Knowledge, attitudes, and practices towards childhood tuberculosis among healthcare workers at two primary health facilities in Lusaka, Zambia

Abstract

Background

Zambia is among the 30 high-burden countries for tuberculosis (TB), Human Immunodeficiency Virus (HIV)-associated TB, and multi-drug resistant/rifampicin resistant TB with over 5000 children developing TB every year. However, at least 32% of the estimated children remain undiagnosed. We assessed healthcare workers’ (HCWs) knowledge, attitudes, and practices (KAP) towards childhood TB and the factors associated with good KAP towards childhood TB.

Methods

Data was collected at two primary healthcare facilities in Lusaka, Zambia from July to August 2020. Structured questionnaires were administered to HCWs that were selected through stratified random sampling. Descriptive analysis was done to determine KAP. A maximum knowledge, attitude, and practice scores for a participant were 44, 10, and 8 points respectively. The categorization as either “poor” or “good” KAP was determined based on the mean/ median. Logistic regression analysis was performed to assess the associations between participant characteristics and KAP at statistically significant level of 0.05%.

Results

Among the 237 respondents, majority were under 30 years old (63.7%) and were female (72.6%). Half of the participants (50.6%) were from the outpatient department (OPD) and antiretroviral therapy (ART) clinic, 109 (46.0) had been working at the facility for less than 1 year, 134 (56.5%) reported no previous training in TB. The median/mean KAP scores were 28 (IQR 24.0–31.0), 7 (IQR = 6.0–8.0) and 5 points (SD = 1.9) respectively. Of the participants, 43.5% (103/237) had good knowledge, 48.1% (114/237) had a good attitude, and 54.4% (129/237) had good practice scores on childhood TB. In the multivariate analysis, clinical officers and individuals with 1–5 years’ work experience at the facility had higher odds, 2.61 (95% CI = 1.18–5.80, p = 0.018) and 3.09 (95% CI = 1.69–5.65, p = 0.001) of having good attitude respectively, and medical doctors had 0.17 lower odds (95% CI = 0.18–5.80, p = 0.018) of good childhood TB practice. Other participant characteristics didn’t show a significant association with the scores.

Conclusion

The study found suboptimal levels of knowledge, attitude, and practices regarding childhood TB among HCWs. Targeted programmatic support needs to be provided to address the above gaps.

Introduction

Globally, an estimated 10.6 million people developed tuberculosis(TB) in 2022 of which about 12% were children [1]. Of these children, only 46% were diagnosed and started on treatment [1]. In Zambia, one of the 30 high-burden countries for Tuberculosis (TB), Human Immunodeficiency Virus (HIV)-associated TB, and multi-drug resistant/rifampicin resistant TB, only 68% of the estimated children with TB were diagnosed and started on treatment in 2022 [1]. Between 2020 and 2021, this proportion did not exceed 50% in either year [2–4].

Diagnosing TB in children can be difficult due to the pauci-bacillary nature of TB in the age group and its variable presentation in children [5–7]. This is compounded by sub-optimal to variable knowledge, attitudes, and practices (KAP) concerning childhood TB among healthcare professionals [8–10]. In some settings, healthcare workers (HCWs) hold stigmatizing beliefs and have misconceptions about TB diagnosis, treatment, and infection prevention [8]. Children with symptoms of TB commonly present to primary healthcare facilities [11,12] but due to limited capacity to recognize presumptive TB in children and due to the complexities of diagnosing childhood TB, they are often referred from primary health facilities to referral hospitals and specialized pediatric units resulting in delayed diagnosis [11,12]. Optimizing the knowledge, attitudes, and practices (KAP) of healthcare workers, especially at primary healthcare level, is critical to early diagnosis and treatment of childhood TB.

To the best of our knowledge, there is currently no local literature on KAP among health workers towards childhood TB in Zambia. We undertook a study to assess healthcare workers’ (HCWs) knowledge, attitudes, and practices towards childhood TB and to determine the factors associated with good knowledge, attitudes, and practices towards childhood TB.

