Abstract

The aim of the present study was to evaluate knowledge, attitudes and practices regarding tuberculosis (TB) among transvestites and transsexual women. A cross-sectional study was conducted with a convenience sample (n = 124; 58 transvestites and 66 transsexuals) in the city of São Paulo, Brazil, in 2014 and involved the administration of the Knowledge, Attitudes and Practices questionnaire. Absolute and relative frequencies were calculated for all variables and the comparisons of percentage distributions between groups were performed using Pearson’s Chi-square test, Fisher’s exact test or its generalization, with a 5% significance level. Most participants were young and non-white. Transvestites had lower levels of schooling, reported more passages through the prison system and declared themselves to be sex workers more frequently. Little more than half of the participants were aware that treatment for TB was free of charge. Knowledge on TB was modest, permeated with misunderstandings regarding signs/symptoms, transmission and prevention, which influence attitudes and practices in relation to the disease. The findings demonstrate that health education actions do not achieve their goals in the control of tuberculosis.

Key words
Tuberculosis; Health; Knowledge; Attitudes; Practice; Transgender persons; Health education

Introduction

Tuberculosis (TB) has advanced in the 21^st century. This advancement is associated with poverty and the human immunodeficiency virus (HIV), which is the cause of acquired immunodeficiency syndrome (AIDS)¹1 Nascimento RN. As pestes do século XX. Rio de Janeiro: Editora Fiocruz; 2005.. Despite the numerous control efforts, TB continues to be a huge public health challenge²2 Bertolli CF. História Social da Tuberculose e do Tuberculoso: 1900-1950. Rio de Janeiro: Editora Fiocruz; 2001.. According to the World Health Organization, TB was one of the main causes of mortality in 2016, with approximately 1.4 million deaths, 0.4 million of which resulted from the co-infection of TB and HIV/AIDS³3 World Health Organization (WHO). Global Tuberculosis Report 2016. Geneva: WHO; 2016.. Moreover, a total of 5.8 million cases of TB occurred throughout the world between 2001 and 2011, 82% of which were concentrated in 22 countries, with Brazil occupying the 17^th position⁴4 Organização Pan-Americana da Saúde (OPAS). Direitos humanos, cidadania e tuberculose na perspectiva da legislação brasileira. Brasília: OPAS; 2015..

Studies on the knowledge of TB among transgender individuals are rare in the international literature and practically nonexistent in Brazil. However, studies conducted with other populations reveal that a lack of knowledge on the disease is one main barriers to the perception of symptoms, early diagnosis, adherence to treatment and the cure⁵5 Alvarez-Gordilho GC, Alvarez-Gordilho FJ, Dorantes-Jiménez JE, Halperin-Frish D. Percepciones y prácticas relacionadas com La tuberculosis y La aderência al tratamiento em Chiapas, México. Salud Pública Méx 2000; 42(6):520-528.^,66 Savicevic AJ, Popovic-Grle S, Milovac S, Ivcevic I, Vukasovic M, Viali V, Zivkovic K. Tuberculosis knowledge among patients in out-patient settings in split, Croatia. Int J Tuberc Lung Dis 2008; 12(7):780-785..

Transgender individuals around the world experience stigma, discrimination and abuse throughout life. At greater risk due to the adoption of behaviors that are unfavorable to health, such individuals face difficulties with regard to access to information and care, which demonstrates inequities between transgender and cisgender individuals⁷7 Winter S, Diamond M, Green J, Karasic D, Reed T, Whittle S, Wylie K. Transgender people: health at the margins of society. Lancet 2016; 388(10042):390-399..

