Knowledge and perception of treatment among tuberculosis patients attending primary care clinics in Malaysia

Introduction: Tuberculosis is a disease of public health concern. It can be treated effectively with good knowledge about the disease and complete adherence to the recommended treatment regime. This study is intended to assess the level of knowledge and perception of treatment among tuberculosis patients attending primary care clinics. Methodology: We conducted a cross-sectional study using a validated self-administered questionnaire among tuberculosis patients attending primary care clinics in Johor Bahru district. A total of 208 tuberculosis patients were enrolled in this study through convenience sampling. We assessed the general knowledge, transmission, causes, and prevention of tuberculosis, where higher scores indicated better knowledge. For the perception of treatment, a higher mean score indicated a more negative perception. Results: The mean score for knowledge on tuberculosis was 54.33 ± 12.78, ranging from 25 to 88.9%. The mean score for perception was 2.75±0.52, ranging from 2.15-3.39. We found that although 88.9% of respondents knew a person could be infected with TB through inhalation of tuberculosis bacilli, a majority believed that smoking (68.2%), sharing food (69.2%), and eating from the same plate (66.8%) are causes of tuberculosis. Moreover, there was still a negative perception regarding the treatment of tuberculosis with the highest mean score for the statement ‘I am afraid if I am told I am tuberculosis positive’. Conclusions: We found that there were gaps in knowledge among tuberculosis patients. Intermittent counseling during the treatment re-enforces the knowledge of tuberculosis. An updated standardized counseling sheet of tuberculosis Health Education should be included along with staff training to update their knowledge as part of their important role in health education in tuberculosis prevention.


Introduction
Tuberculosis (TB) caused by the Mycobacterium tuberculosis bacteria can affect many systems in the human body with a wide clinical presentation of signs and symptoms. In 2016, the World Health Organization (WHO) reported that 10.4 million people were diagnosed with tuberculosis with an estimated 600,000 cases of multi-drug resistant TB [1]. Ending the TB epidemic by 2030 is one of the targets of the newly adopted Sustainable Developmental Goals by the WHO [1]. TB control is being achieved in countries with highincome economies, however, TB continues to plague people living in countries with low-income and lowermiddle-income economies [2]. In 2019, the incidence of TB in Malaysia was 92 cases per 100,000 population [3].
The National TB Control Program in Malaysia was established in 1961, and has been striving to improve TB control and outcomes. This program encompasses prevention strategies, early detection, treatment, and management of TB. Starting in 1973, each state in Malaysia had a dedicated TB team to conduct the above tasks. Progressing forward, in 1994, with the implementation of an integrated primary care concept in Malaysia, this program is placed under the general medical and health system. Every year, the state level must report to the Disease Control Division in the Ministry of Health regarding their progress [4]. This shows that treating TB is one of the priorities in the Malaysian health care system.
Studies regarding knowledge, attitude, and perception have been carried out throughout different parts of the world. Many of them show that lack of adequate knowledge affects the patient's compliance. In northwest Rajasthan, 100 percent of the respondents in the community did not know the name of the vaccine for TB [5]. In another community study in India, the majority did not know TB symptoms [6]. Misconceptions and wrong beliefs held by patients contribute to poor compliance [7]. In Malaysia, it has been shown that poor knowledge about tuberculosis among TB patients is associated with poorer compliance [8]. TB patients are being treated in primary care clinics throughout Malaysia. However, knowledge regarding TB and perception on treatment in the primary care clinic setting is lacking. The health care providers in the primary care clinic are supposed to provide relevant health education during the initiation of TB medications. Generally, there is a checklist for educating TB patients before commencing their treatment. The objective of this education is to ensure the patients understand their disease, medications during the treatment, and the medication side effects. Thus, the researchers aimed to determine the level of knowledge and perception of treatment among TB patients attending selected primary care clinics in Malaysia.

