Knowledge, Attitude, and Practice of Tuberculosis Among Healthcare Workers in Karachi, Pakistan: A Cross-Sectional study

doi:10.21203/rs.3.rs-3585776/v1

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Knowledge, Attitude, and Practice of Tuberculosis Among Healthcare Workers in Karachi, Pakistan: A Cross-Sectional study

https://doi.org/10.21203/rs.3.rs-3585776/v1

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Background:

With over half a million new tuberculosis (TB) cases surfacing each year, Pakistan is among the 30 high TB burden countries. Being deeply underfunded in its fight against TB, much of the awareness among the general population comes from the healthcare workers (HCWs) who are at risk of acquiring nosocomial infection. Thus, this research aims to assess TB's knowledge, attitude, and practice (KAP) among HCWs in Karachi, Pakistan.

Methods:

An institution-based cross-sectional survey was conducted in nine hospitals providing TB services in Karachi, Pakistan, using an anonymous, self-administered questionnaire. Three hundred eighty-four responses from HCWs were assessed for their knowledge, attitudes, and practices on TB infection control.

Results:

The knowledge of TB infection control among almost half (45.8%) of HCWs was poor and much poorer among administration and lower-level staff. The knowledge level was significantly associated with educational status and TB training and orientation received. The majority (73.2%) of HCWs were positive about TB infection control. Sixty-five percent of HCWs were found to be concerned about being infected with TB. The use of respirators among the HCWs was limited, and triage of TB suspects was also lacking.

Conclusions:

The results revealed some knowledge gaps and poor practices among healthcare workers regarding TB. Therefore, health professionals must undergo periodic training customized to their needs.

Occupational Medicine

Health knowledge

Health education

Tuberculosis

Healthcare worker

Attitudes

Tuberculosis (TB) is the 13th leading cause of death and the second leading killer of a single infectious agent worldwide after COVID-19 (1). In 2021, an estimated 10.6 million people fell ill with TB worldwide, while TB took the lives of 1.6 million people globally (1). According to the World Health Organization (WHO), Pakistan accounts for 61% of the total TB burden in the Eastern Mediterranean, with 510,000 new cases and approximately 15,000 developing drug-resistant TB cases emerging yearly (2). The following factors contribute to developing drug resistance forms of TB: delayed diagnosis, unsupervised, inappropriate, and inadequate drug regimens, poor follow-up, and a lack of social support for high-risk populations (2). Although many reasons can account for this, healthcare workers (HCWs) can play a pivotal role in reducing the TB burden. Several stigmas and misconceptions surround this disease that keep people from getting tested or adhering to long-term treatment. In this regard, HCWs can provide guidance and clear up misconceptions attached to the illness by imparting TB-related knowledge, having the right attitude, and implementing the possessed expertise in their practices.

It is found, however, that there are gaps in knowledge, attitude, and practices of TB amongst HCWs in high TB burden countries such as Ethiopia, Southern Mozambique, Nigeria, and Nepal (3–5). According to some studies, HCWs are at an increased risk of acquiring TB compared to the general population, regardless of economic setting and local TB incidence, and it is also termed an occupational disease (6–8). Healthcare facilities in low-and middle-income countries (LMICs) like Pakistan, where TB is more likely to be endemic, lack the resources to implement effective TB Infection Control (TBIC), placing HCWs at serious risk (9–13).

There is a paucity of reliable literature depicting the current knowledge, attitude, and practice of healthcare workers in Pakistan. Pakistan is listed among 30 countries with high multi-drug-resistant TB burdens (14). This study is much needed to evaluate the loopholes in the implementation of (TBIC) by the Pakistan National TB Program. An earlier study by Ahmed et al. explored this association among private practitioners in a rural district of Sindh (15), but no literature exists for cosmopolitan cities like Karachi. HCWs will employ good TBIC practices if they demonstrate adequate KAP, which would decrease their risk of contracting the disease. Hence, this study assesses the KAP of Karachi's HCWs toward tuberculosis.

Study Design, Setting, and Population

This cross-sectional study on knowledge, attitude, and practice regarding TB among HCWs of Karachi was conducted between the 11th and 18th of June 2022. The HCWs included doctors (excluding undergraduates), nurses, teachers, midwives, pharmacists, and laboratory workers. Nine hospitals were targeted, of which 6 were government: Ruth KM Pfau Civil Hospital, Abbasi Shaheed Hospital, Jinnah Postgraduate Medical Center (JPMC), Sindh Government Hospital, Lyari General Hospital, and Dow University Hospital (Ojha), while 3 were private hospitals: Agha Khan University Hospital, Saifee Hospital, and Liaqat National Hospital. The minimum sample size estimated was 377, determined using a margin of error of 5% and a confidence interval (CI) of 95%. We distributed 500 questionnaires to account for mistakes and non-respondents. With 384 appropriately filled questionnaires, our study had a 76.8% response.

