Knowledge, attitude, practices, and determinants of them toward tuberculosis among social media users in Bangladesh: A cross-sectional study.

OBJECTIVES: Tuberculosis (TB) is an infectious disease that causes thousands of deaths in Bangladesh. Bangladesh is one of the 30 high TB burden countries. In this study, we aimed to assess the knowledge, practices, and attitude toward TB, and to determine the factors associated with them among people who have internet access in Bangladesh. Design, Setting, and Participant: A web-based anonymous cross-sectional survey was conducted from May 20 to August 10, 2021, among people (age> = 18 years) who have internet access in Bangladesh. A comprehensive consent statement was included at the beginning of the survey and informed consent was taken. OUTCOME MEASURES: This study's outcomes of interest were respondents' adequate knowledge, good practices, and positive attitudes toward TB and were coded binarily. The association between respondents' socio-demographic factors and knowledge, attitude, and practices toward TB was inspected using the Chi-square test and Multivariable logistic regression model.
RESULTS: Among 1,180 respondents, 58.64% were males, and 62.37% were married. The majority of the participants (78.28%) were aged between 18 to 44 years. Overall adequate knowledge, favorable attitudes, and good practices about TB were found respectively in 47.8%, 44.75%, and 31.19% of the people with internet access in Bangladesh. Almost the same sets of associated factors were found to influence adequate knowledge, favorable attitudes, and good practices toward TB among social media users in Bangladesh. Males, young, unmarried, social media users with higher education, and urban social media users were more likely to have adequate knowledge, favorable attitudes, and good practices toward TB.
CONCLUSION: Policymakers need to design programs and interventions to improve knowledge, attitudes, and practices toward TB in Bangladesh with a particular focus on females, young and older people, people who live in rural areas, and illiterate/less educated people. Social media can be a powerful medium for disseminating scientific facts on TB and other diseases.

Introduction

Tuberculosis (TB) is an infectious bacterial disease caused by Mycobacterium tuberculosis (MTB) [1]. TB remains a severe health problem worldwide, despite a tremendous performance in controlling the disease, with an estimated 37 million lives saved by improved diagnosis and treatment since 2000 [2]. Per a 2015 global health report, tuberculosis (TB) is the leading cause of morbidity and mortality globally, ranking alongside the human immunodeficiency virus (HIV) [3]. Globally, 10.4 million people were reported to have contracted tuberculosis in 2015, with 1.8 million people dying from the disease [4]. However, developing countries bear the brunt of tuberculosis’s impact. In 2015, almost 95% of the estimated 1.8 million TB deaths occurred in low- and middle-income countries [3].

Among those who were infected with tuberculosis in 2019, 79% were from 30 high-burden countries [5]. In 2019, Bangladesh was one of the 30 countries with the highest TB burden, accounting for 3.6% of the global total [6]. According to the Global TB Report 2020, 0.7% of new cases and 11% of previously treated patients in Bangladesh were positive for multidrug-resistant tuberculosis (MDR-TB), which has an incidence rate of 2.0 per 100,000 people [5].

Even though tuberculosis is a preventable and treatable disease, the situation in Bangladesh has remained essentially constant over the years, with moderate progress and no signs of a breakthrough in the near future [6]. Bangladesh established End TB goals, including a 95% reduction in TB mortality and a 90% reduction in TB incidence by 2035 compared to 2015 levels, with intermediary goals set for 2020, 2025, and 2030 [7]. The Stop TB Partnership has issued TB diagnosis and treatment targets for Bangladesh for 2018–2022 as a result of the United Nations High-Level TB Meeting (UNHLM). To meet the UNHLM’s cumulative five-year TB targets, Bangladesh must raise diagnosis and treatment by 45% above the total notifications reported during the pre-UNHLM five-year period (2014–2017) [8].

The National Tuberculosis Control Program (NTP) has chosen the Directly Observed Treatment, Short-course (DOTS) technique to lessen this burden, which is predominantly given through government-run health institutions [9]. However, considerable impediments to implementation exist, mainly due to insufficient infrastructure and suitable health workers [10]. Therefore, the World Health Organization recommends that national TB Control Programs use an Advocacy, Communication, and Social Mobilization (ACSM) framework to address these issues. This strategy framework targets four significant issues: enhancing case detection and treatment adherence, eliminating stigma and prejudice, empowering tuberculosis patients, and mobilizing the resources and political commitment needed to combat the disease [11].

Despite the efforts, the expected degree of improvements in controlling the TB crisis has not been made yet in Bangladesh [12]. One of the primary challenges in preventing, controlling, and eliminating tuberculosis is a lack of awareness and knowledge and a negative attitude about the disease [1]. There are also a lot of misconceptions concerning the etiology and mode of transmission of TB in Bangladesh [13, 14]. A lack of understanding about tuberculosis and old misconceptions are linked to delays in case detection and treatment for TB [15, 16]. The widespread prejudice toward TB/HIV patients, misapprehension of transmission of TB and other infectious diseases, and poor knowledge about the treatment of infectious diseases are serious restrictions in achieving millennium development goals related to TB and other infectious diseases [17-19].