Study population and sample
The cross-sectional study was conducted among tuberculosis patients taking treatment from all 13 primary care clinics in Johor Bahru district. Johor Bahru is the capital state of Johor, which is a state located in the South of Peninsular Malaysia. There are almost 500,000 people who live in Johor Bahru. The method of sampling was convenience sampling. We included all TB patients aged 18 and above, on treatment or surveillance, and those who understood Malay or English language. Those who were acutely ill and did not consent were excluded from the study. Ethical approval for the study was obtained from the Secretariat of Research and Innovation Universiti Kebangsaan Malaysia (FF-2017-199) and the Medical Research and Ethics Committee (NMRR-17-663-34746). This study was done from June 2018 to November 2018.

Questionnaire and variables
We used a self-administrated validated questionnaire available in both Malay and English language. This questionnaire on Knowledge of Tuberculosis and the Perception of Tuberculosis Treatment Among Tuberculosis Patients in Malaysia was developed and validated with Cronbach's alpha of 0.751 [9].
The questionnaire has three sections. The first section is about the respondent's sociodemographic information. The second section tested on the knowledge of patients about TB which consists of general knowledge, causes, prevention, and mode of transmission of TB whereby the respondents were required to answer 'Yes', 'No', or 'Unsure' for each of the 36 questions. The correct answer was given one mark while incorrect and 'Unsure' answers were scored zero. The score was then converted to a percentage. The higher the score indicated better knowledge. The third section assessing the perception of TB treatment consists of 10 questions. The perception was scored according to five Likert scale options of 'Strongly disagree', 'Disagree', 'Unsure', 'Agree' and 'Strongly agree'. Scores of 1 to 5 were given respectively with a higher mean score reflecting a more negative perception.
The clinical characteristics of the patients were obtained from their TB folders, particularly from the TBIS 10A-1 form. TBIS 10A-1 form is the standard form used by the Ministry of Health Malaysia to record the details of a TB patient before commencing TB treatment. The data gathered from this form included the underlying medical conditions and symptoms experienced by the patient before commencing TB treatment.

Statistical analysis
Data were analyzed using SPSS version 23. Categorical data were described as frequency and percentage, while continuous data were described as mean and standard deviation. Responses to all questions on knowledge and perception were recorded in numbers and percentages. Pearson Correlation analysis, Independent T-test and One-way ANOVA were the statistical analysis used in the study. The two-tailed pvalue < 0.05 were taken as statistically significant for all analysis.

Results
Test of normality was done using Shapiro-Wilk. The sample was normally distributed with a p-value of more than 0.05. Table l showed the sociodemographic and clinical characteristics of our respondents. We recruited 208 TB patients in this study with the majority being males (60.1%). The mean age of patients was 40.7±15.75 years ranging from 18 to 83 years old. Most of the patients were of Malay race (66.8%) and about half were married (55.3%). Almost all had formal education (95.2%) and more than half were working (61.5%). About one-quarter of the respondents were known diabetics and one-third of them were active smokers. The majority had pulmonary TB (81%). There was good compliance among the respondents (99.5%). The top three symptoms experienced by the patients were reduced appetite (52.4%), cough with phlegm (50.0%), and reduced body weight (43.3%).
The mean for TB knowledge score in percentage was 54.33±12.78, with the lowest score of 25.0% and the highest score of 88.9%. Table 2 shows the responses of TB knowledge. General knowledge of TB is somewhat poor, with many believed that smoking (68.2%), sharing food (69.2%), and eating from the same plate (66.8%) as reasons why someone gets infected with TB. A good thing to note is that majority of the respondents (88.9%) knew that people could get TB by inhaling TB germs in the air. For the domain on prevention, many still believed that avoiding sharing food (79.3%), washing hands after touching items in public places (88.9%), taking healthy food (89.4%), and praying (77.9%) can prevent TB infection. Surprisingly, more than half (51.9%) of the respondents did not know the role of BCG vaccination. We also noted that our respondents had good knowledge of who can get TB (93.8%). However, they did not know much about the higher risk group population who can be infected with TB and many believed TB is a sexually transmitted disease (75.5%) and could also be transmitted from sharing cigarettes (91.3%). There was good knowledge on the cure of TB (86.5%) and taking treatment from the clinic to cure TB (95.7%). However, many still believed in herbal mixtures to treat TB (46.2%).
The mean for the perception of TB treatment was 2.75 ± 0.52, ranging from 2.15-3.39. There were 10 statements assessing the patient's perception of TB treatment as shown in Table 3. The top 3 most negative perceptions are 'I am afraid that I will be told that I am TB positive' (3.39±1.24), 'I am afraid that I will lose my job/income' (3.03 ± 1.21), and 'I am afraid that TB treatment will be unpleasant and difficult' (2.97 ± 1.20). We looked into the association between knowledge and sociodemographic as well as knowledge and clinical variables of 208 respondents with the mean knowledge score as shown in Table 4. All analyses showed no statistical significance (p>0.05).

