Kenyan TB Cultural Profile

Summary

Kenya has a high incidence of tuberculosis (TB) disease, ranking 15th highest in the world and 6th highest in Africa. There is a significant population of Kenyans in King County, with several TB disease cases reported annually. The common belief that the Bacillus Calmette-Guérin (BCG) vaccine offers lifelong protection against TB can contribute to confusion. Other misconceptions, such as the belief that a normal chest radiograph excludes TB infection, further complicate screening and diagnosis. Many community members also work in healthcare or childcare, where annual testing is mandated (often with skin testing), leading to additional doubt surrounding the accuracy of Latent TB Infection (LTBI) test results.

King County TB Community Navigator:

In King County, many Kenyan community members are reluctant to undergo LTBI treatment. Many expressed concern about the side effects of medications used for the treatment of TB disease and LTBI, with some individuals reporting adverse drug reactions to LTBI treatment. The widespread feeling that the deleterious effects of medication may outweigh the benefits of therapy has led some community members to lose confidence in the medical care they receive and in the efficacy of medications.

Recommendations

• TB Screening for all individuals from Kenya using blood tests (e.g., IGRA, QuantiFERON) rather than skin testing (e.g. tuberculin skin testing, Mantoux).
• Clarify the BCG vaccine’s limited protection, emphasizing that it does not prevent TB disease in adults and may lead to false-positive Purified Protein Derivative (PPD) skin test results.
• Emphasize the importance of LTBI treatment in preventing progression to active TB disease, even if individuals feel asymptomatic.
• Explain that LTBI tests will remain positive even after successful treatment; the effectiveness of treatment is determined by preventing TB disease, even if the test result remains positive after treatment.
• Close follow-up in clinic once treatment has been initiated to ensure continued adherence to the regimen.
• Spoken education delivered at community events and prayer meetings: “Talking is a more effective type of communication.

Audio clip from Kenyan community leader, Reverend Paul Karume:

Methods

The following sections are based on interviews with six Kenyan community members in King County, Washington, conducted by Ethnomed and translated by a Kenyan community navigator through Public Health—Seattle & King County (PHSKC). One participant had previously received treatment for active TB disease. All respondents were from the Kikuyu ethnic group. The interviews were conducted in English, Kikuyu, and Swahili, with the Kenyan community navigator providing interpretation. A supplemental literature review was also performed.

Burden of Disease

2023 WHO TB statistics of Kenya1
Total tuberculosis (TB) incidence (number): 128,000
Total TB incidence (rate per 100,000 per year): 223
HIV-positive TB incidence (number): 26,000
HIV-positive TB incidence (rate per 100,000): 48
Total Population (2023): 53,339,003

Languages Spoken

Kenya is a linguistically diverse country with 69 distinct languages spoken across its regions. The official languages are English and Swahili (Kiswahili). Several region-specific languages are also commonly spoken, including Kikuyu, Luo, Luhya, and Maasai. In King County, Swahili is the most widely spoken language among the Kenyan community. TB is frequently referred to as “Kifua Kikuu” in Swahili, which translates to “big chest,” which may carry different connotations depending on the local dialect. In Kikuyu, TB is called “morimo wa ihori”: disease of the lung. “It used to be called the disease of curse… like your forefathers caused you to get the disease.”

In addition to Swahili, it is important to recognize that Kenyan community members may also use their local language when discussing health-related matters, especially in informal settings. Healthcare providers should be aware of the need for language-appropriate resources and interpretation to ensure effective communication, particularly when addressing the nuances of TB testing, treatment options, and the long-term management of LTBI.

Bacillus Calmette-Guerin (BCG) Vaccination

In Kenya, over 90% of infants receive the BCG vaccine as a single dose at birth. There is an estimated BCG coverage of 95%2,3

Many Kenyans believe the BCG vaccine provides lifelong immunity, leading to confusion when an LTBI diagnosis is made. One respondent noted, “I thought the [BCG] vaccine meant I couldn’t get TB.”

