Introduction:
Tuberculosis (TB) has become a major public health concern. It has become the leading cause of mortality among infectious diseases in the world; in 2014, 9.6 million people fell ill with TB and 1.5 million people died from the disease.[1] Each person who develops the most infectious form of the disease will infect about another 20 people in his or her lifetime. Transmission of TB infection results in the huge global burden of TB cases and deaths, and has significant economic consequences for individuals, families, communities, employers, and countries.[2] The major risks for TB infection are through close contact to the infectious case before diagnosis and household members are at a higher risk.[3] The undiagnosed or suspected patient with TB is the primary risk to the general population.[4] The transmission risk of M. tuberculosis from patients to the members of the household is a neglected problem in many low and middle-income countries.
TB infection control is a combination of measures aimed at minimizing the risk of TB transmission within populations. The foundation of such infection control is early and rapid diagnosis of Presumptive TB cases, and proper management of TB patients.[5] The infection occurs even before they contact the health system. Thus it is important that TB suspects (now called as presumptive patients)[6] and TB patients have basic knowledge of the disease and the correct infection control practices to minimise exposure to their caregivers and other non-infected individuals.
The TB health visitors play a major role in advocating and communicating to the patients and their care-givers about correct infection control practices. We wanted to know if the patients and caregivers follow the infection control practices. To reduce the transmission of TB in households, any information, education and communication activity for prevention and management of TB should include behaviour and social change campaigns.
Hence, this present study was carried to identify the knowledge and practices gap about infection control among the Presumptive TB patients and also to know the perception of TB Health Visitors on the actual infection control practises followed by the TB patients.
Material and Methods:
Study area and setting:
The study was carried out in the patients seeking health care from Sri Manakula Vinayagar Medical College and Hospital (SMVMCH), Puducherry located in the semi-urban of Puducherry Union territory. The present study was undertaken by the Department of Community Medicine, SMVMCH which is an active member in STF-RNTCP (State Task Force-Revised National Tuberculosis Control Program) mechanism. The study was held at the Designated Microscopy Centre (DMC) supervised by the Core Committee of STF at SMVMCH. On an average, monthly 200 presumptive TB cases are identified at SMVMCH, all cases are sent to the DOTS centre of SMVMCH for appropriate diagnosis and referral.
Study design:
An exploratory sequential design where quantitative methods (Hospital based cross sectional survey) and followed by qualitative methods (Focus Group Discussion [FGD]) was used (Fig.1). This study design was selected as we also wanted to know whether the TB patients really follow the infection control practices.
 |
Fig.1: Diagram of the study design |
Sample size and sampling:
Quantitative method:
The sample size 384 was determined by using Epi Info version 7.1.3.0 software (Centre for Disease Control and Prevention) by single population proportion formula with the assumptions of 95% confidence level, 5% precision. The sample size was calculated for variables such as proportion of patient awareness about infection control of Tuberculosis (using a hand kerchief or a towel while coughing) which is 51% based on studies reported from Chinnakali P, et al. Considering 10% non-responses rate, the calculated sample size was further inflated to 422 respondents.[7] We recruited 422 patients during the study period of four months and all Presumptive TB cases and TB patients reporting to DMC from Department of Pulmonary Medicine were included as study subjects.
Qualitative study:
Two Focus Group Discussions (FGD) were conducted among 20 Tuberculosis Health Visitor (TBHV) with 10 participants in each group who were selected by purposive sampling for obtaining information about the infection control practice among the Presumptive TB cases and TB patients.
Data collection:
The questionnaire was prepared in English by referring the published literature[8,9] and was pilot tested among 20 Presumptive TB cases to check the wording and the appropriateness of the questions in the questionnaire. The First and fourth authors were oriented to the survey technique by the guide. After obtaining the informed consent from the participants privacy was ensured before conducting the one to one interview. First and fourth authors administered the questionnaire consisting the Socio-demographic Information and domains related to Knowledge, Attitude, and Practice to infection control of Tuberculosis. To assess cross ventilation the participants were shown pictures with and without cross ventilation and were asked to choose which picture depicted cross ventilation. The participants were asked to demonstrate how they coughed and cough etiquette was assessed by the principle investigator.[10] The completed questionnaires were checked for completeness of information to enhance quality and feedback was given by the guide. The second investigator supervised the entire data collection.
