High School Students' Knowledge on Tuberculosis Prevention: A Quantitative Survey in Bhaktapur of Nepal

Background and Aims

Tuberculosis (TB) is a common and deadly infectious disease caused by mycobacterium tuberculosis. It spreads through the air, when people having the disease cough, sneeze or spit[1]. Vast majority of tuberculosis deaths are occurring in developing countries with more than half of all deaths are occurring in Asia[2]. Weakened immune system is also the risk factors of tuberculosis[3]. Symptoms of tuberculosis of the lungs include cough for three or more weeks, blood stained in sputum and chest pain[4]. For the prevention of tuberculosis including; protection against exposure to tuberculosis, encourage diagnosis and treatment of patients with positive pulmonary tuberculosis, and good ventilation[5].

Globally, the TB mortality rate has decreased by nearly half between 1990 and 2013, and decreasing at around 3% per year with overall reduction between 2000–2017 was 42%[6]. Over 95% of tuberculosis deaths occur in low and middle income countries (LMICs), and it is among the top causes of mortality for women aged 15 to 44[7]. Every other person in the world is infected with tuberculosis[8]. Most of the human faces of the epidemic are adults of productive age group (15-49 year)[7]. In Nepal, every year about 40,000 people were infected with tuberculosis and among them 20,000 develop infectious pulmonary disease[9]. Under the National tuberculosis program of Nepal, many positive cases of TB had been treated[10].

A study in India revealed there was ignorance, wrong knowledge and wrong practices demonstrated by senior secondary students. Therefore, the researcher focused the inclusion of tuberculosis education in the syllabus of upper level school students[11]. Similarly, the study in India, Bangladesh, Italy and Nigeria concluded the poor knowledge on TB need to be addressed through health education and awareness among university students, individuals and spouses about tuberculosis[12–14]. In developing countries, the knowledge on tuberculosis is generally poor, so, the researcher recommended for additional effort for educating public and clarifying the taboos about tuberculosis[15].

Several studies had focused on regular awareness program on causes, disease transmission and preventive measures of TB among students focusing one health[5,8,16–19]. Similarly, a study suggested medical undergraduate students could also be involved to change the behaviors towards TB[20]. Few studies suggested for more researches on older adolescents for investigating their knowledge and behavior is needed[21]. Likewise, a study in Nepal revealed the lack of knowledge on effects of incomplete treatment and suggested to emphasis on providing education to the patients on the treatment[22].

Adolescents are at high risk of increasing and spreading the tuberculosis infection as well as they are the message carriers to home. It would be very helpful to aware public and also reduces the disease rates by providing more information and knowledge about tuberculosis to adolescents.

The aim of the study is to assess the level of knowledge on tuberculosis and its preventive measures among secondary level student of Bhaktapur district of Nepal.

Methods

A cross sectional study design was applied for conducting the research in the high school Students in Bhaktapur district of Nepal. A total of 192 high school students present on the day of data collection were selected for the study. The samples (high school students of class 9 and 10) were selected from two purposively identified schools in Bhaktapur. Similarly, semi-structured questionnaires were developed and pretested before data collection through self -administered techniques.

Prior to data collection, ethical clearance was taken from research committee of Asian College for Advance Studies and taken permission from the selected schools. Study participants were explained about the purpose of the study and provided assurance of confidentiality through anonymity and privacy of data use. Written consent was taken from all the student participants.

The collected data was checked for the completeness and correctness, coded and entered in database. Likewise, data analysis was done using SPSS 20v to measure frequency, percentage and chi-square tests for associations between knowledge on the preventive measures of tuberculosis and socio-demographic variables. In addition, the level of knowledge was categorized into adequate scoring above 75 percentages, moderate scoring 50 to 75 percentages and inadequate scoring below 50 percentages for the interpretation.

Results

Socio-demographic characteristics

The study participants were from the age13 to 17 years where majority of participants were from 14 and 15 years. Among them more than half (51%) of the participants were male and came from municipalities. Similarly, most of the participants (61.5%) were from Newar ethnic community and 88.5% were from Hindu religion. In addition, more than two third of the participants (76%) belonged to nuclear family. Among the parents of all respondents, almost all of the fathers (97.9%) and more than two third of the mothers (75.0%) were literate respectively. Regarding the occupation of the parents, about one third of the fathers (30.2%) were engaged in business and more than half of the mothers (57.3%) were housemakers.

Knowledge on Tuberculosis

Almost all the participants (93.8%) had heard about tuberculosis and among them, maximum (85.4%) had received information from teachers followed by television (54.2%), radio (26.0%), newspaper (20.8%), health professionals (18.8%), family members (17.7%), friends (11.5%) and others (3.1%). Likewise, about one tenth of family members (9.4%) of participants had suffered from tuberculosis in past.

Most of the participants (90.6%) had known that tuberculosis is an infectious disease whereas rest of the participants said it is hereditary, highly contagious and others.

Knowledge on risk factors, symptoms and treatment of tuberculosis

Most of the high school students has responded the smoking (53.7%) and bacteria (46.3%) are the risk factors, and other responses were lack of hygiene (18.9%), malnutrition (15.8%), over working (15.8%), virus (12,6%) and curse of god (2.1%).

Figure 1: Participants knowledge on risk factors of TB

Likewise, most of the participants (96.9%) had agreed TB is transmissible. Regarding the mode of transmission, mix thoughts were presented during the survey among high school students as it is transmitted through coughing and sneezing (21.3%), living with infected persons (21.3%), mother to infant (21.3%), having meal together (12.8%), drinking in a same glass (12.8%) and sharing cloths (6.4%). Among the total participants, majority (68.9%) of the participants told that coughing more than 2 weeks followed by chest pain (55.6%), blood in sputum (37.8%), loss of appetite (37.8%), weight loss (31.1%) and fever during night time (30%) as the symptoms of TB.

