1. · TB. TB incidence and prevalence is higher among men than women, although large numbers of women are also infected. Understanding gender differences in knowledge may offer insight

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Gender Differences in Knowledge of Tuberculosis in the Bateyes of the Dominican

Republic

Barbara Zsembik1, Heather Covington, Julia Arroyo and Chuck W. Peek

Department of Sociology and Criminology & Law

University of Florida

Abstract:

Tuberculosis is relatively common in the bateyes of the Dominican Republic, with very

high co-infection rates with HIV. Barriers to TB control include lack of comprehensive

and correct knowledge about the curability, symptoms, transmission, and treatment of

TB. TB incidence and prevalence is higher among men than women, although large

numbers of women are also infected. Understanding gender differences in knowledge

may offer insight into mechanisms to reduce barriers to TB diagnosis and treatment,

and thus improve control over TB transmission. Data for this research are drawn from

the 2013 DHS survey of the Bateyes Estatales of the Dominican Republic. Women have

higher levels of knowledge about the curability, treatment, symptoms, and transmission

vectors of TB than men, yet almost one third of all women do not know it is curable and

more than half fail to identify its air-borne transmission. We conclude that lack of

comprehensive and correct knowledge base that is gendered, likely yields gender-based

transmission patterns, and thus a need for gender-based health education interventions.

Keywords: tuberculosis knowledge, gender, bateyes, Dominican Republic

1 Corresponding author: 3219 Turlington Hall Gainesville FL 32611-7330, [email protected] 352.294.7190

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1. Introduction

People in the bateyes are among the most poor and vulnerable populations in the

Dominican Republic (DR) (Bernier 2003; Ferguson 2003; López-Severino & de Moya

2007; Matibag & Downing-Matibag 2011; Parikh et al. 2010). Most residents of the

bateyes are Dominicans of Haitian descent and undocumented Haitian immigrants

(Bernier 2003; Ferguson 2003; United Nations 2012). The number of Dominicans of

Haitian descent is estimated to be around 200,000 (IPPF 2008; ONE 2012; OPS 2013;

United Nations 2012; Verité 2011). The number of Haitian immigrants varies by time

period and source of estimate from 458,000 (ONE 2012), and whether immigrants and

Dominicans of Haitian descent are aggregated, yielding as few as 500,000 and as many

as 1 million Haitian-origin persons (IPPF 2008; PAHO 2012; United Nations 2012).

Bateyes have disproportionately high levels of communicable conditions, especially

tuberculosis (TB) (Chamberlin et al. 2007; OPS 2013; PAHO 2012; Perez-Then, Acosta,

Marcelino & Espinal 2007). Women are appreciably more economically and socially

disadvantaged than men (Brewer et al. 1996; CARICOM 2002; López-Severino & de

Moya 2007; Wooding & Petrozziello 2013; Verité 2011), which are key social

determinants of TB risk, yet TB prevalence is higher among men (OPS 2013). Despite

their higher levels of TB, men in the bateyes have lower levels of knowledge about the

disease and its treatment (CESDEM y ICF International 2015) and are less likely than

women to seek medical diagnoses of TB or HIV (Lambert 2009). Having

comprehensive and correct knowledge about the disease is critical to meet the new

WHO goal of globally eradicating TB by 2035 (WHO 2013). Understanding gender

differences in the comprehensive and correct character of knowledge may offer insight

into mechanisms to reduce barriers to TB diagnosis and treatment, and thus improve

control over TB transmission.

2. Background

2.1 Tuberculosis in the Dominican Republic

Tuberculosis is a deadly but preventable disease that is lingering among the Caribbean’s

poorest populations due to inconsistent national surveillance efforts and

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implementation of TB control programs, increases in multidrug-resistant TB (MDR-

TB), and the co-epidemic of TB and HIV (TB/HIV) (PAHO/WHO 2015). In the

Americas, Haiti had the highest TB incidence (206 per 100,000 in 2011) and the DR had

the fifth highest TB incidence (60 per 100,000 in 2011) (PAHA 2015). The DR and Haiti

also ranked among the top 10 countries in the America for MDR-TB (Haiti = 4, DR = 7)

and TB/HIV (Haiti = 2, DR = 5) (PAHO 2015). TB, MDR-TB and TB/HIV are

disproportionately high in the bateyes (Lambert 2009; Perez-Then, Acosta, Marcelino &

Espinal 2007). Continued migration from Haiti is thought to sustain transmission of all

forms of TB in the DR (OPS 2013; PAHO 2006; 2011; 2012), although repatriation

following the DR’s Regularization Plan in 2015 now raises concern that TB and HIV

transmission will follow returnees and drive up prevalence in Haiti (López-Severino &

de Moya 2007; OCHOA 2015). There is general agreement that a binational

coordination is needed.

