Knowledge, Attitude, and Practice on Pediatric Tuberculosis Management among Healthcare Workers in the Centre Region of Cameroon: A Cross-Sectional Study

Background This study was designed to assess the level of knowledge, attitude, and practice (KAP) of healthcare workers (HCWs) on pediatric TB management and its associated factors in the Centre Region of Cameroon. Methods A cross-sectional study was conducted between January and March 2022. HCWs, selected through a multistage sampling technique in 21 health facilities, were interviewed using a KAP questionnaire on pediatric TB management. Logistic regression analyses were used to test associations between HCWs' characteristics and knowledge, attitudes, and practice levels at a 0.05 level of significance. Results The median age of the participants was 35 years (IQR = 30–42), and the majority (73.2%) were females. About half (50.9%) of the participants (173/340) had good knowledge, 55.6% (189/340) had a good attitude, and 57.1% (194/340) had good practice scores on pediatric TB management. Having a bachelor's degree and above, working in the TB unit, and having received training on pediatric TB in the last five years were significantly associated with good knowledge of pediatric TB management. Similarly, having a bachelor's degree or higher and more than five years of experience providing TB services were significantly associated with a good attitude towards pediatric TB management. Being a general practitioner, nurse, and lab technician was significantly associated with good practice in pediatric TB management. Conclusion The level of knowledge, attitude, and practice on pediatric TB management among HCWs was suboptimal, as substantial gaps were identified. The Ministry of Health and other international organizations need to prioritize training, coaching, and mentoring support to help HCWs improve their knowledge, attitude, and practice to detect, diagnose, and treat pediatric TB.


Introduction
Pediatric tuberculosis (TB) is a major public health challenge and has not been given high priority by the National TB Control Programs (NTCP) because children are believed to be less likely to transmit the disease [1,2]. TB in children is a direct consequence of adult TB and is a good indicator of current community transmission [3]. From 2018 to 2019, approximately 500,000 children were diagnosed and notifed of having TB globally, which represents approximately 11% of the total TB caseload [4]. Infants, young children, and HIV-positive children are more likely to develop TB after being infected with Mycobacterium tuberculosis (M.tb) [5,6] and have a higher risk of severe TB disease and death than adults [6,7].
In Cameroon, TB is a major cause of mortality among people living with human immunodefciency virus (PLHIV), and Cameroon is included on the global list of TB high-burden countries by the WHO from 2021 to 2025 [8]. Te HIV epidemic has exacerbated TB in the country, as it is the most common opportunistic infection among PLHIV. In the general population, the prevalence of HIV is estimated to be 2.7% [9]. Among the 22,499 cases of all forms of TB detected in 2020, 1,158 (5.2%) were diagnosed among children (<15 years), which suggests that 50% of pediatric TB cases are not diagnosed [10].
Cameroon's 2019 revised TB guidelines provide guidance and direction on the screening and diagnosis of TB in children. Tese guidelines also include algorithms to help healthcare workers (HCWs) identify symptoms, diagnose pediatric TB, and follow up on children with suspected TB [11]. Based on these revised guidelines, the most efective procedures for reducing prevalence, drug resistance, and poor treatment outcomes for pediatric TB include timely diagnosis, efcient reporting, follow-up, and a new case identifcation system [12,13]. Efective performance of pediatric patient-managed care programs is often reliant on the number, distribution, knowledge, skills, levels of motivation, and competence of supporting HCWs [14]. HCWs play an important role in the global fght against TB, although they have a heightened risk of being infected with the disease given their exposure to TB patients [15][16][17]. Tese individuals are expected to have adequate knowledge, skills, and competencies to properly detect and manage pediatric TB cases.
Some studies have reported that the limited knowledge of HCWs remains a barrier to the diagnosis, treatment, and prevention of pediatric TB [18][19][20]. Even though pediatric TB is of public health signifcance in Cameroon, very limited studies have been conducted to examine the knowledge, attitude, and practice (KAP) of HCWs providing pediatric TB care and treatment. As a result, there are limited data on the knowledge and skill levels of HCWs providing TB management among children. Te lack of such data makes it challenging for the Ministry of Health (MOH) and the NTCP to determine which areas to target capacitystrengthening programs for HCWs.
Te objectives of this study were to (1) assess the level of knowledge, attitude, and practice of HCWs on pediatric TB management and its associated factors and (2) determine if there is a correlation between knowledge, attitude, and practice among HCWs in the Centre Region of Cameroon. Tis study will identify capacity-building needs and barriers in program delivery to assist HCWs in providing quality pediatric TB care.

