Analysis of the current status and associated factors of tuberculosis knowledge, attitudes, and practices among elderly people in Shenzhen: a cross-sectional study

The Global Tuberculosis (TB) Report issued by the World Health Organization (WHO) showed approximately 10 million new TB patients worldwide in 2019, 86% of whom were concentrated in 30 countries with a high TB burden [1]. China has a high TB burden, with approximately 833,000 new TB patients every year, ranking second in the world behind India [1]. The TB epidemic is growing markedly, with a progressive increase in the notification rate with age, and a peak among those aged 65 years or older [1]. As the population has aged rapidly in China in recent years, the WHO estimates that the number of elderly people in China will reach 402 million by 2040, accounting for 28% of the total population [2]. A cohort study in 2020 showed that the incidence and risk of TB among the elderly population increased with the ageing of the population in China, and the detection rate of TB among the elderly population was 481.8/100,000 [3]. The high incidence of TB among elderly people has introduced considerable challenges to the lives of Chinese people and China’s economy. Understanding the knowledge, attitudes, and practices (KAP) and associated factors related to TB among elderly people is very important to the targeted development of TB prevention and treatment tasks in China.

Previous studies have investigated TB KAP among medical interns, nurses, teacher trainees, healthcare workers, and community residents [4‐8]. Berg-Johnsen et al. conducted a study on 270 medical interns and found that the surveyed interns had an adequate level of TB-related knowledge and acceptable attitudes [4]. Akande reported that small proportions of the respondents had a good score for knowledge (10.5%) and practices (6%) [5]. Dorji et al. surveyed 420 trainees and revealed that 58.6% had low knowledge of TB [6]. Alotaibi et al. conducted a study of 540 healthcare workers and found that the participants had average knowledge, above-average attitude, and good practice regarding TB [7]. Wang et al. conducted a national survey of 33,357 residents and showed an overall TB awareness rate of 74.45% [8]. However, no studies have investigated TB KAP and associated factors among elderly people in the community. Therefore, this study aimed to address this important research gap. The findings from this study may contribute to developing TB prevention and treatment policies for elderly people.

Initially, a total of 1200 elderly people were randomly recruited for the survey. Eleven elderly people refused to participate and 1189 completed questionnaires were received. Then, we excluded 17 interviewees aged < 65 years, residing in the area for less than half a year, and with communication disorders and mental illnesses. During the statistical analysis, 94 samples with more than 10% missing values for the items of knowledge, attitudes, and practices were excluded. Finally, a total of 1078 samples were included in this study, yielding a response rate of 90.66% (see Fig. 1).

Table 1 shows the basic characteristics of elderly people. Among 1078 respondents, 488 (45.40%) were females, and 587 (54.60%) were males. Most elderly people (77.68%) were nonlocal residents. A total of 582 (54.65%) respondents had a primary school education or below. Most (89.37%) elderly people were married, 80.95% were farmers or worked in other occupations and 72.89% had medical insurance. Elderly people with a family annual income per capita lower than 100,000 RMB accounted for 71.44% of the total sample. A total of 494 (47.45%) and 481 (46.21%) respondents reported a good or fair self-perceived health status respectively. A total of 118 (10.97%) and 100 (9.28%) elderly individuals were current cigarette smokers or alcohol drinkers, respectively. Among the population, 33 (3.13%) had previously been treated for TB, and 33 (3.09%) had family members or friends with a previous TB history. In addition, the average age of the elderly individuals was 71.42 (SD = 5.22) years, and the average BMI was 23.67 (SD = 3.33) kg/m².

The mean TB KAP scores were 3 (IQR = 2; range 0 to 5), 2 (IQR = 1; range 0 to 5), and 3 (IQR = 2; range 0 to 6). The percentages of elderly people who were aware of TB and had positive attitudes and practices were 69.23%, 48.87%, and 42.62% respectively.