In Brazil, a large portion of transvestites and transgender individuals (TTs) live in unfavorable social conditions as a result of transgressing gender⁸8 Kulick D. Travesti: prostituição, sexo, gênero e cultura no Brasil. Rio de Janeiro: Editora Fiocruz; 2008.. Excluded from the nuclear family and school at an early age, TTs often turn to prostitution as means of survival⁹9 Pelúcio L. Nos Nervos, na Carne, na Pele, uma etnografia sobre prostituição travesti e o modelo preventivo de AIDS [tese]. São Carlos: Universidade Federal de São Carlos; 2007.. In this context permeated by violence as well as alcohol and drug abuse, many pass through the prison system¹⁰10 Ferreira GG. Travestis e prisões: a experiência social e a materialidade do sexo e do gênero sob o lusco-fusco do cárcere [dissertação]. Porto Alegre: Pontifícia Universidade Católica do Rio Grande do Sul; 2014. and shelters, whereas other are homeless¹¹11 Garcia MRV. Alguns aspectos da construção do gênero entre travestis de baixa renda. Psicologia USP 2009; 20(4):597-618., all of which are favorable conditions to the transmission of TB and co-infection by HIV¹²12 Brasil. Ministério da Saúde (MS). Manual de recomendações para o controle da tuberculose. Brasília: MS; 2011..

Considering the conceptions of individual, social and programmatic vulnerability proposed by Ayres et al.¹³13 Ayres J, Calazans GJ, Saletti Filho HC, França Júnior I. Risco, vulnerabilidade e práticas de prevenção e promoção da saúde. In: Campos G, Minayo MCS, Akerman M, Drumond Júnior M, Carvalho YM, organizadores. Tratado de Saúde Coletiva. São Paulo: Fiocruz; 2006. p. 375-417. and the invisibility of the transgender population in official health¹⁴14 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Boletim Epidemiológico 2015; 46(9)1-19. and sociodemographic¹⁵15 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amestra de Domicílios. Síntese de Indicadores, 2014. Rio de Janeiro: IBGE; 2014. data, the aim of the present study was to evaluate knowledge, attitudes and practices regarding TB among transvestites and transsexual women in the city of São Paulo, Brazil.

Methods

A cross-sectional study was conducted with a convenience sample (n = 124) in the city of São Paulo between February and August 2014. The participants were adults (≥ 18 years) of the male biological sex who described their sexual identity as transvestite or transgender (trans)¹⁶16 World Health Organization (WHO). Advocacy, communication and social mobilization for TB Control. A Guide to developing knowledge, attitude and practice surveys. Geneva: WHO Stop TB partnership; 2006..

Interviews were conducted at the Integral Health Clinic for Transvestites and Transgender Individuals (IHCTT), the City of São Paulo Reference and Diversity Defense Center (RDDC) and in the community of Largo do Arouche. The IHCTT is part of the State of São Paulo STD/AIDS and Viral Hepatitis Reference and Training Center and receives TTs, with a multidisciplinary team that offers accompaniment throughout the gender transition process and other specific health demands¹⁷17 Biancarelli A. A diversidade revelada. Centro de referência da diversidade sexual (CRD Pela Vidda/SP) e ambulatório de saúde integral de travestis e transexuais (CRTDST/AIDS-SP). São Paulo: Secretaria do Estado da Saúde; 2010.. The RDDC is a place for assisting in the social inclusion of intersex individuals, lesbians, gays, homosexuals, bisexuals, transvestites and transsexuals located in the central region of the city. It integrates the municipal social assistance network and performs social initiatives through the offering of services, benefits, programs and projects aimed at protecting populations in situations of social vulnerability, exclusion and risk¹⁷17 Biancarelli A. A diversidade revelada. Centro de referência da diversidade sexual (CRD Pela Vidda/SP) e ambulatório de saúde integral de travestis e transexuais (CRTDST/AIDS-SP). São Paulo: Secretaria do Estado da Saúde; 2010..

The historical central region of São Paulo, especially the area in which Republic Square, Vieira de Carvalho Street and Largo do Arouche are located, has served as a meeting place for the homosexual group in São Paulo, which is facilitated by public transportation (municipal and inter-city bus lines, metro stations and railroad lines) that enable individuals from distant areas to reach the center of the city in search of entertainment, services and sexual encounters. The surrounding area has public restrooms, saunas, gay night clubs, internet cafés, movie houses, hotels/inns with high turnover and motels. The region is also known for both female and male prostitution due to the numerous night clubs, explicit sex/striptease shows and meeting places for call girls, call boys and transvestites¹⁸18 Green JN, Trindade R, Barbosa JF, organizadores. Homossexualismo em São Paulo e outros escritos. São Paulo: Editora UNESP; 2005..

