Tuberculosis knowledge, attitudes, and practices among northern Ethiopian prisoners

15 Pages·2017·0.65 MB·English

RESEARCHARTICLE
Tuberculosis knowledge, attitudes, and
practices among northern Ethiopian
prisoners: Implications for TB control efforts
KelemeworkAdane1,2*,MarkSpigt2,LaturnusJohanna3,DorscheidtNoortje3,Semaw
FeredeAbera4,Geert-JanDinant2
1 DepartmentofMedicalMicrobiologyandImmunology,CollegeofHealthSciences,MekelleUniversity,
Mekelle,Ethiopia,2 MaastrichtUniversity/CAPHRISchoolforPublicHealthandPrimaryCare,Department
ofFamilyMedicine,Maastricht,theNetherlands,3 MaastrichtUniversity,FacultyofHealth,MedicineandLife
a1111111111 Sciences,Maastricht,theNetherlands,4 DepartmentofPublicHealth,CollegeofHealthSciences,Mekelle
a1111111111 University,Mekelle,Ethiopia
a1111111111
*[email protected]
a1111111111
a1111111111
Abstract
Introduction
OPENACCESS
Althoughawarenessisanimportantcomponentintuberculosis(TB)control,wedonot
Citation:AdaneK,SpigtM,JohannaL,NoortjeD,
AberaSF,DinantG-J(2017)Tuberculosis knowhowmuchEthiopianprisonersknowaboutTB.Thisstudyassessedthelevelof
knowledge,attitudes,andpracticesamong knowledge,attitudes,andpractices(KAP)ofprisonersaboutTBineightnorthernEthio-
northernEthiopianprisoners:ImplicationsforTB
pianprisons.
controlefforts.PLoSONE12(3):e0174692.
https://doi.org/10.1371/journal.pone.0174692
Editor:Jose´-Mar´ıaGarc´ıa-Garc´ıa,HospitalSan Methods
Agustin,SPAIN
Datawerecollectedcross-sectionallyfrom615prisonersusingastandardizedquestion-
Received:November22,2016 nairebetweenMarchandMay2016.Theoutcomevariablesweredefinedconsideringthe
Accepted:March12,2017 basicelementsaboutTB.
Published:March30,2017
Copyright:©2017Adaneetal.Thisisanopen Results
accessarticledistributedunderthetermsofthe
Outof615prisoners,only37.7%mentionedbacteriaasacauseofTBwhile21.7%related
CreativeCommonsAttributionLicense,which
permitsunrestricteduse,distribution,and TBtoexposuretocoldwind.Eighty-eightpercentcorrectlymentionedtheaerialroute
reproductioninanymedium,providedtheoriginal ofTBtransmissionand27.3%hadperceivedstigmatowardsTB.Themajority(63.7%)
authorandsourcearecredited.
wasnotawareofthepossibilityofgettingmulti-drug-resistantstrainswhentheywouldnot
DataAvailabilityStatement:Allrelevantdataare adheretotreatment.Overall,only24%knewthebasicelementsaboutTB,41%hadfavor-
withinthemanuscriptanditsSupporting
ableattitudes,and55%hadagoodpractice.Prisonerswhowereurbanresidentsweregen-
Informationfiles.
erallymoreknowledgeablethanruralresidents(adjustedOR=2.16;95%CI=1.15–4.06).
Funding:Thisstudywasfinanciallysupportedby
Illiterateswerefoundtobelessknowledgeable(adjustedOR=0.17;95%CI=0.06–0.46),
MaastrichtUniversitythroughNufficscholarship
lesslikelytohaveafavorableattitude(adjustedOR=0.31;95%CI=0.15–0.64),andless
andMekelleUniversity.Thefunderhadnorolein
studydesign,datacollectionandanalysis,decision goodpractice(adjustedOR=0.35;95%CI=0.18–0.69).Significantdifferenceswerealso
topublish,orpreparationofthemanuscript. observedbetweenthedifferentstudyprisons.
Competinginterests:Theauthorshavedeclared
thatnocompetinginterestsexist.
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Tuberculosisknowledge,attitudes,andpracticesamongprisoners
Conclusions
KnowledgeofprisonersregardingthecauseofTBandconsequencesofnon-adherenceto
TBtreatmentwaslow.Knowledgeonthetransmission,symptoms,andpreventionwas
fairlyhigh.Healtheducationinterventions,focusedonthecauseandthetranslationofthe
knowledgetoappropriatepractices,areneededinallthestudyprisons.Specialattention
shouldbegiventolesseducatedprisoners,andtoprisonswithahighnumberofprisoners
andthoseinremoteareas.
