Knowledge, Attitudes, and Practices of People living with TB infected patient in

selected Barangays in Tuguegarao City

A Research Proposal Presented to the College

Of Medicine, Cagayan State University
Carig Sur, Tuguegarao City

In Partial Fulfillment of the Requirements for

The Degree of Doctor of Medicine

By:

Kayessa Ylona M. Bunagan

Angelita R. Calica
Pauline Faith G. Miguel
Roda Maire T. Pamittan
Roane Crispina P. Robles
Yowerie Ched Q. Sedano
Rajat Vishwakarma

May, 2019
 Chapter 1

INTRODUCTION

Background of the Study

Tuberculosis (TB) is a diseased caused by Mycobacterium tuberculosis and is

transmitted from an infected person to a susceptible person by airborne particles, called

droplet nuclei. Transmission occurs when a person inhales droplet nuclei containing

tuberculosis bacteria. These droplet nuclei travel via mouth or nasal passages and move into

the upper respiratory tract. Thereafter they reach the bronchi and ultimately to the lungs and

the alveoli, which causes progressive coughing, hemoptysis, chest pain, weight loss, fatigue,

fever, night sweats, and loss of appetite. (Mandal, 2018)

TB is one of the leading causes of death worldwide. Despite the effective treatments,

patients themselves may undermine TB control efforts that may result to multidrug-resistant

(MDR) and extensively drug-resistant (XDR) TB. Drug-resistant TB has been reported since

the early days of introduction of chemotherapy, but multidrug-resistant tuberculosis (MDR-

TB) and more recently extensively drug-resistant tuberculosis (XDR-TB) has been an area of

growing concern and is posing a threat to global efforts of TB control. Poor or high-risk

infection control practices or non-adherence to treatment, poor patient conduct, negligence

and resistance to participation in appropriate TB control efforts are motivated by individual,

socio-economic and structural factors. Mismanagement of MDR-TB with erratic use of

second-line drugs may lead to development of XDR-TB. (Prasad, 2012)

Persons who are at high risk with being infected with TB includes those who are in

contact with high-risk groups for TB, despite efforts to scale up infection and reduce TB

transmission. Philippines has high prevalence of TB and rising cases of MDR TB and XDR

TB. Understanding the knowledge, attitudes and practices among people in contact with TB

patients is fundamental when it comes to decreasing future TB cases. Therefore, this study
aims to assess the Knowledge, Attitudes, and Practices of people living with TB infected

patient in selected Barangays in Tuguegarao City.

Statement of Objectives

1. What is the profile of respondents in terms of:

a. Demographic

b. Socio- economic

2. What is the level of knowledge of respondents about Tuberculosis in terms of:

a. Causes

b. Treatment and management

c. Diagnosis

3. What is the attitude of respondents on Tuberculosis?

4. What are the practices of respondents on Tuberculosis?

5. Is there a significant difference on the knowledge, attitude, and practices of

respondents on tuberculosis when grouped according to profile variables?

6. Is there an association between the knowledge of respondents on tuberculosis with

that of attitude and practices?

Literature Review

Tuberculosis

Tuberculosis (TB) is caused by bacteria (Mycobacterium tuberculosis) that typically

affects the lungs (pulmonary TB), but can also affect other sites (extrapulmonary TB). The

disease is spread when people who are sick with pulmonary TB expel bacteria into the air, for

example by coughing (WHO, 2018). The risk of progression to active TB and development of

symptoms is about 10% over the course of a lifetime (Frieden 2003), but co-infection with
human immune deficiency virus (HIV) increases this risk to about 10% per year. It is both

curable and preventable.

About one-quarter of the world's population has latent TB, which means people have

been infected by TB bacteria but are not (yet) ill with the disease and cannot transmit the

disease. People infected with TB bacteria have a 5–15% lifetime risk of falling ill with TB.

However, persons with compromised immune systems, such as people living with HIV,

malnutrition or diabetes, or people who use tobacco, have a much higher risk of falling ill.

When a person develops active TB disease, the symptoms (such as cough, fever, night

sweats, or weight loss) may be mild for many months. This can lead to delays in seeking care,

and results in transmission of the bacteria to others. People with active TB can infect 10–15

other people through close contact over the course of a year. Without proper treatment, 45%

of HIV-negative people with TB on average and nearly all HIV-positive people with TB will

die.

