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Assessing Oman's knowledge, attitude and practice regarding tuberculosis: a cross-sectional study that calls for action

Open AccessPublished:June 10, 2022DOI:https://doi.org/10.1016/j.ijid.2022.06.002
      • First contemporary study to survey national and non-national Omanis on KAP of TB
      • Findings show social media to be the main source of information regarding TB
      • Omanis score high in knowledge and attitude where others have higher practice

      Abstract

      Background

      Tuberculosis (TB) remains a major public health issue. Elimination mandates collaboration between decision makers, practitioners and the community. Few studies address the knowledge, attitude and practice (KAP) from countries with low incidence.

      Aim

      Assess KAP regarding TB in Oman.

      Method

      A cross-sectional survey based on validated questionnaire conducted via phone on randomly selected participants.

      Results

      A total of 1048 participants completed the questionnaire. Males accounted for 63% (n=664) of respondents, Omanis 76% (n=796) and 18–39-year-olds 50% (n=527). The overall knowledge was fair (53%), overall attitude scored good and fair (46%) equally and a good score (78%) for overall practice. While female gender associated with higher knowledge (53.9%, n=201), males showed higher attitude and practice, (48.5%, n=322) and (80.3%, n=533) respectively. Omani nationality correlated with higher knowledge (49.1%, n= 391) and attitude (46.9%, n=373) whereas non-Omani nationality correlated with higher practice (85.3%, n=214). Literacy was associated with higher knowledge (73.3%, n=11) and attitude (60%, n=9).

      Conclusion

      Despite efforts by the Ministry of Health, more must be done to raise TB knowledge to encourage preferable attitudes and practice. Interventions to improve KAP are required to speed up disease reduction rate. Utilization of different resources, especially digital platforms, for knowledge dissemination should consider community diversity, including the presence of expatriates.

      Keywords

      Introduction

      Despite its roots in antiquity, TB continues to be a major public health issue of concern. This has been underscored by the impact of the COVID-19 pandemic, how resources shifted from one communicable disease to another, leaving TB glossed over and leading to a global drop in new diagnoses and reporting of cases. Between 2019 and 2020, there was a fall of 18% (from 7.1 million to 5.8 million) in the number of notifications of people newly diagnosed with TB. In addition, compared to 2019, there was a decline in the TB incidence rate by 1.9%. As a reflection of delayed access to the diagnosis and management, there were an estimated 1.3 million TB deaths among HIV-negative people in 2020 and around 214,000 among people living with HIV (

      WHO, Global TB report 2021. https://www.who.int/publications/i/item/9789240037021, 2021 (accessed 12 January 2022).