Effective TB control and reductions in transmission and incidence require that

populations have a comprehensive and correct knowledge, i.e., know the symptoms of

the disease, and that it is curable in order to screen, diagnose, and treat effectively those

who have acquired the disease (Marks, DeLuca & Walton 2008). To effectively prevent

transmission requires that people understand transmission vectors and are willing to

adopt preventive behaviors.

2.2 Gender Differences in Knowledge of Tuberculosis

Persons who have appropriate health-seeking behavior tend to have higher levels of

education, self-efficacy, and health care access to a variety of communications media.

Women often are the caregivers in families and communities, and are more likely to

have regular access to the health care system through maternal and child health

programs. This suggests that women may have more accurate knowledge of TB

transmission, symptomology and treatment than men, through more exposure to

evidence-based clinical practices.

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Virtually all women in the bateyes receive timely and sufficient prenatal and postnatal

care, deliver their babies under the care of an obstetrician or general medical doctor,

and receives modern family planning care (CESDEM y ICF International 2015). Few

infants remain unvaccinated, and mothers seek care from a health professional for

severe infant illnesses, indicating women’s regular access to health care professionals

through routine pediatric care (CESDEM y ICF International 2015). Extensive access to

evidence-based clinical practice suggests that women will have greater access to high

quality health information on TB and a variety of other health topics.

Despite extensive access to professional medical care, the relatively high rates of

maternal, infant and child mortality indicates poor quality medical care (Lambert

2009). Indeed women in the bateyes report they face significant barriers to access care

when they need it because of a lack of money (50%) or distance (39%) (CESDEM y ICF

International 2015). Lower quality health care likely signifies barriers in patient-

provider interactions, but TB information may be passively acquired through print

media and thus attenuates the effect of health care quality.

We note that 7.6% of women in the bateyes report that they do not receive needed

medical care because they did not have permission to seek health care (CESDEM y ICF

International 2015), presumably permission denied by male partners. Gender norms,

we are reminded, shape women’s and men’s positive and negative health behaviors.

Haitian women are more likely than Dominican women to accept that husbands should

provide permission to go out and that wife-beating is justified (Bott, Guedes, Good &

Mendoza 2010), and perhaps Haitian immigrants and Dominicans of Haitian descent in

the DR hold similar beliefs about women’s roles and status. Consequently, if women

have comprehensive and correct knowledge of TB, but it is contrary to their partners’

myths and misconceptions, women may be unlikely to successfully replace men’s

misperceptions with correct knowledge, and may lose confidence in their own

knowledge.

Gender norms, especially those embedded in traditional ideals of masculinity and

femininity, contribute to gendered vulnerabilities. In particular, hegemonic masculinity

directs men to deny physical or mental weakness, deny the need for health care, and

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demonstrate physical superiority through engagement in risky behaviors (Courtenay

2000; Gupta 2002). As a result, men in the bateyes may devalue information on TB,

minimize troubling symptoms and thus delay diagnosis, and not complete TB treatment.

Women’s economic dependence on men and relative lack of power further supports

traditional gender ideologies. Their economic vulnerability prompts women to

undertake risky health behaviors such as sex work, including transactional sex (Brewer

et al. 1996; CARICOM 2002; López-Severino & de Moya 2007; WHO 2008; Wooding &

Petrozziello 2013).

