Abstract

Introduction

Confined populations, especially those comprised of incarcerated individuals, represent a serious problem in the control of infectious and contagious diseases, such as tuberculosis (TB) and AIDS.¹ Even when surrounded by prison walls, these individuals are never entirely isolated from society. Bonds with the outside world continue through contact with both visitors and prison workers. Inmates also inter-relate with the community in general through releases to work, granted leaves, escapes and return to society when sentences have been served. In addition, prison workers maintain contact with their own families and the community in general,² and this represents a double risk of contamination. In other words, an uncontrolled epidemic of TB in a prison facility may represent a serious risk to individuals and to society at large. In the opposite direction, TB brought in from the outside community can trigger off an epidemic among inmates.³

Moreover, rules related to prison environments influence the relationship of TB patients with this disease. In this regard, TB can affect the social⁴ interaction between individuals with TB and other inmates, thus reducing awareness of the seriousness of its symptoms.

Among both the general population and incarcerated groups, TB is a topic that is not easily discussed nowadays. It is associated with poverty, isolation, social exclusion, irregular and immoral behavior, as well as with social depravation. These values are strongly present in the stigmatization of TB patients.^5-8

Currently, treatment is usually conducted in outpatient clinics, where health workers are exposed to infection. For this reason, and due to these individuals' vulnerability, it is essential that they have considerable knowledge about the disease.⁹

Very few studies have been published on knowledge about TB among inmates, prison workers and public health workers, and even these indicate the lack of information about this disease as one of the major barriers to greater awareness of symptoms, early diagnosis, adhesion to treatment, and cure.^10,11

The KAP (Knowledge, Attitudes and Practices) Questionnaire¹² has been used for gathering data on knowledge, attitudes and practices about many different health problems and diseases¹³ in terms of what is known, believed and done about specific topics. This instrument was constructed in the 1950s and it was originally designed to estimate resistance against the idea of family planning among different populations.¹³

KAP-TB surveys can be especially designed to gather information on topics related to TB. This may include questions about general health practices and beliefs regarding the disease. The purpose is often to identify knowledge, patterns of gaps, and cultural or behavioral beliefs that facilitate understanding and action. They can also detect problems, barriers and obstacles that arise with the efforts to control TB.¹⁴ Data can be analyzed quantitatively or qualitatively, depending on the study objectives.¹²

The use of this instrument has fostered a certain amount of social mobilization as well as investigations of the knowledge, practices and attitudes about TB in the population. Some of these studies have been conducted in the context of control programs in different countries with high rates of occurrence of this disease, aiming to strengthen interventions for behavioral changes.¹² One increasingly important use of the KAP Questionnaire has been to provide essential data on the impact of activities related to advocacy, communication and social mobilization (ACSM).

The present study was based on the assumption that, due to their access to training programs, public health workers and prison workers would have adequate knowledge about TB. The study was thus specifically designed to compare knowledge, attitudes and practices about TB among three distinct groups, namely, inmates, prison workers, and public health workers.

Methodology

A cross-sectional study was carried out on a sample consisting of inmates and workers of P-III Penitentiary which is a closed prison, and public health workers, in the city of Hortolândia, State of São Paulo, Brazil. This penitentiary was selected because it had had no participants in any projects involving educational intervention for TB.

It was not possible to obtain a statistically valid sample of inmates due to the penitentiary conditions and security requirements. The inmates were chosen at random, according to the routine and the institution's criteria for transferring them to a meeting room. Participants from among the prison employees and public health workers were selected on the basis of their own interest.

An adapted semi-structured version of the KAP Questionnaire¹² was designed and applied. It consisted of closed questions organized into four sections dealing with the socio-demographic situation of respondents and the following aspects related to TB: history of the patient's disease, knowledge, behavior toward the possibility of contracting TB, and attitudes toward patients with TB. The adapted questionnaire was pre-tested in the PI Penitentiary, located in the same complex.

The instrument was applied individually by an interviewer to both inmates and prison workers. The questionnaire for health workers was distributed to all professionals working at the selected public health units and each participant filled it out individually.

Data were entered into the Epi-Info Program, version 6.04. The frequencies of variables were analyzed, with occupational factors (inmates and prison workers/public health workers) being the independent variable. To compare the categories of dependent variables according to the independent variable, the Chi-square test was used with a statistical significance of p<0.05. Several questions allowed more than one response. Comparisons were made between the results from inmates and prison workers, and between those from prison workers and public health workers.

Ethical IssuesPrior to application, the present research project was authorized by the State of São Paulo Department of Penitentiary Administration and by the City of Hortolândia Department of Health and approved by the Research Ethics Committee of the State University at Campinas, under official expert opinion 942/2009 of the National Board of Health Research Ethics Committee, pursuant to Resolution 196/96. All participants signed an informed consent form and confidentiality of information was guaranteed.

Authors declared there were no conflicts of interest.

Results

At the time of the application of the questionnaire, 233 prison workers were assigned to the PIII Penitentiary. Of these, 88 were on leaves of absence for medical reasons, temporary transferences, vacations or bonus leaves. A total of 115 were interviewed (79.3% of those 145 actively working). According to prison authorities, 1,153 male inmates were under detention at the time, 141 (12.2%) of whom were interviewed. For security reasons, the data collected from inmates had to be discontinued.

