A STUDY TO ASSESS THE KNOWLEDGE,

ATTITUDE AND PRACTICE AMONG TB

PATIENTS UNDER GOING DOTS
TREATMENT IN A TERTIARY CARE
GOVERNMENT HOSPITAL

Dr. Nirmal Joseph Emmanuel

1
 INTRODUCTION
DEFINITIONS:
TUBERCULOSIS- TB is an infectious disease caused by
Mycobacterium tuberculosis. It typically affects the lungs
(pulmonary TB) but can affect other sites as well (extra-
pulmonary TB). It spreads from person to person through
droplets from the throat and lungs of people with the active
respiratory disease.

KAP- KAP stands for knowledge, attitude and practice.

A KAP survey is a quantitative type method (predefined
questions and formatted in standardized questionnaires) that
provides access to quantitative and qualitative information.
Focusing on knowledge and attitudes of the respondents, these
questions are intended to identify key knowledge, social
skills, and know-how commonly shared by a population or
target group about particular issues.
2
TB- INDIAN SCENARIO
India with 1.252 billion people is the second most populous
country in the world. 2.2 million people are affected by TB
making it the country with the highest burden of TB.
RNTCP estimated in 2011 that 2,80,000 deaths in India
are caused by TB.

REVISED NATIONAL TUBERCULOSIS

CONTROL PROGRAM (RNTCP)
In 1993, on the recommendation of an expert committee a
program named Revised National Tuberculosis control Program
was tested in a pilot study.
RNTCP is a centrally sponsored program. It provides free
diagnosis and treatment including a supply of anti -TB
drugs.

3
RNTCP IN TAMIL NADU
RNTCP has been implemented in Tamil Nadu since 2001. It
covers 33 districts with a total population of 754.72 lakhs. In the
year 2013 about 6,59,389 presumptive TB cases were screened
and 80,407 patients were registered for TB.
RNTCP IN TAMILNADU (Contd….)
There are 220 TB units and 784 designated microscopy centers
across the state. The total TB case notification was 109 cases per
lakh per year in 2013.

In Erode district, RNTCP program is monitored from the District

Tuberculosis center located at the Erode General Hospital. 26 Public
Health Centers comes under the ambit of the Erode DTC center
providing a wide coverage in the district.

4
 AIM OF THE STUDY
The aim of our study is to explore the
knowledge, attitude and practice of TB among patients
undergoing DOTS treatment in a tertiary care hospital.

5
 OBJECTIVES OF THE STUDY
To assess the knowledge, attitude and practice of DOTS
among tuberculosis patients.
To find out the association between the levels of
knowledge on DOTS with selected demographic variables.
To develop and distribute patient information booklet on
TB .

6
 PLAN OF THE STUDY
Phase-I ( October 2015 – November 2015)
Obtaining consent from the hospital authority.
Literature review.
Designing of questionnaire.

Phase-II ( November 2015 – March 2016)

DATA COLLECTION
Patient interview.
Collection of patient details.

Phase-III (March 2016 )

Data analysis.
Compilation.
Submission of report. 7
 LITERATURE REVIEW
•Nwankwo Mercy Chinenye et al., (2015) Knowledge about
tuberculosis among TB patients was not good; however,
there are poor understanding of some symptoms. Diagnosis
of TB is associated with increase anxiety/tension
concerning prolonged time on treatment, fear of infecting
others and stigma, along with threatened self-esteem and
quality of life. There are still some problems with practices
based on health promotional and TB prevention guidelines,
that still need to be addressed. Mass media can be better
utilized to remove misconceptions that still exist among
some of the participants.
•Lou Joseph Kenyi et al., (2014) The key knowledge among
Juba patients enrolled on treatment. These knowledge gaps
are probably responsible for the high treatment defaulter
rates reported in Juba , South Sudan.
8
• Hetvi D Mahida et al., (2014) Knowledge about symptoms
and treatment of tuberculosis among respondents was quite
good, however, misconceptions also exist. Misconceptions
about transmission of disease lead to discrimination like
separate utensils for food or drink. Mass media can be
better utilized to remove misconceptions. Knowledge about
“free treatment” and “duration of treatment” has to be
stressed during health education activities.
• Madhu Vidhani et al., (2012) lower level of knowledge
about symptoms, transmission and etiology of the disease
were observed in females and in illiterate patient. From the
forgoing awareness study of patients, we would infer that
although knowledge regarding etiology, symptoms, mode of
transmission was satisfactory, however female and illiterate
individual need to be focused on a priority basis for
education regarding the disease. Misconceptions and
incorrect knowledge like utensils and food as mode of
transmission need to be removed. 9
• Mohammed A I et al., (2007) Education level of the
respondents seems to be the determining factor in the
overall process of health education. Higher the education
level, no doubt, helps the patients to understand the
educational messages.

