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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 10  |  Issue : 1  |  Page : 18-21

Assessment of patient's knowledge, attitude, and practice regarding pulmonary tuberculosis in a tertiary care hospital


Department of Medicine, Seth GSMC and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission20-Jun-2018
Date of Decision17-Jul-2018
Date of Acceptance25-Jul-2018
Date of Web Publication17-Oct-2018

Correspondence Address:
Dr. Smrati Bajpai
Seth GSMC and KEM Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJMS.INJMS_3_18

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  Abstract 


Background: Tuberculosis (TB) is one of the most common respiratory illnesses in India, to the extent that about 1/4th of the population afflicted by TB in the world, is found in India. The knowledge of the patient about the disease, his attitude toward it, and compliance to treatment are key factors in management of the disease. Objectives: The objective of this study is to assess the knowledge, attitude, and practices of the patients with regard to pulmonary TB. Methodology: A cross-sectional observational study was conducted among patients suspected of or diagnosed with pulmonary TB in a Tertiary Care hospital using a prestructured questionnaire. Results: A total of 100 patients participated in the study. Out of these, 74% had never suffered from TB in the past. Cough was identified as a symptom of TB by 75% participants. About 15% participants said they used no precautions while coughing. Conclusion: The study reveals that there are quite a few misconceptions regarding causes, transmission, and prevention of TB. There is still a long way to go to educate the population regarding such a common illness.

Keywords: Attitude and practice in patients, hospital based study, knowledge, patient awareness, pulmonary tuberculosis


How to cite this article:
Deogaonkar VN, Kuwelker S, Bajpai S. Assessment of patient's knowledge, attitude, and practice regarding pulmonary tuberculosis in a tertiary care hospital. Indian J Med Spec 2019;10:18-21

How to cite this URL:
Deogaonkar VN, Kuwelker S, Bajpai S. Assessment of patient's knowledge, attitude, and practice regarding pulmonary tuberculosis in a tertiary care hospital. Indian J Med Spec [serial online] 2019 [cited 2019 May 24];10:18-21. Available from: http://www.ijms.in/text.asp?2019/10/1/18/243625


  Introduction Top


Tuberculosis (TB) is known to cause pulmonary and extrapulmonary lesions. It is also one of those communicable diseases whose chemotherapeutic treatment was discovered years ago. Prevention strategies are also in place to tackle it. More than 9 million people developed TB worldwide in 2013 alone[1] 1/4th of which were in India, making India the country with the highest TB burden.

There are numerous lifestyle determinants such as patient compliance, patient attitude, standard of living, quality of life, healthcare delivery, and policies that contribute to the festering of this disease. These are lacking in developing countries. The knowledge of the patient, his attitude toward disease, and compliance to treatment are key factors in management of the disease.

India is one of the major TB affected countries of the world with prevalence rates of 211 per 10000 population and incidence rates of 171 per 10,000 population per year.[2] A rise in the rates of drug-resistant TB is also a major worry. In such a community where TB, a highly communicable infectious disease is so prevalent and where the social stigma attached to the same is so high, the knowledge, attitude, and practice of a TB patient gains tremendous importance. This study is, therefore, directed toward evaluating the patients understanding and subsequent response to the disease and treatment. This will give us an insight into why TB even after being totally preventable and curable is still the second most common cause of death attributable to infectious disease and may be also the reason behind the increase in drug-resistant cases.

The objectives of the study are:

  1. To evaluate the knowledge of patients regarding the disease
  2. To evaluate the attitudes of friends and family of the patients as per patient
  3. To evaluate the practices of patients suspected of or diagnosed with pulmonary TB.