Methods

Study design

We conducted a cross-sectional prospective study which was nested within an the main TB REACH Wave 7 study whose objective was to strengthen case finding in children [13].

Setting

The study was conducted between July 2020 to August 2020 at two primary healthcare facilities, Kanyama and Chawama first level hospitals, that have since been upgraded to secondary healthcare facilities. In 2019, Kanyama and Chawama hospitals had annual TB notification rates of 814 per 100,000 and 663 per 100,000 respectively. However, only 6% and 4% of their respective total notifications are children.

Population, sampling and sample size

Our targeted population was registered healthcare workers (nurse, clinical officer and medical officer) supporting departments that should routinely provide TB screening and/or treatment, specifically outpatient department (OPD), Inpatient department (IPD), Antiretroviral therapy (ART) clinic, Maternal Child Health (MCH) clinic and TB clinic.

Stratified random sampling was done; the sample size was calculated using OpenEpi calculator for descriptive studies [14] and the population size in the human resource for health database in 2019. At Kanyama hospital, from a population of 90 nurses, 17 clinical officers and 5 medical doctors, our sample size was 74 nurses, 17 clinical officers and 5 doctors while at Chawama hospital, from a population of 140 nurses, 15 clinical officers and 8 medical doctors we sampled 103 nurses, 15 clinical officers and 8 medical doctors. The overall sample size was 222.

Data collection and study tools

A paper-based structured questionnaire with 36 questions was used. The questions were adapted primarily from the national pre-training test on childhood TB and the World Health Organisation(WHO) guide to developing KAP surveys [15]. The questionnaire contained five sections including: Demographics (8 questions), Knowledge (18 questions), Attitudes (6 questions) and Practices (4 questions). While some questions required a single response, other questions required multiple responses. All the questionnaires were self-administered by the healthcare workers.

De-identified participant data was entered into the DHIS 2-based electronic database.

Validation of correct responses

Three medical officers, all trainers on the consolidated training package on TB, independently responded to the KAP questionnaire. Agreement by at least 2 of them was considered as a correct response.

Statistical analysis

Data was analysed using STATA Statistical Software (Stata Corporation Version 14. College Station, Texas 77845, USA). Descriptive analysis was done to describe the population and summarize the responses. Participant characteristics were reported as frequencies and percentages.

All knowledge, attitude and practice questions were assigned a scoring system wherein correct responses were awarded 1 point, while incorrect responses received 0 points. Responses categorized as "don’t know" or “not sure” or "other" were treated neutrally, with a score of 0 points assigned. A total knowledge, attitude, and practice score for each participant was calculated based on the total correct response of 44, 10, and 8 points respectively. The categorization as either “poor” or “good” knowledge, attitude, and practices was determined based on the mean for normally distributed data and median for data that did not exhibit a normal distribution.

Logistic regression analysis was done to investigate the association between characteristics of study participants and knowledge, attitude, and practice. Univariable analysis was initially applied to identify characteristics associated with knowledge, attitude, and practice. Subsequently, multivariable analysis was conducted, accounting for potential confounding variables. A statistical cutoff point of 0.2 (20%) was used to select variables for inclusion in the multivariable analysis.

Ethical considerations

Approval for study implementation was obtained from the University of Zambia Biomedical Research Ethical Committee (UNZABREC), IRB Reference number 635–2020 under the TB REACH wave 7 study. The respondents provided written informed consent before being allowed to complete the paper based self-administered questionnaire. The survey protected the confidentiality of the respondents by maintaining anonymous responses.

Results

Participant demographics

A total of 237 HCWs participated in the survey (Table 1). Majority of the participants were under 30 years of age, females and nurses at 63.7%, 72.6%,70.5% respectively. HCWs from the outpatient department (OPD) and inpatient department (IPD) accounted for 70.4% of the participants. About half of the participants had been at their respective health facilities for less than a year and more than half of them had not received any training in TB. Among those who had been trained, 47% had been trained on adult TB, 35% had been trained on childhood TB and 43% were trained less than 6 months from the date of the survey.