There is a recognition that PPD testing remains positive after receiving the BCG vaccination: “Anybody who got BCG will always test positive. But it doesn’t mean you are ill.” Respondents also noted that the scar from the BCG vaccine is a marker of identity and protection: “Immediately when you’re born, you get a shot, which is BCG. And we have that mark all the days of our lives . . . Whenever you want to know a Kenyan person, you see that mark of a BCG.”

Diagnosis and Clinical Features

Kenyans recognize common TB disease symptoms, including persistent cough, chest pain, weight loss, fever, and loss of appetite, and there is also awareness of disease manifestations outside of the lungs. However, there is less knowledge regarding the distinction between TB disease and LTBI.

Some individuals believed that a negative chest radiograph indicates the absence of TB infection, leading to reluctance in receiving LTBI treatment. Respondents also noted that some community members who tested positive for LTBI or TB disease would hide this diagnosis from their community.

Most community members are not concerned with respiratory symptoms in general, unless they are prolonged or if there are accompanying symptoms such as those stated above. Many community members refer to “homa”, a cold that lasts for days. Respondents noted that they would usually seek homeopathic treatments rather than Western medicine. Drinking water boiled with lemon and ginger is a common treatment recommendation. Respondents noted that individuals will present to a clinic for TB testing only if they experienced additional symptoms, such as loss of appetite.

Testing for TB Disease and LTBI

Testing and treatment of LTBI are uncommon in Kenya. Several respondents voiced the concern that starting LTBI treatment could lead to “waking it [TB] up…”. “If something’s not causing a problem, don’t awaken it.” “Let the sleeping dog lie.” Additionally, many people do not feel concerned if they test positive for LTBI (typically through blood testing with an IGRA). If someone is diagnosed with LTBI in the community, they typically still go out in public. However, respondents reported that individuals have been told not to work when IGRA testing returns positive. Respondents also note that community members often push back against the diagnosis of LTBI and recommendations against working, particularly if they remain asymptomatic. One respondent stated, “If it’s not transferable to someone else, just let it be in the body.”

A large subset of the Kenyan community in King County works in healthcare or childcare. Annual LTBI screening is required for many of these positions, though testing is typically done with skin tests (e.g. PPD) rather than blood tests (e.g. IGRA). Many community members consistently test positive for LTBI, but there is a widespread belief that these test results reflect false positives due to prior BCG vaccination. Because of this belief, many decline LTBI treatment themselves and discourage others from receiving treatment. They state a concern about adverse effects from medications for LTBI treatment: “I’ve seen somebody taking those medicines… the eyes are yellow.”

Respondents indicated that many of those diagnosed with LTBI would subsequently have a clear chest radiograph. This is often interpreted as further proof that initial testing reflected a false positive result (although a clear chest radiograph is a common finding in the setting of LTBI). Respondents also noted that many community members who had undergone LTBI treatment were surprised to repeatedly test positive for LTBI despite having undergone treatment. This appears to stem from a misconception that subsequent LTBI testing would be negative following LTBI treatment.

TB/HIV Co-Infection

Kenya is among the 30 countries with the highest burden of TB and TB/HIV coinfection. In 2021, 24% of TB patients in Kenya with known TB status were HIV positive.4 TB disease in the setting of HIV infection has been shown to have an impact on treatment-seeking behavior by patients, as well as adherence.5 This is because for Kenyans, TB and HIV are tightly interwoven subjects. One respondent noted, “If you have HIV, you must have TB,” reflecting how overlapping symptoms (weight loss, chronic cough, fatigue) fuel a dual stigma. Several respondents also noted that a TB diagnosis often triggers automatic HIV testing, reinforcing fears that one disease inevitably implies the presence of the other.

