Acceptability of masking and patient separation to control nosocomial Tuberculosis in Uganda: a qualitative study

Abstract

Objectives

This study explored the acceptability of cough etiquette, wearing masks and separation by tuberculosis (TB) suspects and TB patients in two districts in Uganda.

Design

The study was conducted in Mukono and Wakiso districts in central Uganda. Eighteen in-depth interviews with patients and eight focus group discussions with health workers were conducted. Patients were asked for their opinions on cough etiquette, patient separation and wearing of masks.

Results

Patients and health workers felt that physical separation was ideal, yet separation and masking were regarded as embarrassing to patients, emphasizing their potential infectiousness. Patients reported greater willingness to cover their mouth with a handkerchief than to wear a mask. Good counseling and health education were suggested to improve patients’ adoption of separation and masking. However patients expressed concerns about equity, coercive and stigmatizing approaches. Universal precautions were more acceptable than targeted ones, with the exception of separating TB patients. Lack of community awareness about airborne transmission of TB was identified as a barrier to accepting and adopting TB infection control measures.

Conclusion

Scaling up effective TB infection control norms and behaviors requires a patient-centered, rights-based, and evidence-based approach. Socially acceptable measures like covering the mouth and nose with a handkerchief should be promoted. We recommend that further studies are needed to explore how community advocacy impacts on acceptability of masking. Furthermore, the efficacy of covering the mouth using a handkerchief or piece of cloth compared to wearing a mask in TB prevention needs to be evaluated.

Appendix 1: An example of some of the questions asked in the focus group discussion and in-depth interview guide

An example of some questions in the in-depth interview guide

• 1. Think about your community, what are the main health problems in this community? (Probe for TB if not mentioned) What is TB? (Probe for people’s opinions on TB, e.g., When you think about TB, what comes to your mind? (Encourage participants to reflect on the general opinion of TB in the community).(Probe: causes, signs and symptoms, transmission, disease associated, risk of getting TB in the community).

• 2. Tell me about the waiting area (outpatient department) and what happens there. (Probe if they received any verbal health info, and if TB was mentioned, what was mentioned about TB)

• 3. (If there was a talk) what kinds of information were they given in these talks? What kinds of requests did the health workers make of you?

• 4. 4. What kinds of instructions did you receive about how you were expected to wait? Were you asked to wear or do anything specific?

• 5. How did you feel about these requests/instructions or how would feel if you were asked to;

  • a. What did it feel like to be told to cover your mouth while coughing/how would you feel to be told to cover your mouth while coughing?

  • b. What did it feel like to wear the mask/how would you feel if you were asked to wear a mask? (Hint: Show the patients the picture of a patient wearing a mask. Explain to them that wearing a mask by a TB suspect or TB patient helps in reducing transmission of TB).

  • c. How did you feel when you were separated/how would feel if you were separated from the other OPD attendees/patients because you were coughing/TB suspect?

• 6. How do/would you feel being seen by a health-care worker wearing a mask? Please explain.

• 7. Please tell me what can be done by TB suspects/patients to reduce their chances of transmitting their infection to other TB patients? (probe for patients understanding of cough hygiene or cough etiquette.)

• 7. Suggest ways on how best TB suspects (patients with cough for 2 weeks or more) and patients can be handled in order to reduce chances of transmitting TB infection to other patients but without stigmatizing them?

An example of some questions in the focus group discussion guide

• 1. How common is TB in this health facility?

• 2. Which TB infection control measures is this facility implementing? Please tell me which administrative measures are implemented in the patient’s waiting area?

• 3. What are patients’ attitudes towards the following?

• a. Separating of patients suspected of having TB (cough for 2 weeks and above) from the other patients in the waiting area (OPD)

• b. Cough etiquette/covering their mouth when coughing and sneezing

• c. Wearing of surgical masks in the waiting area by those patients suspected of having TB or with confirmed TB