Questions regarding the N95 respirator seemed to confuse most of the responders. To avoid this, only those responders who knew that HCWs should use N95 for prevention were directed to fill in the rest of the questions regarding N95 (203/384). This was done to eliminate any subsequent N95-related correct responses produced purely out of fluke. Hence, all further replies regarding N95 were marked incorrect. Each questionnaire was filled under the supervision of a research team member to clear respondents' confusion, if any. Completed questionnaires were reviewed, and the data was entered on the same day.

Survey Design and Scoring System

A self-administered, structured questionnaire was initially developed using "a guide to knowledge, attitude, and practice surveys" by the WHO and existing questionnaires in the literature [15]. For the pilot study, 20 random HCWs were chosen to fill out one questionnaire each, after which the questionnaire was reviewed. After that, the approved questionnaire was available in both English and Urdu. A scoring system was developed in which every correct response scored one, and an incorrect answer received two as its score. All questions, except the questions on N95, were closed-ended and had a fixed set of options. A mean score was then calculated for each of the three KAP categories. The mean value ranged between 1 and 2. The following scale was developed to access the mean score of each of the three categories: good (1-1.2), above average (> 1.2–1.4), average (> 1.4–1.6), below average (> 1.6–1.8) and poor (> 1.8-2.0).

Statistical Analysis

Statistical analyses included the calculation of mean and standard deviation for quantitative variables while calculating frequency and percentages for the categorical variables. The Mann-Whitney U test or Kruskal Wallis test was applied as appropriate to analyze the relationship between KAP mean scores and categorical data. Correlation between KAP scores was calculated using Spearman's correlation coefficient. All the significance tests were 2-tailed, and a p-value less than 0.05 was considered significant. Data was coded, entered, and analyzed using IBM SPSS Statistics 24.

Ethics and Confidentiality

Participants were informed about the study before enrollment, and their verbal consent was taken. Confidentiality was maintained at all levels of the study. The Ethical Review Committee of Dow University of Health Sciences approved the study.

Table 1 shows the socio-demographic characteristics of 384 HCWs. They had a mean age of 30.6(S.D.13.25), ranging between 22 and 67 years. There were more females than males (1.84:1). Almost half of the HCWs were physicians (49.2%) and belonged to the general ward (47.9%), while more than half were from the government sector (56.0%). The second leading profession and job location were health officers (28.4%) and OPD (29.4%). Among those who reported "others" (65) as their job location, 38 (9.90%) were from the isolation ward for infectious diseases and 27(7.03%) were from Pediatrics, Gynecology and Ear, Nose and Throat (ENT) wards. More than two-thirds of HCWs (67.5%) had experience of up to 5 years of service, of which (26.6%) worked for less than a year, and the rest (40.9%) served for 1 to 5 years. About one-third of HCWs (32.6%) had experience of more than five years. Most HCWs (83.1%) had not taken training for TBIC. Almost twice as many HCWs reported "some time" or "rare" interaction with TB patients as compared to "frequent" (1.98:1.00).

Table 2 shows the knowledge related to symptoms, transmission mode, diagnosis, prevention, and spread of TB among HCWs. The HCWs had "above average" knowledge regarding symptoms of TB (overall mean 1.25 SD = 0.150) according to our scale. 62.2% of HCWs answered correctly to 9–12 symptoms, 33.9% answered 5–8 symptoms correctly, and 3.9% responded correctly to less than five symptoms. Two symptoms of TB, chills and chest pain, were thought to not occur in TB by (48.2%) and (29.9%) HCWs, respectively. (67.4%) HCWs considered a headache to be a symptom of TB, followed by watery eyes (37%), blurry vision (32.6%), and ear pain (28.4). Regarding the mode of transmission of TB, the HCWs had "above average knowledge" (overall mean = 1.36 SD = 0.208) according to our scale. (63.9%) questions were answered correctly. Although almost everyone knew that TB spreads by airborne droplets (97.1%), only one-third of HCWs (33.1%) knew about it prenatally. About half of the HCWs thought that TB spreads by sharing utensils (48.2%), and 39.6% thought its transmission as bloodborne. Regarding diagnosis, prevention, and spread of TB, our results show that HCWs had "above average" knowledge regarding TB according to our scale (overall mean score of 1.38 SD = 0.151). All the knowledge questions are shown in Table 2, except regarding which respirator is used for TB prevention, and N95 had 68.2% incorrect responses. However, significant gaps in knowledge were present. 73.4% of HCWs thought that gloves provide complete protection against TB transmission. Almost half of the HCWs (49%) thought that people who receive Bacillus Calmette-Guérin (BCG) vaccination do not develop TB. Moreover, (44.5%) of HCWs thought that TB patients become infectious as soon as TB treatment begins, while (40.1%) said that there is no difference between TB infection and disease. Adding to this, more than one-third of HCWs (34.9%) believed that patients with LTBI are also infectious. Lastly, (29.4%) of HCWs did not know that TB can be diagnosed by tuberculin skin test. Regarding the type of respirator, nearly half of the HCWs (47.1%) did not realize that N95 was used to prevent TB spread (203 or 52.9% knew). Only those who knew about N95 (203 or 52.9%) as the choice of respirator were asked further about N95. They responded with 80.1% correct responses regarding N95 usage. However, 36.5% responded that N95 should be used for more than a day. Those who didn't know about N95 were automatically marked incorrect for further N95-related questions. Thus, the overall knowledge score for N95-related questions fell to 45%. The overall mean knowledge score was calculated by merging all questions from Tables 2, 3 and 4 and HCWs displayed "above average" overall knowledge of TB (mean = 1.33, S.D.=0.103).