Introduction
Eventhoughtheincidenceoftuberculosis(TB)hasdecreasedworldwide,itremainsaglobal
healthchallenge.Anestimated10.4millionpeopledevelopedTBintheyear2015ofwhich
one-quarterwasfromAfrica[1].Thediseaseismoreprevalentincongregatesettingssuchas
prisons[2].Especially,itismuchworseinsub-Saharanprisonsduetotheaddedproblemsof
humanimmunodeficiencyvirus(HIV)andpoverty[3].InEthiopianprisons,afourtonine-
foldhigherprevalenceofTBhasbeenreportedcomparedtothegeneralpopulation[4,5].
TheglobalfocusofTBcontrolprogramsisonearlydiagnosisandtreatmentofcasesin
highTBandHIV-endemicareas[1].However,thelowTBcasedetectionrateandtheemer-
genceofmulti-drug-resistantstrainshavebeenachallenge[1,6].Raisingcommunities’aware-
nesscontributesforearlydiagnosisofTBwhichisoneofthepillarsoftheEndTBStrategy[1].
StudiesdocumentedapositiveassociationbetweenTBknowledgeandcareseekingandtreat-
mentadherence[7–9].However,thelevelofknowledgeshouldbeknown,alsoinrelationto
previousreports,beforeinformeddecisionscanbemadewhendesigningandimplementing
appropriateeducationalinterventions.Inthisregard,studiesconductedinthegeneralpopula-
tionsofsub-Saharancountriesdocumentedmisconceptionsrangingfrom66.3%to99.7%of
thepopulationontheetiology(cause)ofTB,27.6%to90.1%onthesymptoms,0.1%to48.6%
onthetransmissionand33.4%to92.9%onpreventionmethods[10–16].StigmatowardsTB
patientshasbeenreportedinupto58.3%oftherespondents[10,14].Literacystatus,socio-cul-
turaldifferences,gender,andspatialvariationshavebeenreportedtobefactorsaffectingTB
knowledge,attitudeandpractices(KAP)[11,13,16].
Baselinedataregardingprisoners’knowledgeofTBandrelatedfactorsarelimited.Studies
conductedinprisonsofBrazil[17]andTexas[18]reportedgapsonsomespecificTBKAPvar-
iables.InaBrazilianprison,only5.0%and3.6%oftheprisonerscouldmentiontheTBsymp-
tomsandpreventionmethods,respectively,andinaUSAprison43.0%oftheprisonershada
perceivedstigmatowardsTB.Toourknowledge,insub-Saharanprisons,onlyonestudy
assessingprisonersknowledgewasconductedsixyearsagoinEasternEthiopianprisons[19].
ThisstudyreportedamoderatelevelofknowledgeaboutTBandrevealedsomemisconcep-
tionsaboutitscauses,controlandprevention.Thisstudywas,however,limitedinscopein
thatitdidnotaddresstheattitude,andwasonlyconductedamongpresumptiveTBcases.
Moreover,inculturallydiversifiedcountrieslikeEthiopia,TBknowledge-levelhasbeen
reportedtoshowsignificantspatialvariations[16].Inaddition,throughtheInternetand
intensiveeducationalcampaigns,healthcareinformationcanreachmanypeoplequicklyand
increasethelevelofknowledgeamongpeople[20].InapreviousstudyamongEthiopianpri-
sonsweobservedquitesomeTBcaseswithlong-lastingsymptomswithoutbeingdiagnosed
[4],soweexpectthatKAPamongEthiopianprisonersisstillverylow.Thisstudyaimedat
assessingthelevelofknowledge,attitude,andpracticesofprisonersaboutTBandrelated
factors.
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Tuberculosisknowledge,attitudes,andpracticesamongprisoners
Methods
Studysetting
ThisstudywasconductedineightnorthernEthiopianprisonslocatedintheregions
Tigray(Mekelle,AbiAdi,Alamata,Humera,andWukro)andAmhara(Dessie,Debre
Tabor,andFinoteSelam)betweenMarchandMay2016.In2015,Ethiopiaranked10th
amongthe22highTBburdencountrieswithanestimatedTBincidenceof192per100,000
people[1].Thecountryhadaregisteredprisonpopulationof112,361(136/100,000per-
sons)in2010[21],whichishigherthantheimprisonmentratesobservedinsomesub-Saha-
ranAfricancountriessuchasinKenya(121/100,000persons),andMalawi(76/100,000
persons)[21].
Studydesignandsamplingtechnique
Thiswasacross-sectionalstudy,whichwasalsopartofabaselinemeasurementforanedu-
cationalinterventionalstudyaimedtoincreaseTBscreeningandcasedetectionratein
northernEthiopianprisons.LargerprisoncenterslocatedinthemaincitiesofAmharaand
Tigrayregionswereconsideredaseligiblewhilesmalljailswereexcluded(n=22).Larger
prisonsweredefinedasinstitutionsthatincarceratepeopleforlongerperiodsoftime,such
asmanyyears,whilesmalljailswereinstitutionsthatconfinepeopleforshorterperiodsof
time.Amultistageclustersamplingtechniquewasemployedtorandomlyselectthestudy
prisonsandtheprisoners.Onlyprisonerswhowouldstayimprisonedforayearorlonger
fromthedateoftheselectionwereincluded,sincethisbaselinemeasurementwaspartof
aninterventionstudy.Prisonersyoungerthan18yearsofageandthosementallyillwere
excluded.