The distribution of participants’ responses regarding TB KAP is shown in Table 2. In the knowledge section, more than 70% of the elderly individuals (72.60%, 73.94%, and 71.62%) were aware of TB infectivity, symptoms, and preventive measures, respectively. The awareness rate for TB curability was 45.30%. However, less than one-third of survey respondents (31.03%) knew the route of TB transmission. In terms of attitudes, most elderly people (86.03% and 86.89%) wanted to learn about TB or participate in TB education activities, respectively. More than one-third of respondents (36.44%) were willing to be screened for TB if they had suggestive symptoms. Only 225 (21.15%) and 261 (24.90%) participants did not think that TB is a terrible disease or were willing to complete treatment if diagnosed with TB. Regarding practices, most elderly individuals (84.08% and 85.69%) would visit health facilities if they had a cough for more than 2 weeks or if they suspected that they had TB, respectively. More than half of elderly people (60.54%) would urge their friends with suspicious symptoms to visit the doctor. Approximately one-third of participants (33.08% and 33.02%) had ever taken the initiative to learn about TB or would stop spitting in public, respectively. Only 265 (25.09%) respondents covered their mouths and noses when coughing or sneezing.

Table 3 presents the results of the univariate linear regression analysis of TB KAP among the elderly population. Significant differences in TB knowledge among elderly people were observed across education levels, medical insurance statuses, family annual incomes per capita, self-perceived health statuses, previous TB histories, and family members or friends with a previous TB history (P < 0.05). Significant differences in TB attitudes among elderly people were found across BMIs, education levels, occupations, medical insurance statuses, family annual incomes per capita, previous TB histories, and family members or friends with a previous TB history (P < 0.05). Significant differences in TB practices among elderly people were identified across ages, residences, education levels, occupations, medical insurance statuses, family annual incomes per capita, self-perceived health statuses, previous TB histories, and family members or friends with a previous TB history (P < 0.05).

Multiple stepwise regression analyses showed that education level (junior high school or higher: β = 0.278, 95% CI 0.108 to 0.447; P = 0.001), annual family income per capita (more than 100,000: β = − 0.377, 95% CI − 0.563 to − 0.191; P < 0.001), self-perceived health status (β = − 0,245, 95% CI − 0.387 to − 0.103; P = 0.001), and having family members or friends with a previous TB history (yes: β = 0.624, 95% CI 0.157 to 1.091; P = 0.009) were associated with TB knowledge among elderly people (Table 4). Medical insurance (no: β = − 0.409, 95% CI − 0.584 to − 0.235; P < 0.001), education level (junior high school or higher: β = 0.208, 95% CI 0.052 to 0.364; P = 0.009), family annual income per capita (more than 100,000: β = − 0.224, 95% CI − 0.394 to − 0.053; P = 0.010), and having family members or friends with a previous TB history (yes: β = 0.753, 95% CI 0.332 to 1.174; P < 0.001) were associated with TB attitude scores (Table 5). In addition, age (β = 0.028, 95% CI 0.007 to 0.048; P = 0.007), medical insurance (no: β = − 0.494, 95% CI − 0.716 to − 0.272; P < 0.001), education level (junior high school or higher: β = 0.331, 95% CI 0.127 to 0.536; P = 0.002), and family annual income per capita (more than 100,000: β = − 0.340, 95% CI − 0.564 to − 0.117; P = 0.003) were associated with TB practice scores (Table 6).

Previous studies have shown that TB KAP were directly associated with the detection rate and TB treatment and prevention effects [14]. The results showed that the core knowledge awareness rate for TB prevention and treatment among elderly people in Shenzhen City was 69.23%, which is higher than the rates reported for residents of Zhejiang Province (48.0%) [15], Guizhou Province residents (41.5%) [16], and hospitalized elderly TB patients in Hunan (56.2%) [17]. However, this rate is considerably lower than the nationwide public TB knowledge awareness rate reported in 2009 (89.0%) [18]. In terms of each key piece of information about TB, the elderly people had the highest level of correct knowledge about TB’s symptoms, which was much better than participants in Lesotho [20]. But what is noteworthy is that a small proportion of respondents knew the transmission routes and curability of TB, which should be strengthened in health education. The percentages of elderly people with positive attitudes and practices regarding TB were 48.87 and 42.62%, respectively, which are slightly higher than the positive attitude rate (40.8%) and lower than the positive practice rate (45.9%) found in residents of Ethiopia [19] and considerably lower than the incidence of positive attitudes reported by Luba et al. [20] for residents of Lesotho (72.8%). Therefore, implementing further TB health promotion and education efforts among elderly people in the community is an urgent task for the government and related sectors to improve TB prevention and treatment for elderly people.