3. Methods

3.1 Data and Sample

Data for this research are drawn from the 2013 Demographic and Health Survey (DHS)

of the Bateyes Estatales of the Dominican Republic, conducted by the Center of Social

and Demographic Studies of the Ministry of Public Health. The DHS are population-

level household surveys that collect information on population, health, HIV and

domestic violence (www.dhsprogram.com). The DHS-Bateyes is a multi-stage stratified

cluster sample of 2,834 households across approximately 500 bateyes. Face-to-face

interviews were used to collect four data components: a household survey (n=2,569,

response rate = 98.8%), a survey of women between the ages of 15 and 49 (n=1,707,

response rate = 96.0%), a survey of men between the ages of 15 and 59 (n= 2,101,

response rate = 90.6%), and a household health and expenditures module. We pool the

data from the women’s and men’s surveys, appending relevant data onto individual

records from the household survey.

3.2 Measures

Outcomes

The women and men were asked questions about whether they had heard of TB and

whether and how it can be cured, how it is transmitted, and symptoms of the disease.

The gender distributions of TB knowledge are presented in Table 1.

[Table 1 about here]

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TB General Knowledge

Persons were asked “Have you heard of tuberculosis?”, “Can tuberculosis be cured?” and

“How can tuberculosis be cured?” Responses available for the first two items were no,

yes, and don’t know. Responses available to TB treatment were: specific medications,

staying home without medications, home remedies, diet, other and don’t know. All

reported gender difference were statistically significant, revealing that women were

more likely than men to have correct information, yet that there are appreciable

knowledge gaps among women as well.

Women are more likely than men to have heard of TB (90.5% vs. 83.8%), and if they

have heard of it, more likely than men to say it can be cured (64.8% vs. 59.2%). It is

noteworthy that about 20% of women and men do NOT believe it is curable, and a

sizeable proportion of women (14.4%) and men (20.2%) do not know if it is curable. Of

those who have heard of TB, a large proportion of women (86.8%) and men (81.0%)

correctly name TB-specific medications as the treatment. Nearly 10% of women and

men incorrectly name an ineffective health behavior, an indication of misinformation in

the bateyes.

Knowledge of TB Transmission Vectors

Those who reported that they had heard of TB were subsequently queried as to their

knowledge of transmission mechanisms and TB symptoms. Respondents were asked

“How is tuberculosis transmitted?” Of the seven mechanisms provided, and a “don’t

know” category, the correct mechanism is: through the air from an infected person

coughing or sneezing. The remaining six mechanisms are incorrect, identifying levels of

misinformation about transmission that may inhibit population barriers to TB control:

shaking hands, sharing eating utensils, eating from the same plate, touching items in a

public place, sexual relations, and “other” (e.g., witchcraft). There is a higher level of

misinformation or lack of knowledge about how TB is spread than there is correct

information. Women (40.5%) are more likely than men (28.2%) to correctly name the

transmission vector. There are comparable levels of misinformation among men

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(46.4%) and women (42.9%), although 25.5% of men do not know how TB is

transmitted.

Knowledge of TB Symptoms

Women and men were asked to identify whether a series of symptoms indicated possible

TB: coughing more than 15 days, weight loss, fever, severe headache, difficulty

breathing, chest pain, fatigue, vertigo, rash, and don’t know. We separated answer

categories into: knows the main symptom of severe chronic cough, knows minor

symptoms, or cannot identify any symptoms. Women (70.9%) were more likely than

men (52.9%) to correctly identify the main symptom of TB, although 19.6% of women

and almost a third of all men (31.4%) could not name any symptom.

Correlates

We consider the following key correlates of gender differences in TB knowledge: age,

education, wealth, access to health information, and province of residence. Gender

variation in the correlates are presented in Table 2. All differences are significantly

different between women and men. It is not surprising that the average age of men is

higher than that of women because men aged 15-59 were interviewed whereas women

aged 15-49 were interviewed. We expect comprehensive and correct knowledge of TB to

positively correlate with age because older persons were alive during periods when TB

rates were higher than current rates.

Women have more favorable educational achievement profiles, as is typical throughout

the Caribbean (Lambert 2009). A smaller proportion of women (9.6%) than men

(12.9%) have no education, whereas a larger proportion of women (6.8%) than men

(2.8%) have completed some postsecondary education. Level and quality of knowledge

generally correlates positively with level of education. The economic vulnerability of the

bateyes population is evident in the majority of women (56.8%) and men (66.5%) who

occupy the lowest segment of the wealth scale. More than 80% are in the lowest two

categories of the wealth scale. Approximately 10% fewer women than men occupy the

poorest wealth category. Higher economic resources allows women and men to afford

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out-of-pocket medical costs, costs associated with travel to health care providers, and

absorption of opportunity costs of lost incomes from missing work.