We also did qualitative exploration from the Tuberculosis Health Visitors (TBHV) about the practice of infection control measures adopted by Tuberculosis patients and their care givers. Two FGDs were conducted and each consist of about 10 participants and lasted for 60 minutes. The FGDs were conducted in the local language Tamil by the second author who is trained in qualitative research and the first author was the note taker. The FGDs were audio recorded by the social worker and a sociogram was drawn to ensure uniform discussion among the participants. The FGDs were conducted in a common venue conference room at NRHM office, Puducherry were all members could attend. The FGDs were conducted under the observation of the third author who is also trained in qualitative research. The FGD was concluded after sharing the summarized FGD findings and confirming the same with the participants. At the end of the FGD, refreshments and stationary items were provided to the participants as a token of appreciation.
Data Analysis: The quantitative data was entered and analysed using Epi Info version 7.1.3.0 software (Centre for Disease Control and Prevention). Initially the frequency tables were obtained for discrete variables such as socio demographic characteristics, Knowledge, Attitude, and Practice related to infection control of Tuberculosis. Continuous variable were expressed as mean and standard deviation. To find out the strength of association, Odds ratio (OR) was computed and 95% CI was calculated and statistical significance was set at 5% (p<0.05). Multiple regression analysis was computed for the independent variables that were statistically significant to predict the practice of demonstration of cough.
FGD data was transcribed in English and manual content analysis was done. The unit of the analysis was statements under a given code. These findings were reviewed by third author who is trained in Qualitative Research Methods.
Ethical issues: Ethical principles such as respect for the persons, beneficence and justice were adhered. Ethical clearance was obtained from the Research Committee and Institutional Ethics Committee (IEC) (No.EC/DD/AP/116/2016) of Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Puducherry.
Results:
Socio-demographic information of the study participants:
A total of 422 Presumptive TB cases were included in the study, out of which 305 (72.3%) were males and 117 (27.7%) were females. As shown in Table 1, the mean age of the respondents was 52.03 (+ 15.77 standard deviation [SD]) years, where the mean age of the male was 51.75 (± 16.02) years and the mean age of the female was 52.75 (± 14.94 SD) years. Regarding education, 202 (47.9%) were illiterate, Illiteracy was higher among females (67.5%) than males (40.3%). Most of the respondents, 331 (78.4%) were from rural areas and 91 (21.6%) from urban areas.