  Methodology Top


An institution-based observational study was conducted at the tertiary care hospital, Seth G. S. Medical College and KEM Hospital after ethical clearance by the Institutional Ethics Committee. It was a cross-sectional study conducted from April 2015 to January 2017 among patients suspected of or diagnosed with pulmonary TB. The suspected case for our study was defined as any patient with cough for more than 2 weeks with or without fever. A total of 100 participants, including both indoor and outdoor patients under the medicine department of KEM Hospital, Mumbai, who were suspected or diagnosed of pulmonary TB and aged over 12 years, were included in this study. Participants excluded from the study were patients of extrapulmonary TB, patients not consenting for the study participation, patients having severe neurologic deficits and may have problem in understanding and filling the questionnaire, patients whose vital parameters were unstable. Data were collected using a prestructured questionnaire containing both multiple choice and open-ended questions to assess the knowledge, attitude, and practices of the participants. The questionnaire was divided into four sections: sociodemographic data and comorbidities, knowledge of the patients regarding TB, attitude of the patients with regards to TB as a disease as well as the attitude of their family members, and friends toward them. The last section covered certain norms and practices followed by the patients and how long it took for the patients to actually come to the hospital for treatment. Questions were also asked pertaining to the preventive measures taken by the patients to prevent the spread of the disease as well as the treatment followed by them. This questionnaire was prevalidated by experts as well as 10% of the sample before the commencement of the study. These questionnaires were translated to the local languages spoken (Hindi and Marathi) and completed in the presence of a member of the research team. Written informed consent was taken of all the participants. Data were entered in MS-Excel and analyzed using descriptive statistics.


  Results Top


Sociodemographic characteristics

A total of 100 patients were assessed for their knowledge, attitude, and practices regarding pulmonary TB. The mean age of participants was 42.0 (±5.83) years. Majority of the participants, i.e. 74 (74%) had never suffered from TB in the past. 26 (26%) had TB in the past, half of them having received treatment in the same hospital. Majority participants, i.e. 59 (59%) belonged to poorer socioeconomic strata. Out of 100 participants, 45 (45%) had a close relative suffering from TB in the past. The participants were also questioned regarding pertinent comorbidities, namely their diabetic and retroviral status. The sociodemographic characteristics and comorbidities of the participants are given in [Table 1].
Table 1: Sociodemographic characteristics and comorbidities of the study participants

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Knowledge about the disease

Information and knowledge regarding the disease were acquired from four sources i.e. doctors/hospital staff 76 (76%), family members 14 (14%), papers 5 (5%), and television 5 (5%). Majority of the participants i.e. 90 (90%) said that TB was a communicable disease. The knowledge of the participants about cause, source, and transmission is given in [Table 2].
Table 2: Participants knowledge of tuberculosis

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Risk factors for TB mentioned by the participants were low body weight by 64 (64%), lack of drugs 53 (53%), overcrowding 43 (43%), lack of hygiene 34 (34%), poverty 24 (24%), low immunity 21 (21%), and sharing food 22 (22%). The common symptoms as identified by the participants were cough by 75 (75%), fever 42 (42%), and weight loss 33 (33%). A quarter of the participants (25%) could not identify even a single symptom of the disease.

About the treatment of the disease, 86 (86%) of them believed TB could be completely cured and 14 (14%) did not. The knowledge regarding free medication availability for TB was known only to 31 (31%) while 69 (69%) thought that the medication would require some expenditure. Most of the participants 66 (66%) were unaware about where the medications were available in hospital. The duration of treatment was recognized as 6 months by 48 (48%) and 9 months by 19 (19%) participants while the remaining 33 (33%) did not know the standard duration of treatment. Almost all i.e. 98 (98%) of the participants were unaware of the Directly Observed Treatment Short Course (DOTS).

Out of 100 participants, 80 (80%) agreed and 5 (5%) disagreed that the spread of TB could be prevented by observing coughing etiquettes in public places whereas 15 (15%) believed coughing has nothing to do with spread of TB.

Attitude and practices

Majority of the participants i.e. 78 (78%) strongly agreed that they were scared of being diagnosed with TB. More than half i.e. 66 (66%) were not confident about talking to their family and friends about the disease. However, only 22 (22%) believed that the attitude of their family and friends would change toward them on being diagnosed with TB.