• Javaid Ahmed khan et al., (2006) Poor knowledge of TB

patients concerning their disease may contribute to high
burden of TB disease. The level of knowledge and
awareness about TB is known to correlate with seeking
health care and time of presentation. By educating the
patients and removing their misconceptions, patient
compliance with therapy and spread of disease is likely to
improve.

10
 MATERIALS AND METHODS
The goal of this section is to provide an overview and
rationale for the research methodology applied in the study to
determine knowledge, attitude and practice among TB
patients.

STUDY SITE
This study was conducted in RNTCP centre of Erode
Government Hospital (GH) in Erode district of Tamil Nadu,
PMCH and Chithode PHC whereby a random sample of TB
patients was selected who were undergoing CAT 1 and CAT 2
therapy.

STUDY DURATION
Duration of the study was 6 months (October 2015 -
March 2016). 11
STUDY DESIGN
A quantitative, hospital-based, cross-sectional study was
conducted among TB patients under DOTS regimen between
October 2015 and March 2016 in RNTCP, Erode Government
Hospital.
STUDY POPULATION
Sample size:194
INCLUSION CRITERIA
Out-patients undergoing CAT-I and CAT-II therapy at RNTCP
centre, Erode GH between October 2015 and March 2016
EXCLUSION CRITERIA
•Patients with MDR TB and XDR TB
•Patients who respond inadequately to questionnaire
•Patients who lack interest to respond
•In-patients

12
Step 1: Data collection method
Data was collected through interviews with the patient or
his/her representative using a well structured questionnaire which
contains four sections:-
1.Socio-demographic
2.Knowledge.
3.Attitude
4.Practice

Step 2: Statistical analysis

Statistical analysis was done by using chi-square test.

13
RESULTS AND DISCUSSION

14
 GENDER RATIO OF THE PATIENT (n=194)

.
P-VALUE WAS FOUND TO BE < 0.0001which is highly significant

15
GENDER RATIO OF THE PATIENT

16
 AGE DISTRIBUTION OF PATIENTS (n=194)
   
PRIMARY SECONDARY
AGE ILLITERATE EDUCATION EDUCATION TOTAL
UNDER 15 0 2 0 2
 
15-24 1 9 16 26

25-34 9 11 18 38

35-44 13 12 7 32

45-54 29 5 3 37

55-64 30 3 2 35

ABOVE 65 22 2 0 24

17
number of patients

Age Distribution of patients

 

18
 EDUCATIONAL STATUS (n=194)
 
 
PRIMARY SECONDARY
AGE ILLITERATE EDUCATION EDUCATION

UNDER 15 0 2 0

15-24 1 9 16

25-34 9 11 18

35-44 13 12 7

45-54 29 5 3

55-64 30 3 2

ABOVE 65 22 2 0

19
number of patients

Educational Status

20
 INCOME OF THE PATIENT (n=194)
 
INCOME ILLITERATE PRIMARY SECONDARY
(RUPEES) EDUCATION EDUCATION

1000-5000 21 6 0

5000-10000 66 13 4

10000-15000 11 8 13

15000-20000 6 14 17

Above 20000 0 3 12

21
number of patients

P-VALUE WAS FOUND TO BE < 0.0001

INCOME OF THE PATIENT

22
KNOWLEDGE OF SIGNS AND SYMPTOMS OF TB
(n=194)
ARE YOU ILLITERATE PRIMARY SECONDARY
AWARE OF EDUCATION EDUCATION
SIGNS AND
SYMPTOMS
Cough with 92 39 42
sputum
Cough more than 42 17 29
2 weeks
Blood in sputum 28 19 23
Fever 43 28 36
Loss of appetite 32 26 29
Weight loss 27 21 24
Chest pain 37 32 22
Shortness of 19 18 13
breath
Not aware 12 2 0 23
 KNOWLEDGE OF TRANSMISSION OF TB
(n=194)
 

HOW CAN A ILLITERATE PRIMARY SECONDARY

PERSON GET EDUCATION EDUCATION
TB
(through)

