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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 2 | Page : 167-175
Tuberculosis preventive practices among treatment supporters in Lagos, Nigeria
Oluchi Joan Kanma-Okafor1, Patricia Adaobi Okechukwu1, Obianuju Beatrice Ozoh2, Adedoyin Oyeyimika Ogunyemi1, Sonnen Atinge1, Olukemi Arinola Longe-Peters3
1 Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
2 Department of Medicine, College of Medicine, University of Lagos, Lagos, Nigeria
3 Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria
Correspondence Address:
Oluchi Joan Kanma-Okafor
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_215_21
Abstract
Context: Tuberculosis (TB) treatment support is one of the recommended strategies to enhance treatment adherence and outcomes. Treatment supporters are at risk of contracting TB and adequate knowledge of TB and good preventive practices are required for their protection. Aims: This study aimed at assessing the knowledge and preventive practices of TB treatment supporters at Directly Observed Treatment Short-course (DOTS) centers in Lagos Mainland Local Government Area of Lagos state, Nigeria. Settings and Design: This cross-sectional study was conducted among 196 TB treatment supporters selected from five DOTS centers in Lagos. Methods: Data were obtained using an adapted pretested questionnaire. Statistical Analysis Used: Bivariate and multivariate analyses were performed to determine the factors associated with self-protection practices. A P < 0.05 was considered statistically significant. Results: The mean age of the participants was 37.3 ± 12.1 years. More than half of the respondents were females (59.2%) and immediate family members (61.3%). Overall, 22.5% had good knowledge of TB, while 53.0% had positive attitudes toward TB. Only 26.0% adequately protected themselves from infection. The caregiver's level of education (P = 0.001) and their relationship to the patient (P = 0.001) were significantly associated with good preventive practices in bivariate analysis. Not being related to the patient was a predictor of adequate TB prevention practices (adjusted odds ratio = 2.852; P = 0.006; 95% confidence interval = 1.360–5.984). Conclusions: This study revealed low levels of TB knowledge and fair preventive practices, especially among caregivers who are relatives. There is, therefore, a need to improve population literacy about TB and its prevention and a more focused orientation of relatives who volunteer as treatment supporters, through health education, with periodic monitoring during clinic visits, of how they prevent TB.
Abstract in French Résumé
Contexte: Le soutien au traitement de la tuberculose (TB) est l'une des stratégies recommandées pour améliorer l'observance du traitement et les résultats. Traitement les supporters courent le risque de contracter la tuberculose et une connaissance adéquate de la tuberculose et de bonnes pratiques préventives sont nécessaires pour leur protection. Objectifs: Cette étude visait à évaluer les connaissances et les pratiques préventives des accompagnants du traitement de la tuberculose au traitement directement observé Centres de formation courte (DOTS) dans la zone de gouvernement local de Lagos Mainland, dans l'État de Lagos, au Nigéria. Réglages et conception : Cette section transversale L'étude a été menée auprès de 196 agents de soutien au traitement de la tuberculose sélectionnés dans cinq centres DOTS à Lagos. Méthodes: Les données ont été obtenues à l'aide de un questionnaire prétesté adapté. Analyse statistique utilisée : Des analyses bivariées et multivariées ont été effectuées pour déterminer les facteurs associés aux pratiques d'autoprotection. Un P < 0.05 était considéré comme statistiquement significatif. Résultats: L'âge moyen des participants était 37.3 ± 12.1 ans. Plus de la moitié des répondants étaient des femmes (59.2 %) et des membres de la famille immédiate (61.3 %). Dans l'ensemble, 22.5 % avaient bonne connaissance de la tuberculose, tandis que 53.0 % avaient des attitudes positives à l'égard de la tuberculose. Seuls 26.0% se sont protégés de manière adéquate contre l'infection. Les le niveau d'instruction de l'aidant (P = 0.001) et sa relation avec le patient (P = 0.001) étaient significativement associés à une bonne prévention. pratiques en analyse bivariée. Ne pas être apparenté au patient était un facteur prédictif de pratiques adéquates de prévention de la tuberculose (rapport de cotes ajusté = 2.852 ; P = 0.006 ; Intervalle de confiance à 95 % = 1.360–5.984). Conclusions: Cette étude a révélé de faibles niveaux de connaissances sur la tuberculose et des pratiques préventives équitables, surtout chez les soignants qui sont des proches. Il est donc nécessaire d'améliorer les connaissances de la population sur la tuberculose et sa prévention et de une orientation plus ciblée des proches qui se portent volontaires pour soutenir le traitement, par le biais d'une éducation à la santé, avec un suivi périodique pendant la cliniquevisites, de la façon dont ils préviennent la tuberculose.
