This study was conducted to assess the TBIC-related knowledge and practices of nurse in 2 secondary health facilities in Ibadan, Nigeria, and their association with sociodemographic characteristics of the nurses. The results showed that the mean knowledge and practice scores were of 68.2% and 79.9% respectively. Furthermore, with the cut-off score for good knowledge and practice scores set at 80% and 100% respectively, it was found that only 10.5% and 6% of the nurses had good TBIC-related knowledge and practices respectively. The poor levels of TBIC knowledge and practice found in this study are consistent with reports from other studies in Nigeria, where generally, poor levels concerning TBIC have been demonstrated among HCWs [20,21,24].
It is noted here that there are several ways to assess and categorize knowledge and practices concerning TBIC. In the literature, some studies simply stated the mean scores and used this as the cut-off to categorize the scores while others used arbitrary cut-off points [26,28]. Even then, the categories may be varied: (i) good, moderate, and poor ; (ii) good and poor; (iii) good, fair, and poor; and (iv) proper, and improper [9,17,28,29]. The majority of the nurses in this study (>80%) were able to correctly identified the constitutional symptoms of TB (cough of 2-3 weeks duration, bloody sputum, night sweats weight loss and fever). This is somewhat similar to the finding by Bhebhe et al. among HCWS in Lesotho, except that in the Lesotho study, only 53.5% considered fever to be a symptom of TB [9]. Most of the nurses answered correctly the questions related to the mode of transmission of TB. For instance, 95% recognized that TB can be transmitted through coughing (96.5%) and reduction of transmission by employing cough etiquette/hygiene (96%) and opening of windows in a room where there is a TB patient (90%). This agrees with the findings in studies conducted in Lagos, Nigeria and Northwest Ethiopia [25,29]. It is also in conformity with findings from South Africa, where Kanjee et al. reported that “most of the information (knowledge) items were answered correctly by over 70% of respondents with some exceptions” and that the “HCWs were generally well informed about TB transmission” [15]. Similar observations were made in a study involving HCWs in Free State Province, South Africa [17].
The overall mean knowledge score of 68.2% reported in the study is higher than the findings of 61%, and 61.5% reported by previous investigators [9,35]. The poor knowledge level of TBIC is aligns with the results of a study by Woith et al. among HCWs in Russia [36]. In contrast to the poor knowledge noticed in the current study, some previous studies reported “good” or “adequate” TBIC knowledge among HCWs, although lower cut-off points were used in these studies. For instance, Bhebhe et al. reported that 89.2% of HCWs in their study in Lesotho had “appropriate” TBIC knowledge, but the cut-off used to categorize “good” was 70%, which is lower than 80% used in the present study [9]. The mean score of 61.5% reported by them was even lower than 68.2% recorded in the present study. Similarly, Buregyeya et al. reported that 69 % of the HCWs were thought to have adequate TBIC knowledge, with a cut-off of 70% [28]. Using a cut-off of 60%, 74.4% of health professionals in the study by Temesgen and Demissie were found to have “good” knowledge [27].
In terms of practice of TBIC measures, most of the nurses reported scores that were less than 80% as “always” practised for all the 5 items considered. Only 2 out of the 5 items had more than 70% of the nurses reporting them as “always” practised: cough etiquette/hygiene and opening of windows. Ekuma et al. also reported similar poor “always” findings for practice items [25].This was however different from the reports in the South African study by Engelbrecht et al., where 4 items out of 12 had more than 80% of the respondents who “always” practiced them: fast-tracking, screening, window opening, and collection of sputum specimens from coughing patients [17]. Of particular importance, however, is that the frequency of the TBIC mentioned in the South African study, just like in the current study, were self-reported by the respondents. In that study, the researchers noted a discrepancy between self-reporting and observed practices. We noticed in our study that the proportions of nurses reporting various TBIC measures as “always” practised were less than the proportions that recorded correct answers to related questions under the knowledge scale. This discrepancy suggests that although good levels of nurses’ TBIC knowledge have been shown to be closely associated with good TBIC practices, it is not its only determinant [17]. Other factors that influence proper TBIC practice include clear TBIC policy directives, appropriate triage system and separation facilities, availability of personal protection equipment, reasonable work load, adequate and well-ventilated clinic space, among others [37]. Findings from studies conducted in LMIC, where cost-effective TBIC measures are best suited, are in overwhelming support of the results of the practices in the present study. Inadequate practice of TBIC measures have been reported in Nigeria, South Africa, Lesotho and Ethiopia [10,11,17,29]. Tamir and his co-workers (2016), using 80% as their cut-off, found that only 38% of the HCWs in their study had overall proper TBIC practices [29]. Even where Temesgen and Demissie reported an overall “good” TBIC practice (with a cut-off of 50%- lower than the present study), specific practices were still poor [27]. Poor levels of implementation of TBIC measures were also reported by Bhebhe et al. in Lesotho and Kanjee et al. in South Africa [9,15]. The discrepancy noticed in the proportions with good knowledge and practice between the current study and previous ones could be due to the different cut-off points and scoring systems used. It is important to note that higher cut-off points were used in the current study. The finding of small proportions of nurses with good levels of TBIC-related knowledge and practices in this study is not completely unexpected as TBIC guidelines had just been released in the country at the time of the study and the implementation of the guidelines was still in its early stages [21,24].