The authors of this study understand that the lack of knowledge, misconceptions, and bad practices among the general population, around 43% of them were active internet users in 2021 [20], could be the reasons for slow and unsatisfactory progress in the fight against TB in Bangladesh. Unfortunately, there is a lack of large-scale studies in Bangladesh that explore the knowledge and attitude about TB and practices to prevent it. Therefore, this study aimed to investigate knowledge, attitudes, and practices toward TB among the general population who have access to the internet. Also, this study explores the risk factors associated with poor knowledge, attitude, and practices toward TB among the participants. The government should renew its commitment to national tuberculosis control activities based on data-driven, effective methods to meet the stipulated goals. The findings of this study would be a significant help for the government and policymakers in this regard.

Methods

Study design and study participants

This study was a cross-sectional approach to collect data regarding knowledge, attitude, and practices about tuberculosis in Bangladesh. It was an online anonymous, self-interviewed survey conducted from May 20 to August 10, 2021. People aged 18 and over and living in Bangladesh were eligible to participate in this survey. In the beginning, there was a section describing the study’s objective, the idea of the questionnaire, assurance about the respondents’ confidentiality, and the study’s voluntary nature. It was also mentioned that participants could skip a question if it seemed sensitive. The online survey started with the respondents’ informed consent and the eligibility check. The voluntary participants were also requested to share the survey link with their connections after completion. An online survey link (KoBoToolbox) was shared with almost 4000 internet users in Bangladesh through social media (FB, WhatsApp, Instagram, Email, etc.). A total of 1,205 (response rate was 30%) people filled out and submitted their responses; among them, 25 of the respondents were not eligible (either aged less than 18 or living outside of Bangladesh) for this study.

Sample size

In this study, we aimed to examine the knowledge, practices, and attitude toward TB and their associated factors among the general population in Bangladesh. We did not find previous literature from Bangladesh that examined the knowledge, practices, and attitude toward TB and their associated factors among the general population. For calculating the desirable sample size, we assume that 50% of the general population has adequate knowledge about TB, good practices, and a favorable attitude toward TB. Using an online sample size calculator [21], we found that this study requires a sample size of 591 to represent a population size of 164,689,383 [22] with 5% absolute precision, 95% confidence, and an expected response rate of 65%.

Instruments

The study instrument/questionnaire was adapted from previously developed validated questionnaires and translated into Bangla [1, 23, 24]. Then, the final questionnaire (S1 Questionnaire) was validated by several experts and pilot surveys. The structured questionnaire was made of 3 main sections: (i) Background characteristics of the respondents; (ii) Risk behaviors related to tuberculosis; (iii) Knowledge of tuberculosis; (iv) Attitudes toward tuberculosis; and (v) Practices of tuberculosis.

At the outset of the survey, we checked the aptness of the participants by asking two questions, "How old are you (in years)?" and "Do you currently live in Bangladesh?" We also added respondents’ socio-demographics and some personal details in this section (not identifiable). The socio-demographic details were gender, current marital status, religion, educational qualification, and socioeconomic details were monthly household income level, occupational status, residence, etc. The second part of the survey questionnaire contained questions linked to risk behaviors related to tuberculosis, including diabetes status, smoking status, the status of drinking alcohol in the last three months, the status of exposure to indoor cooking smoke, etc. Demographic covariates of this study were categorized in the following way: Residence: Rural, Urban; and Religion: Muslims, Hindu, Buddhists/Cristian; Sex: Female, Male; Age (year): 18–29, 30–44, 45–59, 60–74, 75+; Marital Status: Married, Unmarried, Others (Divorced, Widowed, Separated); Education: Less or equal SSC (10th grade), HSC (12th grade), undergraduate, Master’s or higher, Never been to school; Last month income (Taka): Less than 10 thousand, 11–20 thousand, 21–30 thousand, 31–40 thousand, greater than 40 thousand, No income; Occupation: Business, Housewife, Govt. employee, Non-govt. employee, Unemployed, Self-employed, Student. The level of knowledge about tuberculosis was assessed by asking a series of questions under a few sub-segments, "Source of knowledge on TB", "Knowledge about TB causes", "Knowledge about the transmission of TB", "Knowledge about symptoms of TB", and "Knowledge about availability of TB treatment". In addition, the participants were also asked a series of questions to assess the level of attitude and practices regarding tuberculosis.

Consent and ethical considerations

At the outset of the survey, a section described the study’s eligibility, aims, the questionnaire’s concept, assurances regarding respondents’ confidentiality, and the study’s voluntary nature. Additionally, it was indicated that participants could omit a question if it appeared to be sensitive. This study was reviewed and waived the requirement of an IRB approval by the Ethical Review Committee, Faculty of Biological Science and Technology, University of Science and Technology, Jashore, Bangladesh. Because this was an anonymous online survey, it was voluntary, and it did not include any clinical operations.