| Table 1: Socio-demographic Information of study participants |
| Socio Demographic Variables |
Male
n = 305 (72.3%) |
Female
n = 117 (27.7%) |
Total
(N = 422) (%) |
Age (in years) Mean ±SD |
51.75 ± 16.02 |
52.75 ± 14.94 |
52.03 ± 15.77 |
Education |
|
|
|
Illiterate* |
123 (40.3) |
79 (67.5) |
202 (47.9) |
Primary |
64 (21.0) |
20 (17.1) |
84 (19.9) |
Middle |
34 (11.1) |
6 (5.1) |
40 (9.5) |
Secondary* |
49 (16.1) |
8 (8.8) |
57 (13.5) |
Higher secondary and above* |
35 (11.5) |
4 (3.5) |
39 (9.2) |
Marital Status |
|
|
|
Married* |
262 (85.9) |
72 (61.5) |
334 (79.1) |
Never Married |
32 (10.5) |
14 (12.0) |
46 (10.9) |
Widowed* |
11 (3.6) |
31 (26.5) |
42 (10.0) |
Number of family Members |
< Four |
179 (58.7) |
65 (55.5) |
244 (57.9) |
> Four |
126 (41.3) |
52 (44.5) |
178 (42.1) |
Type of family |
Joint Family |
99 (32.2) |
36 (30.8) |
135(33.0) |
Nuclear family |
206 (67.5) |
81 (69.2) |
287(68) |
Religion |
Hindu |
289 (94.8) |
108 (92.3) |
397(94.1) |
Muslim |
14 (4.6) |
7(6.0) |
21(5.0) |
Christian |
2(0.6) |
2(1.7) |
4(0.9) |
Area of Resident |
Rural |
233 (76.4) |
98 (83.8) |
331 (78.4) |
Urban |
72 (23.6) |
19 (16.2) |
91 (21.6) |
Occupation |
Farmer* |
132 (43.3) |
35 (29.8) |
167 (39.6) |
Labourer* |
46 (15.1) |
30 (25.6) |
76 (18.0) |
Business* |
48 (15.7) |
7 (6.0) |
55 (13.0) |
Government staff |
4 (1.3) |
1 (0.9) |
5 (1.2) |
Professional * |
50 (16.4) |
3 (2.6) |
53 (12.6) |
Student |
4 (1.3) |
3 (2.6) |
7 (1.7) |
House wife |
0 |
25 (21.4) |
25 (5.9) |
Retired |
10 (3.3) |
2 (1.7) |
12 (2.8) |
Unemployed |
11 (3.6) |
11 (9.4) |
22 (5.2) |
| Figures in parenthesis are percentages |
Knowledge, Attitude and Practice regarding infection control of tuberculosis:
Among the total respondents, 284 (67.3%) said they had heard about tuberculosis. But only 136 (32.2%) knew that the TB spreads from one person to another, 136 (32.2%) responded that it spread through air. The proportion of females who did’t have knowledge of spread of TB was significantly higher when compared to males. It was also found that 225 (53.3%) were aware that using a handkerchief or towel while coughing will help in controlling the spread. Our data revealed that 167 (39.6%) knew how to safely dispose sputum. When asked if cross ventilation reduced the risk of infection of the respiratory tract, 325 (77.0%) said that it did. Regarding the attitude of the respondents towards TB, 236 (55.9%) said that they would share their status as a TB patient to others if they were diagnosed with the disease. Around 151 (35.8%) participants said that a TB patient should not be allowed to use public transport or be present at crowded places like the cinema or temple. About 160 (37.9%) were of the opinion that a TB patient should be kept in isolation. Regarding infection control practices, 206 (49.4%) of the respondents said that they used a handkerchief or a cloth to cover their mouth when they coughed or sneezed. Among the total participants, 262(62.5%) said they washed their hands after coughing and 195(46.4%) were able to demonstrate good cough hygiene.
Determinants of infection control practice of the participants:
We performed multiple logistic regression analysis to identify the independent variables that predict the practice of demonstration of cough. In this, three variables emerged as significant predictors for demonstrating practise of good cough hygiene. The odds of participants demonstrating correct cough etiquette was 1.02 times (CI:1.01-1.03) higher in those aged less than 45 years than those aged above 45 years (P< 0.005). The odds of demonstrating correct cough etiquette was 1.91 times (CI: 1.08-3.37) higher among participants with at least a primary level education than those who were illiterate (P< 0.02). Among the participants who used a hand kerchief while coughing, the odds of demonstrating correct cough etiquette were 1.429 (CI: 1.05-1.94) times higher than their counterparts (P<0.02). The other variables related to knowledge like having heard of TB, [OR 2.0(CI:1.37-3.2), P<0.0001], knowing the correct mode of transmission, [OR 1.91(CI: 1.26-2.89), P<0.001] and that TB is curable, [OR 1.88(CI:1.27-2.77), P<0.001,] which were statistically significant in bi-variate analysis, were not found to be predictors in multiple regression analysis.