Women have more access to health care information than men, which indicates they

may have more correct and comprehensive knowledge about TB. A higher proportion of

women (42.0%) than men (36.7%) has health insurance, which means more opportunity

to engage with the health care system to acquire information through patient-provider

interaction, encounters with auxiliary health workers, and more passive receipt of

information from print materials. A slightly higher proportion of women (26.6%) than

men (23.5%) lived in a household that received a visit from a health care worker in the

previous 12 months. This offers similar conditions for acquiring TB and other health

knowledge, including distribution of health materials from the health care worker.

The final measure of health communication is receipt, in the past 12 months, of health

education instruction on a variety of topics through multiple media. The most cited

communication channel is television (69.6%), followed by educational talks in the

community (45.3%) and the radio (35.3%) (CESDEM y ICF International 2015).

Educational content included disaster preparedness, management of chronic disease,

water and food safety, and prevention of communicable conditions such as rabies,

malaria and HIV. Women report access to 8.5 health information communications,

whereas men report an average of 7.8 communications.

The sample is designed to be representative of the bateyes’ populations and comparable

to the 2007 DHS. The sample is distributed across ten provinces. Sample size was

sufficient to maintain these distinct provinces: Santo Domingo, Monte Plata, Puerto

Plata and Sánchez Ramírez. We collapsed Bahoruco, Barahona and Independencía into

their region Enriquillo due to small sample size in each province. Also due to small

sample size in El Seibo, San Pedro de Macorís, and Hato Mayor, we collapse these

provinces into the “Higuamo” region. We have taken liberties with defining the

“Higuamo” region, first by separating out Monte Plata. The other two provinces of

“Higuamo” (Hato Mayor and San Pedro de Macorís are officially located in the region.

El Seibo, however, officially belongs in the Yuma region, but it is physically adjacent to

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Hato Mayor and San Pedro de Macorís, and has a sociodemographic profile that is

roughly comparable to Hato Mayor.

Women and men have significantly different distributions across the provinces,

although a third of the total sample reside in Sánchez Ramírez, Puerto Plata and Monte

Plata. Women are disproportionately more likely to reside in Santo Domingo and

provinces in Enriquillo, whereas men are more likely to reside in the provinces of

“Higuamo”, Monte Plata, Puerto Plata, Sánchez Ramírez. The gender distribution is

consistent with federal sex ratio statistics.

[Table 2 about here]

3.3 Procedures

Data are weighted and the estimates are adjusted for complex survey design structures,

using STATA14. For general knowledge of TB, we estimate a logistic regression model of

“heard of it” versus had not “heard of it.” For the remaining TB knowledge items, we

estimated multinomial logistic regressions that incorporated the “don’t know” response

as a comparative information category. Regarding TB as curable, we compare the “don’t

know” respondents and those who incorrectly reported that TB is not curable relative to

those who correctly said that TB is curable. For knowledge of the TB transmission

vector, we estimate a multinomial logistic regression model of : (1) correctly identifies

air-borne transmission only, (2) names an incorrect transmission belief and; (3) does

not know how TB is transmitted. For knowledge of TB symptomology, we estimate a

multinomial logistic regression of : (1) knows major symptom, (2) knows only minor

symptoms, and (3) does not know any symptom. For knowledge of TB treatment, we

estimate a multinomial logistic regression of : (1) correctly identifies TB-specific

medicine regimen, (2) names an incorrect treatment and (3) does not know how TB is

treated. The regression results are presented in Table 3.

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[Table 3 about here]

4. Results

Most of the multivariate models reveal that women demonstrate greater knowledge than

men of TB, its symptoms, transmission vector, curability and treatment. The observed

gender differential remains above and beyond controls for sociodemographic

characteristics, access to health information, and place of residence. Women are more

likely than men to have heard of TB (Model 1), to correctly identify how it is transmitted

compared to misinformation or lack of knowledge (Model 4), and to name TBs’ major

symptom compared to naming only minor symptoms or having no knowledge of

symptomology (Model 5). Women are also more likely than men to know that TB is

curable (Model 2) and how it is effectively treated compared to having no knowledge

(Model 3). In only two contrasts do women and men have equivalent knowledge: they

are equally likely to correctly identify TB as curable and how it is treated, compared to

incorrectly naming the curability and treatment of TB.