Study Setting.
Tis study was conducted in the Centre Region of Cameroon because it is one of the three regions in the country with the highest burden of TB cases. Te littoral, centre, and far north regions accounted for 45% of all notifed TB cases in Cameroon in 2018 [21]. Tere are many health facilities of various categories (general hospitals, central hospitals, regional hospitals, district hospitals, district medical centres, integrated health centres, ambulatory health centres, etc.) in the region, especially in Yaoundé, which is the largest city. Te Centre Region has 55 TB diagnosis and treatment centres (DTCs) and eight TB treatment centres (TCs). As a result, TB activities are implemented in 63 health facilities across the region.

Study Design and Population.
Tis study was a multicenter cross-sectional study. Te study population was frontline HCWs providing TB services across health facilities in the Centre Region of Cameroon. Frontline HCWs who have worked in TB care and management for at least two years, including pulmonologists, pediatricians, general practitioners, nurses, lab technicians, midwives, and allied professionals, and are willing to provide informed consent, were eligible for the study. All HCWs working in the area of TB who were not physically ft at the time of the study and those who refused to provide informed consent were excluded from the study.

Sampling of the Health Facilities.
Te list of the 63 health facilities known as Diagnostic and Treatment Centres (DTCs) in the region was considered the sampling frame. We applied a modifed version of the multistage sampling technique to select 21 health facilities where data were collected. Te 1st stage and 2nd stage of the sampling have been described in another published study [22]. Briefy, in the 1st stage, all the DTCs were stratifed into public, private, and faith-based categories. At the end of the stratifcation, there were 38 health facilities in the public category, seven in the private category, and 18 in the faith-based category.
Based on time and available resources, the study team agreed that data should be collected from one-third (n � 21) of the 63 DTCs in the region. Consequently, in the 2nd stage, simple random sampling (using the lottery method) was used to select health facilities from each of the three categories based on a probability proportional to size. At the end of the random selection process, a total of 21 health facilities (13 public, two private, and six faith-based) were selected to participate in this study.
In the 3rd stage, a mapping was conducted in each of the 21 health facilities drawn from the 3 strata. Te aim was to establish a list of HCWs by category and number in each of these health facilities. Tis listing was done in collaboration with authorities at the health facilities. From each category, a simple random sampling of HCWs was done based on a probability proportional to the size of the HCW category per health facility. Tis sampling procedure was used to ensure that the HCWs who participated in the study represented the diferent categories of HCWs providing TB care at the health facility to a greater extent.

Sample Size Determination.
Te sample size for the study was calculated based on the formula of sample size calculation for cross-sectional studies, as follows: where n is the sample size, z � 1.96 is the critical value of the confdence interval for a standard normal distribution (for 95% confdence intervals). P � 0.5 is an estimated response rate (as this expected proportion p produces the largest sample size (for a given value of m  [15,23], the union course on pediatric TB, and the WHO guidelines for designing TB KAP surveys [24]. After an initial draft of the questionnaire was designed, it was improved using feedback and opinions from a team including clinicians, a social scientist, and an epidemiologist with experience in TB and KAP studies. Tereafter, the questionnaire was translated into French and backtranslated into English to ensure coherence and consistency. Te French version was necessary because the study setting is predominantly French-speaking. Finally, the questionnaire was pilot-tested among a sample of 25 HCWs providing TB care in three health facilities, which were not selected to participate in the fnal study. Based on the pilot study, the questionnaire was modifed, with some questions reworded to ease understanding. All the questions were adjusted to make them culturally sensitive. Te fnal questionnaire consisted of 50 questions divided into 4 sections. Te frst section collected data on respondents' sociodemographic characteristics (e.g., age, sex, level of education, role in the facility, and time spent in the facility); the second section assessed pediatric TB knowledge among respondents; the third section assessed respondents' attitudes towards pediatric TB management; and the fourth section assessed respondents' practices in pediatric TB management. Responses for Sections 2-4 were categorical and/or ordinal. Based on the data from the pilot testing of the questionnaire, the Cronbach's alpha for attitude and practice was 0.69 and 0.87, respectively. Te study team ensured that the items shared covariance and measured the same underlying concept.

