Research Article |
Corresponding author: Rahmat Bakhtiar ( r.bakhtiar@fk.unmul.ac.id ) Corresponding author: Anwar Mallongi ( rawnaenvi@gmail.com ) Academic editor: Valentina Petkova
© 2024 Rahmat Bakhtiar, Krispinus Duma, Hilda Hilda, Romi Hendra, Anwar Mallongi.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Bakhtiar R, Duma K, Hilda H, Hendra R, Mallongi A (2024) Gender differences associated with knowledge, attitude, and behavior about cough etiquette in primary health care. Pharmacia 71: 1-6. https://doi.org/10.3897/pharmacia.71.e119544
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Introduction: Cough Etiquette is a non-pharmacological intervention in preventing respiratory infections caused by viruses or bacteria in health care facilities. This study aimed to analyze the relationship between gender with knowledge, attitude, and behavior about cough etiquette in TB patients.
Methods: A cross-sectional study with 55 new TB cases aged > 18 years taken purposively from the TB 03 register of six Samarinda Health Centers who received treatment from July 2021 to April 2022. We used a questionnaire to measure knowledge, attitudes, and behavior toward cough etiquette. The knowledge variable consists of 13 questions, the attitude variables comprised 6 statements, and the practice variables comprised 6 statements using a Likert scale. Data analysis used the chi-square test with a significance level of < 0.05.
Result: Most TB patients covered their mouth with their hands (56.2%) or did not cover at all (16.6%). As many as 34% of TB patients used their sleeve arm, elbow, or tissue. There was an association between knowledge of cough etiquette in TB patients at primary health care (p = 0.008), attitude (p = 0.004), but not significant with behavior (p = 0.691). Knowledge and attitudes about cough etiquette have a relationship with influenced by gender.
Conclusion: Men with TB who seek treatment at the primary health care tend to understand clearly the required attitude towards practicing cough etiquette. In places with a high risk of transmission, people with TB disease are advised to consistently apply cough etiquette to reduce the transmission of M. tuberculosis to other visitors to health care facilities.
cough etiquette, knowledge, behavior, gender, tuberculosis
According to the Global TB Report 2020, there were 10 million new TB cases, of which 56% were in India, China, Indonesia, Philippines, and Pakistan(
TB prevention and control consists of a combination of measures designed to minimize the risk of M. tuberculosis transmission within populations (
Some experts recommended Infection Control (IC) as one of the key strategies for TB control. The World Health Organization (WHO) recommended Cough Etiquette (CE) in people with presumed or confirmed TB to reduce M. Tuberculosis transmission to health workers and, persons visiting health care facilities or other persons in settings with a high risk of transmission (
The Ministry of Health has instructed the application of CE to all visitors to health facilities who have complaints of coughing to prevent transmission of respiratory infections (
This research was a cross-sectional study. This research was conducted at six public health centers, Samarinda City. The data on TB patients were obtained from the Integrated Information Tuberculosis System (SITT) of the East Kalimantan province and were cross-checked with the TB 03 public health center report. The number of samples comprised 55 TB patients seeking treatment from July 2021 to April 2022 while the number of cases at every primary health care center was as follows: Sempaja Health Center 9 cases, Lempake Health Center 10 cases, Palaran Health Center 11 cases, Temindung Health Center 10 cases, Juanda Health Center 8 cases, and Wonorejo Health Center 7 cases. TB data sources were the primary data obtained from direct interviews by telephone using questionnaires. The researcher looked for the patient’s telephone number information from the TB status card (TB form 01), the family or TB medication supervisor, and made sure they could communicate with the patient. In designing the questionnaire, the researcher involved the expert, and the researcher asked each question directly to each respondent. The independent variables in this study were knowledge, attitude and practice, while the dependent variable was TB cases by gender. Cough etiquette is a series of activities to cover nose and mouth when sneezing and/or coughing using a physical barrier, such as a piece of cloth, tissue, or surgical mask. If such physical barriers are not available, the best practice is for the mouth and nose to be covered with the bend of the elbow or the hands. The application of cough etiquette is good if, when someone sneezes and/or coughs, they automatically cover their nose and mouth.