      ). Oman is a low TB incidence country with an annual incidence rate of less than 7 cases per 100,000 in 2020. Out of a total population of 4.6 million, 38% are expatriates from South East Asia who travel to Oman for employment. The epidemiology of TB in Oman follows that of low incidence countries, and active TB is mainly diagnosed in expatriates arriving from South East Asia as a result of reactivation of latent TB infection (LTBI) acquired in their countries of origin (
      • Al Yaquobi F
      • Al-Abri S
      • Al-Abri B
      • Al-Abaidani I
      • Al-Jardani A
      • D'Ambrosio L
      • et al.
      Tuberculosis elimination: a dream or a reality? The case of Oman.
      ).
      In order to eliminate TB in Oman, the country has launched a TB elimination strategy and has taken initiatives to achieve the strategy's targets and objectives by 2035 (
      • Al Abri S
      • Kowada A
      • Yaqoubi F
      • Al Khalili S
      • Ndunda N
      • Petersen E
      Cost-effectiveness of IGRA/QFT-Plus for TB screening of migrants in Oman.
      ,
      • Al Abri S
      • Kasaeva T
      • Migliori GB
      • Goletti D
      • Zenner D
      • Denholm J
      • et al.
      Tools to implement the World Health Organization End TB Strategy: Addressing common challenges in high and low endemic countries.
      a,b). Most efforts to control tuberculosis focus on the clinical aspects of the disease over the human aspects; however, TB prevention programs require community participation because TB problems are very much influenced by knowledge and behavior (
      • Ramadhany S
      • Achmad H
      • Singgih MF
      • Ramadhany YF
      • Inayah NH
      • Mutmainnah N.
      A review: knowledge and attitude of society toward tuberculosis disease in Soppeng District.
      ). A study conducted in the Somali community living in Finland revealed that 53% of respondents had low knowledge levels, and only 63% had a positive attitude toward TB (
      • Hussein I
      • Sane J
      • Soini H
      • Vasankari T
      • Lyytikäinen O.
      Tuberculosis knowledge, attitudes and practices: a cross-sectional study in the Somali population living in Finland.
      ).
      An example of a negative attitude toward TB would be to believe claims about the disease that are not true. Misinformation affects TB control in many aspects such as transmission, management, and attitude toward infected people. A study conducted in Tunisia showed that 86.1% had misconceptions about transmission, and only 22.1% were aware that there was free care available. It also showed a significant level of stigma with an average score of 54.9% (
      • Bensalah N
      • Hsairi M
      • Snene H
      • Bejar D
      • Mehiri N
      • Fourati R.
      Community knowledge, attitude, and practices towards tuberculosis in Tunisia.
      ). Another regional study conducted in the Kingdom of Saudi Arabia in 2017 revealed that the attitude toward TB was negative among most of the participants (
      • Bin Huwaymil M
      • Alkhalifah M
      • Alsaqabi M
      • Alhabshan R
      • Alzaid A.
      Assessment of knowledge, attitudes and practices regarding pulmonary tuberculosis among community in Riyadh City, 2017.
      ).
      As well as forming a base for public awareness, assessing the level of KAP is considered a tool to determine the best method for delivering effective information on TB to the public. For instance, 46.8% of Tunisians cited television as their main source of TB information (
      • Bensalah N
      • Hsairi M
      • Snene H
      • Bejar D
      • Mehiri N
      • Fourati R.
      Community knowledge, attitude, and practices towards tuberculosis in Tunisia.
      ). For a successful TB program, collaboration with the public is crucial and it starts by assessing and tackling gaps in the knowledge toward better attitudes and practice surrounding TB. A local study from Oman conducted in 2008 showed that private general practitioners had statistically significantly lower TB suspicion and TB knowledge scores than public general practitioners (
      • Al-Maniri AA
      • Al-Rawas OA
      • Al-Ajmi F
      • De Costa A
      • Eriksson B
      • Diwan VK
      Tuberculosis suspicion and knowledge among private and public general practitioners: Questionnaire Based Study in Oman.
      ). However, there is no updated local community based study in this regard so far, hence, the knowledge gaps in the people of Oman, their attitudes and practices is explored in our study.

      Materials and methods

      Study design and participants

      Participants in this cross-sectional phone-based survey were randomly selected from the national phone registry. Registry aiming to be representative of all governorates. Inclusion criteria was that respondents be at least 18 years old (see Supplementary Materials – S1). The interviews were conducted from March 3 to 18, 2021 with the assistance of the National Centre for Statistics and Information (NCSI) and the Ministry of Health call center. Each interview was preceded by verbal consent in one of the three languages used (Arabic, English or Urdu); respondents were excluded if they did not speak any of these languages.

      Sample size calculation

      Sample size was calculated as 1067 with the 95% confidence level and a 3% degree of precision (margin of error); however, we manage to complete 1048 calls to include in the analysis. The sample frame included twenty thousand phone numbers randomly selected for both nationals and non-nationals from all governorates in the country. A total number of 6996 calls were made to reach a completed calculated sample size of 1048 calls. Five thousand, nine hundred and forty-eight respondent's calls were excluded from the study due to a variety of reasons, such as unqualified respondents <18 years, respondents unable to speak any of the three languages offered, those unwilling to participate or who were unresponsive, had a busy signal, or were unable to complete the call for technical reasons or if the respondent terminated the call mid-interview (Figure 1).