Data Collection Process.
We conducted the study between January and March 2022. Before data collection, three research assistants (data collectors) were hired and trained on the study objectives, recruitment of study participants, obtaining informed consent, and use of the data collection tools. Te research team worked with the general supervisor of each health facility to identify the working days of the selected HCWs. Tis was important as it enabled the data collectors to know the days to visit the health facility and collect data from the eligible HCWs. Te data collectors paid a courtesy visit to each health facility to seek permission for data collection. Once granted, data were collected through an interviewer-administered questionnaire with the frontline HCWs working at the TB unit, HIV service, pediatric service, vaccination unit, laboratory service, and outpatient department (OPD) after obtaining written informed consent. Te principal investigator supervised the overall activities through continuous supportive supervision. At the end of each day, all questionnaires were reviewed for completeness and consistency. Each data collector transferred the data in the questionnaires to an electronic tablet using ODK software, which was uploaded to a Google server.

Variables of Interest and Measures. Dependent variables:
the main dependent variables were knowledge, attitude, and practice in pediatric TB management. We used the median score as the cut-of value for all the questionnaires. Tose with a total score below the median were classifed as having poor knowledge, attitudes, and practices, while those with a total score equal to or above the median were considered to have good knowledge, attitudes, and practices.
(a) Knowledge: knowledge of pediatric TB was assessed with 20 questions, and each question had "true," "false," and "do not know" response options. For the 13 positively worded questions, all the "true" responses were given a score of "1," while the "false" and "do not know" responses were given a score of "0." For the 7 reverse-coded questions, all the "false" responses were given a score of "1," and the "true" and "do not know" responses were given a score of "0." Questions not answered were given a score of "0." Te total knowledge score ranged from 0 to 20. Te sum of knowledge scores was dichotomized based on the median, which was 14.0. Respondents with a total score equal to or above the median were considered to have good knowledge and were coded as "1," while those with a total score less than the median were considered to have poor knowledge and were coded as "0." (b) Attitude: attitude towards pediatric TB (Cronbach's alpha � 0.69) was measured using 10 items (6 positively worded and 4 negatively worded) assessing HCWs' attitudes towards pediatric TB transmission, diagnosis, and information regarding pediatric TB. Te response options were measured on a 5-point Likert scale with strongly agree (5 points), agree (4 points), neutral (3 points), disagree (2 points), and strongly disagree (1 point). We reversed the scores of the negatively worded statements and then added the total score for attitude. Te total score ranged from 10 to 50, and the median value (34.0) of attitude response was considered as the cut-of value to code attitude response to "1," which indicated having a good attitude regarding pediatric TB if the response sum was greater than or equal to the median. Similarly, the attitude response was coded "0," indicating having a poor attitude. (c) Practice: pediatric TB practice (Cronbach's alpha � 0.87) included 10 items (7 positively worded and 3 negatively worded) regarding the use of face Journal of Tropical Medicine masks and the practice of other precautionary measures. Te statements related to practice had the following scores and response choices: 1 � never, 2 � sometimes, and 3 � always. We reversed the scores of the negatively worded statements and then added the total score for practice. Te practice statement's total score ranges from 10 to 30, and the median, which was 24.0, was computed to code participants' responses to "1," indicating having good practice towards pediatric TB if the response was greater or equal to the median, otherwise having poor practice.
Te independent variables included age, sex, level of education, professional category, number of years of work experience in the health sector, number of years of work experience in TB care, current working unit, previous training on pediatric TB, and health facility type.

Statistical
Analysis. Data were downloaded in Excel format from the Google server, verifed for accuracy and consistency, and then imported to IBM's SPSS software version 24.0 (Armonk, NY, USA) for analysis. Continuous variables were measured as means and standard deviations, while categorical variables were expressed as frequencies and proportions. Inferential statistics were applied depending on the nature of the data and variables.
Multivariate logistic regression analyses were performed to determine the strength of the association between the dependent variables (knowledge, attitude, and practice) and the independent variables in a full model. Te independent variables were selected for the fnal model purposefully based on the literature review [18,19,25] and the desirability of the authors. In the multivariate model, controlling for potential confounders, there was no evidence of multicollinearity among the independent variables. An adjusted odds ratio (AOR) with 95% confdence levels (CI) was used to quantify the strength of the association. Pearson-rank correlation tests were performed to determine any correlation between the knowledge, attitude, and practice of HCWs regarding pediatric TB management. Te statistical signifcance for all tests was set at p < 0.05.