| Table 2: Multivariate logistic regression analysis for predictors to demonstrate correct cough etiquette |
| Characteristics |
Total (n=422) |
N (%) |
OR (95% CI), p value |
Adjusted OR (95% CI), p value |
Age |
≤45 |
151 |
78(51.66) |
1.38
(0.92-2.06), 0.11 |
1.02
(1.01-1.03), 0.005 |
>45 |
271 |
118(43.54) |
Gender |
Female |
117 |
54(46.15) |
0.99
(0.64-153), 0.4 |
0.89
(0.55-1.42), 0.63 |
Male |
305 |
141(46.23) |
Education |
Illiterate |
202 |
91 (45.5) |
1 |
|
Primary |
84 |
30 (35.71) |
0.81
(0.47-1.37), 0.4 |
1.91
(1.08-3.37), 0.025 |
Middle |
39 |
16(41.03) |
1.01
(0.50-2.04), 0.95 |
1.77
(0.83-3.76), 0.13 |
Secondary |
57 |
29(50.88) |
1.51
(0.83-2.73), 0.16 |
1.26
(0.657-2.41), 0.486 |
Higher secondary and above |
40 |
29(70.73) |
3.85
(1.82-8.15), 0.0002 |
0.549
(0.236-1.28)0.165 |
Heard about Tb |
Yes (Ref) |
284 |
148 (51.93) |
2.0
(1.37-3.2), 0.0001 |
1.183
(0.58-2.37),0.637 |
No |
138 |
47 (34.31) |
Mode of Transmission |
Air borne(Ref) |
138 |
79(56.83) |
1.91
(1.26-2.89), 0.001 |
1.26
(0.75-2.10),0.374 |
Others |
284 |
116 (41.13) |
TB is curable |
Yes(Ref) |
206 |
112(54.37) |
1.88
(1.27-2.77), 0.001 |
1.13
(0.816-1.57), 0.453 |
No |
216 |
83 (38.60) |
Use handkerchief while coughing |
Yes(Ref) |
225 |
124(55.36) |
2.18
(1.47-3.2), 0.001 |
1.429
(1.05-1.94), 0.023 |
No |
197 |
71(36.22) |
Dispose sputum |
Yes(Ref) |
167 |
93(55.69) |
1.86
(1.25-2.7), 0.001 |
0.924
(0.675-1.26), 0.62 |
No |
255 |
103 (40.39) |
Findings from Qualitative Interviews:
Among the TBHV, 15 were female and 5 were male and the mean age was 33.42(±4.51 SD).As per the respondents of FGD with the Tuberculosis Health Visitors (TBHV), the categories that emerged from FGD data were knowledge, attitude, practices and suggestions. As reported in Table 3, according to the TBHV, the knowledge about TB infection control among illiterateTB patients and in caregivers is poor. The TBHVs said that “It is necessary to educate the caregivers and then the patient”. “Literate people tell us that they dispose sputum in restrooms. This should not be done as it is a closed space with inadequate ventilation. If they spit in toilets, infections will spread easily to their family members also”.
The attitude about infection control of TB among the TB patients were related to fear about the disease, social stigma, fear of isolation, and fear of being victimised as a TB patient. The very word TB invokes fear in the minds of the patients. “They feel that the disease will not be accepted by the society and so they don’t tell anyone that they are infected. Sometimes the patients request us not to inform their family for fear of being isolated”.
According to the TBHV, regarding safe sputum disposal the TB patients feel that it is impractical to carry with them a container to dispose sputum wherever they go. For some of them their occupation prevents them from carrying a container to dispose sputum. They follow TB infection control measures only when the TB health visitors are present, “They wear the mask till the hospital gate. When they leave, they remove the mask, spit and cough outside”. TBHV have also suggested developing health education material in the local language and that the pamphlets should be illiterate friendly with pictures. They also suggested that health education should be given in privacy to the patient.
| Table 3: TBHV’s perception on infection control practices |
| Quantitative component/Category |
Themes |
Content |
Knowledge |
Presumptive TB cases |
Presumptive TB cases who are illiterate don’t have any knowledge regarding TB.