Before coming to this hospital, 48 (48%) of the participants had received treatment from a nonallopathic doctor (Ayurvedic, quack, and others). Out of these 48 participants, most i.e. 31 (64%) visited the nonallopathic doctors due to advice from relatives and 12 (25%) due to religious and other superstitious belief. The remaining did not state any reason.

Precautions taken by the patients while coughing included covering mouth with hand by 41 (41%), using any immediately available cloth 19 (19%), handkerchief 16 (16%), mask 8 (8%), and tissue paper 1 (1%). Around 15 (15%) of the participants did not use any precaution while coughing. Other precautions that participants believed a TB patient should take included sleeping well 40 (40%), eating healthy food 38 (38%), taking rest 12 (12%), eating nonvegetarian food 7 (7%), and drinking milk 3 (3%).


  Discussion Top


Despite India having an extensive national health program for the control and prevention of TB, free treatment and directly observed therapy for all patients, it still contributes to nearly 1/4th of the worlds' TB burden with incidence rates higher than most other countries.[1],[2]

There are a lack of studies that focus on factors for delayed healthcare seeking and the knowledge, attitudes, and practices of TB patients in the urban Indian set up, that we emphasize in our study. Unlike studies conducted in Ethiopia, Pakistan, and Madagascar[3],[4],[5] that included predominantly rural communities, our study focuses on the urban city dwelling populations of Mumbai. Specifically looking at the knowledge, attitude, and practice of TB patients hailing from both slum and nonslum areas, socioeconomic strata appears to play a key role in these determinants.

Ignorance about the availability of free treatment appears to be one of the major factors for the delay in seeking treatment and insidious progress of the disease generally not a factor seen in other prior studies in different regions.[6] The knowledge about the causes, symptoms, and other details about TB seem to come from interaction with doctors and other healthcare workers as seen in most other studies as well.[3],[5],[7] Other forms of media contributed very little to the knowledge of patients which highlights the current lack of effort to educate the public through public platforms such as radio, TV, and newspapers. Efforts should be focused on educating lower strata of uneducated public (slum dwellers) who have no access to radio, TV, and newspapers as well through an active approach by healthcare workers in the community. Currently, the Revised National TB Control Programme of India focuses primarily on a passive approach to TB diagnosis and detection which would benefit further by actively seeking out these cases. Lack of awareness about the DOTS course among 85% of the diagnosed TB patients throws light on the significant prevalence of multidrug-resistant TB[1],[2] patients in the city of Mumbai.

Although risk factor for acquiring the disease were generally known by a majority of the patients, wrong information about the spread of the disease, for example, by food, waterborne, or skin contact was seen in nearly half of the patients suffering from the disease which has been a recurrent finding in multiple studies done all around the world.[3],[5],[7] This may be a major factor for the stigmatization of the disease and subsequent delay in seeking treatment.

Among groups to focus on, greater knowledge was not related to any particular age or sex as has been observed in other studies. The patients identified cough, fever, and weight loss as the major symptoms of TB, which was also seen when people participating in the Ethiopian and Pakistani studies were asked this question.[3],[5],[7] However, almost a quarter of the patients in our study could not identify even a single symptom of TB, which proves that more needs to be done by the healthcare system in India to educate the people.

Attitudes of most patients to the disease was with a sense of fear and an inability to discuss it with their family members contributing to delayed health-seeking practice seen pervasively in most studies, especially in a 30 districts survey conducted in India focusing mainly on the stigma surrounding the disease.[3],[8] However, due to close-knit family communities in India, unlike other studies in Ethiopia and Madagascar,[3],[4] patients did not believe that the attitudes of their family members toward them had or would change postdiagnosis. Hence, focused approach on family counseling and the family as an important part in management of a TB patient should be prioritized in urban communities in India.

