Prevalence of Pulmonary Tuberculosis Among Holy Water Attendees and Barriers to Utilizing TB Health Care Services in Addis Ababa, Ethiopia

Abstract

Abstract Background: The probability of transmission of Pulmonary Tuberculosis (PTB) depends on the infectiousness of the source patient and on the nature of the environment where exposure occurs. In the effort of meeting the End TB goal, TB screening among key population and settings is one of the strategies where Holy water sites and its attendees are among them. It is estimated that 80% of the population in Ethiopia uses holy water for various reasons that include chronic illnesses. The huge gatherings in and around holy water places, and the absence of screening for any easily transmissible infectious diseases like TB brings a great concern for potential transmission of TB particularly of pulmonary TB (PTB). Such practice delays timely detection of TB and proper treatment potentially exacerbating the spread of PTB within the community. Objective: To investigate the prevalence of PTB and examine potential barriers contributing to low TB service utilization among presumptive PTB cases attending selected holy water sites in Addis Ababa, Ethiopia. Method: An explanatory mixed-methods study was conducted at 11 purposively selected holy water sites in Addis Ababa, Ethiopia. A quantitative survey of 225 attendees with presumptive TB was followed by in-depth interviews with nine attendees and six healthcare providers. Quantitative data were entered into REDCap and analyzed using R Studio v4.5.1, including descriptive statistics and logistic regression. Qualitative data was managed in MAXQDA 2025, and thematic analysis was employed. Result: A total of 1600 holy water users were screened for potential TB signs and symptoms. Among them, 225 reported having two or more symptoms of TB and were included in the study.The prevalence of PTB was 2.7% (375 per 100,000). In the multivariate model, only cigarette smoking remained significantly associated with PTB (AOR: 6.99; 95% CI: 1.21–41.0; p = 0.024). Qualitative analysis revealed barriers to TB care, including limited awareness, delayed health-seeking, reliance on spiritual healing, stigma, socioeconomic hardship, and systemic healthcare challenges. Conclusion: PTB remains a concern among holy water users, with socio-cultural factors shaping health-seeking behavior. Integrating biomedical case-finding with faith-sensitive, community-based approaches is a key to improving TB detection and control. Keywords: TB, Prevalence, Barriers, Addis Ababa, Holy water