Global impact of TB

TB occurs in every part of the world. In 2017, the largest number of new TB cases

occurred in the South-East Asia and Western Pacific regions, with 62% of new cases,

followed by the African region, with 25% of new cases. In 2017, 87% of new TB cases

occurred in the 30 high TB burden countries. Eight countries accounted for two thirds of the

new TB cases: India, China, Indonesia, Pakistan, Nigeria, Bangladesh and South Africa, the

Philippines.

The Philippines now has the most number of tuberculosis cases in Southeast Asia. But

the Department of Health (DOH, 2018) has clarified that this is only because the country is

using a state-of-the art TB testing machine, which is the most accurate compared to those

used by neighboring countries.

Symptoms and diagnosis

Common symptoms of active lung TB are cough with sputum and blood at times,

chest pains, weakness, weight loss, fever and night sweats. Many countries still rely on a

long-used method called sputum smear microscopy to diagnose TB. Trained laboratory

technicians look at sputum samples under a microscope to see if TB bacteria are present.

Microscopy detects only half the number of TB cases and cannot detect drug-resistance.

The use of the rapid test Xpert MTB/RIF® has expanded substantially since 2010,

when WHO first recommended its use. The test simultaneously detects TB and resistance to

rifampicin, the most important TB medicine. Diagnosis can be made within 2 hours and the

test is now recommended by WHO as the initial diagnostic test in all persons with signs and

symptoms of TB.

Diagnosing multi-drug resistant and extensively drug-resistant TB (see Multidrug-

resistant TB section below) as well as HIV-associated TB can be complex and expensive. In

2016, 4 new diagnostic tests were recommended by WHO – a rapid molecular test to detect

TB at peripheral health centers where Xpert MTB/RIF cannot be used, and 3 tests to detect

resistance to first- and second-line TB medicines.

Tuberculosis is particularly difficult to diagnose in children and as yet only the Xpert

MTB/RIF assay is generally available to assist with the diagnosis of pediatric TB.

Treatment

TB is a treatable and curable disease. Active, drug-susceptible TB disease is treated

with a standard 6 month course of 4 antimicrobial drugs that are provided with information,

supervision and support to the patient by a health worker or trained volunteer. Without such

support, treatment adherence can be difficult and the disease can spread. The vast majority of

TB cases can be cured when medicines are provided and taken properly.
 In the Philippines, TB-related facilities have greatly improved over the years. There

are several DOTS (Directly-Observed Treatment Short course) centers helping people with

TB. In 2000, within a span of five years since 1995 when the Philippine government started

to strengthen its TB intervention, the country reported 100% TB-DOTS coverage nationwide.

Between 2000 and 2017, an estimated 54 million lives were saved through TB

diagnosis and treatment.

Multidrug-Resistant Tuberculosis

The Philippines is 1 of 22 countries considered to have a high burden of tuberculosis

(TB), including multidrug-resistant (MDR) TB (resistant to isoniazid and rifampin).

Compared with treatment for drug-susceptible TB, treatment for MDR TB is longer, more

expensive, and less effective, and it causes more medication side effects. Resistance to anti-

TB drugs has been detected in all regions of the Philippines; an estimated 8,500 MDR TB

cases occurred in 2013. (Tupasi et al, 2016)

Globally, 5% of TB cases were estimated to have developed multidrug-resistant TB

(MDR-TB) (defined as resistance to at least isoniazid and rifampin) in 2013 (3.5% new and

20.5% previously treated TB cases). Likewise, drug resistance surveillance data have shown

that an estimated 480 000 people developed MDR-TB worldwide in 2013, and out of this,

210 000 people died. In 1999, the Green Light Committee (GLC), a partner of the World

Health Organization (WHO), launched the “directly observed treatment, short-course

(DOTS)-Plus for MDR-TB” programs for patients with MDR-TB. The program emphasizes

the usage of appropriate second-line drugs (SLDs) in low- and middle-income settings. By

the end of 2006, more than 50 DOTS-Plus pilot programs had been launched by GLC, and

more than 20 000 patients with MDR-TB were under treatment.

 The DOTS-Plus program, which stresses the combination of first- and second-line

drugs to treat MDR-TB, is becoming increasingly important for MDR-TB control globally.

The core components are comprehensive to ensure that all essential elements of the DOTS-

Plus strategy are included. They are the following: sustained political and administrative

commitment; diagnosis of MDR-TB through quality-assured culture and drug susceptibility

testing; appropriate treatment strategies that utilize SLDs under proper management

conditions; and uninterrupted supply of quality-assured anti-TB drugs. (Kibret et al, 2017)

Extensively Drug-Resistant Tuberculosis

XDR-TB, an abbreviation for extensively drug-resistant tuberculosis (TB), is a

form of TB which is resistant to at least four of the core anti-TB drugs. XDR-TB involves

resistance to the two most powerful anti-TB drugs, isoniazid and rifampicin, also known

as multidrug-resistance (MDR-TB), in addition to resistance to any of the

fluoroquinolones (such as levofloxacin or moxifloxacin) and to at least one of the three

injectable second-line drugs (amikacin, capreomycin or kanamycin).