Knowledge was not significantly related to all the socio-demographic factors considered, although the males, the younger ones, the more experienced, junior rank, and the unmarried ones had greater odds of having good scores. For TBIC practice, those with greater odds of obtaining good scores included the males, younger nurses, the less experienced ones, senior rank, and married ones. The distribution of the nurses in terms of sex and marital status was greatly skewed in favour of females (97.0%) and married respondents (91.5%). This pattern reflects the profile of nursing workforce in Nigeria as reported by other investigators [38]. Furthermore, the wide confidence intervals recorded for the separate regression analysis for the two factors as independent variables and knowledge and practice as dependent variables indicate low precision. These elements should be considered when interpreting the results. The findings from the current study on the association between the nurses’ TBIC knowledge and socio-demographic characteristics are in conformity with results from previous studies. Temesgen and Demissie revealed that TBIC knowledge among HCWs in Ethiopia were not significantly associated with work experience and age category [27]. Buregyeya et al. noted that age and sex were not associated with TBIC knowledge [28]. Gizaw et al. reported that TBIC knowledge was associated with work experience, with HCWs who had more than six years’ work experience in health facility being more knowledgeable than those with less than 3 years’ experience (our study had a cut-off of 18 years) [26]. This contrasts with the present study. The lack of association observed between knowledge and age on one hand and marital status on the other, however, agrees with the findings from the present study.
Regarding TBIC practices, according to Mugomeri et al., the nurses’ age and TB ward work experience did not significantly influence their practice of TBIC measures [11]. Similarly, Temesgen and Demissie noted that TBIC practices among HCWs in Ethiopia were not related to work experience and age category [27]. In another study conducted in Ethiopia, work experience, age, gender, marital status were not statistically related to TBIC practice [29]. Apart from the finding in the current study of the less experienced nurses having statistically significant greater odds of obtaining good practice scores, there is an agreement with the observations concerning the other socio-demographic factors from all the previous studies mentioned here. The greater odds for the less experienced nurses may be because they usually work with directives from more experienced ones and carry out the actual work duties while the more experienced nurses perform mainly supervisory and administrative roles, in line with official responsibilities assigned to the different professional levels [39,40]. The association between knowledge and practice was not statistically significant, although the nurses with poor knowledge scores had greater odds of obtaining good practice scores. This should however be interpreted with caution as the 2x2 contingency table showed that there were no nurses with good knowledge score that also had good practice score, hence the use of exact logistic regression approach to produce the point estimate and confidence interval, in line with recommendations by Hosmer and Lemeshow for analyzing cells with zero or sparse counts [41].
The absence of significant association between TBIC knowledge and practice in this study contracts with others reports from South Africa and Northwest Ethiopia, where TBIC knowledge was shown to be significantly associated with its practice [17,27]. It, however, aligned with the finding by Gizaw et al. in Addis Ababa, Ethiopia [26]. Furthermore, TBIC knowledge was reported to be significantly associated with training on TBIC received by the HCWs in the most of the previous studies mentioned [26-28]. Knowledge might not have significantly influenced practice in the present study because at the time of the study, TBIC guidelines had been newly introduced by the national TB Program and structured TBIC training had commenced but nurses at the study sites were yet to benefit from this [16,24]. The findings from this study suggests that diffusion of actions and professional socialization, which influence work practices, might have been entrenched in the routine of the nurses and played a major role in their practice of TB preventive practices, irrespective of their knowledge and other factors such as age, sex and marital status categories, as these were all not significantly associated with their TBIC practices [42,43]. Apart from knowledge, there are other determinants of proper TBIC practices such as TBIC policy, administrative support, infrastructural compliance, among others [37]. The positive influence of TBIC training on the practice of TB preventive measures revealed in previous studies and the well-known interplay of training and knowledge on practice underscore the importance of conducting trainings on TBIC and equipping the nurses with necessary skills to improve their practices [26-28].