Table 1. Characteristics of the study participants.

Characteristics	Frequency (n)	Percentage (%)
Age Group (years)
Under 30	151	63.7
31–40	61	25.7
41–50	16	6.8
Over 50	7	3.0
Missing	2	0.8
Sex
Male	65	27.4
Female	172	72.6
Profession
Nurse	167	70.5
Clinical Officer	53	22.4
Medical Doctor	17	7.2
Department
OPD	93	39.2
ART	27	11.4
IPD	74	31.2
MCH	38	16.0
TB	4	1.7
Missing	1	0.4
Duration of working at facility
Less than 1 year	109	46.0
1–5 years	104	43.9
5 or more years	24	10.1
Previous training on TB 3
No	134	56.5
Yes	100	42.2
Missing	3	1.3
Focus of previous training
Adult TB	47	47.0
Childhood TB	35	35.0
3 Is	9	9.0
TB preventive therapy	40	40.0
Infection control	29	29.3
Case finding	12	12.0
TB/HIV management	53	53.0
Duration since previous training
Less than 6 months	43	43.0
6 months to 2 years	30	30.0
More than 2 years	27	27.0

Knowledge on childhood TB.

The median knowledge score was 28 (Interquartile range [IQR] 24.0–31.0) points (Table 2). Overall, 43.5% of respondents had good knowledge. Most respondents (89.0%) correctly identified Zambia as a high burden TB country and 99.6% correctly associated coughing with TB transmission. However, knowledge gaps were observed for other modes of transmission. All participants knew that TB affects the lungs but there was variable knowledge on if it affects other parts of the body. About 49.8% of the participants were aware that extra-pulmonary TB is prevalent in children. The majority didn’t correctly distinguish the risk factors for TB infection apart from those for TB disease. At least 88% of participants correctly identified all TB symptoms in children, and about half (48.5%) of the participants knew that Gene Xpert/ Xpert ultra is the first-line TB diagnostic test in Zambia. Less than half of the respondents knew that only one spot sample was required for Xpert testing but 90.5% of the participants knew that Gene Xpert /Xpert ultra is the diagnostic test for drug resistant TB. Close to 90% of the participants knew that uncomplicated pulmonary TB is treated for 6 months, 43% knew the recommended regimen for uncomplicated TB and 46.4% knew that steroids are indicated in children with TB meningitis. There was low to moderate knowledge on indications for TPT in children, TPT regimens in Zambia and evaluation before start of TPT.

Table 2. Knowledge of HCWs on childhood TB.