Mots-clés: Lagos, Nigéria, soutien au traitement, tuberculose
Keywords: Lagos, Nigeria, treatment support, tuberculosis
Introduction 
Worldwide, tuberculosis (TB) is one of the top 10 causes of death and the leading cause of death from a single infectious agent, ranking above HIV/AIDS.[1],[2] Over 2 billion people, globally (about one in every third person) are infected with Mycobacterium tuberculosis - the organism that causes TB.[3] Although the number of TB cases has been declining in recent years, the rate of decline is very slow, thus TB remains a major global health problem.[1],[2] In 2019, there were an estimated 10.0 million new cases of TB around the world, 1.2 million TB deaths among HIV-negative people, and an additional 208,000 deaths among HIV-positive people.[1] TB cases were reported in all regions of the world, but eight high-burden countries account for two-thirds of the global total. Nigeria, in the 6th position, is the highest-ranking country in Africa.[1]
Directly observed treatment short-course (DOTS) is an internationally recommended treatment strategy for TB patients.[4] It requires patients to take their medications daily under the observation of a healthcare worker.[5] DOTS enhances patient adherence to medications, however, it places a high burden of care on the health-care system and the patients who need to commute daily to receive their medication. Consequently, a high rate of default in treatment has been reported among TB patients due to the high transportation costs, considering that TB is a disease of poverty. To mitigate this challenge in TB care, TB treatment supporters are now used to support health-care workers in delivering DOTS preferably in the community.[5]
A TB treatment supporter that is suitable and acceptable for the patient is the key to the success of DOTS and is a mandatory requirement for smear-positive patients in the intensive phase of TB treatment and the entire treatment duration for re-treatment cases.
The available treatment supporter options include health facility-based workers, i.e., health staff members working at the selected treatment centers; community health workers, i.e., any person formally associated with the health services and living close to the patient's home; community volunteers which include a person selected from the community such as teachers, religious leaders, neighbors, co-workers, and friends and female health workers, i.e., a woman formally working with the national program for primary health care and family planning.[6] A family member or any person who is willing to help and is accepted by the patient and answerable to the health services can also be a treatment supporter.[6],[7]
In the DOTS program, therefore, both facility-based and treatment supporter-based treatments are acceptable. Treatment supporters undertake several tasks in performing their roles.[5] These include, but are not limited to, ensuring that the patient takes the TB drugs as prescribed for the full duration of the treatment, that he/she visits the health facility for scheduled follow-up sputum examination, responding quickly when an appointment was missed, visiting the patients' home when necessary and contacting the health facility if unable to find the patient or convince the patient to continue treatment.[8] In performing these functions, however, there is a need to protect the health of the treatment supporter which hinges on their knowledge of self-protection measures and their attitude towards adherence to these measures. This study, therefore, aims to assess TB knowledge and attitude, as well as preventive practices among treatment supporters. This will help to identify gaps that may be amenable to interventions to enhance the protection of these vulnerable persons.
Methods Study design and study population
This was a cross-sectional study conducted between August and October 2018 at DOTS Centers in Lagos Mainland Local Government Area (LGA) of Lagos State, Nigeria, to assess the safety and protection of TB treatment supporters by examining their level of TB-related knowledge, attitude, and preventive practices. Eligible TB treatment supporters were above the age of 18 years and had been providing treatment support for a person receiving treatment for TB for over 1 month.
Sample size determination and sampling technique
The sample size calculation was derived using the Cochran formula,[9] (n = z2 × p × q/d2), where, n is the minimum number of participants required for the study, z-score for 95% confidence level is 1.96, p is the probability of possessing the characteristics being studied, i.e., the proportion of TB supporters with good TB knowledge (0.876),[10]q is calculated as 1 − p (0.124), d is the acceptable margin of error (0.05). The minimum calculated sample size was 166.91, approximately 167. After accommodating a nonresponse of 10%, the minimum sample size required for the study was 185. However, 196 participants were recruited for the study.