Data management

A standard procedure was adopted to minimize the data collection errors and to ensure the high quality of information. A Stata program was developed for monitoring the time-to-time data collection progress. The inconsistency and duplicate checking were also part of the program. Moreover, the questionnaire was programmed in KoBo Toolbox in a way that automatically generates a device id for each of the devices from which participants completed the survey. The duplicate submissions were identified and dropped by using the device id which is expected to be unique. A complete and clean data set was used for the final analysis.

Statistical analysis

This study’s primary outcome of interest was respondents’ adequate knowledge, good practices, and positive attitudes towards TB. Participants’ knowledge of the cause, mode of transmission, signs, and symptoms, and treatment availability of TB was coded as “1” and labeled as “adequate knowledge” if the respondent correctly answered ≥ 50% (≥ 7 questions out of the total 14) of questions. Otherwise, participants’ knowledge was coded as “0” and labeled as “poor knowledge”. The overall participents’ attitude towards TB was defined as “Favorable attitude” and coded as “1” if the respondent correctly answered ≥ 3 questions out of the total 5 and otherwise defined as “Unfavorable attitude” and coded as “0”. We used two questions to assess respondents’ practice toward TB (Q1: If you had symptoms of TB, at what point would you go to the health facility? and Q2: If you had symptoms of TB, where will you go for TB treatment?). The overall respondents’ practices toward TB were defined as “Good practice” if the respondent correctly answered both questions otherwise define as “Bad practice”.

The exploratory analysis (frequencies analysis, means, median, bivariate analysis) was done to check socio-demographic characteristics. The statistical significance of the correlation between socio-demographic factors and knowledge of the respondents and their practice and attitude towards TB was inspected using the Chi-square test. All the significant factors at a 10% level of significance in the Chi-square test were included in the univariate logistic regressions [25]. We did so to recheck the association between socio-demographic factors and knowledge of the respondents and their practice and attitude toward TB. The adjusted odds ratios (AOR) were also calculated using multivariable logistic regression [26, 27] with a 95% confidence interval (CI). All the analyses were done by using the Statistical package STATA version 16.0.

Results

Socio-demographic characteristics

More than four thousand people were invited to participate in the survey through online platforms (WhatsApp, Messenger, Email, Linkedin, etc.). A total of 1,180 (30% response rate) people submitted the self-consent completed surveys. The socio-demographic characteristics of the respondents are presented in Table 1. The majority of the respondent tended to be male (58.64%), aged between 18 to 44 years (78.28%), and married (62.37%). About one-third of the respondents (34.80%) had a Master’s or higher degree. Most of the respondents were Muslim (87.12%), and living in rural areas (56.61%). Almost half of the respondents were students (44.75%).

Table 1

Distribution of socio-demographic characteristics of respondents.

Variable	Labels	N (%)
Gender	Male	692 (58.64)
	Female	488 (41.36)
Age	18–29	404 (34.24)
	30–44	520 (44.07)
	45–59	240 (20.34)
	75+	16 (1.36)
Marital status	Married	736 (62.37)
	Unmarried	328 (27.80)
	Divorced/Widowed/Separated	116 (9.83)
Education	Less or equal HSC (< = 12th grade)	332 (28.14)
	Undergraduate	408 (34.58)
	Master’s or higher (Graduate)	440 (37.29)
Income	Less than 30,000	276 (23.39)
	30,000–45,000	176 (14.92)
	46,000–60,000	160 (13.56)
	61,000–75,000	280 (23.73)
	76,000 and above	288 (24.41)
Occupation	Service holder (govt/private)	324 (27.46)
	Entrepreneur/business	172 (14.58)
	Student	528 (44.75)
	Housewife/Retired/Unemployed/Other	156 (13.22)
Religion	Islam	1,028 (87.12)
	Hinduism	134 (11.36)
	Buddhists/Cristian	18 (1.53)
Region	Urban	512 (43.39)
	Rural	668 (56.61)

Knowledge about tuberculosis and associated factors

All the respondents confirmed that they heard about TB. In response to a multiple-response question, we found that the source of information about TB for 85.76% of the respondents was TV/Radio/Newspaper (Fig 1). The second major source was leaflets/Poster/Signboard/ Billboard (66.78%). Nearly half of the respondents received information from health professionals, and 44.4% received it from the internet. Religious leaders/teachers were the sources of information for 43.05% of the respondents. A similar proportion of the participants (41.36%) learned about TB from friends/relatives/family members. Exposure to TB treatment and inmates suffering from TB were the sources of TB for 27.80% and 17.29% of the participants. Table 2 shows that a large proportion (71%) of the participants knew that TB germ or Bacteria is the major cause of TB. Nearly 42% of the respondents knew the correct transmission mode of TB (TB can be spread from person to person through the air when coughing or sneezing).