The measurement of knowledge about CE include awareness of symptoms of TB, how TB is transmitted, which TB is infectious, as well as the ability of the patient and their family to prevent TB infection. The knowledge variable consists of 13 questions posed directly by the researcher. The assessment of the correctness of each answer given by the respondent was based on the theory contained in the tuberculosis guidebook from the Ministry of Health. The attitude variables comprised 6 statements with response categories using a Likert scale (1–3) ranging from 1-disagree, to 2-neutral, and 3-agree. Meanwhile, the practice variables comprised 6 statements with response categories of never, sometimes and always. The independent variable was classified into two groups, knowledge (good/not good), attitude (positive/negative) and practice (good/not good). The validity test was conducted on 15 respondents and the result of the validity test was 0.523–0.826. The reliability test was conducted using the internal consistency approach aiming at knowing the consistency between items or parts of the test. This study would use Cronbach’s alpha formula (Cronbach’s coefficient α) and it resulted in (r) of 0.72. The knowledge, attitude and practice level were tested for association with gender characteristic at significance level of 0.05. All variables were measured using a cut-off point in the median score. The data analysis described the respondents’ characteristics, univariate analysis, and bivariate analysis using a Chi-square test (χ²).
A total of 8 out of 63 respondent (4.04%) had TB extrapulmonal as exclusion criteria so that the number of respondents involved in this study totaled 55. While enquiring about their practice after seeing a coughing patient in the health facility, 21.8% replied that they asked the patient to cover his/her mouth while 29.1% of them stated that they did nothing. Among them, 36.4% stated that they practice cough etiquette and respiratory hygiene daily.
Table
Characteristic | Male | Female | p | |||
---|---|---|---|---|---|---|
N=29 | % | N=26 | % | |||
Age | < 20 y.o | 3 | 10.3 | 1 | 3.9 | 0.755 |
21 – 30 y.o | 4 | 13.8 | 3 | 11.6 | ||
31 – 40 y.o | 6 | 20.7 | 5 | 19.2 | ||
40 – 50 y.o | 10 | 34.5 | 8 | 30.7 | ||
>50 y.o | 6 | 20.7 | 9 | 34.6 | ||
Mean: 42.8 y (±14.2 y) min-max = 17–67 y.o | ||||||
Education | Primary/Secondary School | 10 | 34.5 | 12 | 46.2 | 0.676 |
High School | 12 | 41.4 | 9 | 34.6 | ||
Graduated/Postgraduate | 7 | 24.1 | 5 | 19.2 | ||
Job status | Working | 8 | 27.5 | 7 | 26.9 | 0.908 |
Not Working | 21 | 72.5 | 19 | 73.1 | ||
Treatment Phase | Intensive | 16 | 55.2 | 17 | 65.4 | 0.620 |
Intermittent | 13 | 44.8 | 9 | 34.6 | ||
TB Case | Bacteriologically confirmed | 19 | 65.5 | 16 | 61.5 | 0.980 |
Diagnosed clinically | 10 | 34.5 | 10 | 38.5 |
Table
Knowledge of cough etiquette among TB patients in Primary Health Center.
Knowledge questions on TB CE | Correct response (%) |
---|---|
What are symptoms of TB? | |
Cough for 2 weeks or more | 33 (60) |
Weight loss | 30 (54.5) |
Fever | 34 (61.8) |
Loss of appetite | 21 (38.2) |
Chest pain | 24 (43.6) |
Blood in sputum | 26 (47.3) |
How is TB transmitted? | 40 (88.9) |
Which TB is infectious? | 36 (65.5) |
In what ways, can patient prevent TB infection? | |
Cover mouth and nose when cough or sneeze | 28 (50.9) |
Washing hands | 30 (54.5) |
Use of masks by patients | 21 (38.2) |
What are CE measures in health facilities? | |
Administrative controls | 24 (43.6) |
Personal respiratory protection | 26 (47.3) |
Average | 53.4% |
Table
Statement | Disagree | Neutral | Agree |
---|---|---|---|
There is a need for posters regarding TB CE in a health care facility | 13(23.6) | 15(27.3) | 27(49.1) |
Cover your mouth and nose with a tissue when you cough or sneeze | 12(21.9) | 20(36.4) | 23(41.7) |
Use mask when you get respiratory symptoms | 10(18.2) | 20(36.4) | 25(35.4) |
Dispose the used tissue in a garbage can | 10(18.2 | 17(30.9) | 28(40.9) |
Use hand hygiene after contact with respiratory secretions | 10(18.2) | 16(29.1) | 29(42.7) |
I am worried that I am the infection source of TB | 9(16.4) | 20(36.4) | 26(46.2) |
While enquiring about their practice after seeing a coughing patient in the health facility, 21.8% replied that they asked the patient to cover his/her mouth while 29.1% of them stated that they did nothing. Among them, 36.4% stated that they were informed practice of cough etiquette and respiratory hygiene on daily basis (Table
Cough Etiquette Practice | Never | Sometimes | Always |
---|---|---|---|
Proportion of use of mask when coughing or sneezing | 14(25.5) | 17 (30.9) | 24(42.6) |
Cover mouth and nose with a tissue when cough or sneeze | 21(38.1) | 19(34.5) | 15(27.3) |
Use elbow when there is no tissue | 6(10.9) | 26(47.3) | 23 (41.8) |
Dispose the used tissue in a garbage can | 11(20.1) | 23(41.8) | 21(38.1) |
Practiced cough etiquette & respiratory hygiene on a daily basis | 9(16.3) | 26(47.3) | 20(36.4) |
Remind the patients who did not practice cough etiquette when sneezing or coughing | 16(29.1) | 27(49.1) | 12(21.8) |
Results from the bivariate analysis are shown in Table
The analysis of the relation of the knowledge, attitudes, and practices of cough etiquette in TB patients.
