Assessment of knowledge, attitude and practice towards tuberculosis infection control among health professionals in Nekemte Referral Hospital, Nekemte, Oromia, West Ethiopia: cross sectional facility-based study

Corresponding author: Eba Abdisa Golja, Wollega University, Institute of Health Sciences, School of Nursing and Midwifery EMAIL: ebajije1355@gmail.com Abstract Poor knowledge, poor practice and poor attitude among health care workers may lead to the increased risk of nosocomial tuberculosis transmission. This study was aimed to assess knowledge, attitudes and practice of health professionals towards tuberculosis infection control in Nekemte Referral Hospital, Nekemte, west Ethiopia.


Tuberculosis (TB) is an infection caused by the bacillus
Mycobacterium tuberculosis, which affects lungs, and causes extra pulmonary TB, which affects other body parts. When the patient discharges bacilli to the air through coughing and sneezing, it can be easily spread to other people. In this case, people living in the same household, and having frequent contact with an infectious patient have the greatest risk of contracting TB. 1 According to World Health Organization in 2017, there were an estimated 10.4 million new TB case. Ethiopia is one of the countries affected by disease, ranked seventh in the world and third in Africa. 2 One study identified that in 2016, new TB cases numbered 219,186, with prevalence of 151,602 cases and 48,910 deaths. 3 Another study found that the number of patients following Nekemte Referral Hospital was very high. 4 In a prison which is located to next Nekemte Referral Hospital, the prevalence of latent TB infection was also 51.2%. 5 Tuberculosis infection control is a subcomponent of the WHO updated Stop TB Strategy contributing to strengthening of health systems. It is one of the three activities to reduce the burden of TB in persons living with HIV/AIDS. 6 It is recommended that all health-care settings should have a TB infection-control program. 7 Healthcare workers, especially those who had frequent contacts with TB patients, are at higher risk of TB infection compared to the general population. The incidence of TB among people working in congregate settings like laboratories, TB clinics and wards exceeds that of the general population. 8 Tuberculosis is highly transmissible in resourcelimited healthcare facilities in which HCWs are at great risk of acquiring TB. 9 Several studies have confirmed that TB is a significant occupational risk among HCWs in low-and middle income countries, 10 and it is estimated that the incidence of TB among HCWs in high burden countries (>100 cases/100,000 population) is 8·4% greater (95% CI 2·7%-14·0%) than the general population. 11 The highest prevalence of TB was found among laboratory staff (43.4%), followed by technician staff (39.4%), doctors (34.4%) and nurses (32.2%), and the lowest was observed in administrative staff (25.2%) in China. 12 In Ethiopia, better HCW knowledge and positive attitude are more common among those who received training and orientation towards TB infection control. Use of face mask among the HCWs was limited. 13 In Ethiopia, the safe infection prevention practice significantly increased if HCWs had received training and had infection prevention guidelines available at their work. 14 Another study done in Addis Ababa indicated that one third of HCWs had poor knowledge and half of them had poor practice towards TB infection prevention, and the level of infection prevention was significantly associated with year of experiences, having TB related training. 15 Thus, in this study, an attempt was made to assess the knowledge, attitude and practice of infection control among HCWs in Nekemte Referral Hospital, Ethiopia.

Study area and period
The study was conducted at Nekemte town from September 2019 to October 2019. This town is found in Oromia region, western Ethiopia; it is 331 km away from Addis Ababa, the capital city of Ethiopia, and currently serves as a capital city of East Wollega zone. This hospital is giving service for about more than 2 million population. This hospital has been serving the population with four big wards and more than ten outpatient departments. It has 18 specialists, 20 general practitioners, 130 nurses, 18 laboratory technicians, 16 pharmacists and more than 250 administrative staff. Currently, more than 3000 TB patients have been following their treatment according to the Administrative office data.

Aim of the study
The main aim of the study was to assess knowledge, attitude and practice toward TB infection control among HCWs of Nekemte Referral Hospital, Nekemte, Oromia, West Ethiopia, 2019.

Study design
An institutional based cross-sectional study design was carried out. not for citation purposes Knowledge, attitude and practice of tuberculosis infection prevention Golja

Study population
All health professionals who were currently working in Nekemte referral hospital including doctors, nurses, midwifes, pharmacy and laboratory personals were the study population. Some of them are currently working in the TB clinic, Others are also having the chance of getting TB patients at their serving units. For example, the clinicians working in obstetrics and gynecology wards have the chance to be infected from the women admitted for delivery or gynecology cases. In other non-specialized staff, they have the chance to rotate to TB clinic. That was why all health professionals were included.

Sample size determination
The total number of health professionals of this hospital is 223. Because of the small study population, we tried to include all health professionals in this study. Therefore, our study sample was 223.

Data collection tools
A semi structured questionnaires was used which was taken from similar studies [16][17][18] for data collection; it has specific components of TB infection control questions, using the Program and Clinical Management of Tuberculosis Guideline of the Federal Ministry of Health (FMOH) in Ethiopia, 19 and the World Health Organization policy on TB infection control in health care facilities with specific activities and evidencebased recommendations between 2009-2019. 20 The tool comprised of HCWs' demographic and servicerelated variables (age, sex, education, job category, duration of employment, training/orientation on TB and TB infection control).
Knowledge was assessed using 11 questions by scoring the response 0 (zero) for wrong answers and 1 (one) for correct answers, and summing the scores. After checking the distribution of the responses, the midpoint was used as cut-off points for categorizing knowledge score as good (those who scored above 5.5) or poor (those who scored below 5.5).
There was a total of 12 questions to measure attitude using a scale ranging from strongly agree to strongly disagree. The scores were divided into two as positive attitude for those who scored above six and negative attitude for those who scored less than six.
Practice was assessed using eleven 11 statements with sub sections such as TB guidelines, ventilation of working area, patient education about TB and availability and use of personal protective equipment. Based on the midpoint, classification was made as good practice for those who scored greater than 5.5 or poor practice for those who scored less than 5.5.