According to the Department of Human Resources, there were 1,216 active workers in the Department of Health at the time of the survey. Of these, 208 were on leaves of absence and 158 of the 508 (31.1%) working in the participating units were interviewed.

Emergency units, the municipal hospital, and the adult and child mental health outpatient clinics were not included in this study.

The respondents in one group of 35 inmates (24.8%) stated that their last arrest had been less than one year before, while 11 (7.8%) reported that it was more than six years before (data not shown). Table 1 shows that inmates and prison workers were different in terms of age, ethnicity, gender and level of education (p<0.001). Among prison workers and public health workers, differences were related to age, gender, length of work (p<0.001) and level of education (p = 0.041).

In the investigation of respiratory symptoms, the inmates had cough with phlegm in a higher proportion than prison workers (15.6% vs. 2.6%, p = 0.0012). A greater percentage of inmates reported having been treated for TB previously (13.5% vs. 2.6% p = 0.007).

Knowledge about Tuberculosis

A higher proportion of prison workers than public health workers (63.5% vs. 29.8%, p<0.001) reported they had received information about TB (data not shown). According to Table 2, there were significant differences in knowledge about symptoms between inmates and prison workers, and between prison workers and public health workers. According to the inmates, TB can be transmitted by air (49.6%), by sharing cigarettes (12.1%) and by sharing cutlery (10.6%). Additionally, 22.0% were not aware of forms of infection. Prison workers (44.3%) and public health workers (39.9%) mentioned transmission by sharing dishes and cutlery.

When asked "How can a person avoid TB?" 38.3% of the inmates did not know the answer. A total of 40.9% of prison workers and 46.8% of public health workers mentioned "Do not share dishes or cutlery" as one of their responses (Table 3).

TB was considered a curable disease by all three categories studied. The difference was found in the item "How to cure TB", when the alternative "Treatment with medical supervision" was checked by 36.9% of inmates and 75.6% of prison workers (p<0.001). Only 24.1% of inmates said that the treatment for TB is provided free of charge. This same response was given by 58.3% of prison workers and 84.8% (p<0.001) of public health workers (Table 3).

Behavior and attitudes toward the possibility of contracting tuberculosis

Table 4 shows that 24.7% of the public health workers believe that being in contact with persons in closed places is considered to be a factor that increases contamination. In this group, 22.1% could not respond "Because you can catch TB."

One question in the KAP Questionnaire was "How would you feel if you had TB?" The objective of this question was to investigate feelings aroused by the disease. Many inmates answered "sad" (39.7%) and "worried" (16.3%); while prison workers mentioned "sad" (41.7%) and "afraid" (26%); and health workers, "afraid" (25.9%) and "surprised" (22.8%).

All (100%) inmates and prison workers answered affirmatively when asked if they would talk about the disease, whereas 135 (85.4%) (p<0.001) public health workers gave the same answer (data not shown).

The greatest concern about TB among inmates is contracting it and how to obtain treatment and be cured. Death was mentioned by 12.8% of respondents in this group.

Attitudes regarding tuberculosis patients

Regarding the question "How is a TB patient regarded by other persons?" (see Table 5), 41.1% of inmates said that "Many people reject them." The answer "Many people are friendly but they try to avoid patients," was given by 25.2% of prison workers and 22.8% of public health workers.

When asked why a person who has HIV may also have tuberculosis, 44.3% of prison workers mentioned low immunity, but this same answer was given by a much greater number of public health workers (61.4%) (p = 0.005). It should be noted that 21.5% of public health workers said they "Do not know."

Discussion

Increased drug use is one of the factors that has contributed to the increase in violence in Brazil and, consequently, to the greater number of incarcerated persons.¹⁵ Inmates come from social classes characterized by poverty and difficulties in accessing health services, education and information. Consequently, this population usually has a low level of education, a characteristic also found in the populations most affected by TB. These conditions tend to perpetuate beliefs concerning the disease and the lack of information as to its existence, forms of transmission, infection and control.

In this study, 53.2% of the population of inmates was white, similar to the ethnic proportion found in the city of São Paulo,¹⁶ 22% having fewer than five years of education. According to the National Health Plan for the Penitentiary System,¹⁷ the Brazilian prison population is usually comprised of single white men under the age of 30 years. Few are literate and many had no definite profession before their arrest by the police. This means that the majority were in a situation of social exclusion prior to prison. Therefore, one might consider that the prison population studied in Hortolândia has a higher level of formal education than the national Brazilian average, since 78% had at least five years of education.