MDR-TB and XDR-TB both take substantially longer to treat than ordinary (drug-

susceptible) TB, and require the use of second-line anti-TB drugs, which are more

expensive and have more side-effects than the first-line drugs used for drug-susceptible

TB.

Acquisition of XDR-TB

People may get XDR-TB in one of two ways. It may develop in a patient who is

receiving treatment for active TB, when anti-TB drugs are misused or mismanaged, and is

usually a sign of inadequate clinical care or drug management. It can happen when

patients are not properly supported to complete their full course of treatment; when health-

care providers prescribe the wrong treatment, or the wrong dose, or for too short a period
of time; when the supply of drugs to the clinics dispensing drugs is erratic; or when the

drugs are of poor quality.

The second way that people can develop XDR-TB is by becoming infected from a

patient who is already ill with the condition. Patients with TB of the lungs can spread the

disease by coughing, sneezing, or simply talking. A person needs only to breathe in a

small number of these germs to become infected. However only a small proportion of

people infected with TB germs develop the disease. A person can be infected by XDR-TB

bacteria but not develop the active disease, just as with drug-susceptible TB.

XDR-TB Transmission

Studies suggest that there is probably no difference between the risk of

transmission of XDR-TB and any other forms of TB. The spread of TB bacteria depends

on factors such as the number and concentration of infectious people in any one place

together, and the presence of people with a higher risk of being infected (such as those

with HIV/AIDS).

The likelihood of becoming infected increases with the time that a previously

uninfected person spends in the same room as an infectious case. The risk of spread

increases where there is a high concentration of TB bacteria, such as can occur in poorly-

ventilated environments like overcrowded houses, hospitals or prisons. The risk of spread

is reduced if infectious patients receive timely and proper treatment. (WHO, 2019)

TB-DOTS and Updates

According to WHO, "The most cost-effective way to stop the spread of TB in

communities with a high incidence is by curing it thus, all countries with a TB problem were

to provide standardized short course drug treatment to, at least, all sputum smear positive TB

patients. Due to its prevalence, WHO implemented the directly observed therapy short course

(DOTS) in 1993. DOTS involved treatment with a four drug regimen. These were isoniazid
(INH), Rifampicin (Rif), Pyrazinamide (PZA) and Ethambutol (EMB) for 6-9 months. One of

the major achievement of DOTS since its implementation has been its apparent ability to

limit the development and spread of acquired drug resistance by improving adherence by

requiring health workers, community volunteers or family members to observe and record

patients taking each dose (Chaundry et.al 2012). However, outcomes are poor when patients

who are infected with Mycobacterium tuberculosis resistant to isoniazid and rifampicin

(multidrug resistant tuberculosis) are treated with the standard regimen. Reserve or second

line anti-tuberculosis drugs have therefore become components of treatment regimens in

national programs. This approach is known as DOTS-plus. In DOTS-plus, second line anti-

tuberculosis drugs which are more toxic and expensive, and less effective than first line

drugs, are used. Total duration of treatment is 18-24 months. (Tupasi, et.al). According

Quelapio, et.al, DOTS is effective for new smear-positive pulmonary TB. For re-treatment

cases however, the DOTS-Plus strategy appears essential due to the high rate of treatment

failure and multidrug-resistant TB.

In partnership with other sectors, DOTS is covered by the outpatient TB-DOTS

package of the Philippine Health Insurance Corporation (Phil Health) for pediatric and adult

tuberculosis. The outpatient TB-DOTS Package is designed only for new cases of pulmonary

and extra-pulmonary TB in children and adults and does not cover cases of patients who

returned for treatment after interruption for two or more months. (Yao, 2012)

NTP and Updates

A Central team at the National Center for The tuberculosis profile of the Philippines:

A Central team at the National Center for The tuberculosis profile of the Philippines manages

the National TB Control Program (NTP), 2003–2015. Disease Prevention and Control of the

Department of Health. This team develops policies and plans and provides technical guidance

to regional and provincial/ city-level NTP management teams, overseeing the implementation
of the program at the municipal and barangay levels based on NTP policies and standards.