Data collection procedure
Data were collected from volunteer health professionals self-report by using self-administered questionnaires after obtaining informed consent from the participants. The data collection tool was prepared in English considering that all health professionals were above certificate level of education. The questionnaires were distributed and collected by data collectors.

Data quality assurance
Quality of data collection process was supervised and monitored by supervisors and principal investigators. We did our research investigation among all health professionals by giving emphasis on ethical consideration. Prior to data collection, adequate training was given for data collectors and supervisors so that appropriate supervision was made. The questionnaire was prepared and customized to avoid entry of illegal values and skip patterns. Each questionnaire was given an identification number and validated by double entry of SPSS Version 21 (IBM, Armonk NY).

Data management and analysis
The collected data were checked for completeness, inconsistencies, and then data were coded, entered and cleaned using SPSS Version 21 by double entry. The results were presented using figures, tables and statements.   Table I.

Facility and administration related characteristics of healthcare workers towards TB infection control
As it is indicated in the

Knowledge of health professionals towards TB infection control
The majority (172, 86%) of the respondents knew that "Regular screening of HCWs for TB is one of the TB infection control measures" whereas 110 (55%) knew that surgical masks cannot protect the HCW from  Table III.

Attitude of health professionals towards TB infection control
The majority (157, 78.5%) of HCWs had positive attitudes towards TB infection control. As shown in Table IV, the majority (184, 92%) of HCWs agreed that there is a need for a TB infection control guideline in health facilities. More than 75% (159, 79.5%) agreed that they should wear respirators while caring for TB patients. More than half (116, 58%) were concerned about being infected with TB and 87 (43.5%) agreed that cough hygiene alone has no role in TB infection control.

Practice of health professionals toward TB infection control
The range of respondents' practice scores ranged from 1-11. As shown in Table V, 169 (84.5%) of HCWs were opening the window whenever TB suspected or a confirmed patient is in the room. Most (161, 80.5%) had always followed TB treatment guidelines to manage new-smear positive cases while 34 (17%) of them used these sometimes, and 5 (2.5%) never followed the guideline.  There is need to screen HCWs who may be exposed to TB for TB infection or disease

Discussion
In this study, the majority of the respondents had good knowledge towards TB infection control. This finding is almost similar to the finding of the study conducted in Iraq revealed that (98.4%) of HCWs had a 'good' score for knowledge of TB. 21 This finding was higher than the study conducted in Addis Ababa where (63.9%) concluded to had overall good knowledge from the total 582 HCWs 15 and a study conducted in Thailand indicated that 56% of healthcare providers were found to possess a 'good' level of knowledge of TB infection control. 22 The difference could be due to sample size, the level of health institutions and the knowledge level of study participants.
This study showed that 70% of the respondents have good practice. This is slightly higher than the study conducted in Addis Ababa, Ethiopia (48.6%), 15 and the study conducted in the Berea District of Lesotho, South Africa that revealed that half (52.7%) received a 'good' score for practice in the evaluation of occupational exposure to TB infection control among healthcare workers. 17 The difference could be due to sample size, the level of health institutions, training they received and the practice level of study participants. Practice of the HCWs regarding TB infection control (30%) was not good. This low practice might be due to low proportion of trained and experienced HCWs in respective health facilities.
Our study showed that 84.5% of the respondents knew the door and window should be open whenever a TB suspected or confirmed patient is in the room. This finding was higher than the study conducted in St. Luke's Medical Center, Philippines, where 39% of the respondents had good practice towards TB infection control. 23 The difference could be due to the sampled health facility level and methods.
The majority (80%) knew the importance of educating TB patients to cover their mouths with a handkerchief and 86% knew the need of infection control committee. These findings are consistent with WHO TBs treatment guideline. 24 Respiratory protection control is the third level of a TB infection control program and consists of the use of protective equipment in situations of a high risk for exposure to TB disease. 7 However, this study showed that 45% of participants wrongly believed a surgical mask can protect HCWs from inhaling M. tuberculosis containing droplets. This result is nearly consistent with the finding from northwestern part of the country. 18 The present study found that 78.5% of the study participants had positive attitude towards TB infection control, which was consistent with a study conducted in Nepal, in which 73.2% of healthcare providers had positive attitude towards TB infection control. 13

Conclusion
Generally, the results of this study revealed that high proportion of HCWs had relatively good knowledge towards TBIC. Around 60% of HCWs wrongly believed surgical masks can protect HCWs from inhaling M. tuberculosis containing aerosols. Around two thirds of health professionals had relatively good practice towards TB infection control. Low proportions of the participants were trained on TB infection control. More than half of the rooms where HCWs are working had cross ventilated windows.
Training of health professionals with emphasis on practical aspects is vital to strengthen the implementation of TB infection control activities. Giving on the job training for junior staff is important to improve TB infection control practice. Using focus group discussions or in-depth interviews to find out the attitude of HCW towards TB infection control is important. not for citation purposes Knowledge, attitude and practice of tuberculosis infection prevention Golja