Fig 1

Source of information of the respondents about TB.

Table 2

Knowledge of respondents on TB cause, transmission, signs & symptoms, treatment, and attitudes and practices toward TB among participants.

Question	Label	N (%)
Knowledge about TB causes
What is the primary cause of TB?	TB germ /Bacteria	828 (70.41)
	Virus	188 (15.99)
	Cold wind	8 (0.68)
	Smoking	36 (3.06)
	Spoiled soil (soil with a bad odor)	0 (0)
	Poor hygiene Alcohol	4 (0.34)
	Inherited	0 (0)
	Don’t know	112 (9.52)
Knowledge about the transmission of TB
TB is spread from person to person through the air when coughing or sneezing?	Yes	488 (41.36)
	No	672 (56.95)
	Don’t know	20 (1.69)
Can TB be transmitted by sharing utensils?	Yes	584 (49.49)
	No	556 (47.12)
	Don’t know	40 (3.39)
Can TB be transmitted through food?	Yes	572 (48.47)
	No	600 (50.85)
	Don’t know	8 (0.68)
Can TB be transmitted through sexual contact?	Yes	624 (52.88)
	No	532 (45.08)
	Don’t know	24 (2.03)
What is the most common site for TB infection in the body? (Only one answer)	Lungs	952 (80.68)
	Glands	140 (11.86)
	Brain	0 (0)
	Bones	4 (0.34)
	Others (specify) —	0 (0)
	Don’t know	84 (7.12)
Knowledge about symptoms of TB
A person who is infected with TB coughs for several (more than 3) weeks?	Yes	488 (41.36)
	No	684 (57.97)
	Don’t know	8 (0.68)
A person who is infected with TB has a persistent fever	Yes	404 (36.33)
	No	700 (62.95)
	Don’t know	8 (0.72)
A person who is infected with TB sweats during the night	Yes	512 (43.39)
	No	652 (55.25)
	Don’t know	16 (1.36)
A person who is infected with TB has pain in the chest or back	Yes	512 (43.39)
	No	664 (56.27)
	Don’t know	4 (0.34)
Weight loss is one of the symptoms of TB	Yes	492 (41.69)
	No	668 (56.61)
	Don’t know	20 (1.69)
Knowledge about the availability of TB treatment
Is TB management available free of cost in Bangladesh?	Yes	872 (73.9)
	No	176 (14.92)
	Don’t know	132 (11.19)
Is TB curable?	Yes	1020 (86.44)
	No	140 (11.86)
	Don’t know	20 (1.69)
Attitude towards TB
In your opinion, how serious disease is TB?	Very serious	936 (79.32)
	Somewhat serious	112 (9.49)
	Not very serious	132 (11.19)
Do you afraid to get infected with TB? (chose only one)	Yes	544 (46.1)
	No	624 (52.88)
	Don’t know	12 (1.02)
Will you keep it secret when any family member gets TB?	Yes	976 (82.71)
	No	196 (16.61)
	Don’t know	8 (0.68)
Would you be willing to work with someone previously treated for TB?	Yes	528 (44.75)
	No	648 (54.92)
	Don’t know	4 (0.34)
What would be your reaction if you found out that you have TB? (chose only one)	Go to pharmacy	536 (45.42)
	Go to a health facility	448 (37.97)
	Got to a traditional healer	144 (12.2)
	Pursue other self-treatment options (herbs, etc.)	44 (3.73)
	Others (specify)	8 (0.68)
Practice toward TB
If you had symptoms of TB, at what point would you go to the health facility? (choose only one)	When treatment on my own does not work.	208 (17.63)
	When symptoms that look like TB signs last for 3–4 weeks.	336 (28.47)
	As soon as I realize that my symptoms might be related to TB.	568 (48.14)
	I would not go to the doctor.	68 (5.76)
If you had symptoms of TB, where would you go for TB treatment? (chose only one)	Modern drugs	832 (70.51)
	Herbal Remedies	148 (12.54)
	Home Remedies	124 (10.51)
	Praying /holy water	44 (3.73)
	Don’t Know	32 (2.71)

Nevertheless, the misconception was observed among a considerable proportion (57%) of the respondents. Almost half of the respondents knew that TB could be transmitted from person to person by sharing utensils and food or by sexual contact. A more significant proportion (81%) of the respondents correctly knew that the lung is the most common site for TB infection in the body. However, the respondent’s knowledge about the symptoms of TB was deficient. Out of 1,180 persons, 652 (55.25%) did not know that coughing for several (more than 3) weeks is a common symptom of TB infection. Less than 50% (36.33%, 43.39%, and 41.69%, respectively) of the respondents knew that persistent fever, sweats during the night, and weight loss are TB symptoms. Knowledge about the availability of TB treatment was considerably high among the respondents. Almost 85% of the respondents knew that TB is curable, and 74% knew that TB treatment is available and accessible in Bangladesh.