      Questionnaire and data collection

      Phone-based questionnaires were used for data collection. The survey included 27 standardized questions (see Supplementary Material – S2) adapted from A Guide to Developing Knowledge, Attitude and Practice Surveys (

      WHO and Stop TB Partnership. A Guide to Developing Knowledge, Attitude and Practice Surveys. https://www.fsnnetwork.org/resource/guide-developing-knowledge-attitude-and-practice-surveys, 2008 (accessed 12 January 2022).

      ). The questionnaire was divided in to four parts; the first section gathered sociodemographic characteristics such as age, sex, nationality, educational status, employment information and governorate of residence; the second part assessed knowledge; the third part elicited attitudes toward tuberculosis and people infected with it; and the final, fourth part included questions on practice toward tuberculosis.
      In order to check for compatibility, the questionnaire was translated to Arabic then to English again. A one-day training course was conducted by the research team for interviewers regarding survey and data collection. Fifty-six calls were made as a pilot study to test the reliability of the questions (test-retest) and the time required to interview a participant. These results were not included in the final study analysis. The research team made sure that data was appropriately collected, saved and reviewed daily.
      Thirteen questions regarding knowledge of TB were included. The response was classified as good, fair or poor (see Supplementary Materials – S3). To calculate the score, a good answer was computed as “1” and a poor answer as “0”. For other questions, a third option was added as fair and computed as “2”. For questions where more than one answer was to be selected, response options were recorded as good = “selecting the accurate answer”, poor = “selecting inaccurate answer” and fair = “selecting any of inaccurate answers with the accurate answer”. The score for the question about signs and symptoms was classified into three categories as follows: 3 = “very evident symptoms”, 2 = “less frequent symptoms”, 1 = “rare symptoms” and 0 = “don't know”.
      The attitude section included five items evaluating the level of personal and community attitude toward TB as a disease and people infected with it. The response options were classified as good, fair or poor (see Supplementary Materials – S3), regarding personal and community feelings toward TB infected people, good = “selecting the favorable answer”, poor = “selecting unfavorable answer” and fair = “selecting neutral answer”. A question about personal reaction in cases found to have TB has no score as it expresses personal feelings. Same with a question about knowing someone with TB in which response options were 0 = “No” and 1 = “Yes”.
      The practice section consists of five items. The questions where more than one answer could be selected, response options were recorded as: good = “selecting the favorable answer”, poor = “selecting unfavorable answer” and fair = “selecting any of the unfavorable answers with at least one favorable answer” (see Supplementary Materials – S3).

      Statistical analysis

      Data was analyzed by using Statistical Package for Social Sciences software, version 16.0 (SPSS Inc., Chicago, IL). Categorical variables were presented as weighted proportions whereas continuous variables were presented as mean and standard deviation. Normality of data was tested using the Kolmogorov–Smirnov test. Both descriptive and inferential statistics involving Chi-square test were used to present results. Mann-Whitney test and Kruskal-Wallis test were used to investigate the correlations between different factors and the KAP regarding tuberculosis. For each test, a P value of less than 0.05 was considered statistically significant.

      Results

      Sociodemographic characteristics

      A total of 6996 calls were made of which 5948 were excluded and 1048 were included wherein participants completed the phone-based questionnaire (Figure 1A). Males accounted for 63% of the respondents. Omanis constituted 76% of the participants. The highest percentage of non-national respondents came from India (9%). Half of the respondents were in the 18–39-year-old age group (50%) with the mean age 40.03 and a standard deviation of 11.4. The highest number of participants were from the Muscat governorate (31%) and the lowest from Al Wusta and Musandam governorates (1% each) (results are proportional to the governorate populations). Most participants were high school graduates (34%). Around 57% of participants were employed and most (70%) worked in a non-health care specialty.
      The baseline characteristics of the respondents are shown in Table 1.
      Table 1Sociodemographic profile of study participants.
      Demographic characteristicTotal number (%)
      1048 (100)
      18–39527 (50.3)
      40–59449 (42.8)
      60+69 (6)
      Male664 (63)
      Female373 (36)
      Omani796 (76)
      Non-Omani251 (24)
       Bangladesh31 (3)
       India97 (9.3)
       Pakistan60 (5.7)
       Philippines14 (1.3)
      Muscat