Knowledge questions	Responses	Frequency	Percentage
TB epidemiology and transmission
Zambia is a high burden TB country	Yes	211	89.0
	No	3	1.3
	Not sure	18	7.6
	Missing	5	2.1
TB transmission	Coughing	236	99.6
	Sneezing	167	70.5
	Singing	90	38.0
	Laughing	89	37.6
	Skin contact	15	6.3
Body parts affected by TB	Lungs	237	100
	Larynx	118	47.8
	Heart	100	42.4
	Spine	219	92.4
	Meninges	195	82.3
	Lymph nodes	168	71.2
	Abdomen	199	84.0
	Pleura	154	65.0
Extra-pulmonary TB is common in children	Yes	118	49.8
	No	96	40.5
	Not sure	10	4.2
	Missing	13	5.5
Risk factors for childhood TB infection	Not being vaccinated with BCG	211	90.2
	HIV	207	88.5
	Malnutrition	196	83.8
	Being <5 years of age	130	55.6
	Living in Zambia	70	30.0
	Being a contact to a TB case	203	86.8
Diagnosis of TB
Symptoms of TB in children	Cough	226	96.7
	Low appetite	211	90.2
	Tiredness/reduced playfulness	198	84.6
	Weight loss	220	94.0
	Fever	204	87.2
	Chest pain	162	69.2
	Shortness of breath	176	75.2
	Do not know	0	0.0
	Other	7	3.0
Risk factors for childhood TB disease	No BCG vaccination	209	89.3
	HIV	213	91.1
	Malnutrition	196	83.8
	Being less than 5 years old	125	53.7
	Living in Zambia	45	19.3
	Being a contact to a TB case	200	85.5
First line TB diagnostic test in Zambia	Chest X-ray	73	30.8
	Gene Xpert/ Xpert ultra	115	48.5
	Smear microscopy	43	18.1
	Do not know	2	0.8
	Missing	4	1.7
Number and type of samples needed for Gene Xpert testing	One spot sample	63	26.6
	One morning sample	78	32.9
	Two samples: spot and morning	67	28.3
	Two spot samples	4	1.7
	Three samples: Spot, morning, spot	14	5.9
	Missing	11	4.6
Diagnostic tests for diagnose drug resistant TB	Chest x-ray	77	32.6
	Gene Xpert /Xpert ultra	213	90.5
	Smear microscopy	106	44.9
	Do not know	24	10.2
	Other	1	0.4
Treatment of TB
Duration of treatment of uncomplicated pulmonary TB in children	1 month	5	2.1
	6 months	210	88.6
	12 months	9	3.8
	Not sure	11	4.6
	Missing	2	0.8
Treatment regimen for uncomplicated pulmonary TB in children	2HERZ/4HR	102	43.0
	2HRZ/4HR	96	40.5
	2HERZ/10HR	12	5.1
	2HRZ/10HR	10	4.2
	Missing	17	7.2
TB and HIV treatment can be started on the same day in children	Yes	62	26.2
	No	154	65.0
	Not sure	19	8.0
	Missing	2	0.8
Children with TB meningitis must always be given steroids	Yes	110	46.4
	No	58	24.5
	Not sure	62	26.2
	Missing	7	3.0
Prevention of TB
Children eligible for TB preventive therapy (TPT)	Children living with HIV (CLHIV) irrespective of age	158	67.0
	CLHIV > 1 year	105	44.5
	All children	61	25.9
	CLHIV <1 year in contact to a TB case	127	53.8
	< 5 contacts to bacteriologically confirmed TB cases	129	54.7
Recommended TPT regimens in Zambia	Ethambutol for 6 months	19	8.1
	3H	56	24.0
	6H	153	64.8
	3RH	37	15.7
	Pyrazinamide for 3 months	12	5.1
	3HP in children > 2 years	19	8.1
Children with symptoms of TB can be started on TB preventive therapy	Yes	78	32.9
	No	134	56.5
	Not sure	22	9.3
	Missing	3	1.3
Before starting TB preventive therapy, the following must be done	Gene Xpert	163	69.7
	Chest x-ray	153	65.1
	Symptom screening	190	81.2
	Mantoux	44	18.7
Overall knowledge level	Median Knowledge score = 28 points (IQR 24.0–31.0)
	Good knowledge = 43.5% (103/237) Poor knowledge = 56.5% (134/237)

Abbreviations: BCG- Bacillus Calmette–Guérin; HIV- Human Immunodeficiency virus; TB- Tuberculosis; 2HERZ/4HR- 2months of isoniazid, ethambutol, rifampicin and pyrazinamide followed by 4 months of isoniazid and rifampicin; 2HRZ/4HR- 2months of isoniazid, rifampicin and pyrazinamide followed by 4 months of isoniazid and rifampicin; 2HERZ/10HR- 2months of isoniazid, ethambutol, rifampicin and pyrazinamide followed by 10 months of isoniazid and rifampicin; 2HRZ/10HR- 2months of isoniazid, rifampicin and pyrazinamide followed by 10 months of isoniazid and rifampicin; 3H- 3 months of isoniazid; 6H- 6 months of isoniazid; 3HR- 3 months of isoniazid and rifampicin; 3HP- weekly dose of isoniazid and rifapentine for 12 weeks.

