0)
Trading/Business
220(62.1)
134(37.9)
354(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
Monthly Income
Above 50,000
37(52.1)
34(47.9)
71(100.0)
3
6.096/1.107
Less N10,000
60(68.2)
28(31.8)
88(100.0)
N10,000 -20,000
98(63.2)
57(36.8)
155(100.0)
N21,000-50,000
64(55.2)
52(44.8)
116(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
*significant
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Table IV (cont’d): Association between Socio-demographic Factors and Awareness of PTB among Women in
Rural Communities in Orlu
Variable
Level of
Awareness/knowledge of
PTB
Total % N=430
Socio-demographic
Factors
Poor level of
awareness/knowledge
Moderate-Good level of
awareness/knowledge
Total (%)
df
χ
2
/p-value
Highest educational level
Type of residence
Communal
51(71.8)
20(28.2)
71(100.0)
2
5.175/0.075
Owned
102(59.6)
69(40.4)
171(100.0)
Rented
106(56.4)
82(43.6)
188(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
Number of rooms grouping
1-3 rooms
130(53.7)
112(46.3)
242(100.0)
2
12.792/0.002*
4-6 rooms
99(65.6)
52(34.4)
151(100.0)
More than 6 rooms
30(81.1)
7(18.9)
37(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
Number of persons grouping
0-2 persons
52(71.2)
21(28.8)
73(100.0)
2
4.448/0.108
3-5 persons
104(57.8)
76(42.2)
180(100.0)
More than 5 persons
103(58.2)
74(41.8)
177(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
Number of children grouping
0-2 children
139(63.8)
79(36.2)
218(100.0)
2
2.704/0.259
3-5 children
95(55.6)
76(44.4)
171(100.0)
More than 5 children
25(61.0)
16(39.0)
41(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
Table IV demonstrates that respondents’ level of awareness and knowledge of pulmonary tuberculosis (PTB)
was significantly associated with their educational level (p = 0.002), occupation (p = 0.020), and the number of
rooms in their household (p = 0.002).
Figure III Level of Access to PHC services among Women in Rural Communities in Orlu
Figure III shows that close to half of the respondents (47%) had poor access to primary health care (PHC).
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Table V: Association between PHC Access and Awareness of PTB among Women in Rural Communities in Orlu
Variable
Level of Awareness/knowledge
of PTB
Total %
N=430
Level of PHC
Access
Poor level of
awareness/knowledge
Moderate-Good level of
awareness/knowledge
Total (%)
df
χ
2
/p-value
Poor PHC Access
129(64.5)
71(35.5)
200(100.0)
2
4.258/0.119
Moderate PHC
Access
50(61.7)
31(38.3)
81(100.0)
Good PHC
Access
80(53.7)
69(46.3)
149(100.0)
Total
259(60.2)
171(39.8)
430(100.0)
Table V shows that respondents’ level of awareness and knowledge of pulmonary tuberculosis (PTB) was not
significantly associated with their level of access to primary health care (PHC) services (p = 0.119).
DISCUSSION
This study examined factors influencing access to primary health care (PHC) services and their impact on
tuberculosis (TB) awareness among adult women residing in rural communities in Orlu. The findings revealed
a consistently poor level of awareness and knowledge of pulmonary TB, coupled with limited access to PHC
services, despite the generally good self-reported health status of respondents. The inadequate awareness
observed aligns with earlier studies in Nigeria, which also documented low levels of TB knowledge among rural
populations.
195–197
The proportion of women with poor TB knowledge in this study exceeded the national
estimate of 59.7%,198 suggesting that substantial information gaps persist within these communities. These
deficiencies in knowledge may be attributed to several socio-demographic determinants, including poverty,
limited formal education, and entrenched cultural beliefs, all of which shape health-seeking behaviour and
perceptions of disease.
199,200
Although the region has experienced significant disruptions due to separatist group
activity and associated security issues, respondents surprisingly reported relatively good health status. This
finding contrasts with studies from other conflict-affected regions where instability is typically associated with
worsened health outcomes and reduced access to essential services.
201,202
The persistence of good health
perceptions among women in Orlu may reflect strong community resilience, reliance on traditional healing
practices, and adaptive coping strategies, particularly during periods when health facilities become inaccessible
due to sit-at-home orders. Such movement restrictions disproportionately affect vulnerable groups, including
older adults and those living with chronic illnesses, often forcing them to seek non-formal alternatives to modern
healthcare.