      Dhofar

      Musandam

      Al Buraimi

      Ad Dakhiliyah

      N. Batinah

      S. Batinah

      S. Sharqiyah

      N. Sharqiyah

      Al Dhahirah

      Al Wusta
      324 (31)

      93 (9)

      10 (1)

      26 (2)

      122 (12)

      141 (13)

      135 (13)

      66 (6)

      60 (6)

      56 (5.3)

      10 (1)
      No school42 (4)
      Religious school only24 (2)
      Literacy classes only13 (1)
      Elementary179 (17)
      High school361 (34)
      Higher education (post-graduate and professional)233 (22)
      college189 (18)
      Non-health care733 (70)
      Health care (government)45 (4)
      Health care (private)6 (0.6)
      Employed595 (57)
      Retired103 (10)
      Self-employed or business owner24 (2)
      Student29 (3)
      Unemployed289 (28)

      KAP scoring and correlation

      Overall, knowledge scores for TB were 70%, attitude 69% and practice 67%. The overall knowledge scoring was fair (53%) while the attitude had an equal score for good and fair (46%) each. On the other hand, a good score (78%) was seen in the practice of respondents as shown in Figure 2.
      Figure 2
      Figure 2Effects of different factors (gender, nationality, education level and working status) on the overall knowledge, attitude and practice scores.
      Table 2 and 3 summarize the scoring and the correlation between KAP based on gender, nationality, education level and working status. Although female gender is associated with higher knowledge (53.9%) (P = 0.000), male gender is associated with higher attitude and practice (48.5%) (P = 0.024) and (80.3%) (P = 0.028) respectively. Omani nationality is associated with higher knowledge (49.1%) (P = 0.000), and attitude (46.9%) whereas non-Omani nationality is associated with higher practice (85.3%) (P = 0.001). Attending a literacy class was associated with higher knowledge (73.3%) (P = 0.000) and attitude (60%) and those who did not attend school showed higher practice (97.6%) (P = 0.009). In addition to that, retirees showed higher knowledge and attitude (56.6% and 57.5%) (P = 0.020 and 0.024) respectively in comparison to those who were employed.
      Table 2The scoring of the knowledge, attitude and practice based on gender, nationality, education level and working status.
      FactorsKnowledgeN(%)Good / Fair / PoorAttitudeN(%)Good / Fair / PoorPracticeN(%)Good / Fair / Poor
      Gender

       Male

       Female


      269

      (40.5)


      387

      (58.3)


      8

      (1.2)


      322

      (48.5)


      300

      (45.2)


      42

      (6.3)


      533

      (80.3)


      125

      (18.8)


      6

      (0.9)
      201

      (53.9)
      171

      (45.8)
      1

      (0.3)
      157

      (42.1)
      181

      (48.5)
      35

      (9.4)
      278

      (74.5)
      88

      (23.6)
      7

      (1.9)
      Nationality



       Omani

       Non-Omani


      391

      (49.1)


      400

      (50.3)


      5

      (0.6)


      373

      (46.9)


      366

      (46)


      57

      (7.2)


      598 (75.1)


      188

      (23.6)


      10

      (1.3)
      86

      (34.3)
      161

      (64.1)
      4

      (1.6)
      113

      (45)
      118

      (47)
      20

      (8)
      214

      (85.3)
      34

      (13.5)
      3

      (1.2)
      Education level

       No school

       Elementary

       High school

       College

       Higher education

       Religious school

       Literacy classes


      11

      (26.2)


      31

      (73.8)


      0

      (0)


      23

      (54.8)


      15

      (35.7)


      4

      (9.5)


      41

      (97.6)


      1

      (2.4)