Attitude about childhood TB

The median attitude score was 7 (IQR = 6.0–8.0) (Table 3). Overall, 48.1% had a good attitude. The majority of participants reported a proactive role in diagnosis of children with presumptive TB. Almost all participants reported compassion and a desire to help children with TB (97.1%) and 95.4% expressed willingness to be more involved in TB activities. About 5% of participants would either be angry or scared if they were assigned to work at the TB corner. The most frequent concerns about TPT were pill burden (28.7.3%) and potential side effects (46%). Two-thirds of the healthcare workers believed that benefits of TPT outweigh the risks.

Table 3. Attitudes of HCWs towards childhood TB.

Childhood TB Attitude items	Responses	Frequency	Percentage
What do you feel is your role in diagnosis children with TB?	Refer children with presumptive TB to the TB corner	203	86.4
	Request children with presumptive TB to submit sputum	172	73.2
	Fast track the children so that they can see a clinician quickly	148	63.0
	Document these children in the presumptive TB register	148	63.0
	I don’t know	3	1.3
Which statement is closest to your feeling about children with TB disease?	I feel compassion and desire to help	230	97.1
	I feel compassion but I tend to stay away from these people	1	0.4
	It’s their problem, and I cannot get TB	1	0.4
	I fear them because they may infect me	1	0.4
	I have no particular feeling	1	0.4
	Other	1	0.4
	Missing	3	1.3
Would you like to be more involved in TB activities?	Yes	226	95.4
	No	3	1.3
	Not sure	6	2.5
	Missing	2	0.8
What would be your reaction if you were asked to work at the TB corner?	I would refuse	2	0.8
	I don’t mind	138	58.2
	Scared	9	3.8
	Angry	2	0.8
	Happy	76	32.1
	Other	7	3.0
	Missing	3	1.3
What is your biggest fear/concern about TPT?	Pill burden	68	28.7
	TB preventive therapy promotes drug resistant TB	42	17.7
	It does not have much benefit in a high burden setting	3	1.3
	Side effects	109	46.0
	Other	5	2.1
	Missing	10	4.2
Do you think the benefits of TB preventive therapy outweigh the risks?	Yes	174	73.4
	No	33	13.9
	Not sure	25	10.6
	Missing	5	2.1
Overall attitudes levels	Median attitude score = 7 (IQR = 6.0–8.0)
	Good attitude = 48.1 (114/237) Poor attitude = 51.9 (123/237)

Childhood TB-related practices

Then mean practice score was 5 points (SD = 1.9) (Table 4). Overall, 54.4% had good childhood TB practice. Gaps in regular educational practices were recorded, only 31.7% reported that their departments had provided health education on childhood TB diagnosis or prevention in the past week. Of the participants, 61.7% reported to interact with children exhibiting TB symptoms at least once a week. The most common practices when a child is identifying with presumptive TB is identified is to send them to the TB corner to submit sputum sample (74.4%).

Table 4. Practices of HCWs on childhood TB.

Childhood TB practices questions	Responses	Frequency	Percentage
Has your department provided any health education on childhood TB diagnosis or prevention in the past 1 week?	Yes	75	31.7
	No	145	61.2
	Not sure	15	6.3
	Missing	2	0.8
How often do you interact with children with symptoms suggestive of TB?	At least once week	142	59.9
	Once a month	48	20.3
	Never	40	16.9
	Missing	7	3.0
What do you do when you identify a child with symptoms of TB?	Ask the patient to go to TB corner to submit a sputum sample	174	74.4
	Request the patient to submit a sputum sample	131	55.7
	Fast track the child	132	56.7
	Provide education on cough etiquette	138	59.0
	Document the child in the presumptive TB register	100	42.7
	Nothing	2	0.9
What do you do for children not able to produce sputum?	Prescribe antibiotics for 1 week and then ask them to return to the health facility for review	18	7.8
	Collect gastric aspirates	186	80.5
	Use chest x-ray to make a diagnosis	121	52.4
	Give mother sputum bottle to continue trying to get sputum from the child	36	15.7
	Request for LAM	52	22.5
	Other	5	2.2
	N/A	1	0.4
Overall practice	Mean practice score = 5 points (SD = 1.9)
	Good practice = 54.4 (129/237) Poor practice = 45.6 (108/237)