The study was announced with the assistance of employees at the institutions involved and an open invitation was offered to all TTs who visited these places. Interviews were held at the institutions in an individual, private and voluntary manner. In Largo do Arouche, interviews were established through previous contact with the researcher at the RDDC with a community leader to sought condoms for a group who did not visit the center, thereby enabling access and inclusion in the study. At this site, the interviews were also held an individual, private and voluntary manner.

Data collection involved the administration of the Guide to Developing Knowledge, Attitude and Practice Surveys¹⁶16 World Health Organization (WHO). Advocacy, communication and social mobilization for TB Control. A Guide to developing knowledge, attitude and practice surveys. Geneva: WHO Stop TB partnership; 2006., which has been translated and adapted to the language of the populations surveyed and is composed of 45 closed-ended questions and one open-ended question. All closed-ended questions and response options were read to the interviewees and the responses were recorded. Answers referring to knowledge on the prevention and transmission of TB were categorized as correct and incorrect, following the norms of the tuberculosis control guidelines in Brazil¹⁹19 Brasil. Ministério da Saúde (MS). Manual de recomendações para o controle da tuberculose. Brasília: MS; 2011.. For the open-ended question (“What worries you the most when you think about TB?”), the answers were recorded based on the interviewees’ statements considering only the first thing mentioned and classified as death, transmission, treatment/internment/cure, becoming ill, nothing and others.

The socio-demographic variables considered in the study were age group (18 to 29, 30 to 39, 40 to 49 and ≥ 50 years), skin color (white and non-white), schooling (0 to 4, 5 to 8, 9 to 11 and ≥ 12 years of study), passage through the prison system (yes or no) and sex worker (yes or no). If the latter response was “yes”, time in the profession was categorized as < 1, 1 to 10, 11 to 20 and ≥ 21 years.

Data on knowledge regarding TB, forms of transmission and prevention, attitudes, practices and stigmas related to the disease were obtained as described below:

Knowledge on TB, forms of transmission and prevention: received information about TB (yes or no) and sources of information among those who received it (flyers/posters, TV/radio/internet, lectures/classes/health professional); opinion regarding the disease (very serious, serious, not serious, does not know); whether TB is curable (yes or no); how TB is cured (with treatment at a primary care center/medication with medical supervision and rest without medication, treatment with herbal medicines, prayer, blessings, does not know, others [which?]); cost of treatment (free, expensive [combined responses of expensive, reasonably expensive and very expensive], does not know); transmission of TB, classified as correct (airways) and incorrect (all other forms cited and does not know)¹⁹19 Brasil. Ministério da Saúde (MS). Manual de recomendações para o controle da tuberculose. Brasília: MS; 2011.; prevention, categorized as correct (eat well, cover the mouth when coughing/sneezing, adequate ventilation and light, and use of a mask) and incorrect (other answers, does not know)¹⁹19 Brasil. Ministério da Saúde (MS). Manual de recomendações para o controle da tuberculose. Brasília: MS; 2011.; contagiousness/who can get TB? (anyone, others, does not know; “others” category included only HIV+ individuals, children, old people, gays, smokers, whoever consumes cold beverages, whoever does not take care of himself/herself, whoever lives in unsanitary conditions and whoever lives in closed environments).