Table 3 presents the mean scores for the attitude of HCWs regarding TB. The attitude of HCWs was above average according to our scale (mean = 1.29, S.D.=0.179). The questions regarding attitude, except for the ones regarding N95 and surgical masks (203 respondents), had a positive response of 76.5%. Most HCWs (> 85%) agreed that coughing patients should be told about cough hygiene and that TB suspects their visitors should wear masks within and outside health facilities around TB suspects. 84.4% of HCWs agreed that TB patients should be separated from HIV patients, and 82.2% agreed to offer TB tests to all TB suspects. Also, 79% of HCWs decided that it was essential to know their HIV status and that if they were to develop symptoms of TB, they would request a diagnosis comfortably. However, some gaps in attitude were seen. About 36.7% of HCWs didn't believe they should minimize their time with TB patients in the health facility. 31.8% responded that they would not feel comfortable requesting to get relocated to a low-risk TB area if they were HIV positive and working in a high-risk TB area, while 31.8% also thought that when a TB patient leaves the room they are in, they cannot get TB. Furthermore, 29.7% did not trust the laboratory test results, while 29.9% felt uncomfortable opening doors and windows to prevent TB spread. In addition, 26.6% and 26.3% said that staff rotation to avoid the same HCWs around high-risk TB areas was not essential and that TB suspects should not be isolated from other patients respectively.

Table 4 shows the mean scores for the practice of HCWs regarding TB. According to our scale, HCWs had average responses to practice questions (mean = 1.51, SD = 0.233). The questions regarding practice, with 384 respondents, had a mean percentage of 57.5% positive responses (always, often), while those regarding the N95 respirator, with 203 respondents, had a mean rate of 73.7% positive responses. 82.8% of HCWs agreed that they always washed their hand after encountering respiratory secretions and that they ordered sputum specimens for active TB suspects. In contrast,35.4% of HCWs did not (never or sometimes) educate patients about cough hygiene, and 26.3% did not open doors or windows. Furthermore, 88.5% of HCWs said they wore respirators for less than 50% of their shift, and 70.6% of HCWs said they sometimes or never offer surgical masks to TB patients sitting in the wards. The questions regarding N95 answered by 203 participants were generally better answered. 81.8% of HCWs knew how to wear an N95 mask,86.7% always threw their N95 mask when it got dirty, and 72.4% said they wore N95 when transporting TB patients. However, about 40.4% of HCWs noted that they never or sometimes wore N95 when in a room with TB suspects, and 32% said that they used each N95 for more than a day before throwing it away.

As seen in Table 5, there is a significant difference in the knowledge of HCWs concerning their profession, period of service, employment sector, and TBIC training. Lab technicians, physicians, private sector employees, and those with more years of experience, except for 11–20 years, were seen to have better knowledge scores. Those who took TBIC training also performed significantly better in the knowledge section. Profession, job location, and TBIC training were seen to have a significant effect on the attitude of HCPs. At the same time, mean practice scores were significantly affected by gender, profession, employment sector, period of service, and TBIC training. It is also seen that profession and TBIC training have a significant p-value on all three KAP scores.

In contrast, the employment sector and service period significantly affect mean knowledge and practice scores. Amongst the professionals, lab technicians and physicians had the highest and second-highest mean knowledge and attitude scores, respectively. Nurses outperformed all other professionals in practice scores, followed by lab technicians and physicians. Those with TBIC training also performed significantly better in all three categories (knowledge, attitude, and practice. There was a moderate and statistically significant positive correlation between knowledge and attitude (R_s=0.478, p < 0.001), knowledge and practice (R_S=0.454, p < 0.001), and attitude and practice scores (R_s=0.574, p < 0.001).

Knowledge gaps amongst HCWs regarding TB can result in poor TBIC, substandard care of the patients, inefficient resource use, increased risk of TB transmission, and undesirable health outcomes. It is partly due to the knowledge of HCWs that patients either conform to or resist the extended treatment. Conducting this study in Pakistan was imperative as HCWs, especially physicians, observe the role of a messiah (savior), and their guidance is valued; hence, HCWs could play a vital role in not only removing the TB-related stigmas and misconceptions harbored by the ill-informed Pakistani population but also in guiding them regarding TBIC. Consequently, those disseminating knowledge must be thoroughly informed about the recent advancements in disease prevention, detection, and treatment. A dearth of literature on KAP of HCWs towards TB in Pakistan was observed, presenting the need to conduct the study. Pakistan reported one of the most significant funding gaps (90 million USD) in 2019; hence, the funding needs for TB prevention, diagnosis, and treatment couldn't be met (14). Therefore, this study and similar literature become essential in formulating focused strategic plans so that the meager resources can be efficiently used to restrict the TB burden.