In instances where children are not able to produce sputum, majority of HCWs (80.5%) reported collecting gastric aspirates.

Association between characteristics of study participants and Knowledge, attitude, and practices in childhood TB

In the univariable analysis (Table 5), those working in IPD and MCH had lower odds of good knowledge about childhood TB: 0.40 (95% CI = 0.21–0.76, p = 0.005) and 0.36 (95% CI = 0.16–0.80, p = 0.013) respectively. On the other hand, clinical officers and previously undergoing training on TB had 2.82 higher odds (95% CI = 1.49–5.31, p = 0.001) and 1.95 higher odds (95% CI = 1.15–3.31, p = 0.013) respectively of having good knowledge. Regarding attitude, those working in MCH had 0.34 lower odds (95% CI = 0.15–0.78, p = 0.011) of good attitude while clinical officers and those with 1–5 years of working at the facility had higher odds of good attitude: 1.99 times (95% CI = 1.05–3.76, p = 0.034) and 2.58 times (95% CI = 1.48–4.49, p = 0.001) respectively. In terms of practice, participants trained on childhood TB more than 2 years ago had 0.25 times lower odds (95% CI =, 0.09–0.70, p = 0.008) of good practice compared to those trained less than 6 months ago. Other participant characteristics did not show statistically significant associations with the scores.

Table 5. Univariable logistic regression analysis of characteristics with Knowledge, attitude, and practices in childhood TB.

Characteristics	Knowledge score		Attitude score		Practice score
	Unadjusted odds ratio (95% CI)	p-value	Unadjusted odds ratio (95% CI)	p-value	Unadjusted odds ratio (95% CI)	p-value
Age group (years)
Under 30	Ref.		Ref.		Ref.
31–40	1.01 (0.55–1.84)	0.975	1.12 (0.62–2.03)	0.713	1.28 (0.70–2.33)	0.425
41–50	1.06 (0.37–2.99)	0.916	0.46 (0.15–1.39)	0.169	0.69 (0.24–1.95)	0.484
Over 50	3.40(0.64–18.08)	0.151	0.41 (0.08–2.15)	0.289	5.33 (0.63–45.30)	0.126
Sex
Male	Ref.		Ref.		Ref.
Female	0.79 (0.44–1.40)	0.413	0.81 (0.46–1.44)	0.472	0.69 (0.38–1.23)	0.207
Profession
Nurse	Ref.		Ref.		Ref.
Clinical Officer	2.83 (1.49–5.37)	<0.002	1.99 (1.05–3.76)	<0.034	1.32 (0.70–2.49)	0.395
Medical Doctor	2.52 (0.91–6.97)	0.074	1.12 (0.41–3.01)	0.845	0.45 (0.16–1.27)	0.132
Department
OPD	Ref.		Ref.		Ref.
ART	0.78 (0.33–1.84)	0.571	1.56 (0.65–3.76)	0.324	1.63 (0.67–3.93)	0.279
IPD	0.40 (0.21–0.76)	<0.005	0.82 (0.45–1.52)	0.532	1.40 (0.76–2.61)	0.282
MCH	0.36 (0.16–0.80)	<0.013	0.34 (0.15–0.78)	<0.011	0.81 (0.38–175)	0.598
TB	Omitted	Omitted	2.75 (0.28–27.42)	0.389	Omitted	Omitted
Duration working at facility
Less than 1 year	Ref.		Ref.		Ref.
1–5 years	1.23 (0.71–2.12)	0.461	2.58 (1.48–4.49)	<0.001	1.19 (0.69–2.05)	0.522
5 or more years	1.02 (0.42–2.5175)	0.961	0.97 (0.39–2.41)	0.941	1.28 (0.52–3.12)	0.595
Previous training on TB
No	Ref.		Ref.		Ref.
Yes	1.95 (1.15–3.31)	<0.013	1.28 (0.76–2.16)	0.351	1.12 (0.66–1.89)	0.671
Duration since previous training
Less than 6 months	Ref.		Ref.		Ref.
6 months to 2 years	0.55(0.21–1.41)	0.215	0.87 (0.34–2.21)	0.769	0.57(0.21–1.50)	0.252
More than 2 years	09.(0.34–2.38)	0.832	0.94 (0.36–2.46)	0.894	0.25 (0.09–0.70)	<0.008