Ethical Considerations.
Ethical approval for this study was granted by the Centre Region Ethical Committee for Human Health Research with reference number CE N0 031/ CRERSH/2022. Administrative approval was obtained from each of the selected health facilities and the Centre Regional Delegation for Public Health. All participants gave their written informed consent before the interviews, and participation in the KAP study was voluntary. Te questionnaires were completely anonymous and did not include any data that could be used to identify the respondents.

Results
Of the 403 respondents approached, 340 expressed an interest in participating, giving a response rate of 84.4%. Te most common reason for refusal was a lack of time to participate in the study, given the busy schedules of HCWs at the health facility. Table 1 shows the sociodemographic characteristics of study participants. Te median age of the participants was 35 years (IQR � 30-42), and the majority were females (73.2%). Most (193,56.8%) of the respondents had at least a bachelor's degree. Te majority were nurses (164, 48.2% and 107, 31.5%) working in the outpatient unit. Also, about half (54.4%) had worked in the health facility for more than fve years, and 251 (73.8%) had provided TB care for between 2 and 5 years. Only 140 (41.2%) of the HCWs had received training on pediatric TB in the last fve years. Table 2 shows the knowledge of HCWs on pediatric TB management. Te results showed that 173 (50.1%) HCWs had good knowledge, while 167 (49.1%) had poor knowledge of pediatric TB management. Most (282, 82.9%) of the respondents were aware of persistent cough for more than 14 days as a typical symptom of TB in children. Only 140 (40.2%) knew that pulmonary TB is more common in children than extrapulmonary TB. Only half (173, 50.9%) of the participants could identify induced sputum as an appropriate specimen for the diagnosis of TB in children. Table 3 shows the attitude of HCWs towards TB management among children. Of the total respondents, 189 (55.6%) had a good attitude towards pediatric TB management, while the rest (151) (44.4%) had a poor attitude towards pediatric TB management. One hundred and twenty-one (35.5%) of the HCWs "strongly disagreed" or "disagreed" to continue to socialize with a child if he/she was diagnosed with TB, and 165 (46.8%) of the HCWs "strongly agreed" or "agreed" that they would recommend a chest X-ray for a presumptive child who is negative for gene Xpert. Detailed attitude results are presented in Table 3.  Table 4.

Association between the Demographic Characteristics and
Knowledge, Attitude, and Practice in Pediatric TB Management. Table 5 shows adjusted models for the association between the demographic characteristics and knowledge, attitude, and practice in pediatric TB management. In multivariate analysis, HCWs with a bachelor's degree and above were more likely (AOR � 2.61; 95% CI, 1.20-5.66, p � 0.015) to have had good knowledge on pediatric TB compared to those with at most a high school certifcate. HCWs working in the TB unit were more likely (AOR � 7.26; 95% CI, 2.07-43.60, p � 0.010) to have good knowledge on pediatric TB than those working in any other unit. HCWs who had received training on pediatric TB management in the last fve years were more likely (AOR � 3.63; 95% CI, 2.15-6.10, p < 0.001) to have had good knowledge than those who did not receive any training.
HCWs with a bachelor's degree and above were more likely (AOR � 1.99; 95% CI, 0.98-4.05, p � 0.045) to have had a good attitude towards pediatric TB management than those with at most a high school certifcate. HCWs with more than fve years of experience providing TB services were more likely (AOR � 0.56; 95% CI, 0.34-0.94, p � 0.029) to have a had good attitude towards pediatric TB management than those with between 2 and 5 years of experience.

Correlation Analysis between Knowledge, Attitude, and
Practice. Table 6 shows the correlation analysis between knowledge, attitude, and practice. All three variable scores (knowledge, attitude, and practice) were normally distributed, and therefore, we conducted a Pearson-rank correlation. We found a signifcant positive but weak correlation between knowledge score and practice score (r � 0.199, p < 0.001), knowledge score, and attitude score (r � 0.174, p � 0.001). Moreover, there was also a weak but signifcant positive correlation between attitude and practice scores (r � 0.130, p � 0.017).

