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 they had mean knowledge and practice scores 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 observed that the majority of them had poor TBIC-related knowledge and practices. This is consistent with reports from other studies in Nigeria, where generally, poor levels concerning TBIC have been demonstrated among HCWs [18,19,23,24].
Several ways of assessing and scoring TB-related knowledge and practices were observed in the literature. While some studies simply stated the mean scores and used this as the cut-off to categorize the scores, others used arbitrary cut-off points [25,27]. 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 [7,15,27,28]. 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 . 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 [24,28]. It is also agrees 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” . Similar observations were made in a study involving HCWs in Free State Province, South Africa .
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 [9,33]. The poor knowledge level of TBIC aligns with the results of a study by Woith et al. among HCWs in Russia . In contrast to the poor knowledge noticed in the current study, some researchers have previously 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 define “good” was 70%, which is lower than 80% used in the present study . Also, the mean score of 61.5% reported by them was lower than 68.2% recorded here. Similarly, Buregyeya et al. reported that 69 % of the HCWs were thought to have adequate TBIC knowledge, with a cut-off of 70% . Using a cut-off of 60%, 74.4% of health professionals in the study by Temesgen and Demissie were found to have “good” knowledge .
In terms of practice of TBIC measures, 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 .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 . 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-reports 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 . Other factors that influence proper TBIC practice include clear TBIC policy directives, appropriate triage system and separation facilities, availability of personal protection equipment, reasonable workload, adequate and well-ventilated clinic space, among others . 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 [8,9,15,28]. 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 . 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 . Poor levels of implementation of TBIC measures were also reported by Bhebhe et al. in Lesotho and Kanjee et al. in South Africa [7,13]. 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 a large proportion 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 and many facilities, including the study sites, had not been benefited from the roll-out package. [14,19,20,23].
Knowledge was not significantly related to all the socio-demographic factors considered. 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 . Furthermore, the wide confidence intervals recorded for the regression analysis for the two factors as separate 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 . Buregyeya et al. noted that age and sex were not associated with TBIC knowledge while 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) [25, 27]. This is at variance with the present study. The lack of association observed between knowledge and age, however, agrees with our findings.
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 . Similarly, Temesgen and Demissie noted that TBIC practices among HCWs in Ethiopia were not related to work experience and age category . In another study conducted in Ethiopia, work experience, age, gender, marital status were not statistically related to TBIC practice . Apart from the finding in the current study of the more experienced nurses having statistically significant less 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. That the more experienced nurses are less likely to obtain good practices may be because most of them, who are usually in the senior cadre, serve as unit heads/managers and their work duties include mainly managerial functions such as establishing patient care goals, managing work schedule and roster, ensuring compliance with work policies and protocols, commodity management, coordinating review meetings, among others. They may not necessarily carry out actual TBIC practices, in line with official responsibilities assigned to the different professional levels. Some investigators in Nigeria have reported that nurse managers tend to focus more on their managerial duties at the expense of their clinical roles [37,38]. 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 scores that also had good practice scores, 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 .
The absence of significant association between TBIC knowledge and practice in this study contracts with reports from South Africa and Northwest Ethiopia, where TBIC knowledge was shown to be significantly associated with its practice [15,26]. It, however, aligned with the finding by Gizaw et al. in Addis Ababa, Ethiopia . 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 [25-27]. 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 [14,23]. The findings from this study suggest 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 most of the socio-demographic factors, as these were mostly not significantly associated with their TBIC practices [40,41]. 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 [25-27].
Limitation of the study
It was difficult to carry out direct observation of TBIC practices by the nurses as this is time-consuming and requires the engagement of more research personnel as observers. Self-reports were relied on and there is the likelihood of a discrepancy between this and direct observation of actual practice, as previously reported by Engelbrecht et al. . There could be over-reporting of the performance of TBIC measures by the participants because of the social acceptability of being perceived as doing the proper thing (social desirability bias). For the purpose of having an all-inclusive sample, the participants included nurses in all the units of the hospitals (out-patient units, wards, emergency room, operating theatre, among others). Various schedules and duties are involved in the different units although the nurses rotate through all of them, and some of their assigned tasks may not be directly related to TB care. Also, some of the them might not have been involved in TB care in the recent past and this could possibly affect their response to the practice items (recall bias). The study questionnaire tended more toward administrative and environmental control measures (specifically, natural ventilation systems) as managerial measures are more in the purview of facility management and personal protection equipment (respirators) are mostly available for use in specialized DR-TB care facilities. For the implementation of an integrated package of TBIC interventions, it would be beneficial to have further review of the instrument to make it more exhaustive.