Literate people have some knowledge. |
Care givers |
Care givers of TB patients are very apprehensive about the disease.
Isolation of TB patient is practiced to prevent transmission among the family members.
It is also necessary to create awareness about TB among the care givers. |
Knowledge |
Majority of TB patients do not have adequate knowledge on infection control. |
Attitude |
Stigma |
The disease will not be accepted by the society and so they don’t tell anyone if they get infected.
Most of the patient request not to inform the family members about their TB status. |
Practices |
Sputum disposal
and
Cough etiquette |
The patients feel inconvenient to carry a sputum disposal container during travel.
Employed patients shy out to carry container for sputum disposal.
Mostly not followed by the illiterate and elderly patients.
They follow cough etiquette only when the TB health visitors are present. |
Drug regimen |
Literate people understand the importance of consuming the drugs. Illiterate people don’t understand the importance and frequently stop following the regimen.
Some of the patients feel embarrassed to come to the DOTS centre and consume the drugs. |
Others |
TB patients belonging to lower socioeconomic classes, living in
overcrowded houses with lack of adequate ventilation do not follow the infection control practices |
Suggestions |
Methods to improve awareness |
Mass media should be used.
Skit or drama can be conducted in the villages.
Awareness about TB should be given from school itself.
Pamphlets with more of pictures and how to identify a TB suspect?
Care givers should also be given awareness.
School students and Community volunteers should be trained to disseminate health education material. |
Messages given |
Sufficient privacy should be followed when patient receives health education.
Cover mouth with a kerchief when speaking to others or coughing or sneezing.
Dispose sputum safely.
Don’t cough in public.
Follow the drug regimen correctly.
Keep the windows open and allow maximum sunlight inside the house.
Avoid face to face encounter with children.
Avoid crowded areas, drinking alcohol and smoking.
Keep the house ventilated. |
Discussion:
Among the 422 Presumptive TB cases and patients studied, 305 (72.3%) were males and 117 (27.7%) were females. The mean age of the respondents was 52.03 (+15.77). Regarding education, 202 (47.9%) were illiterate, and illiteracy was higher among females (67.5%) than males (40.3%). Majority of the respondents, 331 (78.4%) were from rural areas. It was also found that 225 (53.3%) were aware that using a handkerchief or towel while coughing will help in controlling the spread. Our data revealed that 167 (39.6%) knew how to safely dispose sputum. When asked if cross ventilation reduced the risk of infection of the respiratory tract, 325 (77.0%) said that it did. Among the total participants, 160 (37.9%) said that a TB patient should be isolated. Regarding infection control practices, 206 (49.4%) of the respondents used a handkerchief or a cloth to cover their mouth during cough and practiced hand washing after coughing, 262 (62.5%). Nearly half 46.4%) of the respondents were able to demonstrate good cough etiquette. In multiple logistic regression analysis to identify the independent variables that predict the practice of demonstration of cough, the odds of demonstrating correct cough etiquette was 1.91 times (CI: 1.08-3.37) higher among participants with at least a primary level education than those who were illiterate(P< 0.02). Among the participants that used a hand kerchief while coughing, the odds of demonstrating correct cough etiquette were 1.429 (CI: 1.05-1.94) times higher than their counterpart ( P<0.02).