We observed adequate overall knowledge regarding TB in only 47.8% of the respondents (Table 3). About 68.21% of males and only 18.85% of females had adequate knowledge about TB. The findings from multivariable regression also show that females had a 90% lower chance of having adequate knowledge about TB than their male counterparts. The age of the respondents was also a significantly associated factor for having adequate knowledge regarding TB. Middle-aged people were more likely to have more knowledge about TB. More explicitly, respondents aged 30–40 had a 2.13 times higher likelihood of having adequate knowledge than respondents aged 18–29. However, older respondents (aged 45–59) had around 84% lower chance of having adequate knowledge about TB than the young respondents (aged 18–29). Marital status, education level, and income were strongly correlated with the overall level of knowledge. Around 42% of married and 75.61% of unmarried respondents had adequate knowledge about TB. The odds of having adequate knowledge among the unmarried respondents were 4 times (95% CI: 2.51–6.42) higher than the odds of having adequate knowledge among the married respondents. Among respondents who completed undergraduate or running, 62.75% had adequate knowledge, and among respondents with master’s or higher degrees, 58.18% had adequate knowledge. However, only 15.66% of the respondents with less or equal HSC degrees (< = 12 grade) had adequate knowledge. The respondents with education level undergraduate and graduate had respectively 5 times (95% CI: 2.93–8.74) and 3 times (95% CI: 2.2–6.27) higher chance of having adequate knowledge than respondents with an education level less or equal to HSC (grade 12). Respondents having higher incomes were more likely to have adequate knowledge about TB. People living in urban areas were more likely to have adequate knowledge. The respondents who live in rural areas had a 69% (95% CI: 0.2–0.48) lower chance of having adequate TB knowledge.

Table 3

Associated factors with knowledge of TB among participants.

Factors	Bivariate analysis					Multivariable analysis
	Adequate knowledge n (%)	Poor knowledge n (%)	P-value	UOR (95% CI)	P-value	AOR (95% CI)	P-value
Total	564 (47.8)	616 (52.20)
Gender
Male	472 (68.21)	220 (31.79)	< .001	Ref		Ref
Female	92 (18.85)	396 (81.15)		0.11 (0.08–0.14)	< .001	0.1 (0.07–0.15)	< .001
Age
18–29	184 (45.54)	220 (54.46)		Ref		Ref
30–44	332 (63.85)	188 (36.15)	< .001	2.11 (1.62–2.75)	< .001	2.13 (1.37–3.32)	< .01
45–59	44 (18.33)	196 (81.67)		0.27 (0.18–0.39)	< .001	0.16 (0.08–0.31)	< .001
75+	4 (25.00)	12 (75.00)		0.4 (0.13–1.26)	NS	1.94 (0.19–19.45)	NS
Marital Status
Married	308 (41.85)	428 (58.15)		Ref		Ref
Unmarried	248 (75.61)	80 (24.39)	< .001	4.31 (3.22–5.77)	< .001	4.01 (2.51–6.42)	< .001
Other£	8 (6.90)	108 (93.10)		0.1 (0.05–0.21)	< .001	0.02 (0–0.06)	< .001
Education
Less or equal HSC (< = 12th grade)	52 (15.66)	280 (84.34)		Ref		Ref
Undergraduate	256 (62.75)	152 (37.25)	< .001	9.07 (6.34–12.97)	< .001	5.06 (2.93–8.74)	< .001
Master’s or higher (Graduate)	256 (58.18)	184 (41.82)		7.49 (5.27–10.65)	< .001	3.71 (2.2–6.27)	< .001
Income
Less than 30,000	108 (39.13)	168 (60.87)		Ref		Ref
30,000–45,000	36 (20.45)	140 (79.55)		0.4 (0.26–0.62)	< .001	0.27 (0.14–0.53)	< .001
46,000–60,000	48 (30.00)	112 (70.00)	< .001	0.67 (0.44–1.01)	NS	0.35 (0.18–0.69)	< .01
61,000–75,000	132 (47.14)	148 (52.86)		1.39 (0.99–1.94)	NS	0.94 (0.54–1.65)	NS
76,000 and above	240 (83.33)	48 (16.67)		7.78 (5.25–11.52)	< .001	9.12 (4.35–19.11)	< .001
Occupation
Service holder (govt/private)	220 (67.90)	104 (32.10)		Ref		Ref
Entrepreneur/business	108 (62.79)	64 (37.21)	< .001	0.8 (0.54–1.18)	NS	0.64 (0.33–1.25)	NS
Student	168 (31.82)	360 (68.18)		0.22 (0.16–0.3)	< .001	0.09 (0.05–0.17)	< .001
Other¥	68 (43.59)	88 (56.41)		0.37 (0.25–0.54)	< .001	0.21 (0.11–0.42)	< .001
Religion
Islam	468 (45.53)	560 (54.47)		Ref		Ref
Hinduism	86 (64.18)	48 (35.82)	< .001	2.14 (1.48–3.12)	< .001	2.54 (1.36–4.74)	< .01
Buddhists/Cristian	10 (55.56)	8 (44.44)		1.5 (0.59–3.82)	NS	2.37 (0.4–14.02)	NS
Region
Urban	284 (55.47)	228 (44.53)	< .001	Ref		Ref
Rural	280 (41.92)	388 (58.08)		0.58 (0.46–0.73)	< .001	0.31 (0.2–0.48)	< .001