The HCWs were assessed for their knowledge, attitude, and practice of disease. The results of this study were also compared with studies conducted in other countries to evaluate the progress and efforts of the National TB Program of Pakistan. The studies included for comparison had different scales for the evaluation of KAP. Our study showed that symptoms-related questions were generally well answered, with 75% correct responses. More than 90% of people knew about blood in cough and cough for over two weeks as crucial symptoms in suspecting TB. It was consistent with the findings of a study in Sindh and Iraq in which 2/3 of HCWs and 93.2%, respectively, considered it a cardinal symptom (15, 16). Weight loss and night sweats were correctly answered in more than 80% of the responses. Despite the overall good response, some gaps were observed. Pakistan is not alone, as some gaps in knowledge of symptoms were also observed in a study conducted in Russia (11). Our study showed that 48.2% and 30% of HCWs didn't suspect complaints of chills and chest pain, respectively, as indicative of TB. Deficits in the knowledge of symptoms can increase the risk of transmission while simultaneously exacerbating the illness. Thus, knowledge of symptoms is imperative for HCWs so that timely interventions can be made.

Knowledge of the transmission mode can limit the spread of disease, given that proper TBIC measures are taken. While this is true for every person who has direct contact with TB patients, special precautions must be taken by HCWs who are at a greater risk since they face job situations of exceptionally high risk, such as those involving the generation of respiratory aerosols from patients, including bronchoscopy, endotracheal suctioning and intubation, cough and sputum induction and the administration of irritation medications (e.g., pentamidine) by aerosol (17). Although the transmission-related knowledge score was above average, and 97.1% knew about its airborne transmission, a staggering 48.2% of the participants thought it possible to spread TB by sharing utensils. Was quite appalling that almost 2/3rd (67%) of HCWs did not know about the rare yet highly fatal condition called congenital TB, which transmits vertically from TB-positive mothers to babies intrauterine or during parturition (18). Gaps in knowledge regarding the transmission mode are also evident in a study conducted in Russia, where HCWs believed that transmission is possible through the shared use of needles and liquid products (11).

Our study reports above-average overall knowledge (67%) of HCWs in Pakistan. This score was more significant than countries like Russia and South Mozambique while being comparable to Peru (67.3%) (4, 11, 19). On the contrary, HCWs in Iraq, Northwest Ethiopia (74.4%), and Chennai (India) had higher knowledge scores than those found in our study (16, 20, 21). According to 73% of respondents, gloves provide complete protection against TB, possibly related to the misconception that TB spreads through sharing utensils. Misconceptions of this nature could undermine WHO's End TB Strategy, which seeks to decrease global TB incidence by 80%, TB deaths by 90%, and catastrophic costs for TB-affected households by 2030 (22). There is no one-size-fits-all approach to the Strategy, and its success depends on adapting to diverse country settings.

Our data suggests a generally positive attitude towards working with TB patients, although some negative attitudes were also noted. The overall practice scores (49%) were found to be relatively poorer than both mean attitude (71%) and knowledge (67%) scores. About 36.7% of HCWs didn't agree that they should minimize the time spent with TB patients, which could intensify their high risk of contracting TB. About 79% of HCWs would request a test on experiencing symptoms that could be related to lesser stigma concerning TB. However, in Southern Mozambique, 48.2% believed that the stigma of TB was greater than that of HIV (4). Most HCWs (> 85%) agreed that coughing patients should be told about cough hygiene, which is comparable to Northwest Ethiopia (86%), but only 64.6% of HCWs educated their patients about cough hygiene (20). However, it's a worrisome figure but is better than Nepal, wherein only 38% of the HCWs are informed about cough etiquette (5). This is discussed because one of the barriers to patient education is the gaps between the attitude and practice of HCWs, leading to poor infection control. Cracks in attitude (29.9%) and practices (26.3%) regarding opening doors and windows were observed. Similar figures are observed in other studies, such as Ethiopia, wherein only 43% opened doors and windows (3). Educating HCWs to maximize natural ventilation by opening windows is an easy, low-cost intervention that may reduce patients' and HCWs' exposure to airborne TB and is fit for LMICs like Pakistan. The practice score to order sputum specimens for active TB is high (83%), indicating sound knowledge of the test for diagnosis, unlike the results of the research conducted in rural Sindh and Delhi, where the majority of the HCWs order multiple tests resulting in inefficient resource use which can be burdensome for a developing country like Pakistan (15, 21).