Samplesizedetermination
Thesamplesizewasdeterminedusingasingleproportionformula,n z2p(1-p)/d2,wheren
1= 1
wastheinitialsamplesize,consideringaconfidencelevelof95%,anestimatedoverallpropor-
tionofgoodknowledgeaboutTBof52%[12],andaprecisionof5%.Afterusingafinitepopu-
lationcorrection,n n /(1+(n /N)),whereNwasthetotalnumberoftheprisonersinthe
2= 1 1
studysites(N=8,874),multiplyingby1.5toaccountfortheclusteringeffect,andaddinga
15%non-responserate,weobtainedafinalsamplesizeof634.Thisfigurewasthenpropor-
tionallyallocatedtoeachprisonasperthetotalnumbersofprisoners.
Questionnaireandinterviewing
Weusedasemi-structuredstandardizedKAPquestionnairetocollectdata.Thequestionnaire
wasdesignedinEnglishfollowingtheWHOguidelines[22]andwastranslatedintothelocal
languages,AmharicandTigrigna.Thequestionnaireconsistedof38questions,dividedinto
twoparts.Partoneaddressedthesocio-demographiccharacteristicsandprisonhistory.The
secondpartaddressedaspectsrelatedtoTBknowledge,attitude,andpractices.Briefly,ques-
tionsregardingtheetiology,transmission,prevention,andtreatmentofTB,beliefs,andfeel-
ingsaboutTBandTBpatientswereincluded.Theinterviewingwasdonebytraineddata
collectors(prisonnurses,ortrainedinmates).Forsiteswithashortageofprisonhealthprofes-
sionals,prisonerswhowererelativelyeducated(somewithadiplomainclinicalnursing)were
recruitedandtrainedfortwodaysonhowtoundertaketheinterview.Theinterviewingpro-
cesswascloselymonitoredbytheinvestigatorsinwhichthefirstone-fourthoftheinterviews
weremonitoredbylisteningandobservingtheinterviewingprocess.Theinvestigatorsalso
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Tuberculosisknowledge,attitudes,andpracticesamongprisoners
stayedclosearoundtheinterviewingareatoassisttheinterviewersoncallforanyambiguity
fortherestoftheinterviews.
Statisticalanalysis
DatawereenteredinEpiDataversion3.1softwareandtheanalysiswasperformedusingSPSS
version20.0.Descriptivestatisticswasusedtoreportfrequenciesandproportions.Bivariate
andmultivariatelogisticregressionanalysiswasperformedtoexaminetheassociationofinde-
pendentvariableswithouroutcomevariables.Ouroutcomevariablesofinterestwereknowl-
edgeaboutTB,attitudetowardsTB,andpractice.Wecheckedwhethertherewasaclustering
effectattheprisonlevelfortheoutcomevariablesfollowingthemixedprocedureforapossible
considerationofthemultilevellogisticmodel.Wefound,however,thattherewasnostatisti-
callysignificantvariabilityintheinterceptsoftheoutcomevariablesacrosstheprisonsites;the
pvaluesfortheinterceptestimatesofknowledge,attitude,andpracticewere0.14,0.25,and
0.13,respectively.
Knowledgewasassessedconsideringthefollowingcrucialelements:abletorecognize
germ/bacteriaasacauseofTB,abletorecognizetheairbornerouteoftransmission,ableto
recognizeacoughof2weeksandlongerasasymptom,abletorealizecoveringmouthand
nosewhencoughing/sneezingasapreventionmeasure,andabletoknowthefreeTBtreat-
mentavailability.Prisonersthatmentionedallthesefiveitemswerecategorizedashavinga
‘good’knowledgeandthosewhomissedoneormoreoftheseitemswerecategorizedashaving
‘poor’knowledge.Attitudewasassessedusingthreequestions:abletomentionthatTBisa
veryseriousdisease,showingafavorablereactionifsuspectedhavingTBrelatedsymptoms
(i.e.seekinghealthcareinsteadofbeingashamedoforhopeless),andshowingacompassion
anddesiretohelppeoplewithTB.Prisonersthatmentionedthesethreeitemswerecategorized
ashavinga‘favorable’attitudeandtheotherswerecategorizedashaving‘unfavorable’attitude.