*P value <0.005.

In the multivariate analysis (Table 6), clinical officers and individuals with 1–5 years work experience at the facility demonstrated higher odds, 2.61 (95% CI = 1.18–5.80, p = 0.018) and 3.09 (95% CI = 1.69–5.65, p = 0.001) respectively, of having good attitude. With regards to good practice, medical doctors had 0.17 lower odds (95% CI = 0.18–5.80, p = 0.018). However, the other participant characteristics didn’t show a significant association with the scores.

Table 6. Multivariable logistic regression analysis of characteristics with Knowledge, attitude, and practices in childhood TB.

Characteristics	Knowledge score		Attitude score		Practice score
	Adjusted odds ratio (95% CI)	p-value	Unadjusted odds ratio (95% CI)	p-value	Unadjusted odds ratio (95% CI)	p-value
Age group
Under 30	-	-	Ref.		Ref.
31–40	-	-	1.28 (0.63–2.60)	0.490	2.69 (0.87–8.31)	0.085
41–50	-	-	0.31 (0.08–1.26)	0.103	1.05 (0.20–5.41)	0.956
Over 50	-	-	0.33 (0.04–2.65)	0.299	Omitted	Omitted
Sex
Male	-	-	-	-	Ref.
Female	-	-	-	-	0.60 (0.22–1.61)	0.311
Profession
Nurse	Ref.		Ref.		Ref.
Clinical Officer	1.94 (0.93–4.07)	0.078	2.61 (1.18–5.80)	<0.018	0.83 (0.30–2.29)	0.717
Medical Doctor	2.25 (0.78–4.07)	0.134	0.96 (0.32–2.85)	0.940	0.17 (0.03–0.97	<0.046
Department
Outpatient department	Ref.		Ref.		-	-
ART	0.82 (0.33–2.05)	0.675	1.75 (0.66–4.66)	0.259	-	-
In Patient Department	0.52 (0.26–1.07)	0.074	1.09 (0.54–2.22)	0.812	-	-
MCH	0.51 (0.21–1.25)	0.139	0.48 (0.19–1.26)	0.136	-
TB	Omitted	Omitted	9.97 (0.81–123.03)	0.073	-	-
Duration working at facility
Less than 1 year	-	-	Ref.		-	-
1–5 years	-	-	3.09 (1.69–5.65)	<0.001	-	-
5 or more years	-	-	1.50 (0.45–5.03)	0.513	-	-
Previous training on TB
No	Ref.		-	-	-	-
Yes	1.46 (0.82–2.60)	0.203	-	-	-	-
Duration since previous training
Less than 6 months	-	-	-	-	Ref.
6 months to 2 years	-	-	-	-	0.79 (0.27–2.31)	0.669
More than 2 years	-	-	-	-	0.18 (0.06–0.56)	<0.003

*P value <0.005.