Kenya’s adult HIV prevalence has declined from double‐digit levels in the early 2000s to approximately 3.2 percent in 2023, following years of expanded antiretroviral therapy (ART) access and prevention efforts. Nevertheless, HIV remains the single most significant risk factor for progression from LTBI to active TB disease, and co-infection rates among TB patients are high. In 2022, 23% of Kenyans treated for TB were also living with HIV, a figure that underscores the need for integrated services.6

To mitigate this dual burden, Kenya’s National Tuberculosis, Leprosy and Lung Health Programme (NTLDP) follows WHO‐endorsed guidelines: all TB patients receive routine HIV testing and antiretroviral therapy (ART). People living with HIV are screened regularly for TB through symptom screening and chest radiography. Directly observed therapy (DOT) for TB is often delivered within HIV clinics. This may inadvertently heighten stigma as patients worry that daily clinic visits will “out” them as having HIV, even if they are only at the HIV clinic for TB treatment.

Experiences with Healthcare in United States

All respondents were aware of two specific cases in the local Kenyan community where it was widely believed that isoniazid (INH) toxicity directly led to liver failure. One of these individuals was interviewed for this article and reported requiring a liver transplant following treatment with INH. A second individual in the community passed away. Although we were unable to confirm the underlying details of these two cases, community understanding has significantly influenced conceptions of safety regarding LTBI treatment and testing in the Kenyan community and greatly affected trust in the medical system more broadly. Furthermore, respondents were concerned that the two community members who were treated did not warrant treatment in the first place, and that their positive LTBI testing results were false positive results due to previously receiving the BCG vaccine. Even if these individuals had LTBI, respondents maintained that this “sleeping TB” should have been allowed to remain asleep. “If you rattle a snake, it will rattle you back”.

Size and Composition of the Kenyan Diaspora

According to the Migration Policy Institute, approximately 102,000 first- and second-generation Kenyan immigrants resided in the United States as of 2019. Unlike some African populations, Kenyans rarely arrive via the U.S. Refugee Admissions Program. Instead, most Kenyan-born individuals enter with visas based on employment, family sponsorship, education, or asylum.

Insurance Coverage and Access to Care

Noncitizen immigrants face markedly higher uninsured rates than U.S. citizens. In 2017, 23% of lawfully present immigrants were uninsured, nearly three times the 8% uninsured rate among the US average7. Among undocumented immigrants, the uninsured rate exceeded 45%. Kenyan nationals who hold nonimmigrant visas or are awaiting asylum decisions often lack eligibility for Medicaid, encounter complex enrollment procedures, and struggle with language and health-literacy barriers. Consequently, even when public health campaigns offer LTBI screening, many Kenyan immigrants discover that follow-up treatment requires out-of-pocket payment or face enrollment delays, discouraging completion of therapy.

Multiple respondents expressed a lack of trust in the medical system. They expressed concerns that their provider lacked engagement and was sometimes dismissive. One respondent noted that Kenyans place a high value on spiritual authenticity, empathy, and sincerity in their interactions with others, including with providers. She contrasted this approach with the sometimes rushed and transactional nature of care in some medical settings, where patient questions are unanswered. “Genuine empathy is important . . . our community is very spiritual. We know fake and we know real.”

Community members stressed that practices and communication styles that might be standard in the American healthcare system, such as directly addressing serious illness and poor prognosis, can cause a breakdown in trust with the patient. “They tell the patient: ‘You’re going to die.’ So why are you going to the doctor?” “That makes the doctor the enemy, not a friend.”

Grounding patient interactions with a commitment to transparency and collaboration can help establish trust with members of the Kenyan community. Respondents also recommended first eliciting a patient’s understanding of the disease process and having the patient accompanied by family members to help process the diagnosis. “We value life so much. It’s not the expense. It’s about dignity.”

Community members often undergo repeated TB testing for work or school without understanding the rationale behind this. This can lead to fatigue and distrust: “They don’t get any information. They are told: background check, TB test, go… They ask: I’ve been tested 10 years in a row, why every year if I’ll always be positive?”