Similarly,practicewasassessedusingtwoquestions:preferenceofmodernhealthcarefor
treatmentandtheintentiontovisitthefacilityassoonasrealizinghavingaTBrelatedsymp-
tom.Prisonerswhomentionedthesetwoitemswerecategorizedashavinga’good’practice
andtherestwerecategorizedashavinga‘poor’practice.Allthepotentialpredictorvariables
weretestedagainstthedichotomizedknowledge,attitude,andpractice.Multi-collinearity
amongtheindependentvariableswasassessedconsideringthevarianceinflationfactorof
greaterthan10(forourdata,themaximumwas3.86).Covariateswithp-valuesof(cid:20)0.25in
thebivariateanalysiswereconsideredforinclusioninthemultivariatemodel.Accordingly,
themultivariatemodelsforthelevelofknowledge,attitude,andpracticeconsistedoffive,
four,andsixvariables,respectively.Educationalstatusandprisonsitewereincludedinthe
threemodels.Inaddition,agegroupandoccupationwereaddedtothefinalmodelsofthe
knowledgeandpracticelevelwhereasresidencewasincludedintheknowledgeandattitude
model.Durationofimprisonmentwasaddedtotheattitudemodelandknowledgeandatti-
tudeleveltothepracticemodel.Comparisonsbetweensubgroupswiththeoutcomeswere
expressedasoddsratios(OR)witha95%confidenceinterval(CI).Ap-valueof(cid:20)0.05was
consideredtodeclareastatisticallysignificantassociation.
Ethicalconsideration
ThestudyprotocolwasapprovedbytheethicalreviewcommitteeoftheCollegeofHealthSci-
ences,MekelleUniversity.Allparticipantswereaskedforawritteninformedconsent,and
thoseconsentedwereenrolled.Forallilliterateparticipants,datacollectorsinformedeachof
themandconfirmedthewillingnessoftheparticipantstosigntheinformedconsentsheet.
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Tuberculosisknowledge,attitudes,andpracticesamongprisoners
Theconsentprocedurefortheseilliterateparticipantswasalsoapprovedbytheethicsreview
committee.
Results
Socio-demographiccharacteristics
Ofthetotalnumberofinvitedparticipants(n=634),five(1%)refusedtoparticipateinthe
study.Fourteenquestionnaireswithmissingdemographiccharacteristicswereexcluded,so
thefinalanalysiswasperformedwith615participants.Thenumberofparticipantsincluded
rangedfrom22inAbiAdito173inMekelleprison.Ofthe615participants,themajority597
(97%)wasmale.Themedianagewas28yearswithaninterquartilerange(IQR)of12years.
Themediandurationofimprisonmentwas13months(IQR=29months).Almosthalf(46%)
oftheparticipantswasfarmerand13%wasilliterate.Thirty-sevenparticipants(6%)reported
ahistoryofhavingTBdisease.
Knowledgeabouttuberculosis
Theprisoners’knowledgeaboutTBisshowninTable1.Inthisstudy,only37.7%ofthepartic-
ipantsrecognizedgerm/bacteriaasacauseofTB.Twenty-twopercentmentionedthatitis
mainlycausedbyexposuretocold.Themajority(88.0%)correctlymentionedthatTBistrans-
mittedthroughcoughingdropletsand65.7%mentionedcoveringthemouthwhencoughing/
sneezingasameasuretopreventTB.However,11.9%and15.0%oftheparticipantsmentioned
inappropriatemethodsincludingkeepingwindowsclosedwhentheyarewithchronically
coughingpeopleand/orTBpatientsinaroomandavoidingshakinghands,respectively.The
majority(88.3%)describedthatTBiscurablewithmoderndrugs,butaboutone-third(35.5%)
didnotknowthefreeTBtreatmentavailability.
TBknowledgeandassociatedfactors
Table2showstherelationshipsbetweenTBknowledge,usingthefivecrucialpoints,and
potentialpredictorvariables.Of615participants,149(24%;95%CI=21%-28%)hada
goodlevelofknowledgeaboutTB.Governmentemployeeshadasignificantlyhigherlevel
ofknowledgecomparedtofarmers(AOR2.92;95%CI=1.21–7.03).Prisonersthatwere
urbandwellersweremoreknowledgeablethanruralprisoners(AOR=2.16;95%CI=1.15–
4.06).TherewasalsoanassociationbetweenthelevelofeducationandTBknowledge.
Anotherinterestingfindingwasthatthereappearedtobeasignificantvariationinthelevelof
TBknowledgeacrossthestudyprisons:comparedtoprisonersofMekelle,prisonersofDebre
Tabor(AOR=2.71;95%CI=1.36–5.42),andFinoteSelam(AOR=4.16;95%CI=2.05–8.43)
weremoreknowledgeable,whereasthoseimprisonedinWukro(AOR=0.12;95%CI=0.03–
0.57),andHumera(AOR=0.21;95%CI=0.06–0.74)werelessknowledgeable.