Discussion
Tis study was designed to assess the level of knowledge, attitude, and practice of HCWs on pediatric TB management and its associated factors in the Centre Region of Cameroon. Tis KAP study found suboptimal knowledge, attitude, and practice on pediatric TB management among HCWs. Overall, only half (50.9%) of the HCWs had good knowledge on pediatric TB management. Our fndings are similar to those of previous studies conducted in South Arabia [26] and Uganda [27], which also reported that 52% of HCWs had good knowledge on pediatric TB management. However, the proportion of HCWs with good knowledge found in our study was lower compared to studies conducted in Gabon (79.7%) [15] and Peru (67.3%) [28]. Te diference may be due to the variation in study design, methods, and the tools that were used to measure knowledge in these studies [29]. Tis study found that 82.9% (283/340) of HCWs knew that persistent cough for more than 14 days is a typical symptom of TB in children, similar to fndings from a study in Cambodia (86.8%) [19] and higher than a study in Ethiopia (68.5%) [30] but lower than a study in Nigeria (99.5%) [31]. Also, in our study, 90.6% (308/340) of HCWs knew that HIV-infected children have a high risk of exposure to TB infection and disease. Tis fnding is similar to that in Ethiopia (87%) [30] but higher than in a study in Nigeria (77%) [31]. Tis diference in knowledge might be    due to the diferent target populations selected for the studies. In our study, HCWs were selected from both referral hospitals and health centres, whereas participants in the previous study were selected only from referral hospitals. In addition, our study found that 55.3% (205/340) of HCWs indicated that a negative biological test (e.g., microscopy, gene Xpert, or culture) is an indication of no TB in children.
Tese fndings are similar to those of studies conducted in Mozambique [18] and Cote d'Ivoire [27], which found that less than 30% of respondents could identify that Xpert MTB/ RIF ® was a test used to diagnose TB and less than 50% of HCWs knew that Xpert is a molecular test for TB, respectively.
In this study, training on pediatric TB management in the last fve years was signifcantly associated with good knowledge on pediatric TB management. HCWs who had received training on pediatric TB in the last fve years had signifcantly higher knowledge levels than their colleagues who did not receive such training. Previous studies conducted in Gabon [15] and Mozambique [18] reported similar factors infuencing pediatric TB knowledge among HCWs. Tis fnding highlights the importance of providing HCWs with training opportunities (e.g., refresher training, regular in-service training programs by external institutions, etc.) in pediatric TB management. Tere is scientifc evidence that the capacity-building of frontline HCWs contributes to improved childhood TB management [25].
Our study found that overall, 44.4% (151/340) of HCWs had a poor attitude towards pediatric TB management. Tis was observed in key areas like recommending a chest X-ray for a presumptive child who is negative for Gene Xpert (36.7% disagreed and strongly disagreed); continuing to socialize with a child if he/she was diagnosed with TB (35.5% disagreed and strongly disagreed); bringing close contacts of index cases for TB testing (34.4% disagreed and strongly disagreed); and sharing the same cutlery, plates, and glasses with a family member infected with TB (44.4% disagreed and strongly disagreed). Te poor attitudes found in this study might be due to the low proportion of trained and experienced HCWs providing TB services in the respective health facilities. Tis implies that there are common gaps in attitudes among some HCWs on how TB is transmitted and diagnosed, and similar fndings have been previously reported in Cameroon [32] and Gabon [15].
Tis study found that HCWs with more than fve years of experience in pediatric TB management were signifcantly more likely to have a good attitude towards pediatric TB management than their colleagues with less than fve years of experience. Previous studies conducted in Ghana [33], Saudi Arabia [26], and South Africa [34] have demonstrated that the number of years of experience HCWs have in pediatric TB management has shown to positively infuence HCWs' attitudes. Tis could be because, in the years of implementing childhood TB activities, HCWs learn from the job and from colleagues through experience sharing; thus, they are more likely to have a good attitude towards pediatric TB management. Tis may explain why a majority of the HCWs with less than fve years of experience in childhood TB care stated that they would like to learn more about childhood TB.
Our study found that 57.1% (194/340) of HCWs had good practice in pediatric TB management, and similar results have previously been reported in studies conducted in Mozambique [18] and Ethiopia [29]. Tere were several poor practices identifed among HCWs in this study, which is consistent with fndings from previous studies [15,35,36]. For example, during consultation, 23.5% (80/340) of HCWs did not separate children who were coughing from those who had no cough. Furthermore, 10.3% (35/340) of HCWs are not always wearing a mask when consulting TBsuspected children. Tese fndings are not surprising, as in Cameroon and other settings in sub-Saharan Africa, there is a lack of resources (equipment, space, sufcient medical supplies, etc.), particularly in peripheral health facilities for pediatric TB control and management [15]. HCWs are prone to employing poor practices when these resources are lacking, as it hinders their ability to be efcient and efective at work.
In this study, there was a signifcant association between the HCWs' profession and pediatric TB practice, which is consistent with a previously conducted study in Mozambique [18]. In this study, general practitioners were more likely to employ good practices in pediatric TB management than nurses and lab technicians. General practitioners have a better level of education given their thorough medical training, they are more likely to have experience in childhood TB as they participate more in seminars and workshops on pediatric TB. Tus, the lessons learned and experience shared on childhood TB among each other makes them more likely to employ good pediatric TB practices.
Te fndings of this study should be interpreted taking into consideration some limitations. Firstly, this study was cross-sectional, so the associations found do not necessarily infer a causal relationship. Secondly, we relied on selfreported attitudes and practices; hence, there may have been an overestimation or underestimation of good attitudes and practices among HCWs. Lastly, the fndings of the study cannot be generalized to the entire frontline HCWs providing TB services in Cameroon. Despite these limitations, the study has gathered information on where gaps exist with regard to the knowledge, attitude, and practices on pediatric TB management among HCWs. Tese fndings are useful for the MOH and international organizations working on pediatric TB in Cameroon. It underscores the need for the MOH and these organizations to allocate substantial resources to strengthen the health system by enhancing pediatric TB training, and strengthening the capacity of HCWs, and ensuring equitable access to medical equipment and supplies. Further studies should be conducted at the national level with a qualitative component so that the practices of HCWs would be observed while providing pediatric TB management. Te barriers and facilitators affecting childhood TB diagnosis among HCWs in Cameroon are other areas for research. Additionally, the agreement and disagreement among frontline HCWs providing TB services regarding attitudes present signifcant areas for further study that may have the potential to highlight particular issues with the NTCP.