Selection of participants
A multistage sampling technique was used in recruiting participants for the study. In stage one, simple random sampling by balloting was used to select five DOTS centers out of the 16 functional DOTS Centres in Lagos Mainland LGA. In stage two, by consecutive recruitment, every eligible treatment supporter that accompanied a patient to the clinic at the DOTS centers and gave consent to participate in the study was included. This was continued within the study period of about 3 months until the required sample size was attained.
Data collection and data management
Data were collected using a pretested, semi-structured, interviewer-administered questionnaire, adapted from a WHO questionnaire validated for similar studies in other settings.[11] A scoring system in which 12 questions was used for scoring the respondents' level of knowledge of TB and TB preventive practices were adopted.[12] Each correct answer was scored one mark and any wrong or “I don't know” answers were scored 0. The percentage of correct answers was calculated and interpreted as follows: Poor (0%–59%), Moderate (60%–80%), or Good (>80%).[12] A 5-point Likert scale was used for scoring the respondents' attitudes toward TB. The five options with points used for scoring were as follows: 1 = Strongly disagree, 2 = Disagree, 3 = Neither agree nor Disagree, 4 = Agree, and 5 = Strongly agree. A summation of the points obtained was termed the “attitude score” of each respondent. A median score was obtained. Scores below the median were classified as having a “poor attitude,” while those equal to or above the median were classified as “good attitude.”
Data were analyzed using the IBM SPSS Statistics software, version 20.0. (IBM Corp. Armonk, NY, USA.). The results were described by frequencies and percentages, means, and standard deviations. The associations between categorical variables were evaluated with the Chi-square or Fischer's exact tests where appropriate. Multiple regression analysis was employed to evaluate the relative importance of independent variables that were associated with TB knowledge, attitude, and preventive practice. A P < 0.05 was considered statistically significant.
Ethical consideration
Ethical approval for the study was obtained from the Health Research Ethics Committee of the Lagos University Teaching Hospital. Permission was also obtained from the Lagos Mainland LGA and the authorities at the sites where the study was carried out. The confidentiality of the participants' responses was guaranteed. Written informed consent was obtained from all the respondents after explaining the nature of the study, and its objectives and after giving full assurance that participation would be purely voluntary without consequences for nonparticipation.
Results One hundred and ninety-six treatment supporters participated in this study. Their ages ranged from 19 to 69 years (mean age 37.3 ± 12.1 years), and the male: female ratio was approximately 2:3. Details of their sociodemographic characteristics are shown in [Table 1]. In addition, a large proportion of the treatment supporters were immediate family members (61.3%), while 38.7% were nonrelatives which included friends or individuals hired or paid to provide the service.
Table 1: Sociodemographic characteristics of the tuberculosis treatment supporters (n=196)Health workers were the main source of information about TB (31.1%) followed by the mass media (28.9%). Weight loss was the most frequently recognized symptom of TB (73.5%), followed by a cough of >3 weeks' duration (66.3%), chest pain (59.7%), and hemoptysis (57.1%). The most reported mode of transmission was through the air when an infected person coughs or sneezes (91.3%) and the most reported measure to reduce transmission was by covering the mouth and nose of an infected person when coughing or sneezing (92.3%). However, 32 respondents (16.3% of responses) wrongly stated that TB could be prevented by praying. Over 90% correctly knew that their role as treatment supporters was long-term as treatment of TB lasted for at least 6 months. Details of the source of information and knowledge about TB transmission, prevention, and treatment are shown in [Table 2].
Table 2: Tuberculosis treatment supporter's sources of information and knowledge of tuberculosis (n=196)About 90% of respondents agreed that TB is a serious infectious disease that could affect anyone and could be prevented by taking the right preventive measures. They agreed to the risk of contracting TB from the patient for whom they provided care and acknowledged the need to take preventive measures. Details of caregiver attitudes are provided in [Table 3].
