Knowledge, Attitude and Practices Regarding Tuberculosis Infection Control Practices among Health Care Workers at Tertiary Care Centre, Rajnandgaon

Tuberculosis infectious disease owns highest burden of respiratory infection. India being the largest contributor to global Tuberculosis cases. Mycobacterium tuberculosis mode of transmission by respiratory route requires airborne precautions to be strictly followed in healthcare settings to minimize the transmission. Research was plan to assess fundamentals of Tuberculosis infection control among healthcare workers. Questionnaire based cross-sectional study which included sociodemographic characteristics, with twenty-five questions on knowledge of Tuberculosis, attitude and practices for Tuberculosis infection control was conducted in Bharat Ratna Late ShriAtal Bihari Vajpayee Memorial Medical College, Rajnandgaon Chhattisgarh from April 2023 to May 2023. 156 HCWs with mean age group 36 ± 9.7 (18-59) years participated in the study. Healthcare workers included were nurses (55.1%) and technicians (44.8%). Knowledge and attitude score observed in our study is 90.3% and 92.3% levelled as good to moderate but at the same time good to moderate practice observed is 59.6%. Certain deficiencies regarding some areas of preventive measures of tuberculosis was observed among participants which require improvement by conducting training sessions.


INTRODUCTION
Tuberculosis (TB) is caused by bacteria named Mycobacterium tuberculosis (MTB), which is accountable for approximately 1.5 million of death in 2020. 1 Around the globe in every second person get infected and in every 10 second a person dies due to TB. 2 It commonly affects lungs and also other parts of the body.Pulmonary tuberculosis patient can spread TB through coughing and spitting.Worldwide 10% of person can acquire TB in their life. 3t is crucial to implement tuberculosis infection control (TB IC) guidelines in hospitals to prevent nosocomial spread of TB, especially the emerging Multi drug resistant Tuberculosis (MDR-TB) spread to Health care workers (HCWs) and others. 4Nosocomial transmission of tuberculosis is of significant concern in health care settings as health care workers have frequent exposure to infected patients. 5Encouraging research and innovation in TB IC specific in resource poor settings to explore cost effective strategies to develop innovative solutions to overcome this challenge should be promoted. 6s HCWs being frontline workers are at higher risk of acquiring infection with MTB henceforth, they should be well acquainted with preventive measures.Any breach in TB IC practices may lead to spread of tuberculosis within health care facilities and community.Assessing knowledge, attitudes and practices of HCWs regarding TB IC provides valuable insight into their current understanding and implementation of TB IC measures, which would help to identify the gaps and area of improvement, enabling targeted interventions to enhance TB IC practices among HCWs.

Aim
This study aims to gather data on the current state of TB IC knowledge, attitudes and practices in health care workers working in specific health care setting, Rajnandgaon.

Study Setting
The study was conducted in Department of Respiratory Medicine, Bharat Ratna Late Shri Atal Bihari Vajpayee Memorial Medical College, Rajnandgaon Chhattisgarh, from April 2023 to May 2023.

Study design
A Cross-sectional observational hospital based study.

Study population
HCWs specially nurses and technicians (X-ray and Lab technicians) working in study area.

Sample size
Total 156 HCWs were included, sampling was based on sample calculation formula n = (Z 2 a X P X (1-P))/d 2 where n = sample size; Z score (based on the confidence level); p = population proportion and d = margin of error.The confidence level was taken as 95% and the margin of error was 8%.Sample size was calculated based on the proportion of TB infection among HCWs, the prevalence was assumed to be 50%. 7

Inclusion criteria
All the HCWs who were willing to participate and gave their consent were included in the study.

Exclusion criteria
HCWs not willing to participate were excluded from the study.