Conclusion
Te level of knowledge, attitude, and practice of pediatric TB management was suboptimal, as substantial gaps were identifed. A higher level of education, current work in the TB unit, and pediatric TB-related training were signifcantly associated with good knowledge, whereas experience in providing TB services and a higher level of education were the independent factors associated with a good attitude. Being a general practitioner, nurse, or lab technician was signifcantly associated with good practice in pediatric TB management. Te Ministry of Health and other international organizations need to prioritize training, coaching, and mentoring support from experienced HCWs to help them improve their level of knowledge, attitudes, and practices concerning pediatric TB management.

Data Availability
Te data used to support the fndings of this study are available from the corresponding author upon request.

Conflicts of Interest
Te authors declare that they have no conficts of interest.

Authors' Contributions
Tomas Achombwom Vukugah contributed to conception, design, protocol development, data collection, data analysis, and interpretation of results, as well as drafting of the original draft and fnalizing of the manuscript. Derick Akompab Akoku contributed to conception, design, protocol development, interpretation of results, drafting, and fnalization of the manuscript. Micheline Mekemnang Tchoupa and Edward Lambert reviewed and provided inputs in the draft manuscript and contributed to fnalizing the manuscript. All authors read and approved the fnal manuscript.

Supplementary Materials
Study questionnaire: Te fnal questionnaire consisted of 50 questions divided into 4 sections (see supplementary appendix). Te frst section collected data on respondents' sociodemographic characteristics; the second section assessed pediatric TB knowledge among respondents; the third section assessed respondents' attitudes towards pediatric TB management; and the fourth section assessed respondents' practices in pediatric TB management. (Supplementary Materials)