It is a well-known fact that knowledge can influence people's practices regarding prevention.¹⁸ Many inmates and prison workers had not received information about TB and several responses regarding its prevention given in the questionnaire were incorrect, as observed in studies by other authors.¹⁹ This suggests that the forms of communication and the strategies used to transfer knowledge in prisons fail to attain their objectives. Additionally, it indicates the absence of health education programs in general, particularly those aimed at TB control, in prison institutions.²⁰

In one study²¹ on the knowledge of the Brazilian population about TB, 34% of the respondents reported that they were acquainted with someone who had the disease or had previously had it. In the present study, 82.3% of inmates and 69.6% of prison workers also responded affirmatively to this same question. This result suggests that many persons in all three groups are familiar with the disease, at least to some degree. Even so, their knowledge is permeated with unfounded beliefs and mistaken information. Even many public health workers, despite their greater knowledge about TB, made basic conceptual mistakes when asked about vulnerability when sharing objects. Similar results appeared in studies on workers in the area of nursing⁹ involved in family health teams,²² although this information can easily be found in manuals and guidelines on the Internet and in departments of epidemiologic surveillance.²³ This fact is indicative of deficiencies in instructions about TB provided to public health workers. It also shows the serious need to disseminate information about TB among other professionals, using an interdisciplinary and intersectoral approach.^9,10 Training programs are important strategies to increase knowledge and practices of employees in TB tracking²⁴ and supervised treatment.²⁵

Many studies that use the KAP Questionnaire fail to present the results obtained about attitudes, due to the risk of falsely generalizing the opinions and feelings of a given population sector. The attempt to measure attitudes and feelings through studies has been criticized for a number of different reasons. One reason is that respondents tend to give answers they believe to be correct, acceptable or otherwise considered relevant. More delicate questions are especially vulnerable to this tendency, and the context of an interview can strongly influence the results.²⁶ This situation was present during the application of the questionnaire in this study. A vague discomfort could be felt in some participants when asked certain sensitive questions, and they tended to simply respond something they thought to be correct, accepted or appreciated. This behavior, for example, was noted among the inmates and prison workers for the two following questions: "How do you feel about people with TB?" and "How is a person with TB considered by others?" For the first question, the high number of interviewees who answered "I feel supportive and want to help," led researchers to suspect that this was an assertion that the participants believed to be meaningful for the context of the interview, although it might not be reflecting their true attitude. To the second question, inmates answered that "Many are rejected," while prison workers stated that "Many people help others." But some in the latter group also reported that "Many people reject them." Participants might have been unaware of the topic and considered the questions strange, answered them with what they felt was an appropriate answer at the moment of the interview, even if it did not reflect the truth.

With regard to how they would feel if they were infected with TB, inmates reported they would feel "sad," but this feeling could be simply associated with their condition of imprisonment and with safety- and survival-related problems, factors that would negatively affect their relationships with other inmates.⁴ Prison workers and public health workers mentioned sadness, surprise and fear. Once again, responses might not have reflected reality, but rather shown the fragility of the instrument for gathering information about attitudes. The feeling of fear is the most common cause of stigma in regard to TB.²⁷ For Ascuntar et al.,²⁸ this feeling is closely related to a complex set of attitudes that could interfere with the interpersonal relationships and increase risky behavior. This, in turn, might suggest the generation of stigma and discrimination, thus limiting access to treatment and reducing adhesion.

Most of the inmates and prison workers expressed confidence in questionable preventive practices regarding TB, such as having good habits of cleanliness, good nutrition, washing one's hands, avoiding the cold and not sharing dishes and cutlery. Better results from public health workers were expected in terms of their knowledge of forms of prevention, but some mentioned danger of infection from sharing dishes and cutlery. These findings are not clear in terms of what logic should be present in deciding ways to prevent infection, but they do indicate deficiencies in the knowledge of these individuals about the clinical and epidemiological management of this disease among the studied groups.¹³

In regard to attitudes, the act of talking about TB and who they could talk to if they had TB, inmates mentioned the need to notify their cell mates or any other individuals who might listen to them about the possibility of falling ill. This behavior can be explained in view of the fragility that TB represents in the context of prisons.⁴ Patients can put their cell mates at risk, and talking about the disease could lead these cell mates to pressure to have the patients transferred in order to lower the chances of infecting others and speed up access to the prison health service. Prison workers reported that they would talk about the disease to a friend or family member, while public health workers would talk to a doctor and relatives. This difference in findings reflects a relationship between knowledge about TB and access to health services.¹⁸

Another source of uncertainty is that the data obtained from KAP studies are often used to plan activities focused on behavioral changes related to certain health issues, based on the false premise that there is a direct relationship between knowledge and behavior. A number of studies have shown that knowledge is only one of the factors that influence practice. Therefore, for there to be changes in behavior, health programs must join socioeconomic, environmental and structural factors with practices when planning prevention programs.¹⁸

Conclusion

In the present study, the use of the KAP questionnaire presented a number of problems, difficulties and drawbacks. It proved to be weak to interpret the data gathered on attitudes, thus hindering the understanding of the information obtained. Therefore, if the objective is to study behavior, practice and attitudes in regard to a given context, combinations of qualitative and quantitative methods would be more indicated.

Since the KAP questionnaire revealed major aspects of mistaken concepts about tuberculosis not only among prison inmates but also among prison workers and health workers, it would seem important to suggest its routine use to aid educational activities. The high prevalence of TB among inmates is a clear indication of the need to involve state and local departments of health in the supervision of educational activities in the prison system.

References

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