Attitudesandpracticesabouttuberculosis
Themajorityoftheparticipants(84.2%)believedthatTBisaveryseriousdisease.Sixty-nine
percentmentionedthattheywouldnotfeelfearedorashamedwhentheywouldhaveTB
symptoms,butwouldsimplyvisitahealthcarefacility.Aconsiderableproportion(27.3%)had
stigmatizingthoughtstowardsTBpatients(i.e.theymentionedthattheyfearsuchpeopleand
wouldstayawayfromthemorwouldnotshowanyfeelinginsteadofshowingcompassionand
adesiretohelp).Themajority(82.6%)preferredtovisitmodernhealthcare(Table3).
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Tuberculosisknowledge,attitudes,andpracticesamongprisoners
Table1. KnowledgeofnorthernEthiopianprisonersabouttuberculosisstratifiedbythestatusoftheprevioushistoryofTBdisease,2016
(N=615).
Variable HadhistoryofTB,n(%) HadnoTBever,n(%) Total,n(%) p-value**
n=37 n=578 N=615
CauseofTB 0.65
Bacteria* 17(45.9) 215(37.2) 232(37.7)
Coldwind 5(13.5) 128(22.1) 133(21.7)
Smoking 3(8.2) 43(7.4) 46(7.5)
Spoiledsoil(soilwithabadodor) 5(13.5) 61(10.6) 66(10.7)
Poorhygiene 2(5.4) 53(9.2) 55(8.9)
Don’tknow 5(13.5) 60(10.4) 65(10.6)
Others¶ 0(0) 18(3.1) 18(2.9)
Modeoftransmission 0.45
Throughcoughingdroplets* 36(97.3) 506(87.6) 542(88.0)
Throughshakinghands 0(0) 28(4.8) 28(4.6)
Thoughsharingdish 0(0) 22(3.8) 17(2.8)
Don’tknow 1(2.7) 22(3.8) 28(4.6)
Signsandsymptoms+
Coughfor2weeksorabove* 28(75.7) 458(79.2) 486(79.1) 0.67
Hemoptysis 20(54.1) 278(48.1) 298(48.5) 0.51
Weightloss 16(43.2) 272(47.1) 288(46.8) 0.73
Ongoingfatigue 11(29.1) 190(32.9) 201(32.7) 0.85
Persistentfever 12(42.4) 157(27.2) 169(27.5) 0.57
Don’tknow 1(2.7) 35(6.1) 36(5.9) 0.72
Others¶¶ 40(108.1) 347(60.1) 387(62.9) 1.00
Preventionmethods+
Covermouthwhencoughing/sneezing* 23(62.2) 381(65.9) 404(65.7) 0.72
Washinghands 11(29.7) 188(32.5) 199(32.4) 0.86
Avoidinghandshakes 6(16.2) 86(14.9) 92(15.0) 0.81
IsolatingTBpatients 12(32.4) 214(37.1) 226(36.7) 0.73
Closingwindows 4(10.8) 69(11.9) 73(11.9) 1.00
Avoidsharingdishes 10(27.0) 163(28.2) 173(28.1) 1.00
Vaccination 10(27.0) 169(29.2) 179(29.1) 0.85
Goodnutrition 14(37.8) 130(22.5) 144(23.4) 0.04
Don’tknow 0(0) 27(4.7) 27(4.4) 0.39
IsTBcurable 0.16
Yes 36(97.3) 507(87.7) 543(88.3)
No 1(2.7) 71(12.3) 72(11.7)
KnowfreeTBtreatmentavailability 0.59
Yes* 26(70.1) 371(64.2) 397(64.5)
No 11(29.9) 207(35.8) 218(35.5)
Riskofdefaultingfromtreatment+
Death 28(75.7) 458(79.2) 486(79.1) 0.54
Relapse 12(32.4) 256(44.3) 268(43.6) 0.17
Nocure 13(35.1) 232(40.1) 245(39.8) 0.61
Drugresistance 17(45.9) 206(35.6) 223(36.3) 0.22
Don’tknow 2(5.4) 8(1.4) 10(1.6) 1.00
VulnerabilityforTB 0.43
Prisoners 26(70.3) 440(76.2) 466(75.8)
(Continued)
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Tuberculosisknowledge,attitudes,andpracticesamongprisoners
Table1. (Continued)
Variable HadhistoryofTB,n(%) HadnoTBever,n(%) Total,n(%) p-value**
n=37 n=578 N=615
Generalcommunity 11(29.7) 138(23.8) 149(24.2)
*:thefivecrucialelements
¶:curse/demon,malnutrition
+:multipleresponsespossible
¶¶:chestpain,skinrash,nausea,severeheadache
**:p-valuefromthechi-squaretest
https://doi.org/10.1371/journal.pone.0174692.t001
Overallattitudeandassociatedfactors
TheattitudeofprisonerstowardsTBandtherelationshipwiththepotentialpredictorvariables
issummarizedinTable4.Lessthanahalf(41%;95%CI=37–45)oftheprisonershadafavor-
ableattitudetowardsTB.RespondentsthatwereabletomentionthatTBisaveryseriousdis-
ease,thoseshowingafavorablereactionifsuspectedhavingTBrelatedsymptomsandadesire
tohelppeoplewithTBwereconsideredashavingafavorableattitude.Significantvariationsin
thelevelofattitudewereobservedbytheeducationallevelandstudysites.Byoccupation,stu-
dents(AOR=1.88;95%CI=1.1–3.5)werefoundtohaveahigherleveloffavorableattitude
comparedtofarmers.