The results of the multiple linear stepwise analyses showed that the TB knowledge scores of elderly people with higher education levels, lower family annual incomes per capita, a better self-perceived health status, and family members or friends with a previous TB history were higher. Elderly people with a junior high school education or above had higher TB knowledge scores, which is consistent with the findings of Chen et al. [15], Wan [21], and Wang et al. [22]. Elderly individuals with higher annual family incomes per capita had lower TB knowledge scores, which is inconsistent with previous studies [23]. One possible reason is that older individuals have different concerns about health knowledge, and high-income groups may be more knowledgeable in other areas of health knowledge [24]. In addition, because the percentage of people with higher self-reported annual family incomes was relatively low in this study and residents may be sensitive about sharing income information, the number of people with high incomes may have been underestimated. Intriguingly, this study showed that elderly individuals with higher education levels were more likely to have higher levels of TB knowledge, but individuals with higher incomes were less likely to have TB knowledge, reflecting an interesting finding that requires further research. Educational interventions should be strengthened for elderly people with low education levels and high incomes. Furthermore, this study showed that people with a better self-perceived health status had higher TB awareness. Elderly people with a better self-perceived health status may direct more attention towards health information and their own health; therefore, they were more likely to acquire more TB information. Elderly people whose relatives or friends previously had TB also had more opportunities to be informed about TB and were strongly influenced by its importance. Therefore, they reported higher awareness rates, which also suggests that some individuals successfully received information from the health care system and spread health knowledge. Therefore, health education activities are needed in medical institutions to further health knowledge among the elderly population.

The TB attitude scores of elderly individuals without health insurance were lower. Elderly people with higher education levels and those whose family members or friends with a previous TB history had relatively positive attitudes towards TB treatment and prevention. The impact of education level on TB attitude and practices scores was consistent with the impact of knowledge scores, indicating that health education regarding TB was the key to establishing appropriate health attitudes and practices. Our finding is consistent with the study by Luba et al. [20] among Lesotho residents. In addition, age was positively associated with TB practices. A possible interpretation may be that people are more likely to adopt active TB prevention behaviours due to decreased immunity and an increased risk of TB with age [23].

The strength of this study is that it is the first study to investigate TB KAP among elderly people in China. The findings may provide targeted guidance for improving health policies. However, this study had some limitations. First, this study targeted elderly people in Bao’an District of Shenzhen; thus, the results are representative of elderly people only in the Shenzhen area instead of China. A survey of elderly individuals in multiple regions across the country is needed to further verify the results of this study. Second, the study population was selected from individuals who received health examinations at the selected health centres. This population already has access to care and may not be representative of those who do not undergo health examinations, which limited the generalizability of our data to other elder populations. Third, we excluded samples with more than 10% missing values from the data analysis. Those who had better memories were more likely to complete the questionnaire than others, which may lead to selection bias. Forth, the survey was cross-sectional, which limited interpretation of the temporality and causality of these findings. Final, other potential predictors, such as the accessibility of health services, social support, and a history of chronic disease, were not included in this study. More comprehensive and rigorous studies based on scientific sampling are needed.

Elderly people in Shenzhen City had low levels of TB knowledge awareness and poor attitudes and practices regarding TB prevention and treatment. Furthermore, this study showed that elderly people with lower education levels and higher family annual incomes per capita had lower overall TB knowledge awareness rates and poor TB-related attitudes and practices. Therefore, the implementation of systemic health education and health promotion activities for elderly people targeting the transmission and curability of TB is recommended.