Regarding respirators, gaps in KAP are observed, and similar cracks were observed in studies conducted in other high TB-burden countries: 38% Of HCWS didn't wear respirators in Nepal (5). Although 34.2% of the HCWs felt that a respirator should be worn to prevent transmission, only 21% used masks in Northwest Ethiopia, and a lower level of knowledge was observed on the use of shows in Uganda (20, 23). One of the reasons for such results could be the limited availability of masks in these countries, as discussed in studies conducted in Ethiopia (3). As Pakistan is an LMIC, the limited availability of face masks could explain knowledge gaps and unwillingness to offer masks to TB patients because, in such countries, access to appropriate levels of PPE may be restricted owing to a lack of resources.

According to the findings, 83.1% of the HCWs didn't take any training for TBIC, and this factor can account for the gaps observed as TBIC training is seen to impact the scores of all three categories significantly. The significance of training in influencing KAP scores is highlighted in the studies conducted in Nepal, Chennai (India), South Africa, Northwest Ethiopia, and Uganda (5, 20, 21, 23, 24). Thus, specialist training could have a positive impact on the KAP of the HCWs. Through these trainings, HCWs could learn about recent scientific literature and advances in TBIC, as well as national and international guidelines and best practices. Moderate and statistically significant positive correlations are found between KAP scores. The correlations were also observed in other studies, such as Nepal and Northwest Ethiopia(5, 20) These figures indicate that TBIC training, even encompassing theoretical aspects, could positively impact the overall KAP scores.

As per this research, there is a significant difference in the knowledge of HCWs concerning their profession, with physicians having the second-best knowledge score, second only to lab technicians. This is consistent with studies conducted in Southern Mozambique, Russia, and Iraq (4, 11, 16). Our analysis also identified a significant association between more extended service periods and knowledge of the disease in Iraq (16). Profession significantly affectsttitude scores, comparable to the study conducted in Saudi Arabia (25). Profession is also associated with higher practice scores in this research and a survey of southern Mozambique (4).

Given the results of the current study, interventions to improve HCWs' KAP are needed. HCWs should receive personalized, high-quality, periodic TB education and training. Training should be determined according to job categories and needs, and attention should be directed to training HCWs from non-clinical and auxiliary staff to prepare them to work safely in high-risk settings, as this profession has a significant p-value on all three KAP scores. The high KAP scores for lab technicians could be attributed to the small sample size (N = 14), which may not represent their population. Training should focus on the theoretical and skill-building components of TBIC to improve the overall scores.

Additionally, the availability of resources such as N95 masks could influence the KAP scores significantly in LMICs like Pakistan, where access to appropriate levels of personal protective equipment may be restricted owing to competing demands for funding in hospital settings. The efficiency of the HCWs can be limited by other factors such as the pay scale, working hours, hospital policies, job satisfaction, infrastructure constraints, and other incentives provided. Addressing these factors would play a part in augmenting KAP scores.

The study conducted has some limitations. The sample size (N = 384) represents a small proportion of HCWs working in Karachi and could be insufficient to gauge the KAP of the HCWs all over the city. Almost ¾ of the questionnaires (77.6%) were filled by physicians and health officers; hence, the data from other HCPs may not accurately represent their KAP. The present study only measured variables that were self-reported by the HCWs and did not consider the availability of resources (such as N95 masks) required for the implementation of TBIC. Practice competency was approximated by self-reporting using a questionnaire rather than direct observation, which may overstate adherence to guidelines and introduce a response bias. Use of the stimulated client method or direct observation usually yields accurate results. The data was collected using a questionnaire, so the responses were prone to information bias. Knowledge regarding 1st and 2nd line anti TB drugs, MDR TB, XDR TB, treatment strategies, and modern diagnostic techniques such as GeneXpert MTB/RIF isn't investigated.

In conclusion, healthcare professionals must receive tailored, ongoing training to combat tuberculosis effectively. Targeted TB infection control (TBIC) training for healthcare personnel can help dramatically reduce our country's TB burden. Future research should concentrate on creating and assessing tailored treatments, with systematic reviews guiding informed decisions about expanding public-private mix DOTS initiatives.