Similarly, for the diagnostic evaluation of the TB, only about half of the high school students (49%) told sputum examination. One third of them had said skin test (31.2%) followed blood test (21.9%), chest X-ray (20.8%) and very few said urine test (1%) as the diagnostic evaluation of TB. The majority of participants (66.7%) told that TB can be treated by anti-TB drugs combination and other participants expressed antibiotics (28.1%), traditional medicine (2.1%), avoiding sex (2.1%) and others (1%). Furthermore, half of the participants had answered the complete treatment for TB will take six months and majority of them (78.1%) heard about the DOTS.

Knowledge on preventive measures of TB

In average, most of the participants were aware on the preventive measures of TB such as covering mouth and nose when coughing and sneezing (97.9%), good ventilation and sunlight (97.9%), eating balance diet (95.8%), sputum discharge in special plastic container (90.6%), hand-washing after coughing and sneezing or touching in public places (88.5%) and BCG vaccination in newborn child (82.3%). However, there are still needs an improvement on avoiding being close to the TB patient (63.5%) and isolation of TB patients (69.8%).

Figure 2: Knowledge on preventive measures of TB

Among the total high school students, more than half of the participants (59.4%) had inadequate knowledge, one third of the participants (36.5%) had moderate knowledge and least of the respondent (4.2%) had adequate knowledge. Likewise, almost all the participants (90.6%) had adequate knowledge on preventive measures of TB followed by moderate knowledge (9.4%).

Table 1: Knowledge score of TB and its preventive measures among high school students
Knowledge level	Overall Knowledge	Knowledge on preventive measures
Frequency	Percent	Frequency	Percent
Less than 50% (inadequate)	114	59.4	0	0
50-75% (moderate)	70	36.5	18	9.4
More than 75% (adequate)	8	4.2	174	90.6

The result showed that the students living in the joint families had more knowledge on TB than the students living in the nuclear families. Likewise, among different ethnicities, Chhetri ethnic groups had more inadequate knowledge on TB followed by Tamang and Newar ethnic groups. However, there is no associations (p>0.005) between knowledge on TB and ethnicity as well as family type.

Discussion

From the results of this study, it has been found that one third of the participants were from 15 years of age and mostly belong to Hindu religion and attendant of class 10. All the participants had heard about tuberculosis whereas a similar study carried out in Kenya and Ethiopia showed 93.3% [21] and 94.9% [23] of the participants respectively had heard about TB. Likewise, this study reveals that maximum (85.4%) of the participants had got information of TB through teacher and television (54.2%).

The study found that more than ninety percentages (90.6%) had known about the meaning of TB. Similarly, 25% expressed that the TB is contagious and 2.1% told it is hereditary disease. In contradiction, the findings of the research conducted at Saudi in 2015 [5] showed around 63.0% recorded that TB was infectious, while only 5.0% thought TB is hereditary.

Most of the study participants (96.9%) had expressed that TB is transmitted while in another study[1], nearly three fourth (73.9%) of the study participants were aware on it. Moreover, regarding the risk factors, more than half of the participants (53.7%) had told that smoking is the risk factors while in contrast to a study at Saudi[5] provided only about one fourth of the participants (27.7%) felt it. Other risk factors are also expressed by the participants including misconception TB caused from virus.

Most of the participants (90.4%) in this study had said that TB is transmitted through coughing, sneezing without covering whereas 15 percentage less found in a study conducted at Bangladesh [13] that is 75 percent. Similarly, a study at Saudi[5] showed the 44.9 percent had prolonged cough which is nearly 20 percent less than in this study (68.9%). Furthermore, majority of the participants (66.7%) had agreed that TB is treated by anti- TB drugs combination while in another study [1], more than eighty percent (80.2%) had known the treatment. The half of the participants (50%) in this study had knowledge about the duration of taking the drugs, however, in similar study it was only 12.6%[5].

A study conducted by Rana et al. (2015)[13] revealed that 90% of the participants had heard about the DOTs while 78.1% had heard about DOTs in the present study. Similarly, in another study in Nepal about 56% had heard DOTs[24]. All the participants agreed that the TB is curable whereas slightly less (84.1%) in a study conducted at Mongolia[1]. Almost all (97.9%) the participants were applying preventive measures such as covering mouth and nose when coughing and sneezing whereas in contrast to this study, only 42.9% were covering during coughing and sneezing[1].

In this study, only 4.2% of the student participants had adequate knowledge of TB and 36.5% had moderate level of knowledge while a similar study conducted in Ethiopia, about 59.8% had good knowledge[25]. Likewise, almost all the participants (90.6%) had adequate knowledge on preventive measures of TB in the study whereas a study conducted in Peru had showed less percentage (43.3%) had adequate knowledge[26].

The study had only participated the students of 9 and 10 class and had not discussed about the family members’ practice, knowledge and attitudes. There are many areas to explore the knowledge and engage broad areas and participants for the study to be thought for the research questions in future.

Conclusions:

The study showed fifty nine percent of participants had inadequate knowledge while only least number of participants had adequate knowledge. Similarly, knowledge on preventive measures is adequate (90%) among the participants. Despite the inclusion of TB on school curriculum and awareness program from the media and government, students’ knowledge level is still very low. Thus, the study is important for the school to plan the sessions and the government to focus the school level students for TB prevention and control.

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Acknowledgements

We would like to express our gratitude to Asian College for Advance Studies (ACAS). We would like to extend our special thanks to all those participants for kind co-operation and supports from our friends throughout the study.