Table 3: Tuberculosis treatment supporter's attitudes to the disease given their role in patient care[Table 4] shows treatment supporters' perceived duties and preventive practices. Observing the patients take their medications was the most frequently identified duty of the treatment supporters (83.2%) followed by encouraging the patients to attend clinics (80.1%). Keeping a record of the treatment, counseling the patient and their family members, and collecting medications on behalf of the patient were other duties perceived by the treatment supporters as theirs. About 9 out of every 10 respondents (89.9%) ensured that the patients practice cough etiquette mostly by coughing either into a handkerchief (84.7%) or, by coughing into the crook of the arm (31.6%). About 90.0% insisted on adequate hand hygiene by the patient, over 70% wore respiratory masks or face coverings or offered masks or something to cover the nose and mouth to patients when needed, over 70.0% had ever received BCG vaccine, 67.3% wore gloves whenever handling the patient's sputum or bodily secretions, while only 33.2% had ever been screened for TB. However, while less than two-thirds (58.2%) had received training on their role as TB treatment supporters, the majority (85.7%) were motivated to keep learning more about TB and how to prevent it.
Table 4: Tuberculosis treatment supporter's perceived duties and preventive practices (n=196)Overall, more than half of the treatment supporters had poor knowledge of TB (51.0%), only about a quarter (26.5%) had fair knowledge and about a fifth (22.5%) had good knowledge. The largest proportion of respondents had a fair level of practice (47.0%) while 27.0% had a poor level of practice and 26.0% had good practices [Figure 1]. [Figure 2] shows that 53% of the respondents had a good attitude toward TB.
Figure 1: TB treatment supporters' overall knowledge and preventive practices. TB = Tuberculosis
Figure 2: TB treatment supporters' overall attitude toward TB. TB = TuberculosisIn bivariate analysis [Table 5], the respondents' level of education and their relationship to the patient was significantly associated with TB preventive practices of the treatment supporters (P = 0.006 and P = 0.001, respectively), with relatives showing mostly poor preventive practices compared to nonrelatives. The worst prevention practices were observed among mothers of patients, siblings of the patients, and spouses. The best preventive practices were found among treatment supporters who are nonrelatives such as friends of the patient and hired help. The nonrelatives (friends and hired help) who function as treatment supporters included health workers or people with some healthcare-related training. The level of knowledge and attitude of the respondents were not significantly associated with their practice of TB prevention. In multivariate analysis [Table 6], the relationship to the patient remained an independent predictor of good practice after controlling for other factors (Adjusted odds ratio = 2.852; P = 0.006; 95% CI: 1.360–5.984).
Table 5: Factors associated with tuberculosis prevention practices of treatment supporters
Table 6: Multiple logistic regression of the predictors of good preventive practices among tuberculosis treatment supporters Discussion The main findings of this study are that most TB treatment supporters are females and family members. Their level of knowledge about TB transmission and preventive practices is poor and their attitude about TB preventive practices is moderate. The independent determinants of the practice of preventive measures were the respondents' level of education and their relationship with the patient.
This finding that most TB treatment supporters are female is consistent with previous reports from Bandung (84.4%) and Depok (91.8%) in West Java Indonesia.[10],[13] Perhaps the cultural factors in most patriarchal societies that attribute responsibilities of providing care to females could contribute to women taking on this role.[14],[15] Further, the extended family support systems in sub-Saharan Africa which usually rely on family members to provide care for the sick may partly account for the higher proportion of family members serving as treatment supporters.[16],[17],[18] Similar findings have been reported in other LMICs such as Thailand and Indonesia which are also culturally based on the extended family system.[10],[19]
Regarding the source of information about TB, health workers were reported to be the highest source of information followed by mass media at variance with reports from other parts of the world where mass media plays a major role. This implies that perhaps the Nigerian TB stakeholders are not adequately harnessing the use of technology and mass media for the education of the community. The role of mass media for community education is an effective approach to improving community literacy because besides providing information, education, instruction, and entertainment to the people, it also motivates people directly or indirectly to adopt new behaviors or to remind them of critical information.[20],[21] In a study from Delhi,[22] health workers were also the source of information reported by more than half of the respondents. However, a previous study from the South-Eastern part of Nigeria[23] reported that the radio was the most common source of information suggesting that there may be disparities in using this resource within the country. Our finding also brings to the fore the need to equip health workers through training and retraining to ensure they deliver the right information to patients and their relatives, especially in this culturally high context society where myths abound and providing correct information is a necessity.