Study procedure
S t u d y i n c l u d e d s e l f-st r u c t u re d questionnaire, which was validated by pilot study on twenty-five health care workers to evaluate its relevance before carrying out the study.Survey was incorporated with socio-demographic factors (age, gender, educational level, job category, duration of experience, TB IC training); knowledge of TB (causative agent, site, symptoms, transmission, risk factor, method of diagnosis); attitude towards TBIC (isolation of chronic cough patients, regular sputum testing, periodic health checkup of HCWs, regular training for health workers about latest updates on TB); TB IC practices(use of personal protective equipment, contact tracing, respiratory etiquette training to patients, ensuring complete treatment to patient).Six questions were asked in knowledge questions having four options with one correct answer to be ticked where as attitude domain had nine questions with three responses agree, disagree and neutral whereas practice domain had ten questions, included always, sometimes and never.This scoring system allows quantification of HCWs knowledge, attitudes and practices regarding TB IC by assigning one point for correct response.The participants could potentially achieve maximum score of 6 for knowledge,9 for attitude and 10 for practice.Scores were classified into two categories: scores below 50% were considered as poor score and above 50% as good to moderate score.

Statistical data-analysis
Data was collected, entered and analysed in Microsoft Excel.Descriptive analysis was carried out by frequency and proportion used for Sociodemographic variables and mean and standard deviation for quantitative variables.Spearman's correlation coefficient was use to find out correlation between score obtained in different domains by participants.Bivariate Skewed analysis by one-way ANOVA was done for three and above socio demographic variables and for two socio demographic variable T test was done for analysing KAP scores of healthcare workers by using p-value <0.05 statistically significant.Association of confidence to handle TB Cases by Trained and Untrained health care workers with respect to different variables was analysed by frequency and percentage.

RESULTS
Pre-testing was done on twenty-five health care workers to evaluate its relevance before carrying out study.Data used in the validation phase were analyzed by Cronbach's alpha.Cronbach's alpha coefficients of knowledge, attitude, and practice were > 0.70, indicating that the questionnaire had good internal consistency (Table 1).
Out of 156 participants, about 141 (90.3%) healthcare workers obtained good to moderate knowledge scores, 144 (92.3%) obtained good to moderate practice scores, and 93 (59.6%) had positive attitude scores regarding tuberculosis and its infection control practices (Table 3).
The results of Spearman's correlation coefficient showed a much weaker positive correlation between knowledge and practice scores (r= 0.143, p value-0.998) as compared to knowledge and attitude scores (r=0.138,p value-0.082) and a somewhat positive correlation between practice and attitude scores (r=0.155,p value 0.049) (Table 4).
The results of the bivariate analysis showed that higher mean knowledge scores were found in the male gender (4.32±0.75,p value -0.538).On the basis of job description of  5).Higher mean attitude scores were found in nurses (7.15±1.85,p value-0.966), the age group more than 41 years (5.50±1.87,p -0.063) and in those with work experience of more than ten years (7.44±1.84,p value -0.132), postgraduate by qualification (7.09±1.84,p value -0.966) who have undergone training (7.09±1.85,p value-0.946) (Table 5).
On analysing confidence level of healthcare workers to deal with the tuberculosis to some of the pertinent questions in the knowledge, attitude and practice sections with respect to TB IC training it is observed that out of 96 participants who have received TB IC training more than 20% strictly adapted standard precaution and contact tracing practices as compared to more than 13% not at all opted the same.Nearly half of them used N-95 mask while taking care of tuberculosis patients and felt responsibility of educating them respiratory etiquettes.Among 60 participants who didn't underwent training nearly 10% totally agreed to practice standard precaution and follow contact tracing, whereas less than 10% always used N-95 mask or educated patient cough etiquettes.(Table 6)