Acknowledgment: None

Financial disclosure: None

Conflict of interest: None

Tuberculosis [Internet]. [cited 2023 Aug 16]. Available from: https://www.who.int/news-room/fact-sheets/detail/tuberculosis
WHO EMRO | Tuberculosis | Programmes | Pakistan [Internet]. [cited 2023 Aug 16]. Available from: https://www.emro.who.int/pak/programmes/stop-tuberculosis.html
Tenna A, Stenehjem EA, Margoles L, Kacha E, Blumberg HM, Kempker RR. Infection control knowledge, attitudes, and practices among healthcare workers in Addis Ababa, Ethiopia. Infect Control Hosp Epidemiol [Internet]. 2013 Dec [cited 2023 Aug 16];34(12):1289–96. Available from: https://pubmed.ncbi.nlm.nih.gov/24225614/
Noé A, Ribeiro RM, Anselmo R, Maixenchs M, Sitole L, Munguambe K, et al. Knowledge, attitudes and practices regarding tuberculosis care among health workers in Southern Mozambique. BMC Pulm Med [Internet]. 2017 Jan 5 [cited 2023 Aug 16];17(1). Available from: /pmc/articles/PMC5217625/
Shrestha A, Bhattarai D, Thapa B, Basel P, Wagle RR. Health care workers’ knowledge, attitudes and practices on tuberculosis infection control, Nepal. BMC Infect Dis [Internet]. 2017 Nov 17 [cited 2023 Aug 16];17(1):1–7. Available from: https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-017-2828-4
Baussano I, Nunn P, Williams B, Pivetta E, Bugiani M, Scano F. Tuberculosis among Health Care Workers. Emerg Infect Dis [Internet]. 2011 Mar [cited 2023 Aug 16];17(3):488. Available from: /pmc/articles/PMC3298382/
de Vries G, Šebek MMGG, Lambregts-van Weezenbeek CSB. Healthcare workers with tuberculosis infected during work. European Respiratory Journal [Internet]. 2006 Dec 1 [cited 2023 Aug 16];28(6):1216–21. Available from: https://erj.ersjournals.com/content/28/6/1216
Chai SJ, Mattingly DC, Varma JK. Protecting health care workers from tuberculosis in China: a review of policy and practice in China and the United States. Health Policy Plan [Internet]. 2013 Jan [cited 2023 Aug 16];28(1):100–9. Available from: https://pubmed.ncbi.nlm.nih.gov/22427258/
Joshi R, Reingold AL, Menzies D, Pai M. Tuberculosis among health-care workers in low- and middle-income countries: a systematic review. PLoS Med [Internet]. 2006 Dec [cited 2023 Aug 16];3(12):2376–91. Available from: https://pubmed.ncbi.nlm.nih.gov/17194191/
Christopher DJ, Daley P, Armstrong L, James P, Gupta R, Premkumar B, et al. Tuberculosis Infection among Young Nursing Trainees in South India. PLoS One [Internet]. 2010 [cited 2023 Aug 16];5(4):e10408. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0010408
Woith WM, Volchenkov G, Larson JL. Russian healthcare workers’ knowledge of tuberculosis and infection control. Int J Tuberc Lung Dis [Internet]. 2010 Nov [cited 2023 Aug 16];14(11):1489. Available from: /pmc/articles/PMC3701102/
Christopher DJ, James P, Daley P, Armstrong L, Isaac BTJ, Thangakunam B, et al. High Annual Risk of Tuberculosis Infection among Nursing Students in South India: A Cohort Study. PLoS One [Internet]. 2011 Oct 12 [cited 2023 Aug 16];6(10):e26199. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0026199
Verkuijl S, Middelkoop K. Protecting Our Front-liners: Occupational Tuberculosis Prevention Through Infection Control Strategies. Clin Infect Dis [Internet]. 2016 May 15 [cited 2023 Aug 16];62 Suppl 3:S231–7. Available from: https://pubmed.ncbi.nlm.nih.gov/27118852/
WHO releases new global lists of high-burden countries for TB, HIV-associated TB and drug-resistant TB [Internet]. [cited 2023 Aug 16]. Available from: https://www.who.int/news/item/17-06-2021-who-releases-new-global-lists-of-high-burden-countries-for-tb-hiv-associated-tb-and-drug-resistant-tb
Ahmed M, Fatmi Z, Ali S, Ahmed J, Ara N. Knowledge, attitude and practice of private practitioners regarding TB-DOTS in a rural district of Sindh, Pakistan. J Ayub Med Coll Abbottabad [Internet]. 2009 Jan 1 [cited 2023 Aug 16];21(1):28–31. Available from: https://europepmc.org/article/med/20364735
Hashim DS, Al Kubaisy W, Al Dulayme A. Knowledge, attitudes and practices survey among health care workers and tuberculosis patients in Iraq. Eastern Mediterranean Health Journal. 2003;9(4).
Tuberculosis I of M (US) C on ROE to, Field MJ. The Occupational Tuberculosis Risk of Health Care Workers. 2001 [cited 2023 Aug 16]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK222462/
Kini PG. Congenital tuberculosis associated with maternal asymptomatic endometrial tuberculosis. Ann Trop Paediatr [Internet]. 2002 [cited 2023 Aug 16];22(2):179–81. Available from: https://pubmed.ncbi.nlm.nih.gov/12070954/
Minnery M, Contreras C, Pérez R, Solórzano N, Tintaya K, Jimenez J, et al. A Cross Sectional Study of Knowledge and Attitudes Towards Tuberculosis amongst Front-Line Tuberculosis Personnel in High Burden Areas of Lima, Peru. PLoS One [Internet]. 2013 Sep 19 [cited 2023 Aug 16];8(9):e75698. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0075698
Temesgen C, Demissie M. Knowledge and practice of tuberculosis infection control among health professionals in Northwest Ethiopia; 2011. BMC Health Serv Res [Internet]. 2014 [cited 2023 Aug 16];14(1). Available from: https://pubmed.ncbi.nlm.nih.gov/25406598/
Ajith Kumar G, Saranya P. A cross sectional study on knowledge, attitude and practice towards tuberculosis among health care workers. International Journal of Research in Pharmaceutical Sciences [Internet]. 2019 Oct 1 [cited 2023 Aug 16];10(4):2632–46. Available from: https://www.researchgate.net/publication/336695003_A_cross_sectional_study_on_knowledge_attitude_and_practice_towards_tuberculosis_among_health_care_workers
Global Tuberculosis Programme [Internet]. [cited 2023 Aug 16]. Available from: https://www.who.int/teams/global-tuberculosis-programme/the-end-tb-strategy
Buregyeya E, Kasasa S, Mitchell EMH. Tuberculosis infection control knowledge and attitudes among health workers in Uganda: A cross-sectional study. BMC Infect Dis [Internet]. 2016 Aug 15 [cited 2023 Aug 16];16(1):1–10. Available from: https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-016-1740-7
Naidoo S, Taylo M, Esterhuizen TM, Nordstrom DL, Mohamed O, Knight SE, et al. Changes in Healthcare Workers′ Knowledge about Tuberculosis Following a Tuberculosis Training Programme. Education for Health [Internet]. 2011;24(2). Available from: https://journals.lww.com/edhe/fulltext/2011/24020/changes_in_healthcare_workers__knowledge_about.9.aspx
Alotaibi B, Yassin Y, Mushi A, Maashi F, Thomas A, Mohamed G, et al. Tuberculosis knowledge, attitude and practice among healthcare workers during the 2016 Hajj. PLoS One [Internet]. 2019 Jan 1 [cited 2023 Aug 16];14(1). Available from: https://pubmed.ncbi.nlm.nih.gov/30682065/

