Preventing Infectious Disease Through Knowledge, Attitude And Practice: A Case Study Of Tuberculosis Patients In Malaysia

Knowledge, Attitude, and Practices

Recent studies in the field of medicine and public health suggest that the use of the Knowledge-Attitude-Practice (KAP) model is in line with the study’s objective of assessing patients’ views on the effectiveness of treatment methods and the ability to change behaviour, especially among patients, and emphasise that it acts as an agent to help reduce the knowledge gap between health service providers and patients ( Arif et al., 2017; Balogun et al., 2019).

Application of KAP

Knowledge influences one’s thinking, attitudes and behaviour ( Kabir et al., 2019; Mahmud & Siarap, 2013). Exposure to new information through campaigns, programmes and health activities can enhance knowledge. According to Khan, Sarriff, Khan, and Mallhi ( 2014), the measurement of a person’s level of knowledge about illness differs based on the person’s own health condition. For example, knowledge of the dangers of TB and the importance of maintaining good health will result in different attitudes and practices among patients compared with the general public. Patients will naturally have a higher level of knowledge as they interact directly with doctors and health institutions. Therefore, their attitudes and practices will be more focussed on better healthcare to prevent further illness and will guide them in the process of recovering from the illness. Meanwhile, the public will tend to be less knowledgeable and will have less information about the illness and its preventive measures.

Ethical consideration

The research has obtained NMRR-11-658-9825 ethical approval from MOH for the purpose of transparency and the protection of human subjects. Written consent was collected from each respondent before the data collection process began. Confidentiality was maintained by using codes instead of respondents’ names (ID: R001, R002, R003, etc.), and personal details were not disclosed. Participation in the study was voluntary, and tokens of appreciation were given to the respondents upon completion of the questionnaire.

Data of patients

The data of TB patients were obtained from the Division of Disease Control, MOH as well as respective states. Patients who had been diagnosed and/or confirmed to have TB symptoms and were undergoing TB treatment at a hospital or health clinic under the MOH were the study respondents. In this study, the majority of respondents were undergoing treatment during the data collection period. Subsequently, the collected data were entered into Statistical Package for the Social Sciences (SPSS) software version 24 for further analysis. Categorical variables were tested using descriptive statistics; in cases of abnormal data distribution, tests of independence were performed using the chi-squared test. For example, to test differences between genders (male/female) and levels of knowledge (high/low), a contingency table (2x2) must be used to explain the differences in meaning ( Kent State University Libraries, 2018). A p-value of less than 0.05 was considered statistically significant ( Moore, Notz, & Flinger, 2013).

General Health Analysis

Since smoking habits are one of the contributing factors to TB disease, respondents were asked if they were smokers, how long they had smoked and whether they knew that smokers had a higher chance of contracting TB. The findings indicate that most of the respondents do not smoke (n = 1,050; 66.2%) but, among smokers, most of them admit that they have been smoking for more than 5 years, more than 10 years (n = 476; 30%), between 11 and 20 years (n = 412; 26%), or more than 20 years (n = 428; 27%). About half of the respondents (n = 825; 52%) agreed that smoking increases the risk of TB infection. Respondents were also found to have a high knowledge of smoking and its association with TB disease. As noted in previous studies, smoking increases the risk of infection and transmission of TB ( Mokhtar & Rahman, 2017; Perriot et al., 2018). In fact, past researchers have stated that smokers have almost twice the risk of TB infection compared with non-smokers ( Bai, Lee, Chien, Suk, & Chiang, 2016; Yen et al., 2014). A study conducted by van Zyl Smit et al. ( 2010) reported that one in five deaths from TB cases could be avoided if the patient did not smoke. In addition, Hutahaean ( 2013) confirmed that smokers among TB patients had a very high mortality rate of nine times higher. On the other hand, nearly one-third of deaths due to TB disease could be avoided if patients quit smoking.

Based on the descriptive analysis, the findings show that the prevention level of infectious diseases, especially for TB disease, is high. In other words, the majority of respondents (n = 1,125; 70.9%) managed to achieve a mean score above 4.25. The determination of the level of prevention of the disease depends on the mean score and standard deviation from Part B of the questionnaire. The study interpreted the level of prevention based on the Min Score Interpretation Table, which employs the 5-point Likert scale. Mean scores of 1.00 to 2.33 are considered low; 2.34 to 3.66 are considered average; and mean scores of 3.67 to 5.00 are considered high ( Rahman, Ahmad, Awang, & Malek, 2016).

TB Disease-Knowledge Analysis

Knowledge of TB disease is assessed through general knowledge of TB, TB symptoms, TB infection, and treatment for TB disease. The findings indicate that the majority of respondents (n = 1,179; 74.3%) admitted that they had moderate general knowledge of TB before they became infected (see Table 1 ). When asked about how TB spreads, many respondents answered correctly: coughing (95.3%), sneezing (76.9%), talking (54.6%) and spitting (52.6%). For the cause of TB, respondents answered germs/bacteria (81.9%), virus (56.5%) and contaminated food/beverages/water (23.2%).