Under NTP, TB control services are provided mainly through public primary health care

facilities (also called DOTS facilities) operated by local government units in a devolved set-

up. The Philippines has achieved improvements in case detection and exceeded the target for

treatment success despite numerous challenges, particularly in making services accessible in

difficult geographic and socioeconomic settings. (DOH,2013)

The country aims to further improve access to diagnostic and treatment services,

especially for highly vulnerable groups, while sustaining high cure and treatment success

rates particularly among smear-positive PTB cases. Efforts will be directed at improving

diagnostic capabilities in DOTS facilities and hospitals, addressing barriers to follow-up

examinations for patients under treatment as well as the factors that promote treatment

default and improving the referral system to reduce transfer-outs. Factors that contribute to

TB mortality such as diagnostic and treatment delay and co-morbidities need to be addressed

as well. Finally, the TB information system will be strengthened to improve its usefulness for

surveillance, planning and decision making. With the current trend of NTP performance, it is

predicted that the country will achieve" At least 40 million people with TB reached with care

in the period 2018–2022, including 3.5 million children and 1.5 million people with drug-

resistant TB At least 30 million people reached with TB prevention services in the period

2018–2022. No TB-affected households facing catastrophic costs due to TB by 2020.

(WHO, 2018)

Knowledge, Attitude and Practices of Health Workers

Healthcare workers’ risk of active TB disease is estimated to be two- to three-fold

greater than the general population (Tudor, C et.al 2014). Their exposure to TB will increase

as the number of patients seeking TB treatment at health facilities increases, increasing

number of HIV/AIDs cases, transmission within overcrowded settings and emergence of

multi-drug resistant TB (Rafiza,S. et al 2011). Nosocomial exposure was attributed to the risk

of TB disease among healthcare workers with a range of 25 to 5,361 per 100,000 yearly, as

reported in a systematic review of healthcare workers in low- and middle-income countries

(Joshi, R et al 2013).

Health care workers should receive high quality periodic TB education and training

including before deployment. Training should be determined according to job categories,

needs, and educational backgrounds. Special attention should be given to training non-

clinical, auxiliary and support staff to improve their KAP and prepare them to safely work in

high risk settings such as TB care (Shrestha A, et al 2017).

Conceptual Framework

Tuberculosis (TB) remains a major challenge to global health. Health care workers

have an increased risk of acquiring TB compared with the general population, as they are

exposed to TB at their place of work. Early diagnosis and appropriate management of TB

cases by knowledgeable and skilled healthcare workers (HCWs) are key in improving

patients' outcome and preventing transmission. (Alotaibi, et.al, 2019).

Chapter 2

RESEARCH METHODOLOGY

Research Design

This is a descriptive and analytical type of Cross-sectional Research Study Design

assessing the Knowledge, Attitudes, and Practices of Health-related and Non-Health Related

workers in hospitals in Tuguegarao City against risk of acquiring TB.

This study will make use of questionnaire that consists of 2 parts. First part involves

demographic profile of respondents (age, sex, marital status, educational status, occupation);

second part involves questions about curability, treatment duration, prevalence, MDR TB,

and the TB control program provisions for free anti-TB drugs and free diagnostic tests. The

questionnaire is based on yes/no and multiple-choice questions. The answered questionnaire

will be collected and subjected for analysis.

Respondents

Total enumeration will be used to gather sample size. The respondents will be health-

related and non-health workers in selected hospitals in Tuguegarao City.

Research instrumentation

A self-administered questionnaire will be the instrument for data collection. Other

methods for investigations such as, interview, observation, gathering of documents

review or analysis will also be used.

Data Gathering and Procedure

A. Questionnaires

The questionnaire will consist of four sections. The first section will

consist of items to explore demographic characteristics of respondents (age,

educational status, marital status, and occupation). The second section will

contain items to assess their practices towards TB. This encompasses the

practices on prevention further spread and progression of TB. The third section

consists of the attitudes of the respondents towards TB. This encompasses the

approach of the respondents when dealing with TB patients and/or specimens.

The fourth section will contain items to assess their knowledge on tuberculosis.

This encompasses the extent of knowledge toward management, treatment and

prevention of TB.

B. Interview

Interviews shall be carried out to both health-related workers and non-health related

workers to determine the factors that affect their knowledge, attitudes and practices.
 C. Observation

Observation shall be utilized to note some factors, such as customs and

practices that may affect certain attitudes and practices they are routinely do.