Attitudes, practices, stigmas and information regarding TB: feeling if affected by the disease (fear, sadness, none, others, does not know; “others” category included surprise, shame/embarrassment and despair); would talk about the disease (yes or no); to whom respondent would talk (doctor, steady partner, parents/relatives, close friend/work mates); action to be taken if symptoms of TB were suspected (seek a primary care service and others, such as seek a preacher, drugstore or self-medication); when respondent would seek a primary care service (when self-medication failed, having symptoms for more than two weeks, as soon as perceiving symptoms as TB, does not know); knows someone who had TB (yes or no); feeling toward individuals with TB (supportive with desire to help, supportive, but distant, indifferent, fear of infection, others; “others” category included no feelings, disgust and rejection); how someone with TB is considered by other people (many reject the person, are supportive, but avoid contact, many help, does not know, others). For the open question (“What worries you most when you think about TB?”), the answers were recorded based on the interviewees statements considering only the first thing mentioned and categorized as death, transmission, treatment/internment/cure, becoming ill, nothing and others, such as having to stop working, isolation, prejudice and discrimination. With regard to information, the questions “Do you feel well informed about TB?” and “Would you like to receive more information about TB?” were categorized as yes or no; desired sources of information were categorized as newspapers/magazines, radio/TV/internet, lectures/conversation/health professionals, pamphlets and others; the “other” category included posters, telegrams, classes, announcements and billboards). Information on the perception of the disease was collected through the question “Can you have TB?” (yes or no) and the reasons given by the interviewees.

Absolute and relative frequencies were calculated for all variables and the comparisons of percentage distributions between groups were performed using Pearson’s Chi-square test, Fisher’s exact test or its generalization, with a 5% significance level. The IBM Statistical Package for Social Science (SPSS, version 16.0) was used for the analyses.

Individuals who did not answer the entire questionnaire, those with mental disorders, those who did not reside in the city of São Paulo and those under the effects of alcohol/drugs that impeded the conduction of the interview were excluded from the study.

This study received authorization from the administration of the RDDC and approval from the ethics committees of the School of Public Health of the University of São Paulo and State of São Paulo STD/AIDS and Viral Hepatitis Reference and Training Center. All participants were assured the confidentiality of the information and signed a statement of informed consent.

Results

One hundred twenty-four individuals participated in the present study, 58 transvestites (46.8%) and 66 transsexual women (trans) (53.2%). The majority of interviews were held at the RDDC (79.8%), followed by the IHCTT (11.3%) and in Largo do Arouche (8.9%).

(Table 1 displays the socio-demographic characteristics of the interviewees according to sexual identity. Nearly half (49.2%) were between 18 and 29 years of age; 62.1% were non-white; 41.1% reported having ≤ eight years of schooling; and 25.0% had passages through the prison system. Approximately 72.0% reported being sex workers, with the majority (53.9%) having ≤ 10 years in the profession. Differences between groups were found with regard to schooling (p = 0.008), passage through the prison system (p < 0.001) and occupation (p < 0.001). The transvestites had lower levels of schooling, reported a greater frequency of passages through the prison system and had a higher proportion of sex workers (87.9%). When filling out the statement of informed consent, many interviewees reported residing temporarily in shelters or being homeless. This information was recorded and considered in the analyses (data not presented in table).

Regarding knowledge about TB as well as forms of transmission and prevention (Table 2), the majority of respondents had received information about the disease, the main sources of which were lectures, classes and health professionals. A total of 88.7% considered TB to be a serious/very serious disease; 95.8% stated that it was curable and 84.3% reported that the cure was achieved through medical treatment. A little more than half of the respondents (53.2%) knew that treatment was free of charge.

Regarding knowledge on transmission, 34.7% mentioned incorrect forms (kissing, sex, cold weather, sharing cigarettes or pipes, contact with saliva, mosquito bite, toilet seat, rat urine, shaking hands, touching doorknobs and sharing plates and cutlery) and 28.2% had no knowledge on forms of transmission. A total of 99.2% reported incorrect forms of preventing TB (separating plates and cutlery, praying, blessing oneself, avoiding contact with an affected individual, not smoking, taking medications, undergoing examinations, wearing a mask, avoiding the cold, avoiding closed environments, maintaining adequate hygiene, not taking illegal drugs, using a condom and basic sanitation) or were unable to respond. The majority of interviewees recognized that anyone could contract the disease (75.8%). No statistically significant differences between groups were found for any of these variables (p > 0.05) (Table 2).