Hand shakes 4 6 2
Air –borne 18 14 19
Sharing dishes 3 3 1

Touching 3 5 17
things in
public place

Don’t know 76 16 7
24
number of patients

KNOWLEDGE OF TRANSMISSION OF TB
 

25
 KNOWLEDGE OF TREATMENT DURATION (n=194)
 

ARE YOU
AWARE OF TB PRIMARY SECONDARY
TREATMENT ILLITERATE EDUCATION EDUCATION

Yes 95 43 46

No 9 1 0

26
number of patients

KNOWLEDGE OF TREATMENT DURATION

27
KNOWLEDGE ABOUT CURABILITY OF TB (n=194)

CAN TB BE ILLITERATE PRIMARY SECONDARY

CURED EDUCATION EDUCATION

Yes 83 39 42
No 12 1 3
Don’t know 9 4 1

28
number of patients

KNOWLEDGE ABOUT CURABILITY OF TB

29
MOST EFFECTIVE SOURCE OF INFORMATION ON TB (n=194)
WHAT YOU THINK ILLITERATE PRIMARY SECONDARY
ARE THE MOST EDUCATION EDUCATION
EFFECTIVE SOURCE
OF INFORMATION
THAT CAN REACH
PEOPLE LIKE YOU
Newspapers 66 21 39
Radio 41 23 27
Tv 65 34 42
Billboards 3 5 7
Brochures and 81 41 44
pamphlets
Health workers 43 32 38
Friends and family 10 7 12
Religious leaders 17 24 23
Teachers 3 21 31

30
 number of patients

MOST EFFECTIVE SOURCE OF INFORMATION ON TB

31
 DOTS UTILISATION
TAKES MEDICATION AS ADVICED BY THE PHYSICIAN (n=194)

DO YOU TAKE ILLITERATE PRIMARY SECONDARY

AS ADVICED BY EDUCATION EDUCATION
THE
PHYSICIAN

Yes 98 41 45

No 6 3 1

32
number of patients

TAKES MEDICATION AS ADVICED BY THE PHYSICIAN

33
BEING CARELESS ABOUT MEDICATION( n=194)

HAVE YOU ILLITERATE PRIMARY SECONDARY

EVER BEEN EDUCATION EDUCATION
CARELESS
ABOUT YOUR
MEDICATION

Yes 9 4 1

No 95 40 45

34
number of patients

BEING CARELESS ABOUT MEDICATION

35
 EXPERINCED DISCOMFORT WHILE TAKING
MEDICATION(n=194)
HAVE YOU EVER ILLITERATE PRIMARY SECONDARY
EXPERIENCED EDUCATION EDUCATION
DISCOMFORT
WHILE TAKING
MEDICATION

Yes 78 32 39

No 26 12 7

36
number of patients

EXPERINCED DISCOMFORT WHILE TAKING MEDICATION

37
STOPPING MEDICATIONS WHILE FEELING
BETTER (n=194)
DO YOU ILLITERATE PRIMARY SECONDARY
SOMETIMES EDUCATION EDUCATION
STOP TAKING
YOUR
MEDICATION
WHEN YOU
FEEL WORSE

Yes 23 7 2

No 81 36 44

38
number of patients

STOPPING MEDICATIONS WHILE FEELING BETTER

39
 ATTITUDE

OPINION ABOUT SERIOUSNESS OF TB (n=194)

HOW ILLITERATE PRIMARY SECONDARY

SERIOUS TB EDUCATION EDUCATION
IN YOUR
OPINION
Very serious 14 5 6

Some what 81 36 38
serious
Not very 9 3 2
serious

40
number of patients

OPINION ABOUT SERIOUSNESS OF TB

41
POINT AT WHICH HELP WAS SOUGHT FROM
A HEALTH CARE FACILITY (n=194)
AT WHAT ILLITERATE PRIMARY SECONDARY
POINT DID YOU EDUCATION EDUCATION
SEEK HELP
FROM A
HEALTH
FACILITY
As soon as I 13 14 13
realized that the
symptoms might
be related to TB
When self 58 28 27
treatment did not
work
When TB 33 2 6
symptoms lasted
for 2-4 weeks

42
number of patients

STOPPING MEDICATIONS WHILE FEELING BETTER

43
 STIGMA OF TB IN COMMUNITY (n=194)
IN YOUR ILLITERATE PRIMARY SECONDARY
COMMUNITY EDUCATION EDUCATION
HOW IS A
PERSON WHO
HAS TB USUALLY
REGARDED OR
TREATED
Many people reject . 12 7 4

Most people are 53 21 19

friendly but they
generally try to
avoid .
The community 39 16 23
mostly supports and
helps
P-VALUE WAS FOUND TO BE 0.5453 , the value is not significant 44
number of patients