Table 3 is not available with this version

Table 1: Socio-demographic variables of the sample population.

(TBIC: Tuberculosis Infection Control)

Characteristics	Category	Frequency	%
Age (in years)	<30	285	74.2
	30-39	30	7.8
	40-49	31	8.1
	50-59	30	7.8
	60-69	8	2.1
Gender	Male	135	35.2
Gender	Female	249	64.8
Profession	Physician	189	49.2
	Health Officer	109	28.4
	Nurse/ Midwife	57	14.8
	Lab assistants	14	3.6
	Pharmacist	10	2.6
	Teacher	5	1.3
Occupation sector	Government	215	56.0
	Private	143	37.2
	Both	26	6.8
Current job location	Outpatient department	113	113
	General ward	184	184
	Laboratory	14	14
	Pharmacy	8	8
	Others	65	65
Interaction with TB patients	Frequently	129	33.6
	Sometimes	165	43.0
	Rarely	90	23.4
Period of service (years)	<1	102	26.6
	1-5	157	40.9
	6-10	44	11.5
	11-20	29	7.6
	21-30	33	8.6
	31-40	19	4.9
Training for TBIC	Taken	65	16.9
Training for TBIC	Not taken	319	83.1

Table 2: Knowledge related to symptoms, mode of transmission, diagnosis, prevention, and spread of Tuberculosis (TB) among healthcare workers. (HIV: Human-immunodeficiency virus, BCG: Bacille Calmette-Guérin)

Knowledge regarding symptoms of TB
	Min	Max	Mean	SD
Overall	1	2	1.25	.150
Blurry vision	1	2	1.33	.469
Coughing for more than 2 weeks	1	2	1.02	.124
Coughing up blood	1	2	1.09	.292
Watery eyes	1	2	1.37	.483
Chest pain	1	2	1.30	.459
Ear pain	1	2	1.28	.451
Fever	1	2	1.05	.228
Headache	1	2	1.67	.469
Night sweats	1	2	1.16	.371
Chills	1	2	1.48	.500
Weight loss	1	2	1.05	.217
Tiredness	1	2	1.16	.366
Mode of transmission of TB
	Min	Max	Mean	S.D.
Overall	1	1.83	1.36	.208
Sharing utensils	1	2	1.48	.500
Shaking hands	1	2	1.30	.457
Airborne droplets	1	2	1.03	.167
Sexual transmission	1	2	1.29	.454
Bloodborne	1	2	1.40	.490
Mother to baby	1	2	1.67	.471
Diagnosis, prevention, and spread of TB
	Min	Max	Mean	SD
TB is contagious	1	2	1.08	.277
TB can be diagnosed by tuberculin test	1	2	1.29	.456
HIV increases the chances of TB infection	1	2	1.19	.395
There is a difference between TB infection and disease	1	2	1.40	.491
Patients with TB usually become noninfectious soon after initiating appropriate treatment	1	2	1.45	.498
People who have received BCG vaccination do not develop TB	1	2	1.49	.501
Usually, only people with active TB in the lungs or throat are infectious	1	2	1.35	.477
Patients with active TB disease are more likely to infect others if they have a cough that produces a lot of sputum	1	2	1.10	.302
Surgical masks protect HCWs and visitors by stopping TB particles from being inhaled	1	2	1.17	.380
Surgical masks keep TB patients from coughing TB particles into the air	1	2	1.23	.424
Gloves provide complete protection against transmission of TB infection	1	2	1.73	.442
Which respirator is used for TB prevention?	1	2	1.47	0.500
N-95 should be thrown away after each day’s use	1	2	1.66	.473
N-95 protects HCW and visitors by stopping TB particles from being breathed in	1	2	1.50	.501
N-95 should be kept in a plastic bag when not in use	1	2	1.56	.497
Mean knowledge score	1	1.80	1.38	.151
Overall knowledge score (spread, symptoms, and knowledge)	1.09	1.67	1.33	.103