When asked about the possibility of acquiring the disease, recognition was high in both groups (98.4% of trans and 93.1% of transvestites). The reasons reported by those who did not consider this possibility were the use of antiretroviral drugs, having had TB already and taking adequate care of one’s health (data not presented in table). When asked why they could contract TB, 25.8% of the trans and 20.7% of the transvestites reported that anyone could contract the disease. During the interviews, 33.3% of the trans and 25.9% of the transvestites stated: I’m exposed. Other reasons included smoking, use of alcoholic beverages and illegal drugs, failure to take adequate care of oneself, contact with homeless people and prior pneumonia (data not presented in table).

(Table 3 displays the data on attitudes, practices, stigmas and information regarding tuberculosis. In the entire sample, 32.3% reported that sadness would be the main feeling if they became ill with TB. The majority reported that they would talk about the disease, with a higher proportion among the transsexuals (p = 0.039). When asked what they would do if they presented symptoms of TB, 88.5% said they would seek a primary care service, whereas others stated they would seek a preacher, pharmacy or self-medication. More than 70.0% knew someone who had had the disease.

With regard to feelings toward people with TB, the majority reported they would be supportive and wish to help. The main perception attributed to others with regard to individuals with TB was rejection. The main concerns among the transvestites and trans when considering the disease were treatment/internment/cure and death, respectively, whereas 17.7% of the overall sample reported not having any concerns at all. The other concerns mentioned were sexual impotence, weight loss, having to stop smoking, having to stop working, lack of medication, the multi-resistance of TB and lasting effects. The majority of both groups did not consider themselves to be well informed about TB; 87.1% wished to receive more information about the disease and 50.0% reported wanting to receive information through lectures/conversations/health professionals or radio/TV/internet (Table 3).

Figure 1 displays the main symptoms reported for TB. Interviewees could mention more than one symptom. Dry cough was the most recognized symptom in both groups. Other symptoms were fever, fatigue, chest pain, weight loss, shortness of breath and back pain. The main symptom of the disease (cough for more than two weeks) was mentioned little in each group (32.8% of transvestites and 24.2% of trans). Symptoms not associated with TM, such as stomachache, bodily pain, sore throat, hoarseness, blindness, hair loss, tooth loss, loss of appetite, AIDS, phlegm, depression, dizziness and loss of locomotion, were mentioned often in both groups, which demonstrates a lack of knowledge regarding symptoms of the disease.

Discussion

The analysis of the socio-demographic data demonstrated a young, non-white profile with a low level of schooling, which is in agreement with previous studies conducted on this population⁹9 Pelúcio L. Nos Nervos, na Carne, na Pele, uma etnografia sobre prostituição travesti e o modelo preventivo de AIDS [tese]. São Carlos: Universidade Federal de São Carlos; 2007.^,1111 Garcia MRV. Alguns aspectos da construção do gênero entre travestis de baixa renda. Psicologia USP 2009; 20(4):597-618.. Moreover, differences between transvestites and transsexuals were found with regard to schooling, passage through the prison system and occupation. San Pedro and Oliveira²⁰20 San Pedro A, Oliveira RM. Tuberculose e indicadores socioeconômicos: revisão sistemática da literatura. Rev Panam Salud Publica 2013; 33(4):294-301. report that socioeconomic indicators can reflect one’s vulnerability to TB due to inequalities with regard to access to information and the benefits stemming from knowledge and purchasing power. The present findings suggest a relationship between socio-demographic characteristics and disparities between transgender and cisgender individuals in terms of access to information on health⁷7 Winter S, Diamond M, Green J, Karasic D, Reed T, Whittle S, Wylie K. Transgender people: health at the margins of society. Lancet 2016; 388(10042):390-399.. Thus, the modest knowledge encountered with regard to TB may be related to the barriers imposed on this subgroup in terms of health care associated with disrespect to gender identity and discriminating health practices stemming from homophobia and transphobia²¹21 Araújo FM. Ações de educação em saúde no planejamento familiar nas Unidades de Saúde da Família no Município de Campina Grande-PB [monografia]. Campina Grande: Universidade Estadual da Paraíba; 2004.^,2222 Buchmueller T, Carpenter CS. Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000-2007. Am J Public Health 2010; 100(3):489-495..