STIGMA OF TB IN COMMUNITY

45
 PRACTICE
TAKING STEPS TO PREVENT TRANSMISSION OF TB (n=194)

ARE YOU ILLITERATE PRIMARY SECONDARY

TAKING ANY EDUCATION EDUCATION
STEPS TO
PREVENT TB
AMONG YOUR
CLOSED ONES

Yes 91 41 44

No 13 3 2

P-VALUE WAS FOUND TO BE 0.2341

46
number of patients

TAKING STEPS TO PREVENT TRANSMISSION OF TB

47
 CORRECT DISPOSAL OF SPUTUM (n=194)

HOW DID ILLITERATE PRIMARY SECONDARY

YOU EDUCATION EDUCATION
DISPOSE
YOUR
SPUTUM

Anywhere 11 3 2

Safely disposed 89 40 44
as advised

other 4 1 0

P-VALUE WAS FOUND TO BE 0.423

48
number of patients

CORRECT DISPOSAL OF SPUTUM

49
INCLUSION OF DIETARY CHANGES (n=194)

HAS THERE ILLITERATE PRIMARY SECONDARY

BEEN ANY EDUCATION EDUCATION
DIETERY
CHANGES

Yes 17 18 36

No 87 26 10

P-VALUE WAS FOUND TO BE 0.001

50
number of patients

INCLUSION OF DIETARY CHANGES

51
 DISCUSSION
•In this study, data on 194 registered Pulmonary Tuberculosis
patients were analyzed from the District Tuberculosis Centre
(DTC) Erode, Chithode Primary Health Centre and Perundurai
Medical College and Hospital (PMCH).

• The study has identified a considerable gap in knowledge,

attitude and practice about tuberculosis among the patients.

•In order to assess the Knowledge, attitude and practice of the

patient, we categorized the patients according to their
educational level i.e, illiterate, primary education and secondary
education.
 

52
• Of the 194 patients interviewed 145 were men while 49 were
female . There were 104 illiterate patients, 44 patients with
only primary education and 46 patients with secondary
education.

• Majority of the study subjects did not know about the cause
of the disease , correct symptoms of the disease or mode of
transmission.

• These findings are consistent with an epidemiological study

conducted to assess the knowledge and attitude about
tuberculosis among the general population in Philippines
(2007) where only a quarter of the respondents knew about
the cause of disease and 21% of them knew about
transmission.

53
• It was found that only 16.3% of the illiterate patients, 13.46 %
of the patients with primary education and 41.3% of patients
with secondary education knew about the correct mode of
transmission of TB .

• Educating the patient about the disease, like the mode of

transmission and about the various misconceptions that are
prevailing helps to remove the stigma attached to the disease.

• Provision of DOTS to the affected patients is not the only

solution in controlling TB since a large number of patients are
expected to continue suffering from the disease due to lack of
awareness, social stigma, misconceptions and discriminatory
attitude towards them hampering their treatment seeking
behavior.

54
• The majority of the patients (79% are illiterates, 88% of
patients with primary education and 91% of patients with
secondary education) believed that tuberculosis can be
curable.

• The duration of the treatment of DOTS (6-9 month) was not

correctly known to 8.65%of the 104 illiterate patients, 2.27%
of the 44 patients with primary education and nil among
patients with secondary education.

• The percentage of the patients who stopped their

medication when they felt worse is 22.11% (Illiterates),
15.90% (Primary education) and 4.34% (Secondary education).

55
• In our study, it was also found that knowledge about the duration
of the treatment is far better compared to the knowledge of
cause or mode of transmission and major symptoms of TB in
all three educational classes.

• When asked about the most effective means by which

information on TB could be provided, most of the respondents
replied that TV, Radio, Newspapers and magazines, Brochures and
pamphlets and health care workers are the most effective.

• In our study, we found that most of the subjects went to a

health facility only when self-treatment didn’t work.

• The social concept of TB in the community plays an important role

leading to negative attitudes like isolation or stigmatization. 59 % of
the patients who were interviewed experienced some sort of stigma.
56
• Community stigma arises from a perceived risk of infection and
perceived link between TB and poverty, where a TB patient has
long been condemned, disgraced and marginalized by the
society.

• Social stigma with a lack of understanding of TB leads to delays in

seeking treatment and poor adherence to therapy. Stigma is serious
barrier to proper and timely health seeking behavior.

• Findings in this study equally disclosed that the negative attitude in

this study may add to illness burden in many ways.

• This is preventable hence if people are educated in the community,

with better understanding, they would be more willing to cooperate
and enhance a more social acceptable environment.
57
• While analyzing the practice of the patient regarding the
disease we found that majority of the patients uses mask to
prevent transmission of TB among closed ones.The majority of
the patients in the three educational levels dispose sputum
safely as advised.

• In our study, we found that the 83.65% of the illiterate

patients, 59.9% of the patients with primary education and
21.7% of patients with secondary education were not making
any changes in their diet. Education level of the respondents
seems to be the determining factor in the overall process of
health education.

• Regarding the drug utilization, most of the patients responded in

the positive that they take their medications as advised by the
physician and most of them have not been careless about taking
their medication.
58
59
 CONCLUSION (Contd..)
 It was found in this study that there is significant level of
association between the lack of knowledge and the socio-
economic status of the patient.

 During our study we found that patient’s lack of

knowledge, attitude, and practice regarding the TB has
played a vital role in increased number of TB patients in
the society.

 Therefore, there is a greater need for educating the patients

and public on TB for which a TB information leaflet was
prepared and distributed.

 RNTCP, being the main center providing treatment, can play

a critical role to improve knowledge among the patients
about TB and its prevention. 60