The main cause of TB is germs or bacteria, Mycobacterium Tuberculosis ( Rahman & Mokhtar, 2015; Zin et al., 2018), and the respondents indicated that they are aware of the mechanism of transmission and causes of TB disease. In terms of TB symptoms, the majority of respondents answered correctly: coughing up sputum (88.5%), bad cough for 3 weeks or longer (93.5%), fever persisting for 3 weeks or longer (81.6%), and bloody cough (87.5%). These results demonstrate that the respondents showed good knowledge of TB and were aware of the symptoms, infections and treatment related to TB disease. Therefore, the patients displayed a high level of knowledge relating to the prevention of TB.

Table 2 summarises the knowledge about TB infection and treatment. The majority of patients answered that TB was an infectious disease (n = 1,419; 89.4%), and 1,262 of them believed that TB disease is preventable. About 87.8% agreed that TB can be cured (n = 1,394). Interestingly, with regard to the duration of TB treatment, most respondents answered that 6 months (n = 1,017; 64.1%) was the usual duration of treatment. However, some medical practitioners believe that TB treatment should be carried out for 9 months (n = 230; 14.5%) because during the 9 months, the bacterial recurrence rate was significantly lower than during the 6 months. Therefore, patients who responded that TB treatment takes 9 months were also considered to have answered correctly.

The Kolmogorov-Smirnov normality test revealed that the data for this study did not follow the normal distribution (p > 0.05). Therefore, non-parametric tests such as the chi-squared test were used for inferential statistics. The chi-squared test was used to investigate the relationship between two (nominal) variables, and each variable had two or more categories ( Pallant, 2013). Given that p-values are higher than significance levels (p > 0.05), it can be concluded that there is insufficient evidence to suggest a link between gender and knowledge level [χ2 (1) = 2.057, p = 0.174]. Similarly, in terms of the age of the respondents, no significant difference could be attributed to the level of knowledge about TB [χ2 (4) = 6.151, p = 0.188] (see Table 3 ). In line with the findings of this study, Abebe et al. ( 2010) reported that patients’ knowledge of a disease is not related to their gender as both genders exhibit similar responses to prevention of disease and maintaining personal healthcare.

TB Disease-Attitude Analysis

To assess patients’ attitudes towards the prevention of TB disease, four categories were analysed, namely, those related to the patient, family members, friends and neighbours. Patients’ attitudes towards TB prevention were measured with a question about how they react if they experience symptoms of TB disease. Most respondents prefer to consult a doctor and get treatment immediately. Attitudes towards family members, friends and neighbours were assessed with questions about a patient’s level of comfort in sharing food/drinks, willingness to communicate, and their openness about their illness. The majority of patients stated that they would not stay away from family members if they were infected (n = 1,237; 77.9%) and would not conceal their illness from family members (n = 1,323; 83.4%). However, in terms of patients’ attitudes towards their friends and neighbours, they showed lower rates of openness than their openness with family members. In another measure, only 1,016 patients (64%) did not mind eating with friends compared with 1,176 patients (74.1%) who did not mind eating with family members. This pattern can also be seen in attitudes towards neighbours, with only 980 patients (61.8%) reporting that they agreed to share food with neighbours. Comparing these three categories, the data indicate that respondents are more comfortable around their family members than around their friends and neighbours. Therefore, the level of prevention in terms of patient attitude was moderate (mean score = 2.55).

TB Disease-Practice Analysis

Nineteen questions were asked to evaluate TB prevention practices among respondents. The overall assessment showed that more than half of the respondents agreed with all the statements. In other words, most respondents recorded positive reactions by answering ‘Yes’ to almost all questions. For example, the total number of respondents who claimed that they maintained cleanliness in their homes was 1,482 (93.4%), while 1,196 respondents (75.4%) reported that they cover their nose when coughing or sneezing and 1,345 respondents (84.8%) reported that they avoid crowded places. Thus a high level of prevention of TB disease was shown in terms of patients’ preventive practices with a mean score of 4.48.

The findings of this study are strengthened by previous studies (Kigozi, Heunis, Engelbrecht, van Rensburg, & van Rensburg; 2017; Salleh, Rahman, Rahman, & Haque, 2018). For example, a study by Salleh et al. ( 2018) also measured the prevention of TB disease among TB patients and found that wearing a mask in public and covering mouths when coughing/sneezing are indicators of good prevention practices. The study emphasised that these actions are considered appropriate, ethical and very important for preventing the spread and transmission of the TB virus to others. Another study on the prevention of TB was conducted in South Africa to reinforce the national health education programmes. Kigozi et al. ( 2017) outlined three practices as good TB disease prevention practices: covering the mouth/nose with a tissue when coughing/sneezing, discarding used tissues in a trash bin, and washing hands after coughing/sneezing. Interestingly, the study by Kigozi et al. ( 2017) also emphasised that socio-demographic factors, such as gender, education level, occupational status and place of residence, played an important role in fostering awareness of TB prevention. In particular, highly educated women, working-class patients and those living in urban areas are reported to simply have better practices and improved disease prevention practices as well as to have successfully completed treatment until they are fully recovered.