Discussion
This study showed that the respondents did not score well for domains on transmission and prevention. This has been seen in previous studies where respondents believed that transmission of TB was through contaminated food [10,11]. Similarly, a high proportion of our respondents did not know the role of BCG vaccination as was seen in another study [5]. More focused counseling should be given to TB patients in the identified areas causing misconception.
Our study also found that the respondents were afraid of the stigma associated with TB. The majority was afraid of being told if they have TB, worry that TB will affect their income, and the treatment being unpleasant. In response to this, TB patients might need to adapt their activities of daily living to avoid the social consequences of the disease. This was seen in a community study done in Sabah, where all patients changed their daily activities (e.g. separation of utensils, new sleeping arrangements, reduced social activities), with one patient's income being affected when his community knew he had TB [11]. Hence, it is important to reduce this negative attitude by conducting health promotion among patients and the public.
In this study, there was no significant association between the level of knowledge with education. However, in a previous study, patients with a higher level of education scored significantly higher than the rest [8,[12][13][14]. This can be because basic knowledge of TB has reached most TB patients in our population through health education; hence, the effect of the educational level was not seen. There was no association seen between knowledge and clinical characteristics in this study. Despite the medical co-morbidities our respondents had, it did not affect their knowledge level on TB. Previous studies have shown that knowledge on TB symptoms improves health-seeking behavior [12]. In this study, despite some knowledge gaps, there was very good compliance. This can be due to our Directly Observed Treatment (DOTs) program and good defaulter tracing system in our primary care. The DOTs is the most effective treatment strategy for controlling TB [15]. The dedicated team in charge of the TB patients in our primary care clinics would trace and contact the defaulters to make sure they completed the treatment.
The prevalence of diabetes among patients with tuberculosis in this study was 25.5%, similar to another study done on TB patients in Malaysia in 2011, 29.9% [16]. This rate is however higher than another recent study in Bhopal that reported a prevalence of 12.39% [17]. In 2011, a 'Collaborative Framework for care and control of Diabetes and TB' was launched by the WHO and the International Union Against Tuberculosis and Lung Disease (The Union) with one of the important aspects being screening for diabetes in a TB patient and vice-versa. Having diabetes is associated with poorer outcomes for TB patients including delayed sputum conversion rates, a higher rate of relapse after treatment, and a higher risk of death [18]. There is a need for increased attention when managing diabetic patients with TB. Diabetes patients should be informed of their risk and the symptoms of tuberculosis.

Conclusions
Counseling should be given to all TB patients. Intermittent counseling throughout the course of treatment helps to reinforce knowledge of TB. It also gives patients a chance to ask and clarify any misconceptions. A standardized counseling sheet on TB Health Education should include the mode of transmission and prevention. This counseling sheet should be used in all patients before commencing treatment. Thus, a revision of the current checklist is indicated along with staff training so that their knowledge on TB can be updated. Doctors and health care staff should be encouraged to attend short training courses held on TB education aids and guidelines as they play an important role in health education in disease prevention.