Stigma

One respondent had recently been diagnosed with extra pulmonary TB. Upon learning of his diagnosis, his housemates asked him to move out, despite reassurances from the TB clinic that he was not infectious. “They saw TB as the monster… something that kills people . . . I had to move out and stay in a hotel for two weeks.”

This respondent also noted the impact of TB disease on work and finances:
“Not being able to work—that was the hardest part.”
“Everything stops for you, but not for the people depending on you.”
“I just waited without pay. That was a big financial stress.”

Relevant Historical Considerations

Land Alienation Under Settler Colonialism

The designation of the “White Highlands” in central Kenya for European settlers dispossessed Kikuyu, Embu, and Meru communities of fertile lands, driving many into wage labor on colonial farms or overcrowded reserves.8 This legacy of expropriation and the enduring perception that land and resources serve external rather than local interests can foster skepticism toward state‐led programs.

Expectant of Hidden Costs

In the 1980s, Kenya adopted World Bank/IMF‐mandated structural adjustment programs that slashed public spending and introduced user fees to public health facilities.9 Later policies capped fees and eventually abolished them for primary care in 2013. However, continued out‐of‐pocket costs and distrust of fee‐based services remain barriers for economically vulnerable patients who recall the era when “no care was free.”

TB Treatments Kenya

Traditional medicine remains a cornerstone of health care for many Kenyans, with a majority relying on local healers as their primary source of care and up to 90 percent incorporating medicinal plants into treatment regimens. Common first‐line home remedies for chronic cough include boiling leaves of the neem tree (Azadirachta indica) and drinking them as tea.10 Patients typically resort to formal health facilities only if symptoms persist or worsen.
While trust in Kenya’s health system is generally strong, particularly in urban areas, awareness and acceptance of modern TB screening and treatment vary by region and socio‐demographic factors.10 Rural residents often face longer travel times to clinics and may hold stronger beliefs in traditional explanations of illness, whereas urban patients tend to access information on TB prevention and services more readily.

Under Kenya’s National Tuberculosis, Leprosy and Lung Health Strategic Plan (2019–2023), TB diagnosis and treatment are provided free of charge through the National Tuberculosis Programme, which operates in approximately 4,500 health facilities and 1,800 testing sites nationwide.11 In 2017 alone, the program notified 85,188 drug‐sensitive and 577 drug‐resistant TB cases, illustrating both the scale of service delivery and the ongoing burden of disease.12,13

Despite the absence of user fees, TB patients incur substantial direct and indirect costs. Mean total patient‐level expenditures in Kenya average USD 97.90, with a significant proportion of households experiencing “catastrophic” health spending defined as exceeding 20% of annual income. 12 Expenses include transportation to clinics, food supplements during prolonged treatment, and lost wages during clinic visits.

Kenya’s National Strategic Plan emphasizes that TB is curable with a six‐month first‐line regimen, and general awareness of treatment duration and effectiveness is high among those reached by public health messaging.14 Nevertheless, stigma surrounding the disease, fears of social isolation, and concerns about side effects can delay care‐seeking and challenge adherence, underscoring the need for patient‐centred support interventions throughout treatment.

Social Factors and Care Delivery in Kenya

Kenya’s health workforce density has improved substantially over the past decade, with 22.3 medical doctors per 10,000 population reported in 2023, surpassing the global average of 17 physicians per 10,000 people.15 However, distribution remains uneven: urban centers attract the majority of clinicians, while many rural and remote regions face critical shortages of qualified staff.

Stigma remains a formidable barrier to timely TB care in Kenya. In a mixed‐methods study of 208 pulmonary TB patients in West Pokot County, high levels of perceived and experienced stigma were documented, including fears of social rejection and internalized shame.16 Qualitative interviews revealed that many patients conceal their diagnosis to avoid ostracism, which can lead to treatment interruption and a prolonged risk of disease transmission.