Analytical Framework

The data collected regarding knowledge about TB, treatment duration, MDR TB,

and the TB control program provisions for free anti-TB drugs and free diagnostic tests will

be

analyzed using SPSS version 20 (IBM Corp., Armonk, NY, USA). Data regarding the basic

demographics will be categorized into different groups, such as male/female, educational

status, occupational status, and marital status. The data collected under the profile of

respondents will be analyzed using frequency and percentage distribution. Knowledge,

attitudes, and practices will be analyzed using mean and standard deviation. ANOVA will

be used in determining if there is a significant difference on knowledge, attitudes, and

practices of respondents on tuberculosis grouped according to profile variables. The

association between the knowledge of respondents on tuberculosis with that of attitudes and

practices will be analyzed using Pearson correlation.

Knowledge, Attitude, and Practices of People living with TB infected patients in selected
Barangays in Tuguegarao City
Instruction: Check the box that corresponds to your answer.

Practices about Tuberculosis/TB

1. Do you wear personal protective equipment when interacting with TB infected

patients?

Yes

No

2. Place/ person to go when a family member is faced with symptoms of TB

Health center

Quack doctors

Hospital

Nowhere/ nobody

Do not know

3. Time to seek treatment when infected with TB

With 24 hours of detection

 2-3 days

4-6 days

7 or more

4. Perceived ways to prevent your self from being infected with TB

Covering mouth when someone with TB coughs and sneezes

Avoiding interaction with others

Separating utensils of TB patient

Washing of hands after being in contact with TB patient

Do not know

Attitudes about Tuberculosis/TB

1. What was your initial reaction when you found out that your family member is

infected with TB?

Sad

Requested for a second opinion

Disgusted

Frightened

2. Do you strictly monitor your patient’s compliance to treatment?

a) Yes b) No

Knowledge about Tuberculosis/TB

1. Do you know what is TB? a) Yes b) No

2. How did you get to know about the disease?

Friends

Family members

Newspaper/pamphlets

Radio

Television

Medical staff

3. what causes TB?

Bacteria

Virus

Over fatigue

Unhealthy lifestyle

Cigarette smoking

Inherited

4. Which sample is used for diagnosis of TB?

 Blood

Urine

Sputum

Cerebrospinal fluid

5. What is the route of transmission of TB?

Airborne (from coughing and sneezing)

Blood borne transmission

Sexual transmission

Direct contact

Ingestion

6. Which organ is mainly affected by TB?

Lungs

Bones

Heart

Kidney
 7. Means for TB diagnosis

Looking at the symptoms

Using X-ray

Sputum Test

Consultation at Health Center, clinic, or hospital

Do not know

8. What is the duration of TB?

3 months

6 months

12 months

15 months

9. Do you know that TB is completely curable? a) Yes b) No

10. Do you know that Philippines has the highest cases of TB in Southeast Asia?

a) Yes b) No

11. Do you know multi-drug resistant (MDR) TB? a) Yes b) No

12. Treatment duration of MDR-TB?

6 months

12 months

18 months

24 months
13. Do you know XDR TB (Extensively Drug Resistant TB)? a) Yes b) No

14. Do you know that XDR TB is non curable? a) Yes b) No

15. Do you know that National TB Control Program (NTP) is providing free of cost

medicines to TB patients? a) Yes b) No

16. Do you know that TB organism Mycobacterium tuberculosis) can be detected via PCR

machine/GeneXpert which detects within 2-3 hours?

a) Yes b) No

ANNEX B

INFORMED CONSENT

Title of Research: Knowledge, Attitudes, and Practices of Health-related and Non-Health

Related workers against risk in acquiring TB in Tuguegarao City

Researchers: Kayessa Ylona M. Bunagan

Angelita R. Calica
Pauline Faith G. Miguel
Roda Maire T. Pamittan
Roane Crispina P. Robles
Yowerie Ched Q. Sedano
Rajat Vishwakarma
Purpose of the study: The purpose of this research is to assess the Knowledge, Attitudes,
and Practices of Health-related and Non-Health Related workers against risk in acquiring TB
in Tuguegarao City.

Procedures to be followed: The respondents will be asked to complete a questionnaire that

includes the demographic profile and questions regarding knowledge, attitudes, and practices
on TB, MDR, and XDR tuberculosis. It will be a Yes or No type of questions.

Risk: There is no risk in participating in this research

Benefit: The respondents can gain more knowledge, evaluate and assess the attitudes and
practices that are needed to be improved.

I confirm that I have read and understood the information about the research as stated
above.
I understand that my participation is voluntary and that I am free to withdraw from the
research at any time, without having to give a reason and without any consequences.
I understand that any information will remain confidential and no information that
identifies me will be made publicly available.
I agree to take part in the above study.

Name of participant Date Signature