Overallpracticeandassociatedfactors
Morethanhalfoftheprisoners,55%(95%CI=51.1–58.9),hadagoodpracticerelatedtoTB.
Therewasasignificantvariationinpracticebythelevelofeducationandstudysites.Havinga
goodTBknowledge(COR=1.49;95%CI=1.03–2.18)andafavorableattitude(COR=1.41;
95%CI=1.02–1.95)werealsoassociatedwithhavingagoodpracticebutwasonlyinthe
bivariateanalysis(Table5).
Discussion
Thisstudyrevealedgapsinknowledge,attitudesandpracticesamongnorthernEthiopianpris-
onerswithregardtoTB.Onlyaboutfouroutoftenprisonerswereabletorecognizegerm/bac-
teriaasacauseofTB.ThelargemajorityrelatedTBtoexposuretocoldwind,spoiledsoil(a
soilwithabadodor),poorhygiene,andsmoking.Themajority(63.7%)wasnotawareofthe
possibilityofgettingmulti-drug-resistantstrainsduetotreatmentnon-adherence.Overall,
only24%knewthebasicelementsaboutTB,41%hadfavorableattitudes,andabitmorethan
ahalf(55%)hadagoodpracticetowardsTB.TBknowledge,levelofattitudeandpracticewere
allsignificantlyrelatedtothelevelofeducation,andstudysites.
WhencomparedtoapreviousreportfromEasternEthiopianprisons,theproportionof
prisonersthatmentionedthecorrectcauseofTBisremarkablyhighinourstudy(37.7%vs.
1.6%)[19].Knowledgeonthetransmission(88.0%vs.74.1%)andfreetreatmentavailability
(64.5%vs.50.3%)isalsohigherinthecurrentstudy.Thisdiscrepancycouldbeduetothetime
difference;knowledgelevelcouldvaryovertimeowingtotheroutinehealtheducationactivities
andimprovedpublicmediaaccess[23].Theprisonhealthpersonnelreportedthattheysome-
timesprovidehealtheducationtoprisonersabouthealthissuesingeneral.Thespatialdifference,
andassociatedsocio-culturaldifferences,betweenthetwoEthiopianstudiesmightalsopartly
explainthediscrepancy[16].Similarly,theknowledgeaboutthecauseofTB(37.7%),acoughof
2weeksormoreasaTBsymptom(79.1%),theairbornerouteoftransmission(88.0%),and
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Tuberculosisknowledge,attitudes,andpracticesamongprisoners
Table2. FactorsrelatedtothelevelofknowledgeabouttuberculosisamongnorthernEthiopianprisonersinthebivariateandmultivariatelogistic
regressionanalysis(N=615).
Variable Knowledgelevel
Good,n(%) Poor,n(%) COR(95%CI) AOR(95%CI)
Allparticipants(N=615) 149(24) 466(76)
Age,years
18–45 136(25) 406(75) 1.55(0.82–2.91) 1.08(0.51–2.26)
(cid:21)46 13(18) 60(82) ref
Educationalstatus
Illiterate 7(9) 72(91) 0.13(0.06–0.29) 0.17(0.06–0.46)
Readandwriteonly 10(14) 62(86) 0.22(0.1–0.43) 0.21(0.08–0.52)
Primary 42(16) 215(84) 0.25(0.16–0.39) 0.27(0.15–0.48)
Secondaryorabove 90(44) 117(56) ref
Occupationbeforeimprisonment
Governmentemployee 45(60) 30(40) 8.11(4.62–14.3) 2.92(1.21–7.03)
Student 22(24) 69(76) 1.73(0.97–3.07) 0.77(0.33–1.76)
Unemployed 5(3) 12(97) 2.25(0.76–6.72) 0.53(0.13–2.09)
Privateworker 33(22) 117(78) 1.53(0.92–2.52) 0.59(0.26–1.33)
Farmer 44(16) 238(84) ref
Residence
Urban 95(34) 185(66) 2.67(1.82–3.92) 2.16(1.15–4.06)
Rural 54(16) 281(84) ref
HistoryofTB
Yes 7(19) 30(91) 0.72(0.31–1.67) -
No 142(25) 436(75) ref
Lengthofimprisonment
>12months 74(19) 323(81) 0.92(0.64–1.33) -
(cid:20)12months 75(34) 143(66) ref
Prisonsite
Wukro 2(5) 40(95) 0.15(0.04–0.65) 0.12(0.03–0.57)
Abi-Adi 4(18) 18(92) 0.67(0.22–2.09) 1.23(0.37–4.47)
Humera 3(5) 57(95) 0.16(0.05–0.53) 0.21(0.06–0.74)
Alamata 11(23) 37(77) 0.89(0.42–1.92) 1.58(0.66–3.79)
Dessie 28(27) 75(73) 1.13(0.65–1.96) 1.12(0.58–2.14)
DebreTabor 27(34) 53(66) 1.54(0.86–2.74) 2.71(1.36–5.42)
FinoteSelam 31(36) 56(64) 1.67(0.96–2.92) 4.16(2.05–8.43)
Mekelle 43(25) 130(75) ref
AOR:adjustedoddsratio;COR:crudeoddsratio;CI:confidenceinterval;TB:tuberculosis;ref:reference
https://doi.org/10.1371/journal.pone.0174692.t002
coveringmouth/nosewhencoughingasamethodofprevention(65.7%)wasalsohigherwhen
comparedwithreportsfromthegeneralpopulationindifferentpartsofEthiopia[10–14,24].