Religious beliefs further shape health‐seeking behaviours. Christianity is the predominant faith, practiced by approximately 85.5 percent of Kenyans, while Muslims comprise 10.9 percent of the population.17 Pastors and imams are trusted community authorities whose endorsements influence decisions around illness and healing. Some patients seek spiritual validation of medical diagnoses through prayer or faith healing services, which can postpone the initiation of TB treatment. Conversely, faith‐based organisations have also partnered with the National TB Programme to deliver community education and peer support, illustrating both challenges and opportunities in leveraging religious networks for public health.

In Kenya, there also exists a significant gender disparity in TB care. Males account for twice the number of TB disease cases compared to females, and are more likely to be non-adherent to treatment.18 Overall, there are minimal interventions geared towards men, which can lead to a decrease in overall access to TB services. Some proposed recommendations include focusing on intervention spaces where men are more likely to gather and proposing male-friendly diagnostic and screening services to reduce undiagnosed TB.

Other Co-Morbidities/Health Concerns in the Community

Malaria

Malaria is endemic in Kenya, with approximately 70% of the population at risk of contracting the disease.19 Due to control efforts, the incidence rate of malaria has decreased in recent years. Still, it remains a significant public health problem.

Non-communicable diseases

Increasing rates of hypertension and diabetes. Concern for undiagnosed chronic conditions due to lack of insurance, fear of deportation, and missed preventive care.

Acknowledgments

The following funders have generously supported this project:
TB Elimination Alliance (2023-2024 Mini-Grant Program)
Firland Foundation (2024-2025 Community Grant)