Another practice found in our study that concurs with other studies was the practice to visit nonallopathic doctors, including quacks, most frequently due to advice from their relatives, while a few others said religious and superstitious beliefs played a role. In countries like India, working in tandem with local practitioners of other forms of healthcare in accordance with religious beliefs will increase patient adherence and healthseeking rather than circumventing these. Methods to educate these traditional nonallopathic doctors would also serve to benefit in improving KAP of TB patients in the community.[9]


  Conclusion and Recommendations Top


The study reveals that there are quite a few misconceptions in the general population regarding the knowledge about the cause of TB and the ways by which it spreads. It also shows that the disease is more prevalent among people in the lower socioeconomic strata. This might probably be because of the lack of education being afforded by the population with regard to the disease as well as poor living conditions. Considering how prevalent TB is among the general population, adequate measures should be taken to remedy this as soon as possible.

With a variety of initiatives taken by the government such as providing free treatment and DOTS program, it is equally surprising as well as disappointing to find out that the majority of the people are not aware of the very existence of those. Every effort should be taken by not only the government but also the healthcare community in spreading the knowledge about TB. Currently, mass media such as television, newspapers, radio, etc., are not being adequately utilized. Making use of these forms of communication would go a long way in making the people more aware about the symptoms of TB. This will lead to an active involvement of the general population in the control of the disease with early diagnosis and treatment.

Equally important to take note of is the fact that almost half of the population would visit a nonallopathic doctor before actually visiting the hospital. This quite often drastically delays the diagnosis and initiation of anti-TB treatment, which may sometimes lead to avoidable complications including death. We feel that the only way to tackle this problem currently is to improve the knowledge regarding TB in general and the importance of initiation of early treatment.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
World Health Organization. Global Tuberculosis Report; 2014. Available from: http://www.who.int/iris/handle/10665/137094. [Last accessed on 2015 Jun 13].  Back to cited text no. 1
    
2.
Cowling K, Dandona R, Dandona L. Improving the estimation of the tuberculosis burden in India. Bull World Health Organ 2014;92:817-25.  Back to cited text no. 2
    
3.
Esmael A, Ali I, Agonafir M, Desale A, Yaregal Z, Desta K, et al. Assessment of patients' knowledge, attitude, and practice regarding pulmonary tuberculosis in Eastern Amhara Regional State, Ethiopia: Cross-sectional study. Am J Trop Med Hyg 2013;88:785-8.  Back to cited text no. 3
    
4.
Rakotosamimanana S, Mandrosovololona V, Rakotonirina J, Ramamonjisoa J, Ranjalahy JR, Randremanana RV, et al. Spatial analysis of pulmonary tuberculosis in Antananarivo Madagascar: Tuberculosis-related knowledge, attitude and practice. PLoS One 2014;9:e110471.  Back to cited text no. 4
    
5.
Mushtaq MU, Shahid U, Abdullah HM, Saeed A, Omer F, Shad MA, et al. Urban-rural inequities in knowledge, attitudes and practices regarding tuberculosis in two districts of pakistan's punjab province. Int J Equity Health 2011;10:8.  Back to cited text no. 5
    
6.
Rondags A, Himawan AB, Metsemakers JF, Kristina TN. Factors influencing non-adherence to tuberculosis treatment in Jepara, Central Java, Indonesia. Southeast Asian J Trop Med Public Health 2014;45:859-68.  Back to cited text no. 6
    
7.
Khan JA, Irfan M, Zaki A, Beg M, Hussain SF, Rizvi N, et al. Knowledge, attitude and misconceptions regarding tuberculosis in Pakistani patients. J Pak Med Assoc 2006;56:211-4.  Back to cited text no. 7
    
8.
Sagili KD, Satyanarayana S, Chadha SS. Is knowledge regarding tuberculosis associated with stigmatising and discriminating attitudes of general population towards tuberculosis patients? Findings from a community based survey in 30 districts of India. PLoS One 2016;11:e0147274.  Back to cited text no. 8
    
9.
Gopu GS, Rao VB, Vadivet J. Impact of health education on the knowledge of tuberculosis among sputum-positive pulmonary TB patients and their care-givers. Nurs J India 2012;103:160-2.  Back to cited text no. 9
    



 
 
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