Variable Independent | Male | Women | P-Value | OR | 95% CI | ||||
---|---|---|---|---|---|---|---|---|---|
N=29 | % | N=26 | % | Lower | Upper | ||||
Knowledge | Not Good | 18 | 62.1 | 6 | 23.1 | 0.008* | 5,455 | 1,674 | 17,770 |
Good | 11 | 37.9 | 20 | 76.9 | |||||
Attitudes | Positive | 20 | 68.9 | 7 | 26.9 | 0.004* | 6,032 | 1,871 | 19,442 |
Negative | 9 | 32.1 | 19 | 73.1 | |||||
Practices | Not Good | 13 | 44.8 | 14 | 53.8 | 0.691 | 0,241 | 2,016 | |
Good | 16 | 55.2 | 12 | 46.2 |
WHO’s policy for administrative TB control in health care facilities includes prompt identification of people with TB symptoms, separation of infectious patients, control of the spread of the pathogen, and minimizing the time spent in health care facilities(
The research showed that the percentage of patients scoring correct knowledge was 53.4%. Previous research in Indonesia in people with suspected and confirmed TB showed that knowledge about CE increased after receiving counseling (
Most respondents covered their mouth and nose when they were sneezing or coughing (67.3%) but nevertheless 32.7% of respondents did not cover their mouth or nose or both when they were sneezing or coughing. The percentage of patients scoring good attitude level was 58.6, relatively higher than research conducted by Ramdan in Bandung Indonesia where the good attitude level was only 46% (
This study showed the knowledge and attitude of CE in TB patients was quite high. This is due to the continuous education of TB patients, especially in the intensive phase. Cough etiquette is formally introduced and practiced in TB patients according to protocol, counseling on cough etiquette is delivered to TB patients before being given the first treatment and when taking medication regularly to health care facilities (
Our findings showed that men were more likely to apply CE than female TB patients. Gender analysis revealed women were more likely than men to have a chronic cough and use hand coverings, while men were twice as likely to sneeze or cough into the air. Men were twice as likely as women to cough or sneeze into the air. In Bangladesh, twenty-two per cent of women covered their coughs and sneezes compared to 13% of men(
The Indonesian Ministry of Health recommends that individuals with TB confirmed bacteriologically should undertake contact surveys and CE education to prevent its transmission (
Predictors of respiratory CE practice were carrying a handkerchief or tissues, prior education on CE, the awareness level of CE, the daily frequency of handwashing, and the knowledge level of CE (
This study found that knowledge and attitudes about CE have a relationship with TB patients’ gender at the primary health center. Our study also highlights the need for TB health workers to work with women with TB, particularly with those with low education in the process to assist them in understanding TB transmission. We believe that the consistent application of CE will minimize bacterial load or droplets, so the risk of transmission is low. The triage of people with TB signs and symptoms, or with TB disease, is recommended to reduce M. tuberculosis transmission to health workers, persons attending health care facilities, or other persons in settings with a high risk of transmission such as primary health care facilities.
RB and AM carried out the conception, design, statistical analysis of this article, KD conducted the analysis and interpretation of the data. Data collection and assembly were completed by RH, HH. The article was drafted by RB, HH and KD. Final approval of the article was confirmed by RB, AM and KD.
The authors would like to express gratitude to the Dean of Faculty of Medicine, Universitas Mulawarman University, and the Head of six public health center of Samarinda City that had given access and data clarification in ethical cough procedure in primary health care.