DISCUSSION
Knowledge empowers individuals to make informed decision and take proactive measures to protect themselves and others. 8Therefore, in order to promote effective prevention practices, it is essential to prioritize knowledge dissemination and education ensuring individuals have access accurate information about disease and its prevention strategy this study was planned.Pre testing on twenty-five HCWs was done to know item clarity before carrying out the study.A reliability test was performed using Cronbach's alpha for knowing internal consistency of the questionnaire.A Cronbach's alpha coefficient in the range of 0.6-0.7 is considered acceptable, whereas a Cronbach's alpha coefficient of 0.8 indicates good reliability.We found that Cronbach's alpha coefficient was >0.70 for all parameters in the pretest of reliability, indicating that the in our study as their close proximity to patients put them at higher risk of contracting disease.Hence, we can say our study was female predominant which is consistent with Wang et al. 12 HCWs have higher baseline knowledge due to education and training they receive during their curriculum.HCWs attributed to poor knowledge level due to lack of training and orientation on TB IC.Knowledge alone is not sufficient to ensure proper implementation of infection control practices. 13nowledge provides foundation but attitude  14 The cause of fear could be not only getting themselves TB but also their family members. 15This is in consistency with the finding of a study by Menzies et al. 16 74.61%HCWs realized the need of regular screening and use of respirator while taking care of MDR patients.This finding supports appropriate attitude and understanding of infection control measures towards tuberculosis. 17Significant (68.46%) number of HCWs agreed with screening of patient with chronic cough for TB which indicates they are well aware of symptoms of TB and the importance of early detection and treatment.2 Overall, in our study, we observed poor adherence to infection control practice (40.38%) which is almost half than Gyem et al. study. 23,24t is concluded that training plays vital role in improving attitude and practice which can be observed in our study and similar finding was observed by Wondimu et al. 25 Thus, by integrating TB IC measures into the day-to-day working environment and ensure these practices become routine and contribute in curbing spread of TB. 26

Strength and limitations
Limitation of our study was Pre and post-test could better assess TB infection control practices as many HCWs had not undergone orientation or training of TB IC.Hence, regular trainings should be given to HCWs to improve their knowledge and health care centres should prepare TB IC plan and orient HCWs.

CONCLUSION
Study reveals more than 90% participants knowledge and attitude regarding tuberculosis is good to moderate, but 40.38% lack in adequate practice.Comparing trained and untrained staff in TB IC practice nearly 85% trained staff were more confident in handing TB patients.hence addressing the gaps in preventive practices towards TB infection control requires comprehensive approach that includes updating knowledge, conducting regular workshop and implementing monitoring system.Health care professionals should time to time assess effectiveness of current strategies by identifying gaps and area of improvement.By doing so, health care facilities can work ensuring safety of both health care workers and patients in context of tuberculosis prevention and control.

Table 2 .
Sociodemographic profile of the healthcare workers health care workers nurses had higher knowledge score (4.25±0.74,p value-0.598) as compared technicians.Similarly, higher mean knowledge scores were also reported in the age group >41 years with experience of 1-5 years.(4.50±0.79,p value -0.023) (Table

Table 3 .
Score grading of the healthcare workers

Table 4 .
Analysis of KAP scores using Spearman's correlation coefficient 10 and only 10.25 % showed poor score which is still less than what observed by Lebena et al. (13.6%). 11Since nurses and Lab technicians two cadres have been included

Table 5 .
Bivariate analysis of different variables with KAP scores of healthcare workers

Table 6 .
Association of confidence to handle TB Cases by Trained and Untrained health care workers with respect to different variables 21rme et al.in their study carried out in thirteen facilities in Papua observed 90% facilities indicated systematic screening for coughing patients.1925.6% of the HCWs claim to always counsel patient correct cough etiquette which indicate they realize the importance of educating patients on how to prevent spread of infection through proper coughing practices.Comparing our finding with Shrestha et al. in Nepal which reported only 38.3% of the HCWs always educate patients on cough etiquette.20Inourstudy,16.6% trained and 46.6% untrained HCWs did not availed standard precautions in spite of hospital policy, whereas Biswas et al. reported 85% deficiency in core components of standard precaution which could be a possible reason of nosocomial transmission of tuberculosis.21Aprianiet al. carried out study in 21 Peripheral health center found only 11.7% staff undergone TB IC training.