NS = not significant at 5% level; UOR = Unadjusted Odds Ratio; AOR = Adjusted Odds Ratio; Other¥ includes Housewife, Retired, and Unemployed; Other£ includes Divorced, Widowed, and Separated

Practices toward tuberculosis and associated factors

Nearly half of the participants preferred to visit health care centers (48.14%) as soon as they realized that their symptoms might be related to TB and wanted to take modern drugs (71%) (Table 2). Less than one-third of 1,180 respondents (31.19%) showed overall good practices (Table 4). According to bivariate analysis, 37.57% of males and 22.13% of females were doing good practices. According to findings from regression analysis, female respondents had a 41% (AOR = 0.59, 95% CI: 0.44–0.79) lower chance of doing good practices towards TB than males. The respondents aged 30–44 had a 1.41 (AOR = 1.41, 95% CI: 1.04–1.92) times higher chance of doing good practices than younger respondents (aged 18–29). Good practices were also observed among 28.26% of married and 41.46% of unmarried respondents. Unmarried respondents had a 1.46, (95% CI: 1.07–1.96) times higher likelihood of having good practices than married respondents. Among respondents with education level undergraduate and graduate, 30% had good practices while 21.69% of respondents with less or equal HSC degrees (< = 12 grade) had good practices. The odds of having good practices among the respondents with a graduate-level education were two times higher than respondents with less or equal HSC degrees. Among the respondents who believe in Hinduism, 55.22% had good practices toward TB, and for those who believe in Islam, 28.21% had good practices. The odds of having good practices towards TB among students and entrepreneurs/businesses, respectively, were 1.45 (95% CI: 0.99–2.12) and 1.93 (95% CI: 1.25–3.06) times higher than the odds of having good practices among service holders (govt/private).

Table 4

Associated factors with practice toward TB among the participants.

Factors	Bivariate analysis					Multivariable analysis
	Good Practice n (%)	Bad practice n (%)	P-value	UOR (95% CI)	P-value	AOR (95% CI)	P-value
Total	368 (31.19)	812 (68.81)
Gender
Male	260 (37.57)	432 (62.43)	< .001	Ref		Ref
Female	108 (22.13)	380 (77.87)		0.47(0.36–0.61)	< .001	0.59 (0.44–0.79)	< .001
Age
18–29	112 (27.72)	292 (72.28)		Ref		Ref
30–44	200 (38.46)	320 (61.54)	< .001	1.63(1.23–2.16)	< .01	1.41 (1.04–1.92)	< .05
45–59	52 (21.67)	188 (78.33)		0.72(0.49–1.05)	NS	0.88 (0.58–1.33)	NS
75+	4 (25.00)	12 (75.00)		0.87(0.27–2.75)	NS	1.34 (0.34–5.26)	NS
Marital Status
Married	208 (28.26)	528 (71.74)		Ref		Ref
Unmarried	136 (41.46)	192 (58.54)	< .001	1.8(1.37–2.36)	< .001	1.45 (1.07–1.96)	< .05
Other£	24 (20.69)	92 (79.31)		0.66(0.41–1.07)	NS	0.75 (0.43–1.3)	NS
Education
Less or equal HSC (< = 12th grade)	72 (21.69)	260 (78.31)		Ref
Undergraduate	124 (30.39)	284 (69.61)	< .001	1.58(1.13–2.21)	< .05	0.97 (0.66–1.42)	NS
Master’s or higher	172 (30.09)	268 (60.91)		2.32(1.68–3.2)	< .001	2.09 (1.42–3.08)	< .001
Income
Less than 30,000	92 (33.33)	184 (66.67)		Ref		Ref
30,000–45,000	24 (13.64)	152 (86.36)		0.32(0.19–0.52)	< .001	0.31 (0.18–0.53)	< .001
46,000–60,000	44 (27.50)	116 (72.50)	< .001	0.76(0.49–1.16)	NS	0.79 (0.49–1.26)	NS
61,000–75,000	100 (35.71)	180 (64.29)		1.11(0.78–1.58)	NS	1.06 (0.72–1.56)	NS
76,000 and above	108 (37.50)	180 (62.50)		1.2(0.85–1.7)	NS	1 (0.67–1.51)	NS
Occupation
Service holder (govt/private)	104 (32.10)	220 (67.90)		Ref		Ref
Entrepreneur/business	68 (39.53)	104 (60.47)	<0.05	1.38(0.94–2.03)	0.098	1.96 (1.25–3.06)	< .05
Student	160 (30.30)	368 (69.70)		0.92(0.68–1.24)	NS	1.45 (0.99–2.12)	< .05
Other¥	36 (23.08)	120 (76.92)		0.63(0.41–0.98)	< .05	0.72 (0.45–1.15)	NS
Religion
Islam	290 (28.21)	738 (71.79)		Ref		Ref
Hinduism	74 (55.22)	60 (44.78)	< .001	3.14(2.18–4.53)	< .001	2.57 (1.74–3.79)	< .001
Buddhists/Cristian	4 (22.22)	14 (77.78)		0.73(0.24–2.23)	NS	0.72 (0.23–2.27)	NS
Region
Urban	164 (32.03)	348 (67.97)	NS	Not retained		Not retained
Rural	204 (30.54)	464 (69.46)