      0

      (0)
      57

      (31.8)
      121

      (67.6)
      1

      (0.6)
      84

      (46.9)
      80

      (44.7)
      15

      (8.4)
      148

      (82.7)
      27

      (15.1)
      4

      (2.2)
      168

      (46.5)
      193

      (53.5)
      0

      (0)
      179

      (49.6)
      152

      (42.1)
      30

      (8.3)
      271

      (75.1)
      88

      (24.4)
      2

      (0.6)
      86

      (45.5)
      101

      (53.4)
      2

      (1.1)
      75

      (39.7)
      102

      (54)
      12

      (6.3)
      143

      (75.7)
      46

      (24.3)
      0

      (0)
      136

      (58.4)
      96

      (41.2)
      1

      (0.4)
      102

      (43.8)
      120

      (51.5)
      11

      (4.7)
      183

      (78.5)
      48

      (20.6)
      2

      (0.9)
      7

      (29.2)
      15

      (62.5)
      2

      (8.3)
      14

      (58.3)
      9

      (73.5)
      1

      (4.2)
      17

      (70)
      6

      (25)
      1

      (4.2)
      11

      (73.3)
      4

      (26.7)
      0

      (0)
      9

      (60)
      5

      (33)
      1

      (6.7)
      9

      (60)
      6

      (40)
      0

      (0)
      Working status

       Employed

       Unemployed

       Student

       Self-employed or business owner

       Retired


      254

      (42.7)


      336

      (56.5)


      5

      (0.8)


      278

      (46.7)


      278

      (46.7)


      39

      (6.6)


      462

      (77.6)


      129

      (21.7)


      4

      (0.7)
      143

      (49.5)
      145

      (50.2)
      1

      (0.3)
      126

      (43.6)
      130

      (45)
      33

      (11.4)
      223

      (77.2)
      60

      (20.8)
      6

      (2.1)
      9

      (31)
      20

      (69)
      0

      (0)
      9

      (31)
      20

      (69)
      0

      (0)
      24

      (82.8)
      5

      (17.2)
      0

      (0)
      11

      (45.8)
      13

      (54.2)
      0

      (0)
      12

      (50)
      12

      (50)
      0

      (0)
      18

      (75)

      6

      (25)
      0

      (0)
      60

      (56.6)
      46

      (43.4)
      0

      (0)
      61

      (57.5)
      43

      (40.6)
      2

      (1.9)
      85

      (80.2)
      21

      (19.8)
      0

      (0)
      Table 3The correlation between knowledge, attitude, practice, and different factors.
      FactorsKnowledgeNumber / Mean rank / P valueAttitudeNumber / Mean rank / P valuePracticeNumber / Mean rank / P value
      Gender

       Male

       Female


      664


      493


      0.000


      664


      533


      0.024


      664


      530


      0.028
      373564373494373499
      Nationality

       Omani

       Non-Omani


      796


      543


      0.000


      796


      527


      0.568


      796


      511


      0.001
      251463251516251564
      Education level

       No school

       Elementary

       High school

       College

       Higher education

       Religious school

      Literacy classes


      42


      423


      0.000


      42


      555


      0.392


      42


      625


      0.009
      179451179520179545
      361528361533361508
      189520189490189512
      233588233515233526
      244152458724482
      156671558815431
      working status

       Employed

       Unemployed

       Student

       Self-employee or business owner

       Retired


      595


      505


      0.020


      595


      524


      0.024


      595


      521


      0.899
      289542289495289517
      294472946629548
      245242455824508
      106580106589106535
      Good knowledge scores were associated with female gender, being of Omani nationality, attending literacy classes and being retired. Good attitude was not statistically significantly associated with any parameter. Good practice was associated with male gender, being non-Omani and not attending school.
      A correlation between different domains of the questionnaire was assessed. A positive correlation was observed between knowledge and attitude, while a negative correlation was noted between knowledge and practice as seen in Table 4.
      Table 4The association between KAP.
      Variables Spearman's RHO test P value
      Knowledge, attitude – 0.75 0.016
      Statistically significant at p < 0.05
      Knowledge, practice – 0.155 0.000
      Statistically significant at p < 0.05
      Attitude, practice – 0.51 0.102
      low asterisk Statistically significant at p < 0.05