Oneexplanationofthisvariationcouldbethefactthatprisonsareidealsettingsforhealthinter-
ventions[25];inprisons,itiseasytoprovidehealtheducationsincealotofpeoplecanbe
reachedatonetimecomparedtothescatteredremoteareasofthegeneralpopulation.
Veryspecificcomparisonwithprisonsofothersub-Saharancountrieswasnotpossibledue
tothelackofsimilarpublisheddata.However,studiesconductedinBrazilian[17]andUSA
(Texas)[18]prisonsreportedamuchlowerknowledgelevel.Inadditiontothetimedifference,
thedifferenceintheprevalenceofTBmightexplainthediscrepancy,especiallyfortheprison
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Tuberculosisknowledge,attitudes,andpracticesamongprisoners
Table3. AttitudesandpracticesofnorthernEthiopianprisonersabouttuberculosisstratifiedbythestatusoftheprevioushistoryofTBdisease,
2016(N=615).
Variable HadhistoryofTB,n(%) HadnoTBever,n(%) Total,n(%) p-value**
n=37 n=578 N=615
ThoughtonseriousnessofTBdiseases 0.23
Veryserious* 30(81.1) 488(84.4) 518(84.2)
Somewhatserious 4(10.8) 71(12.3) 75(12.2)
Notserious 3(8.1) 19(3.3) 22(5.6)
ReactionifhadTBsymptoms 0.29
Fear 6(16.2) 115(19.9) 121(19.7)
Shame 2(5.4) 23(4.0) 25(4.1)
Sadness/hopelessness 4(18.8) 40(6.9) 44(7.2)
Visithealthfacility* 25(67.6) 400(69.2) 425(69.0)
FeelingsaboutpeoplewithTBdiseases 0.69
Ifeelcompassionandadesiretohelp* 30(81.1) 417(72.1) 447(72.7)
Ifeelcompassion,butstayawayfromsuchpeople 4(10.8) 111(19.2) 115(18.7)
Ifearthembecausetheymayinfectme 2(5.4) 35(6.1) 37(6.0)
Ihavenoparticularfeeling 1(2.7) 15(2.6) 16(2.6)
ChoiceforTBtreatment 0.027
Modernhealthcare¶ 29(78.4) 479(82.9) 508(82.6)
Traditionalhealers 5(13.5) 23(4.0) 28(4.5)
Holywater 1(2.7) 39(6.7) 40(6.6)
Don’tknow 2(5.4) 37(6.4) 39(6.3)
Timepointtovisithealthfacility 0.73
Whentreatmentofmyowndoesnotwork 0(0) 16(2.8) 16(2.6)
AssoonasrealizingthesymptomsmightberelatedtoTB¶ 24(64.9) 376(65.1) 400(65.0)
After3–4weeksofhavingsymptoms 12(32.4) 165(28.5) 177(28.8)
Iwouldnotgotoadoctor 1(2.7) 21(3.6) 22(3.6)
TB:Tuberculosis
*:thethreecrucialelementsforattitude
¶:thetwocrucialelementsforpractice
**:p-valuefromthechi-squaretest
https://doi.org/10.1371/journal.pone.0174692.t003
intheUSA[26].Inthoseareas,prisonersmightnotgivemuchattentiontoTBwhileitisa
commonissueinhighburdenareas.
