INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)  
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue XI November 2025  
Factors And Impact of Access to Primary Health Care Services on  
Tuberculosis Awareness Among Women in Rural Communities in  
Orlu, Imo State  
Okeke, Miracle Chidiebere1,Udum, Henry Chinonso2, Amazu, Chidiebube Sonia3, Oluka, Chinwuba  
Benedict4,Okeke, Chibuzor Sochima5 ,Agbo, Obinna Chijindu6,Onuwa, Frankline Chidiebere7.  
1Department of Internal Medicine, Enugu State University Teaching Hospital, Nigeria  
2,3Federal Medical Center Asaba, Delta state, Nigeria  
4Enugu State University of Science and Technology Teaching Hospital, Parklane, Nigeria  
5University of Nigeria Teaching Hospital Enugu, Nigeria  
6Enugu State University of Science and Technology Teaching Hospital, Parklane Nigeria  
7St Raphael Divine Mercy Specialist Hospital Ikorodu, Lagos, Nigeria  
DOI: https://doi.org/10.51244/IJRSI.2025.12110028  
Received: 25 November 2025; Accepted: 01 December 2025; Published: 04 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.  
INTRODUCTION  
Primary health care (PHC) represents the foundation of effective health systems globally and remains central  
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ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue XI November 2025  
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 rural communities in Orlu, Imo State, examining the interplay between  
PHC access, socio-demographic characteristics, health status, and TB awareness. Because women frequently  
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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  
farming and palm oil production, with health services delivered primarily through local primary health care  
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(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  
Middle Aged Women  
Older Adult Women  
Total  
212  
123  
95  
49.3  
28.6  
22.1  
100.0  
430  
Marital status  
Divorced/Separated/Widowed  
Married  
14  
3.3  
300  
116  
430  
69.8  
27.0  
100.0  
Single  
Total  
Family/marriage type  
Monogamy  
296  
118  
16  
68.8  
27.4  
3.7  
No husband/partner  
Polygamy  
430  
100.0  
Total  
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Religion  
Anglican  
Catholic  
50  
241  
2
11.6  
56.0  
.5  
Muslim  
Others  
8
1.9  
Pentecostal  
Traditional  
Total  
115  
14  
430  
26.7  
3.3  
100.0  
Highest educational level  
Primary  
58  
13.5  
65.3  
21.2  
100.0  
Secondary  
Tertiary  
281  
91  
430  
Total  
Table I (cont’d): Socio-demographic Characteristics of Women in Rural Communities in Orlu  
Variables  
Frequency (N=430)  
Percentage  
Occupation  
Civil servant  
Farmer  
24  
2
5.6  
0.5  
0.7  
6
None  
3
Others  
26  
21  
354  
430  
Students  
4.9  
82.3  
100  
Trading/Business  
Total  
Monthly Income  
Above ₦50,000  
Less ₦10,000  
₦10,000 -20,000  
₦21,000-50,000  
Total  
71  
16.5  
20.5  
36  
88  
155  
116  
430  
27  
100  
Type of residence  
Communal  
Owned  
71  
16.5  
39.8  
43.7  
100  
171  
188  
430  
Rented  
Total  
Number of rooms  
1-3 rooms  
242  
56.3  
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4-6 rooms  
151  
37  
35.1  
8.6  
More than 6 rooms  
Total  
430  
100  
Number of persons  
0-2 persons  
73  
17  
3-5 persons  
180  
41.9  
41.2  
100  
More than 5 persons 177  
430  
Total  
Number of children  
0-2 children  
3-5 children  
218  
171  
50.7  
39.8  
9.5  
More than 5 children 41  
430  
100  
Total  
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 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?  
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Yes  
60  
14.0  
No  
370  
430  
86.0  
100.0  
Total  
What is your HIV Status?  
Positive/Unknown 176  
40.9  
Negative  
254  
430  
59.1  
100.0  
Total  
Do you or any family member within your household have any chronic health  
condition?  
Yes/Not sure  
No  
292  
138  
430  
67.9  
32.1  
100.0  
Total  
Have you ever received BCG?  
No / I don't know  
138  
292  
430  
32.1  
Yes  
67.9  
100.0  
Total  
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.  