      Source of information

      While 46% of the respondents heard about TB for the first time from friends, neighbors and colleagues; teachers (21%) and television (11%) were the other common sources of information. Health care workers comprised only 6% as a source. In terms of social media, WhatsApp (2%) was the most predominant source of information among other sources. (Supplementary Material – S1)
      Forty-nine percent of the respondents thought that different social media modalities could most effectively reach people with information on TB as shown in Figure 3 with WhatsApp being the preferred modality (17%) followed by Instagram for Omanis and Facebook for non-Omanis.
      Figure 3
      Figure 3Sources of information on TB that respondents think can most effectively reach people.

      Discussion

      Despite the Omani population's high knowledge of TB, our study showed that the overall KAP score is fair. In addition, there was an equal score of good and fair attitudes. For example, a question about the seriousness of acquiring TB can be scored as good if answered as very serious, scored fair if answered somewhat serious or scored poor if answered not very serious. Another example is the attitude question which asks respondents how a person with TB is treated by the community. Answers were that most people reject him or her (poor); most people are friendly, but they generally avoid him or her (fair); and the community mostly supports and helps him or her (good). In fact, a fair category was added to further elaborate on weaknesses to make it easy to be tackled by education and awareness later. Otherwise, the fair score could be regarded as good as the respondents demonstrated partial favorable knowledge and attitudes.
      Gender differences in TB knowledge and practice have been reported by several studies conducted in China's rural population, and in Ghana and India where women tend to have less knowledge about TB compared to men (
      • Wang J
      • Fei Y
      • Shen H
      • Xu B.
      Gender difference in knowledge of tuberculosis and associated health-care seeking behaviors: a cross-sectional study in a rural area of China.
      ;
      • Zhang T
      • Liu X
      • Bromley H
      • Tang S.
      Perceptions of tuberculosis and health seeking behaviour in rural Inner Mongolia.
      ;
      • Boah M
      • Kpordoxah MR
      • Adokiya MN.
      Self-reported gender differentials in the knowledge of tuberculosis transmission and curative possibility using national representative data in Ghana.
      ;
      • Sreeramareddy CT
      • Harsha Kumar HN
      • Arokiasamy JT
      Prevalence of self-reported tuberculosis, knowledge about tuberculosis transmission and its determinants among adults in India: results from a nation-wide cross-sectional household survey.
      ). In contrast to these studies, our study revealed that women demonstrated higher levels of knowledge than men did, the same finding was observed among females from Pakistan (
      • Khan A
      • Shaikh BT
      • Baig MA.
      Knowledge, awareness, and health-seeking behaviour regarding tuberculosis in a rural district of Khyber Pakhtunkhwa, Pakistan.
      ). This could be related to the increased educational levels among females in our country. Additionally, during the past 10 years, there has been an increase in exposure to media supported by the revolution of smartphones and other devices; hence, there has been a significant rise in the utilization of such devices in social media as an easy access source for health education materials. However, that higher level of knowledge was not translated into a higher level of practice among women.
      Although Omanis showed a higher knowledge score, non-nationals demonstrated a higher practice score. Similar findings were found from a recent study from Saudi Arabia (
      • Alkulaib F
      • AlFuraih I
      • Alabbad Z
      • Almusaad M
      • ALmeshari A
      • ALwesaibie A
      • et al.
      Awareness of tuberculosis among general populations in Riyadh region and its surroundings.
      ). This could be explained by the countries of origin of this population as many come from TB high incidence countries where awareness is high among the general population thus reflected in good practice (
      • Al Yaquobi F
      • Al-Abri S
      • Al-Abri B
      • Al-Abaidani I
      • Al-Jardani A
      • D'Ambrosio L
      • et al.
      Tuberculosis elimination: a dream or a reality? The case of Oman.
      ).
      As inferred by the responses to attitude questions, the level of stigma toward TB patients seems to be low; however, attitudes need to improve to offer support to TB patients, not just acceptance. This finding was opposite to what was reported by another study done in Gambia in which unfavorable attitudes, including avoiding patients with TB, was predominant (77%) (
      • Bashorun AO
      • Linda C
      • Omoleke S.
      • et al.
      Knowledge, attitude and practice towards tuberculosis in Gambia: a nation-wide cross-sectional survey.
      ).
      In comparison to unsatisfactory practice toward TB reported from Mecha District communities in Ethiopia, where only 48% had good practice regarding the prevention of TB, our study demonstrated a good score in the area of practice (78%) (
      • Kasa AS
      • Minibel A
      • Bantie GM.
      Knowledge, attitude and preventive practice towards tuberculosis among clients visiting public health facilities.
      ).
      Our study showed a statistically significant association between better knowledge and a decreased level of education unlike the finding from the Gambian study which showed the biggest effect coming from secondary school and above in which teachers were the second greatest source of information (21%) (
      • Bashorun AO
      • Linda C
      • Omoleke S.
      • et al.
      Knowledge, attitude and practice towards tuberculosis in Gambia: a nation-wide cross-sectional survey.
      ). Suggesting that schools retained significance as a source of information thus can be utilize to enhance public awareness early in life (
      • Bashorun AO
      • Linda C
      • Omoleke S.
      • et al.
      Knowledge, attitude and practice towards tuberculosis in Gambia: a nation-wide cross-sectional survey.
      ). Our study demonstrates the modernization effect of shifting toward social media utilization as a desirable source of information on TB compared to the traditional sources.
      To our knowledge, this is the first nationally representative population study that investigated KAP with respect to TB in Oman. Strengths of the study include randomization through NCSI. In addition, the study represented populations from all governorates and included both nationals and non-national residents of Oman. On the other hand, the lack of participation from people who did not speak one of the three languages offered could be considered a limitation.
      This KAP survey reveals the misconceptions and the misunderstandings that may represent a potential barrier for behavioral change required to implement the planned activities toward TB elimination in Oman. This makes the awareness-raising process easier so that it is directed at changing specific misconceptions. Additionally, the results of this KAP study suggests an intervention strategy that reflects specific local circumstances and the influencing cultural factors thus leading to plan activities that are suited to the respective population involved. Moreover, this data can and will be utilized as a baseline for any future assessments to help measure the effectiveness of health education activities and the ability to change health-related behaviors. Despite the above-mentioned benefits of this KAP study, future studies using in-depth interviews and discussions with the same population groups would be more informative.