Thirty percent of the participants were living either on the streets or at shelters (data not presented in tables). In developed countries, despite the reduction in the incidence of TB in recent years, a high proportion of new cases are found among the homeless population²³23 Moss RA, Hahn JA, Tulsky JP, Daley CL, Small PM, Hopewell PC. Tuberculosis in the Homeless. Am J Respir Crit Care Med 2000; 162(2):460-464.. There is little information on TB in this population in Brazil²⁴24 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Boletim Epidemiológico 2015; 46(9)1-19., but it is recognized the many transvestites and transsexuals live in such conditions¹¹11 Garcia MRV. Alguns aspectos da construção do gênero entre travestis de baixa renda. Psicologia USP 2009; 20(4):597-618.. These findings underscore the vulnerability of this population to TB and further studies are needed to assist in the planning of health education actions at shelters focused on controlling the disease.

The majority of participants in the present study had received information on TB, mainly through lectures and classes given by health professionals. In the Brazilian public healthcare system, these are considered health education actions delegated to the teams of the Family Health Strategy as one of the measures to control TB²⁵25 Alves VS. Um modelo de educação em saúde para o Programa Saúde da Família: pela integralidade da atenção e reorientação do modelo assistencial. Interface (Botucatu) 2005; 9(16):39-52. Health education actions are generally performed by the nursing staff at primary care services through lectures given to individuals in the waiting room and through the formation of educational groups. These actions are not specifically directed toward the control of TB and it should be mentioned that such actions are also not valued within the care context²⁶26 Trigueiro JVS, Silva ACO, Gois GAS, Almeida SA, Nogueira JA, Sá LD. Percepção de enfermeiros sobre educação em saúde no controle da tuberculose. Ciênc. Cuid. Saúde 2009; 8(4):660-666.. Health professionals often fail to recognize the implicit educational nature of their actions and sometimes transmit knowledge in a vertical, impersonal manner²⁷27 Araújo FM. Ações de educação em saúde no planejamento familiar nas Unidades de Saúde da Família no Município de Campina Grande-PB [monografia]. Campina Grande: Universidade Estadual da Paraíba; 2004.. It is therefore important to train these professionals regarding the dissemination of information on the disease to more vulnerable populations.

Knowledge on the risk of infection by TB was demonstrated mainly by feelings of being more exposed to the transmission of the disease. Moreover, the level of understanding with regard to curing the disease through treatment at a primary care service and medication with medical supervision was high in both groups. However, knowledge on free treatment was modest, which may affect access and adherence to treatment. It is therefore necessary to publicize this information through means of communication.

Less than half of the interviewees had correct knowledge on the forms of transmission of the disease and the majority did not know how to prevent it. Some believed in mistaken prevention practices. Similar results were found in a study conducted with an incarcerated population²⁸28 Ferreira Júnior S, Oliveira HB, Marin-Léon L. Conhecimento, atitudes e práticas sobre tuberculose em prisões e no serviço público de saúde. Rev. Bras. Epidemiol 2013; 16(1):100-113., in which a low level of clinical-epidemiological knowledge on the disease was encountered. Moreover, the presence of transvestites at male prison facilities is widely recognized¹⁰10 Ferreira GG. Travestis e prisões: a experiência social e a materialidade do sexo e do gênero sob o lusco-fusco do cárcere [dissertação]. Porto Alegre: Pontifícia Universidade Católica do Rio Grande do Sul; 2014..