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  
Total  
%
N=430  
Awareness/knowled  
ge of PTB  
Health Status Level Poor  
level  
of Moderate-Good level Total (%) df χ2/p-value  
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awareness/knowled of  
ge  
awareness/knowledge  
Poor Health Status  
57(76.0)  
18(24.0)  
75(100.0)  
2
13.435/0.001*  
Moderate  
Status  
Health 91(63.2)  
53(36.8)  
144(100.0)  
Good Health Status 111(52.6)  
100(47.4)  
171(39.8)  
211(100.0)  
430(100.0)  
259(60.2)  
Total  
*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  
Variable  
Level of  
Total  
%
N=430  
Awareness/knowledg  
e of PTB  
Socio-  
demographic  
Factors  
Poor  
level  
of  
Moderate-Good  
level  
Total (%)  
df χ2/p-value  
of  
awareness/knowledge awareness/knowled  
ge  
Age group  
Young  
Women  
Adult 128(60.4)  
84(39.6)  
48(39.0)  
39(41.1)  
171(39.8)  
212(100.0)  
123(100.0)  
95(100.0)  
430(100.0)  
2
0.096/0.953  
Middle  
Women  
Aged 75(61.0)  
Adult 56(58.9)  
259(60.2)  
Older  
Women  
Total  
Marital status  
Married  
Single  
168(56.0)  
91(70.0)  
259(60.2)  
132(44.0)  
39(30.0)  
171(39.8)  
300(100.0)  
130(100.0)  
430(100.0)  
1
2
7.422/0.006  
Total  
Family/marriage  
type  
Monogamy  
163(55.1)  
133(44.9)  
34(28.8)  
4(25.0)  
296(100.0)  
118(100.0)  
16(100.0)  
430(100.0)  
10.664/0.005  
No husband/partner 84(71.2)  
Polygamy  
12(75.0)  
259(60.2)  
171(39.8)  
Total  
Regrouped  
Religion  
Anglican  
30(60.0)  
20(40.0)  
50(100.0)  
3
5.253/0.154  
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Catholic  
Others  
137(56.8)  
19(79.2)  
73(63.5)  
259(60.2)  
104(43.2)  
5(20.8)  
241(100.0)  
24(100.0)  
115(100.0)  
430(100.0)  
Pentecostal  
Total  
42(36.5)  
171(39.8)  
*significant  
Table IV (cont’d): Relationship between Socio-demographic Factors and Awareness of PTB among  
Women in Rural Communities in Orlu  
Variable  
Level of  
Total % N=430  
Awareness/knowledg  
e of PTB  
Socio-  
demographic  
Factors  
Poor  
level  
of  
Moderate-Good Total (%)  
level of  
df  
χ2/p-value  
awareness/knowledg  
e
awareness/know  
ledge  
Educational level  
Primary  
39(67.2)  
180(64.1)  
40(44.0)  
259(60.2)  
19(32.8)  
101(35.9)  
51(56.0)  
171(39.8)  
58(100.0)  
281(100.0)  
91(100.0)  
430(100.0)  
2
12.970/0.002*  
9.852/0.020*  
Secondary  
Tertiary  
Total  
Occupation  
Civil servant  
Others  
8(33.3)  
16(66.7)  
15(48.4)  
6(28.6)  
24(100.0)  
31(100.0)  
21(100.0)  
354(100.0)  
430(100.0)  
3
16(51.6)  
15(71.4)  
220(62.1)  
259(60.2)  
Students  
Trading/Business  
Total  
134(37.9)  
171(39.8)  
Monthly Income  
Above 50,000  
Less N10,000  
N10,000 -20,000  
N21,000-50,000  
Total  
37(52.1)  
60(68.2)  
98(63.2)  
64(55.2)  
259(60.2)  
34(47.9)  
28(31.8)  
57(36.8)  
52(44.8)  
171(39.8)  
71(100.0)  
88(100.0)  
155(100.0)  
116(100.0)  
430(100.0)  
3
6.096/1.107  
*significant  
Table IV (cont’d): Association between Socio-demographic Factors and Awareness of PTB among  
Women in Rural Communities in Orlu  
Variable  
Level of  
Total % N=430  
Awarenes  
s/knowled  
ge of PTB  
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Socio-demographic Factors  
Poor level Moderate-  
Good level  
Total (%) df  
χ2/p-value  
o
awareness/kno  
wledge  
Highest  
educational level  
Type of residence  
Communal  
51(71.8)  
20(28.2)  
71(100.0)  
171(100.0)  
188(100.0)  
430(100.0)  
2
2
2
2
5.175/0.075  
12.792/0.002*  
4.448/0.108  
2.704/0.259  
Owned  
102(59.6) 69(40.4)  
106(56.4) 82(43.6)  
259(60.2) 171(39.8)  
Rented  
Total  
Number of rooms grouping  
1-3 rooms  
130(53.7) 112(46.3)  
242(100.0)  
151(100.0)  
37(100.0)  
430(100.0)  
4-6 rooms  
99(65.6)  
30(81.1)  
52(34.4)  
7(18.9)  
More than 6 rooms  
Total  
259(60.2) 171(39.8)  
Number of persons grouping  
0-2 persons  
52(71.2)  
21(28.8)  
73(100.0)  
180(100.0)  
177(100.0)  
430(100.0)  
3-5 persons  
104(57.8) 76(42.2)  
103(58.2) 74(41.8)  
259(60.2) 171(39.8)  
More than 5 persons  
Total  
Number of children grouping  
0-2 children  
3-5 children  
More than 5 children  
Total  
139(63.8) 79(36.2)  
218(100.0)  
171(100.0)  
41(100.0)  
430(100.0)  
95(55.6)  
25(61.0)  
76(44.4)  
16(39.0)  
259(60.2) 171(39.8)  
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).  
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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).  
Table V: Association between PHC Access and Awareness of PTB among Women in Rural Communities  
in Orlu  
Variable  
Level of  
Total  
%
N=430  
Awareness/knowled  
ge of PTB  
Level of PHC Poor  
Access  
level  
of  
Moderate-Good level Total (%) df χ2/p-value  
of  
awareness/knowled awareness/knowledge  
ge  
Poor PHC Access  
129(64.5)  
71(35.5)  
31(38.3)  
200(100.0) 2  
81(100.0)  
4.258/0.119  
Moderate  
Access  
PHC 50(61.7)  
Good PHC Access  
80(53.7)  
69(46.3)  
149(100.0)  
430(100.0)  
259(60.2)  
171(39.8)  
Total  
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.  
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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 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  
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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  
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