NS = not significant at 5% level; UOR = Unadjusted Odds Ratio; AOR = Adjusted Odds Ratio; Other¥ includes Housewife, Retired, Unemployed; Other£ includes Divorced, Widowed, and Separated

Attitude toward tuberculosis and associated factors

According to 79.32% (936) of the respondents, TB is a severe disease (Table 2). Almost half of the participants were afraid to get infected with TB. A large proportion (83%) of the respondents wanted to keep it secret when any family member gets TB. A significant portion of the respondents (54.92%) were unwilling to work with someone previously treated for TB. Also, a considerable proportion (44.75%) of the respondents had stigmatizing thoughts toward TB patients. Table 5 depicts that almost 45% of the respondents expressed a favorable attitude toward TB. The general population’s attitude in Bangladesh toward TB and associated factors are also shown in Table 5. Gender was one of the significant factors of favorable attitudes toward TB. The odds of having a favorable attitude toward TB among females were 95% (95% CI: 0.03–0.07) lower than the odds of having a favorable attitude toward TB among males. The age of the respondents was also a significantly associated factor for having a favorable attitude toward TB. Middle-aged people were more likely to have a favorable attitude toward TB. More explicitly, respondents aged 30–40 had a 3.78 times (95% CI: 2.44–5.86) higher likelihood of having a favorable attitude toward TB than respondents aged 18–29. However, older (45–59) respondents had around 69% (95% CI: 0.16–0.6) lower chance of having a favorable attitude toward TB than the young respondents (aged 18–29). Marital status, education level, and income were highly correlated with the overall attitude of respondents toward TB. The odds of having a favorable attitude toward TB among the unmarried respondents were 3 times (95% CI: 1.93–4.73) higher than the odds of having a favorable attitude toward TB among the married respondents. The respondents with undergraduate and graduate-level education had respectively 6 times (95% CI: 3.77–11.38) and 1.96 times (95% CI: 1.16–3.29) higher chance of having a favorable attitude toward TB than respondents with an education level less or equal HSC (< = 12th grade). The respondents who live in rural areas had a 54% (95% CI: 0.3–0.69) lower chance of having a favorable attitude toward TB.

Table 5

Associated factors with attitude toward TB among the participants.

Factors	Bivariate analysis					Multivariable analysis
	Favorable attitude n (%)	Unfavorable attitude n (%)	P-value	UOR (95% CI)	P-value	AOR (95% CI)	P-value
Total	528 (44.75)	652 (55.25)
Gender
Male	464 (67.05)	228 (32.95)	< .001	Ref		Ref
Female	64 (13.11)	424 (86.89)		0.07 (0.05–0.1)	< .001	0.05 (0.03–0.07)	< .001
Age
18–29	152 (37.62)	252 (62.38)		Ref		Ref
30–44	332 (63.85)	188 (36.15)	< .001	2.93 (2.24–3.83)	< .001	3.78 (2.44–5.86)	< .001
45–59	44 (18.33)	196 (81.67)		0.37 (0.25–0.55)	< .001	0.31 (0.16–0.6)	< .001
75+	0 (0.00)	16 (100.00)		-		-
Marital Status
Married	280 (38.04)	456 (61.96)		Ref		Ref
Unmarried	232 (70.73)	96 (29.27)	< .001	3.94 (2.97–5.21)	< .001	3.02 (1.93–4.73)	< .001
Other£	16 (13.79)	100 (86.21)		0.26 (0.15–0.45)	< .001	0.55 (0.25–1.23)	NS
Education
Less or equal HSC (< = 12th grade)	52 (15.66)	280 (84.34)		Ref		Ref
Undergraduate	256 (62.75)	152 (37.25)	< .001	9.07 (6.34–12.97)	< .001	6.55 (3.77–11.38)	< .001
Master’s or higher (Graduate)	220 (50.00)	220 (50.00)		5.38 (3.79–7.64)	< .001	1.95 (1.16–3.29)	< .01
Income
Less than 30,000	96 (34.78)	180 (65.22)		Ref		Ref
30,000–45,000	28 (15.91)	148 (84.09)		0.35 (0.22–0.57)	< .001	0.38 (0.2–0.74)	< .01
46,000–60,000	56 (35.00)	104 (65.00)	< .001	1.01 (0.67–1.52)	NS	1.22 (0.64–2.33)	NS
61,000–75,000	120 (42.86)	160 (57.14)		1.41 (1–1.98)	< .05	1.25 (0.72–2.18)	NS
76,000 and above	228 (79.17)	60 (20.83)		7.13 (4.89–10.39)	< .001	9.67 (4.86–19.27)	< .001
Occupation
Service holder (govt/private)	200 (61.73)	124 (38.27)		Ref		Ref
Entrepreneur/business	96 (55.81)	76 (44.19)		0.78 (0.54–1.14)	NS	0.68 (0.36–1.28)	NS
Student	176 (33.33)	352 (66.67)	< .001	0.31 (0.23–0.41)	< .001	0.19 (0.11–0.32)	< .001
Other¥	56 (35.90)	100 (64.10)		0.35 (0.23–0.52)	< .001	0.17 (0.09–0.32)	< .001
Religion
Islam	442 (43.00)	586 (57.00)		Ref		Ref
Hinduism	76 (56.72)	58 (43.28)	< .01	1.74 (1.21–2.5)	< .05	1.65 (0.91–2.99)	NS
Buddhists/Cristian	10 (55.56)	8 (44.44)		1.66 (0.65–4.23)	NS	3.14 (0.46–21.69)	NS
Region
Urban	264 (51.56)	248 (48.44)	< .001	Ref		Ref
Rural	264 (39.52)	404 (60.48)		0.61 (0.49–0.77)	< .001	0.46 (0.3–0.69)	< .001