Older women and men are more likely than younger persons to have heard of TB and,

compared to those who have no knowledge, to correctly identify it as curable, and

correctly report its transmission, major symptom and treatment. TB incidence and

prevalence was much higher during the last half of the 21st century, thus older persons

have more experiential knowledge. Less knowledge among younger bateyes residents

indicates that health education campaigns might be directed toward youth and young

adults.

Higher levels of SES generally are associated with greater levels of correct and

comprehensive information about TB. Level of education is one of the most consistent

effects, associating higher levels of education with more complete and correct

information about TB. The effect of the wealth index is less clear, with poverty

associated with unawareness of TB, including that it is curable, and minor

symptomology rather than the major symptom.

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Access to health information performs rather tepidly; having health insurance is

correlated only with having heard of TB, yet visits from a health care worker are

associated with a lack of knowledge of the TB treatment. Exposure to a higher number

of health-related communications is associated with having heard of TB, correctly

identifying it as curable, naming its treatment, and knowing its major symptom. It is

notable than knowledge of TB seems to be acquired from communication media and

unrelated to interactions with evidence-based clinical practitioners, perhaps signaling

concerns about the quality of care delivered to members of the bateyes. The positive

effect of communication media, however, indicates a potentially powerful avenue to

provide health information.

Province of residence reveals some variation in knowledge across regions of the

Dominican Republic. Compared to residents of Santo Domingo, residents of Puerto

Plata and provinces of “Higuamo” are less likely to have heard of TB. In contrast,

residents of Sánchez Ramírez and the region of Enriquillo, areas in which TB is more

prevalent, are more likely to have heard of TB. It is useful to note that the region of

Enriquillo shares a border with Haiti, a nation in which TB prevalence and incidence

rates are high and there is appreciable population movement across the border. Among

Puerto Platans who have heard of TB, they are more likely to be misinformed as to its

curability, and transmission vector. Monte Platans are more likely to be misinformed as

to curability and major symptomology than residents of Santo Domingo.

Although residents of Sánchez Ramírez are more likely to have heard of TB and know

its’ treatment, they are less well-informed about TB symptomology. Residents of the

Enriquillo provinces, have uneven knowledge about TB. Although they are more likely

than those in Santo Domingo to have heard of TB, knowledge of symptoms is

incomplete, and residents hold incorrect perceptions about its curability, treatment

regimen, and transmission. Residents of “Higuamo,” compared with Santo Domingo,

also have uneven knowledge about TB. The knowledge base is low, though they

correctly name TB treatment, but are more likely to have correct information than

misperceptions about transmission vector.

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5. Conclusions

Our research objective was to describe levels of comprehensive and correct knowledge

about TB among residents of the bateyes, areas in which TB rates are much higher than

the national average. Comprehensive and correct knowledge about TB curability,

treatment, transmission and symptoms is critical to effective TB control in the DR. We

expected that men would have more misperceptions and other knowledge gaps than

women due to less regular access to evidence-based health care practitioners, lower

levels of education, and adherence to an idealized hegemonic masculinity.

Our data clearly support our expectation of more complete and correct knowledge of TB

among women in the bateyes than among men. The gender difference persists above

and beyond gender differences in the social determinants of TB risk. Men’s knowledge

gap is widest in how TB is transmitted and its symptomology, although both women and

men of the bateyes have incorrect or incomplete understanding of how TB is

transmitted. Despite a better knowledge profile among women, we call attention to

their lack of knowledge about symptoms (19.6%) and curability (35.2%).

Strengthening the TB knowledge base in the bateyes would go some distance in

increasing case detection and successful cure of TB in the population. The WHO

promotes the ACSM (Advocacy, Communication and Social Mobilisation) approach to

knowledge development (WHO 2008). Because of continued movement between Haiti

and the bateyes, and areas beyond the bateyes in the DR, a cooperative binational effort

would be an effective and efficient TB control strategy. Recognizing the role of poverty

in morbidity and mortality distributions in a population acknowledges the economic

determinants of TB risk. The WHO encourages development of strategies to address the

co-epidemic of HIV and TB, a critical challenge to TB control in the bateyes, the general

Dominican population and the Haitian population.