No statistically significant differences between transvestites and transsexuals were found in terms of attitudes, practices, stigmas and information regarding TB. The only exception was that transsexuals would be more willing to talk about the disease than transvestites. In the overall sample, more than 25% would not talk about the disease, which may be related to the fear of associating the stigma of TB with that of HIV/AIDS, thereby financially compromising the exercise of prostitution. According to Ascuntar et al.²⁹29 Ascuntar JM, Gaviria MB, Uribe L, Ochoa J. Fear, infection and compassion: social representations of tuberculosis in Medellin, Colombia, 2007. Int J Tuberc Lung Dis 2010; 14(10):1323-1329., the stigma of TB may exert an influence on adherence to treatment. The stigmas of homosexuality and prostitution superimposed on the stigma of TB may increase difficulties in terms of access to healthcare services and affect the relationship between health professionals and patients, thereby compromising treatment.

Most of the participants reported that they would seek a primary care services as soon as the signs and symptoms of TB became evident. However, this is questionable when one considers the results with regard to knowledge of the signs and symptoms of the disease.

The most frequent concerns the interviewees reported when thinking about TB were treatment/internment/cure, death and becoming ill. These data may be related to barriers to healthcare services created by prejudice as well as the need to stop working, which weighs heavily on survival. The fact that 18% reported having no concerns may reflect a lack of knowledge about the disease, which could exert a negative influence on the early diagnosis of TB.

The present study has limitations that should be considered. The cross-sectional design only enables the evaluation of associations among the variables. However, this is the best type of study design for the characterization of a population profile. Since the participants were selected by convenience, the findings may not represent the population of transvestites and transsexuals who reside in the city. Moreover, the small sample size may have restricted the power of the study to identify differences between the two groups. The use of the attitude assessment tool has been criticized due to the possibility of obtaining biased responses involving opinions and feelings (the interviewee may give responses he/she believes to be acceptable or appreciated)³⁰30 Hausmann-Muela S, Mela RJ, Nyamongo I. Health-seeking behavior and the health system's response. Geneva: Disease Control Priorities Project (DCPP) Working Paper. 2003. n. 14., which could lower the validity of the information regarding the questions “How do you feel about people with TB?” and “How do others view a person who has TB?” Launiala³¹31 Launiala A. How much can a KAP survey tell us about people's knowledge, attitudes and practices? Some observations from medical anthropology research on malaria in pregnancy in Malawi. Anthropology Matters 2009; 11(1):1-13. recognizes the usefulness of the assessment tool for collecting general data on public health issues related to treatment and prevention, but, considering the uniqueness of the context in which the study was conducted and the profile of the interviewees (transvestites and transsexuals), the use of quantitative and qualitative methods would be more appropriate for measuring the feelings, attitudes and practices of the interviewees. Despite these limitations, the present results characterize a subgroup for which little data are available.

For a sample of transvestites and transsexual women in the city of São Paulo, insufficient knowledge on TB exerts an effect on attitudes and practices with regard to the disease. The findings seem to demonstrate that health education actions focused on TB have not achieved their goals in this population and greater efforts are required. From the epidemiological standpoint, primary prevention is of the utmost importance. The stratification of the population based on risk enables greater focus on priority subgroups so that educational actions (knowledge) that take socioeconomic factors and context into consideration³²32 Launiala A, Honkasalo ML. Ethnografic study of factors influencing compliance to intermittent preventive treatment of malaria during pregnancy among Yao women in rural Malawi. Trans R Soc Trop Med Hyg 2007; 101(10):980-989. can indeed promote the adoption of specific preventive practices for TB.

Conclusion

The present findings demonstrate that knowledge on TB among the transvestites and transsexuals interviewed in the city of São Paulo was modest and permeated with misunderstandings regarding the signs/symptoms, transmission and prevention of the disease. Considering the living conditions and health of this specific subgroup, which are aggravated by the combinations of stigmas related to TB, HIV/AIDS, homosexuality and prostitution, The National Tuberculosis Control Program should include the gender issue as a topic in the training of health professionals and the planning of heath education actions. Such actions could reduce the occurrence of prejudice and discrimination at public healthcare services and broad access on the part of this subgroup to information and healthcare services, thereby favoring the early diagnosis, adherence to treatment and curing of TB.

References

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