201
The study further demonstrated that education significantly influences TB awareness and
knowledge, consistent with evidence showing that health literacy plays a fundamental role in disease
understanding and behavioural responses.
203–204
However, increased knowledge did not translate into improved
access to PHC services among respondents. This disparity highlights the systemic and structural barriers—such
as infrastructural inadequacy, health worker shortages, negative provider attitudes, transportation challenges,
and persistent insecurity—that hinder equitable access to PHC services, even when awareness is adequate.
203,204
While education fosters critical thinking, informed decision-making, and health-seeking intentions, it cannot
compensate for weaknesses in the health system itself. Housing conditions, captured through the number of
rooms in a household, were also significantly associated with TB awareness. Overcrowded households with poor
ventilation are known to promote airborne transmission of Mycobacterium tuberculosis.
207
The higher burden of
pulmonary TB among respondents living in such settings underscores the role of environmental determinants in
disease transmission and highlights the need to integrate social determinants into TB prevention strategies. The
study also found that access to PHC services was generally poor, reflecting longstanding structural challenges
in rural Nigerian health systems. Infrastructural deficiencies, high user costs, and mistrust of health service
quality contribute to the sustained underutilization of PHC services.
201,202
These factors collectively perpetuate
health disparities in rural communities, where PHC is intended to serve as the cornerstone of the healthcare
delivery system.
203,204
Additional contributors to poor PHC access may include misconceptions about PHC,
ineffective leadership, and health system fragmentation, which impede efforts to achieve universal health
coverage in rural settings. Contrary to expectations, no significant association was found between TB awareness
and access to PHC services. This result mirrors findings by Kirenga,
202
who reported that even where TB
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knowledge is adequate, systemic and socioeconomic barriers may continue to hamper access to health
services.
206
This contrasts with earlier studies suggesting that improved TB awareness should enhance healthcare
utilization, indicating that the determinants of health-seeking behaviour in resource-constrained contexts are
complex and extend beyond individual knowledge. Overall, the findings highlight the dual challenge of poor TB
awareness and limited PHC access in rural Orlu.
201
Addressing these challenges requires targeted interventions
that prioritize socio-economic empowerment, enhanced health literacy, improved community engagement, and
substantial infrastructural investment. Strengthening PHC systems, while simultaneously educating
communities, is essential to reducing TB-related morbidity and mortality and improving overall health outcomes
among women in rural Nigerian communities. This study is limited by its reliance on self-reported and
interviewer-administered questionnaires, which may have introduced reporting and interviewer bias. The use of
non-probability sampling, driven by security and accessibility constraints, also limits the generalizability of the
findings to all rural communities in Orlu. Additionally, the cross-sectional design restricts the ability to infer
causal relationships between TB awareness, PHC access, and health-seeking behavior. Despite these limitations,
the study provides valuable insight into the factors shaping TB awareness and primary healthcare access in the
region.
CONCLUSION AND RECOMMENDATION
This study shows that women in rural communities in Orlu have persistently low awareness and knowledge of
pulmonary tuberculosis (TB), despite reporting generally good health. Although education and living conditions,
especially household overcrowding, were significant factors influencing TB awareness, improved knowledge
did not translate into better access to primary health care (PHC) services. This gap reflects deeper structural
challenges, including insecurity, inadequate PHC infrastructure, limited staffing, and negative perceptions of
healthcare quality. These systemic barriers continue to hinder effective healthcare utilization and contribute to
the ongoing TB burden in the area. To address these issues, interventions must focus on strengthening PHC
facilities, improving security, and enhancing governance within the health system. Increasing community
engagement, particularly through empowering women and improving health literacy, is crucial for promoting
timely care-seeking behaviour. Health workers must adopt more patient-centred approaches and intensify TB
education at the community level. Ultimately, coordinated efforts involving government, health providers, and
community stakeholders are necessary to reduce TB burden and ensure equitable access to quality healthcare
services in rural Orlu.
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Disclosures and declarations Ethics approval and consent to participate: The ethical approval for this study
was gotten from the Research and Ethical Clearance Committee of Imo State University Teaching Hospital.
Availability of data and materials: Data and material are available
Competing interests: The authors declare that they have no competing interests Funding: There is no external
funding for the research