To the extent that these general strategies are customizable to women and to men, it is

highly likely that knowledge diffusion and adoption of TB-management behaviors will

proceed more quickly across the full population. We also note here several gendered-

interventions that have the potential to effectively reduce TB risk and improve health.

We propose efforts to improve women’s status, efforts to supplant traditional forms of

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masculinity and femininity with alternate forms, and efforts to improve the quality of

professional health care delivery and patient-provider encounters.

Women’s status is strengthened when they have greater economic independence from

men, which allows them some purchase in decision-making and communication equity

between partners, reduces financial barriers to seeking professional health care, and

creates choices to separate them and their children from unhealthy household relations.

Women’s relationship empowerment is facilitated by their economic independence, and

thus women may be more effective in changing their partners’ health knowledge and

health behaviors such as seeking diagnoses soon after symptoms emerge and

completing the full therapeutic regimen necessary for successful treatment of the

disease.

There are multiple forms of masculinity and femininity, including the idealized

masculinity that is adverse to men’s health. Health and community education programs

that provide alternative forms of masculinity that are health-positive would directly

increase actions to improve TB case detection rates among men, and indirectly help to

widen effective communication between partners and foster social support of health in

women and men. For example, the idealized masculinity that tells men that they must

have knowledge about sexuality and sexual behaviors might be stretched to frame

sexuality as a health domain that is linked to other health-positive attitudes and

practices.

Access to evidence-based health care is a necessary condition for population health in

general, and effective management of communicable conditions such as TB, in

particular. Women’s and men’s attention to health communications via television, radio

and community education campaigns appears to be a cost-effective, efficient, and direct

route to improve the TB-knowledge in the bateyes. Customizing these communications

to specifically target women and men separately would promote uptake of correct and

comprehensive knowledge. Yet access to health care is an insufficient driver of health if

the quality of care warrants improvement. Health care providers who enable respectful

and culturally-sensitive interactions with their patients are better equipped to identify

barriers to health-positive attitudes and behaviors, and have competency in

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communicating care instructions and thus yielding medical compliance with successful

TB therapeutic regimens. Of course, the undocumented status of many Haitian

immigrants, and long-standing societal exclusion and marginalization of Dominicans of

Haitian descent, are stiff barriers for health care professionals to overcome and build

trust with their clientele.

We observed a gendered-vulnerability to risk of TB, with higher rates of incidence and

prevalence among men in the bateyes. We have demonstrated a gendered-knowledge

arena in which men have less complete and correct information, though all residents of

the bateyes clearly would benefit from expansion of information. We conclude that

there is a utility in investment in gendered-intervention programs to meet the WHO’s

eradication goal, by ending TB in the bateyes and ending TB in the Dominican Republic

by 2035.

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Table 1. Distribution of TB Knowledge Measures by Gender in Dominican Republic Bateyes.

Men (percent) Women (percent) Chi-Square

[DF]

Heard of TB (Percent Yes") 83.8 90.5 37.9 [1]**

Curability of TB: 25.9[2]**

Believes TB is Curable 59.2 64.8

Does Not Believe TB is Curable 20.6 20.8

Does Not Know if TB is Curable 20.2 14.4

TB Treatment: 36.3[5]**

Identified Correct Treatment 81.0 86.8

Identified Incorrect Treatment 8.3 8.1

Does not Know 10.7 5.2

Transmission of TB: 157.7[7]**

Identified Correct

Transmission

28.2 40.5

Identified Incorrect

Transmission

46.4 42.9

Does Not Know 25.5 16.6

TB Symptom Knowledge: 118.8[2]**

Knows Main Symptom 52.9 70.9

Knows Only Minor Symptoms 15.7 9.5

Does Not Know 31.4 19.6

N 2101 1707

Notes:

† .1 < p < .05 * 0.01 < p < 0.05 ** p < 0.01

Estimates based on weighted data. Chi-square tests based on non-weighted data.