Discussion

In this cross-sectional study, we found that a high proportion of HCWs with poor knowledge, attitudes and practices towards childhood TB. The knowledge gaps were most pronounced in the domains TB diagnosis and treatment. Being a clinical officer and work experience of 1–5 years at the facility were associated with good attitude regarding childhood TB while being a medical doctor was associated with poor practice regarding childhood TB.

Our study findings were aligned to the performance on childhood TB case detection in the study sites which was only 4–6% of the total notifications at the time, a performance significantly lower than the target of 10–15% of total notifications in high TB burden settings [1,16]. Overall, our findings are similar to those from other childhood TB KAP studies [9,10,17]. However, it’s worth noting that the multi-country study conducted in Cambodia, Cameroon, Cote d’Ivoire, Sierra Leone and Uganda found more favourable attitudes than we did [10] and the percentage of participants with good knowledge, attitudes and practices was slightly higher in the studies conducted in Cameroon and Saudi Arabia [9,17]. These differences could be due to variations in settings as well as in the questionnaire. Additionally, our findings are similar to those from TB KAP surveys that were not specifically focused on childhood TB [18–20].

The very low KAP scores in our study could be attributed to the fact that a majority of healthcare workers had no previous training in TB, a gap most pronounced in childhood TB. This is secondary to the fact that TB programs in Zambia have traditionally focused on training those working at the TB department. However, this approach inadvertently creates a gap, as majority of the presumptive TB patients, including childhood presumptive TB patients, are identified outside the TB department, most especially at OPD and ART [21–23]. Much as the gap on treatment is significant, it is low impact is somewhat mitigated by the existing procedural norms. Specifically, while patients identified with TB in the IPD can commence treatment within the IPD itself, those diagnosed in other departments are mandated to initiate their TB treatment at the chest clinic.

Although we didn’t find any participant characteristics that were associated with good knowledge towards childhood TB, evidence from other settings suggests that previous training is associated with increased knowledge in childhood TB [9,24] and duration of work experience is associated with a good attitude [9]. Additional evidence from the same setting [13] and other settings [25–27] indicates that capacity development of healthcare workers leads to improved childhood TB case detection. The improvement in case detection is likely driven by a prior enhancement of KAP among healthcare professionals. The positive association between being a clinical officer and having 1–5 years’ experience with a good attitude towards childhood tuberculosis suggests that frontline healthcare providers with moderate levels of experience exhibit more favorable attitudes, possibly due to a combination of practical experience, ongoing learning, and familiarity with the local context. Contrastingly, the association between being a medical doctor and poor practice regarding childhood tuberculosis raises important questions. The potential factors contributing to this finding include heavy workload requiring them to focus on managing other disease conditions and potential gaps in on-the-job training specifically related to childhood tuberculosis.

The strengths of our study include a high response rate and inclusion of departments regularly involved in TB screening and diagnosis which provides true insights into the childhood TB KAP among frontline healthcare professionals. Additionally, this is the first KAP study on childhood TB in Zambia. However, out study has important limitations: we didn’t test the validity and reliability of the questionnaire and the findings from this study cannot be generalized to Zambia.

In conclusion, this study found high levels of poor KAP towards childhood TB at 2 primary health care facilities servicing high burden TB communities. The identified knowledge gaps, attitudes, and practices provide a foundation for strategic interventions. To address these gaps, it is important that the ministry of health (MOH) collaborates with key stakeholders, including non-governmental organizations (NGOs) and the respective study facilities.

Supporting information

S1 Dataset

(XLSX)

S1 File

(DOCX)

Data Availability

Data are available in a code book and correct responses, contained within the Supporting Information files.

Funding Statement

Dr. Monde Muyoyeta received the a grant through the Stop TB Partnership/ TB REACH mechanism with funding support from the Government of Canada (TB REACH wave 7) which facilitated the collection of the data for this study. This funding was obtained under The Centre for Infectious Diseases Research in Zambia (CIDRZ). Grant Number: STBP/TBREACH/GSA/W7-7426 Funders site: https://stoptb.org/global/awards/tbreach/wave7.asp The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.