      Conclusions

      Despite all efforts by the Ministry of Health, more must be done to raise TB knowledge toward preferable attitudes and practice among the public. Interventions to improve TB KAP are required as part of Oman's End TB strategy to speed up the reduction rate of TB in the country. Utilization of different resources, especially digital platforms for knowledge dissemination, should consider the diversity of the composition of the community, including the presence of expatriates.

      Transparency declaration

      This article is part of a supplement entitled Commemorating World Tuberculosis Day March 24th, 2022: “Invest to End TB. Save Lives” published with support from an unrestricted educational grant from QIAGEN Sciences Inc.

      Author contributions

      Conceptualization Sulien Al Khalili, Fatma Al Yaquobi, Bader Al Abri, Khalsa Al Thuhli, Bader Al Rawahi, Seif Al-Abri.

      Funding

      This research received no external funding.

      Ethical standards

      Ethical approval was obtained from the Center of Studies and Research at the Ministry of Health. Verbal informed consent was obtained from all the participants after an explanation of the study purpose and the confidentiality of the information.

      Acknowledgments

      The authors would like to thank all the participants, NCSI, and Ministry of Health Call Center. Maha Alfory and Halima Al Balushi from the Directorate General of Disease Surveillance and Control. Volunteers: Marwa Habib Albalochi, Samir Liyaqat Albalochi, Nawal Abdulgha Albalochi, Zainab Alhsani and Intisar Mohammed Alharthi.

      Declaration of interests

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Appendix. Supplementary materials

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