Table 4: Questions regarding practice concerning tuberculosis (TB) among healthcare workers (HCWs).

Question regarding practice	Min	Max	Mean	SD
The proportion of shifts spent wearing respirators (>50%)	1	2	1.89	.319
How often do you offer surgical masks or N95 to TB patients sitting in the wards?	1	2	1.71	.456
Do you wash your hands after encountering the respiratory secretions?	1	2	1.17	.378
Do you order sputum specimens when you suspect active TB?	1	2	1.17	.378
Do you know how to wear an N95 mask properly?	1	2	1.57	.496
How often do you wear an N95 or a surgical mask when you are in a room with TB patients or suspects?	1	2	1.68	.465
How often do you wear an N95 or a surgical mask when you are transporting TB patients from one part of the hospital to another?	1	2	1.62	.487
How long do you use an N95 before you throw it away?	1	2	1.64	.480
How often do you throw an N95 away when it becomes dirty or wet?	1	2	1.54	.499
How much do you open doors/windows in your workplace?	1	2	1.26	.441
When you see patients cough, how often do you educate them about cough hygiene?	1	2	1.35	.479
Overall score	1	2	1.51	.233

Table 5: Relationship between socio-demographic variables and mean KAP scores. (TB: tuberculosis, TBIC: tuberculosis infection control, OPD: out-patient department)

Variable

Knowledge Scores

Attitude Scores

Practice Scores

Age

20-30

30-40

40-50

50-60

60-70

N¹

285

Mean

1.32

1.33

1.34

1.35

1.28

S.D.²

.10

.11

.10

P value³

.354

Mean

1.29

1.23

1.28

1.36

1.19

S.D.

.17

.18

.19

.21

.17

P value

.068

Mean

1.51

1.44

1.52

1.58

1.43

S.D

.23

.25

.20

.27

P value

.152

Gender

Male

Female

135

249

1.32

1.33

.10

.084

1.29

.20

.16

.327

1.45

1.54

.24

.22

.001

Profession

Physician

Health worker

Nurse

Lab technician

Pharmacist

Teacher

189

109

1.31

1.36

1.34

1.27

1.38

1.39

.10

.11

.10

.09

.10

<.001

1.27

1.34

1.29

1.14

1.32

1.33

.19

.16

.14

.20

.19

<.001

1.50

1.61

1.35

1.42

1.61

1.55

.23

.20

.22

.29

.18

.26

<.001

Employment sector

Govt.

Private

Both

215

143

1.34

1.31

1.35

.10

.006

1.30

1.27

1.32

.17

.19

.17

.233

1.55

1.45

1.54

.22

.23

.25

<.001

Job location

OPD

General ward

Laboratory

Pharmacy

Other

113

184

1.33

1.27

1.34

1.33

.11

.10

.11

.09

.235

1.30

1.14

1.36

1.28

.19

.16

.20

.16

.19

.009

1.51

1.42

1.56

1.50

.23

.29

.20

.23

.602

Period of service

1-5

6-10

11-20

21-30

31-40

102

157

1.35

1.32

1.31

1.38

1.32

1.31

.09

.11

.09

.10

.12

.003

1.31

1.28

1.26

1.34

1.30

1.25

.16

.19

.16

.18

.21

.18

.282

1.53

1.48

1.47

1.61

1.55

1.49

.23

.24

.23

.043

TBIC training

Yes

319

1.30

1.33

.11

.10

.043

1.23

1.30

.17

.18

.004

1.43

1.53

.23

.002

Interaction with TB patients

Frequent

Sometimes

Rarely

129

165

1.32

1.33

1.34

.09

.11

.10

.386

1.28

1.29

1.31

.17

.19

.18

.408

1.54

1.48

1.51

.21

.24

.25

.173

[1] N; no observations

²S.D.; Standard deviation

³P-value; significant p value for Kruskal Wallis or Mann Whitney U test is given in bold.

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Knowledge, Attitude, and Practice of Tuberculosis Among Healthcare Workers in Karachi, Pakistan: A Cross-Sectional study

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