Ingeneral,fromtheabovecomparisons,weseethatnorthernEthiopianprisonershada
fairlyhighlevelofknowledgeaboutthesymptoms,transmission,andpreventionofTB.This
mightsuggestgoodhealthseekingbehavioramongourprisonerssinceseveralstudiesshowed
anassociationbetweenknowledgeofTBandearlytreatmentseeking[7,9].However,this
seemsnotentirelytrueindailypracticesinceinourpreviousTBsurvey,halfoftheTBcases
wereleftundiagnosedforlongperiods;somewereevencoughingformorethantwoyears[4].
Otherfactorssuchasapoorreferralsystemmightalsocontributesignificantlytoseveretreat-
mentdelay[4].Therefore,wesuggestthateducationalinterventionsinthestudyprisons
shouldnotonlyfocusondeliveringthemessage,butshouldalsoensurethattheknowledge
gainedcanleadtoappropriatetreatmentthroughregularmonitoringandevaluationand
clearlydefinedtreatmentprotocols.Wealsoobservedarelativelyhighlevelofknowledgeon
thecauseofTB;but,thiscanbecallednotgoodenoughasthemajority(62%)remainedhaving
severalmisconceptions.The‘exposuretocoldwind’wasthemostfrequentlymentioned
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Tuberculosisknowledge,attitudes,andpracticesamongprisoners
Table4. FactorsrelatedtothelevelofattitudeabouttuberculosisamongnorthernEthiopianprisonersinthebivariateandmultivariatelogistic
regressionanalysis(N=615).
Levelofattitude
Variable Favorable,n(%) Unfavorable,n(%) COR(95%CI) AOR(95%CI)
Allparticipants(N=615) 250(41) 365(59)
Age,years
18–45 220(41) 322(59) 0.98(0.59–1.61) -
(cid:21)46 30(4) 43(96) ref
Educationalstatus
Illiterate 19(24) 60(76) 0.25(0.14–0.45) 0.31(0.15–0.64)
Readandwriteonly 20(3) 52(97) 0.31(0.17–0.55) 0.34(0.16–0.68)
Primary 96(37) 161(63) 0.48(0.33–0.69) 0.46(0.29–0.72)
Secondaryorabove 115(56) 92(44) ref
Occupationbeforeimprisonment
Governmentemployee 33(44) 42(56) 1.88(1.12–3.18) 0.92(0.44–1.94)
Student 50(55) 41(45) 2.92(1.79–4.75) 1.88(1.1–3.5)
Unemployed 8(47) 9(53) 2.13(0.79–5.74) 1.38(0.44–4.41)
Privateworker 76(51) 74(49) 2.46(1.63–3.71) 1.41(0.76–2.62)
Farmer 83(29) 199(71) ref
Residence
Urban 138(49) 142(51) 1.94(1.39–2.68) 0.93(0.56–1.53)
Rural 112(33) 223(67) ref
HistoryofTB
Yes 14(38) 23(62) 0.88(0.44–1.75) -
No 236(41) 342(59) ref
Lengthofimprisonment
>12months 161(41) 236(59) 1.12(0.81–1.55) -
(cid:20)12months 89(40) 129(60) ref
Prisonsite
Wukro 9(21) 33(79) 0.3(0.14–0.67) 0.29(0.13–0.68)
AbiAdi 14(64) 8(36) 1.94(0.78–4.87) 2.44(0.93–6.39)
Humera 30(50) 30(50) 1.11(0.61–1.99) 1.42(0.74–2.71)
Alamata 2(4) 46(96) 0.05(0.01–0.21) 0.06(0.01–0.24)
Dessie 57(53) 46(47) 1.38(0.84–2.24) 1.42(0.75–2.71)
Debretabor 24(30) 56(70) 0.48(0.27–0.83) 0.56(0.31–1.03)
Finoteselam 32(37) 55(63) 0.65(0.38–1.09) 0.94(0.53–1.68)
Mekelle 82(47) 91(53) ref
AOR:adjustedoddsratio;COR:crudeoddsratio;CI:confidenceinterval;TB:tuberculosis;ref:reference
https://doi.org/10.1371/journal.pone.0174692.t004
misconception.ThisisnotsurprisingasthismisconceptioniscommoninEthiopiaasshown
bypreviousstudiesfromthegeneralpopulation[11–13],andeasternEthiopianprisonssix
yearsago[19].ThismisconceptioncouldstillbeanimportantcatalystforthespreadofTB,
especiallyintheseverelyovercrowdedEthiopianprisons[4,27].Itiscompletelycontra-effec-
tiveifpeoplewouldtendtokeeptheirwindowsclosedtoprotectthemfromthe"coldwind",
whileventilationisimportantinpreventingTB.Ourobservationsubstantiatesthisreportin
that12%mentionedkeepingwindowsclosedasapreventivemeasurewhentheyarewith
chronicallycoughingpeopleand/orTBpatientsinaroom.Thisissueshouldbestressedwhen
deliveringhealtheducationinEthiopianprisons.
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