The assessment of the treatment supporter's knowledge of TB was based on their ability to recognize the symptoms, mode of transmission, methods of prevention, and duration of treatment. Although overall knowledge of TB was poor (51.0%), the study revealed that the supporters had basic knowledge about the symptoms of TB and its mode of transmission which is similar to previous reports from India, Croatia, Ethiopia, and Madagascar.[24],[25],[26],[27] The public health implication of poor knowledge about TB is that the treatment supporters are at risk of getting infected since they do not know how to recognize a potential source of infection and therefore protect themselves against becoming TB patients. The symptom most frequently reported by the study participants was weight loss (73.5%) while other studies have reported cough as the most recognized symptom.[23],[28],[29] The recognition of cough as the first symptom of TB may be beneficial for early recognition and diagnosis because weight loss usually occurs as a later symptom of TB which may lead to late diagnosis and increased risk of transmission. Therefore, it is still pertinent to educate TB caregivers on the symptoms and transmission of TB.
Knowledge of the mode of TB transmission was high in this study (91.3%). This potentially empowers the treatment supporters to ensure they do not get infected with TB by avoiding transmission from the patient they are supporting. The majority of respondents knew that TB is an air-borne disease and can be transmitted when someone with TB coughs or sneezes. This implies that treatment supporters would demand cough etiquette from the patient and this may promote community TB prevention. Coughing and sneezing by patients with TB and sharing dishes with patients were the most frequently reported modes of transmission in several other studies.[13],[30],[31],[32] Some respondents had incorrect knowledge about transmission such as through smoking, use of herbal concoctions, and inhalation of dust. This is an indication that gaps in knowledge of TB transmission still exist. The use of face masks by patients to reduce TB transmission was recognized by most participants, similar to other reports.[28] This knowledge is important and should be reinforced because masks worn by the patient can prevent droplet nuclei from being expelled into the air and hence reduce transmission.[33] Caregivers, therefore, need to be aware that mask-wearing by the patent is a priority and their personal use of masks may not be protective if the patient fails to wear theirs. Further, there was poor knowledge about the role of BCG vaccination in TB prevention in the present study which could influence attitudes toward recommended childhood immunization.[34] Poor knowledge about the importance of the BCG vaccine, or vaccines generally, might be the reason for low vaccine coverage.
An important finding in this study is the role of family relationships in TB prevention practices. Non-relatives tended to be more self-protecting in their role as treatment supporters. This is probably so, given that relatives spend a long time with the patients and may become wary of taking protective measures. On the other hand, emotional factors may play a role in preventing relatives from taking protective measures which could be considered stigmatizing by the sick relative and hence culturally unacceptable.
Limitations
A recognized limitation of studies such as this, which are based on self-report, includes the inability to confirm reported behavior. Therefore, knowledge of preventive practices may not necessarily translate to practice. Independent interviews with the TB patient to confirm the reported service received and behavior of the treatment supporter may have helped in strengthening the findings in this study and should be considered in future studies. However, we have provided evidence from a highly cultural society about the knowledge and practice gaps among TB treatment supporters and the need to improve general population literacy about TB and appropriate protective practices. Harnessing the wide reach provided by the media is a veritable approach that could improve knowledge and potentially preventive practices. The national TB programs should ensure that lay treatment supporters are trained to understand their risks and the protective measures required to be safe, especially when caring for relatives.
Conclusions This study reveals that overall about half of the respondents had poor knowledge of TB, less than a third had poor knowledge of its preventive practice, and misconceptions about modes of transmission exist and are a cause of concern. About half of the respondents also had a positive attitude toward TB. Overall, the practice of TB prevention was fair. Nonrelative treatment supporters were more likely to report taking adequate self-protection. There is therefore a need for a more focused orientation of relatives who volunteer as treatment supporters through health education, with periodic monitoring during clinic visits of their TB preventive behavior.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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