Regarding knowledge of TB, 67.3% of the respondents said that they have heard of TB but knowledge of individual components like infectivity, mode of spread, cure was less. The reason for the low level of awareness can be attributed to the study population having a low level of literacy (47.9% were illiterate). Studies by Das P [11] Purohit SD[12] and Yadhav SP[13] have shown that literacy is a key deciding factor for the level of awareness. FGD data given by the TBHV also revealed that the knowledge of TB was lower among the illiterate. It was also found that knowledge of TB was proportionally lower in females than in males. This could be attributed to the high levels of illiteracy among the female respondents (67.5%). These findings are consistent with studies conducted by in Delhi, Aligarh, and Nalgonda.[14-16] The result of the study showed that only half the Presumptive TB cases knew that the disease was infectious. A study done by Malhothra R showed that 95.3% of TB patients knew that TB is an infectious disease.[14] It shows that the knowledge that TB is an infectious disease is higher among TB patients when compared to Presumptive TB cases. About 53.3% were aware that using a handkerchief while coughing will prevent the spread and 49.4% practised the use of a handkerchief or cloth when coughing or sneezing. But, analysis of qualitative study revealed that there was a lack of adherence to cough etiquette among illiterate and elderly patients. Regarding disposal of sputum, 39.6% knew how to safely dispose sputum. FGD data revealed that educated persons had better knowledge of disposing sputum but some of their assumptions made regarding sputum disposal were found to be erroneous. This is in line with the findings of HegdeAM who noted that urban population showed a greater percentage of misconceptions regarding the disease.[17] It was reasoned by them that the attitude and belief of the urban population being resistant to TB deferred them from obtaining knowledge about the same. Regarding cross ventilation, 77% knew that cross ventilation reduced the risk of acquiring Respiratory infections and 83.9% said that they kept the windows and doors open in their home to allow maximum ventilation inside. Qualitative analysis revealed that lack of cross ventilation was a major cause for the spread of TB. A majority of the participants (82%) said that overcrowding played a role in the spread of TB but overcrowding was found to be present in 24.2% of the homes. This figure is significantly lower than those found by Chinnakali P.[7] This could be attributed to the predominance of overcrowding in slums.
More than half the respondents said that they would share their status as a TB patient if they were found to be sputum positive. Kar M reported in a population based study that 92.7% of the respondents did not wish to maintain confidentiality if they contracted TB.[18] However qualitative analysis showed that TB patients were secretive of their status as a TB patient due to social stigma, fear of isolation by the family, and fear of being victimised as a TB patient. Yadhav SP reported that stigma associated with the disease led to poor adherence to treatment.[13] This emphasises the need to dispel such deep rooted negative attitudes. Studies by Das P [11] and Yadhav SP[13] report that discrimination of TB patients existed irrespective of literary status. It is imperative that such social issues are dealt during health education. Regarding infection control practices, quantitative data revealed that nearly half the study population followed good infection control practices. FGD data revealed that elderly patients and people belonging to low socioeconomic classes did not adhere to infection control practices. Lack of cross ventilation and overcrowding and family members affected with TB were seen as risk factors that contributed to spread of TB. According to qualitative data strict adherence to the drug regimen is also an essential component of infection control. Improvement of clinical symptoms contributed to discontinuation of drug regimen. This is in line with conclusions with the following studies.[17,19] Qualitative analysis revealed that mass media will be the best method to provide TB health education to the public. These studies also conclude that mass media is the best method to disseminate TB health education to both rural and urban populations.[17,20,21]
In the present study, information on infection control followed by TB patients was assessed based only on the information produced by the TBHV. Risk factors like lack of cross ventilation and overcrowding were assessed based on the information produced by the respondent. The limitation of this study is that it is a hospital based study; the sample is not a representative sample of the population. The important limitation of the study involving survey technique is self-reporting by the participants. The accuracy of the respondent's response on the knowledge, attitude, and practise cannot be verified. In the present study, some of respondents were presumptive TB cases; their responses could have been influenced by previous encounter with TB patients.
Conclusion:
The advocacy communication strategies related to infection control should be focussed at school level, general population, and widely displayed in the health care centres. It should be focused to the immediate care givers and household members of the pulmonary TB and presumptive TB patients.
Conflicts of Interest: The authors declare that they have no competing interests.
Acknowledgment: We are thankful to Indian Council of Medical Research (ICMR), New Delhi for accepting this work under Short Term Studentship program (STS) and State Tuberculosis Officer & Tuberculosis Health Visitors of Puducherry.
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