Source: Demographic and Health Survey, Dominican Republic Bateyes, 2013

19

Table 2. Distribution of TB Knowledge Correlates Gender in Dominican Republic Bateyes.

Men

(means [SD] or %)

Women

(means [SD] or %)

Test of

Association

Age 32.0 [12.6] 28.6 [10.0] t = 9.6**

SES

Education χ 2 = 66.0**

None 12.9 9.6

Primary 1-4 20.3 18.2

Primary 5-8 36.4 34.6

Secondary 27.7 30.8

Higher 2.8 6.8

Wealth Index χ 2 = 46.7**

Poorest 66.5 56.8

Poorer 18.4 24.6

Middle 9.1 12.4

Richer 5.0 5.0

Richest 0.9 1.1

Health Information

Insurance holder (% Yes) 36.7 42.0 χ 2 = 8.7**

HC worker visited HH (% Yes)

23.5 26.6 χ 2 = 3.3†

Number of health PSAs in past year

7.8 [.12] 8.5 [.13] t = -4.4**

Province χ2 = 26.9**

Santo Domingo 19.7 24.8

Monte Plata 18.3 15.0

Puerto Plata 16.2 15.6

Sánchez Ramírez 1.3 0.9

Enriquillo 19.7 21.6

Higuamo 24.9 22.2

N 2101 1707

† . < p < . 5 * 0.01 < p < 0.05 ** p < 0.01

Estimates based on weighted data. Chi-square tests based on non-weighted data.

Source: Demographic and Health Survey, Dominican Republic Bateyes, 2013

20

Table 3. Logistic and Multinomial Logistic Regression Models of Gender and Other Determinants of Tuberculosis Knowledge.

Independent Variables

Model 1:

Heard of TB?

Model 2: Is TB Curable?

Model 3: Knowledge of TB

Treatment?

Model 4: How is TB

Transmitted?

Model 5: Knowledge of TB

Symptoms?

No vs. Yes

DK vs. Yes

Incorrect vs.

Correct

DK vs.

Correct

Incorrect vs.

Correct

DK vs.

Correct

Minor vs.

Major

DK vs.

Major

Demographics

Gender (Female = 1) 1.78** 0.93 0.62** 0.88 0.40** 0.68** 0.44** 0.44** 0.44**

Age (in Years) 1.04** 0.98** 0.96** 1.01 0.97** 1.01 0.97** 0.99 0.96**

Education 1.89** 0.74** 0.66** 0.97 0.80* 0.80** 0.61** 0.92 0.63**

Wealth Index 1.29* 0.93 0.81** 0.90 1.13 1.07 1.03 0.85* 0.97

Health Information

Health Insurance (Yes = 1) 1.98** 0.98 0.87 0.88 1.00 0.99 0.77 1.25 0.84

Hlth. Worker Visit (Yes= 1) 0.99 1.15 1.05 1.34 1.59* 1.16 1.26 1.04 1.19

# Health PSAs Past Year 1.07** 0.96** 0.96** 0.95** 1.00 0.99 0.98 0.99 0.98*

Province (S. Domingo=ref.):

Monte Plata 0.90 1.46* 1.05 .39† 0.52* 1.05 1.50 1.11 1.59*

Puerto Plata 0.37** 1.53* 1.12 0.43* . 3† 1.80** 1.93** 1.24 1.36

Sánchez Ramírez 1.45* 0.98 0.97 0.39** 0.59** 4.40** 1.65** 0.75 . †

Enriquillo 1.78* 0.73 0.60* 0.58 0.37** 1.16 0.60* 1.04 0.75

Himaguo . † 1.27 0.91 0.26** 0.49** 1.47** 1.20 0.89 1.01

Constant 0.22** 1.60† 6.68** 0.24** 0.77 1.54 6.97** 0.58 5.90**

F [DFn, DFd]

37.91** [12,102]

9.96** [24,90]

4.88** [24,90]

57.08** [24,90]

11.94** [24,90]

N 3770 3285 2026 3283 3284

Notes: † . > p ≥ . * . ≥ p > .01 ** p < .01

Model 1 is estimated using logistic regression. Models 2-5 are estimated using multinomial logistic regression. Coefficients are odds ratios.

Source: Demographic and Health Survey, Dominican Republic Bateyes, 2013.