References

1. World Health Organization. “Kenya.” WHO Data, World Health Organization, 2025, https://data.who.int/countries/404#:~:text=number%20of%20people,51%25%20to%2083%2C593%2C239%20by%202050. Accessed 16 May 2025.
2. BCG Atlas. BCG Atlas, Infectious Diseases Data Observatory, University of Oxford, www.bcgatlas.org. Accessed 16 May 2025.
3. World Health Organization. “Vaccination Schedule for Tuberculosis.” WHO Immunization Data, World Health Organization, https://immunizationdata.who.int/global/wiise-detail-page/vaccination-schedule-for-tuberculosis?ISO_3_CODE=&TARGETPOP_GENERAL=. Accessed 16 May 2025.
4. Centers for Disease Control and Prevention. “Where We Work: Kenya.” CDC Global HIV, TB and Malaria, U.S. Department of Health and Human Services, https://www.cdc.gov/global-hiv-tb/php/where-we-work/kenya.html#:~:text=Estimated%20HIV%20Prevalence%20(Ages%2015,85%25%20(2020). Accessed 16 May 2025.
5. Young, Peter Wesley, et al. “HIV Incidence, Recent HIV Infection, and Associated Factors, Kenya, 2007–2018.” AIDS Research and Human Retroviruses, vol. 39, no. 2, 8 Feb. 2023, pp. 57–67, doi:10.1089/aid.2022.0054. Accessed 16 May 2025.
6. Ministry of Health, Republic of Kenya. National Tuberculosis, Leprosy and Lung Health Strategic Plan 2019–2023. National Tuberculosis, Leprosy and Lung Health Programme, 2019. https://www.health.go.ke/wp-content/uploads/2019/10/NTLDP-Strategic-Plan-2019-2023.pdf. Accessed 15 May 2025.
7. Kaiser Family Foundation. “Fact Sheet: Health Coverage for Immigrants.” Kaiser Family Foundation, n.d., https://files.kff.org/attachment/Fact-Sheet-Health-Coverage-for-Immigrants?utm_source=chatgpt.com. Accessed 16 May 2025.
8. Kahinju, Jefferson, Aaron Ross, and Monicah Mwangi. “Kenya Land Standoff Sends Warning to Foreign-Owned Tea Estates.” Reuters, 17 Apr. 2025, https://www.reuters.com/world/africa/kenya-land-standoff-sends-warning-foreign-owned-tea-estates-2025-04-17/. Accessed 16 May 2025.
9. Thomson, Michael, Alexander Kentikelenis, and Thomas Stubbs. “Structural Adjustment Programmes Adversely Affect Vulnerable Populations: A Systematic-Narrative Review of Their Effect on Child and Maternal Health.” Public Health Reviews, vol. 38, 2017, p. 13, doi:10.1186/s40985-017-0059-2. Accessed 16 May 2025.
10. Gathara, Patrick. “Where Do Kenyans Seek Medical Treatment?” The Elephant, 8 Feb. 2019. https://www.theelephant.info/analysis/2019/02/08/where-do-kenyans-seek-medical-treatment/. Accessed 14 May 2025.
11. “Kenya Recognised in Implementation of WHO’s TB/HIV Collaborative Activities.” Hivisasa, 2016. https://hivisasa.com/posts/kenya-recognised-in-implementation-of-whos-tbhiv-collaborative-activities. Accessed 14 May 2025.
12. Kenya Medical Research Institute. “KEMRI Strides in TB Research.” KEMRI. https://www.kemri.go.ke/kemri-strides-in-tb-research/. Accessed 14 May 2025.
13. Kenya Legal and Ethical Issues Network on HIV & AIDS. Tuberculosis: Data Assessment in Key, Vulnerable and Underserved Populations. KELIN Kenya, Apr. 2018. https://www.kelinkenya.org/wp-content/uploads/2018/04/TB-Data-Assesment.pdf. Accessed 14 May 2025.
14. Yimer, Getnet, et al. “Incidence and Determinants of Households’ Catastrophic Payments for TB Care: Evidence from a Multi-Country Trial (EXIT-TB Project) Implemented in East Africa.” BMJ Public Health 3, no. 1 (Feb. 2025): e001543. https://bmjpublichealth.bmj.com/content/3/1/e001543. Accessed 14 May 2025.
15. World Health Organization. “Medical doctors (per 10,000 population).” Global Health Observatory, WHO. https://data.who.int/data/gho/data/indicators/indicator-details/GHO/medical-doctors-%28per-10-000-population%29. Accessed 8 May 2025.
16. Mbuthia, Grace Wambura, Henry D. N. Nyamogoba, Silvia S. Chiang, and Stephen T. McGarvey. “Burden of Stigma among Tuberculosis Patients in a Pastoralist Community in Kenya: A Mixed Methods Study.” PLOS ONE 15, no. 10 (Oct. 2020): e0240457. https://doi.org/10.1371/journal.pone.0240457. Accessed 14 May 2025.
17. U.S. Department of State. 2023 Report on International Religious Freedom: Kenya. 2023. https://www.state.gov/reports/2023-report-on-international-religious-freedom/kenya/. Accessed 16 May 2025.
18. Abdullahi, Leila H., et al. “Gendered Gaps to Tuberculosis Prevention and Care in Kenya: A Political Economy Analysis Study.” BMJ Open, vol. 14, no. 4, 3 Apr. 2024, e077989, https://pmc.ncbi.nlm.nih.gov/articles/PMC11146361/. Accessed 16 May 2025.
19. U.S. Agency for International Development. Kenya Malaria Factsheet. May 2022, https://www.usaid.gov/sites/default/files/2022-05/Kenya_Malaria_factsheet.pdf. Accessed 16 May 2025.
    Deleted:
20. World Health Organization Regional Office for Africa. Tuberculosis in the African Region: 2023 Report. World Health Organization, Sept. 2023, https://www.afro.who.int/sites/default/files/2023-09/Tuberculosis%20in%20the%20African%20Region_2023%20report.pdf?utm_source=chatgpt.com. Accessed 16 May 2025.