NS = not significant at 5% level; UOR = Unadjusted Odds Ratio; AOR = Adjusted Odds Ratio; Other¥ includes Housewife, Retired, Unemployed; Other£ includes Divorced, Widowed, and Separated

Discussion

A large proportion (43%) of people in Bangladesh have internet access which is substantially increasing over time (19% increased between 2020 and 2021) [20, 28]. This study aimed to inspect the level of knowledge, good attitudes, and practices among the general people who have internet access by circulating a survey link through social media and other electronic platforms. A total of 1,180 online users completed the survey and 58.64% of the participants were male. About 80% of the study participants fell in the age category of 18–44 years, which indicates a young study population. However, this age group is of immense interest because, according to Bangladesh’s national tuberculosis program, three-quarters of TB cases in Bangladesh were in the age bracket of 18–45 years [13]. Only 28.14% of study participants had HSC or less (< = 12th grade) education level, and a substantial portion of the participants were current students (44.75%). The above socio-demographic characteristics are understandable due to the nature of the survey. Participants also showed a good level of urban-rural balance (rural-56%). Young, educated, and student populations understandably have greater access to social media and electronic platforms.

Almost all survey participants in this study had heard of tuberculosis, which is consistent with research undertaken in Nigeria, India, Pakistan, and Lesotho [1, 29–31]. The primary sources of information about TB were TV/Radio/Newspapers, Leaflets/Posters/Signboards/Billboards, health professionals, the internet, teachers/religious leaders, and family/friends/relatives. The sources of information found in this study are parallel with a previous study conducted among adult TB patients in Dhaka Bangladesh [13]. However, a study was conducted to inspect Bangladeshi mothers’ knowledge of childhood tuberculosis and found a large proportion of mothers (84%) had no idea about childhood TB [32]. In this study, we found that just 47.8% of respondents (social media users) possessed sufficient overall knowledge of tuberculosis. A sizable number (71%) of participants knew that tuberculosis germs or bacteria are primarily responsible for TB infection. However, this knowledge level is lower than similar studies conducted in Malawi, Ethiopia, and India (90%, 81.7%, and 81%, respectively) and higher than the study taken part among non-medical university students in Bangladesh (42%) [33]. In addition, less than half of the respondents (42%) were aware of the correct mode of transmission of tuberculosis (TB can be transmitted from person to person via coughing or sneezing). A lower level of knowledge regarding TB transmission among women also was estimated in a previous study (7%) [34]. These findings indicate a substantially low level of knowledge about TB among social media users in Bangladesh compared to the findings of other studies conducted among general people.

The participants’ knowledge regarding signs of TB was insufficient. Less than half of the respondents knew the common symptoms of TB infection (cough for more than three weeks, persistent fever, nighttime sweating, and weight loss). This finding is consistent with similar studies conducted in Bangladesh and Lesotho [1, 35]. On the other hand, respondents were well informed about the availability of tuberculosis treatment, with more than three-fourths of respondents being aware of the curability of the disease and the availability of free treatment in Bangladesh. This is consistent with other global studies in Brazil, India, and Tanzania [36-38]. Female social media users had a significantly lower likelihood of possessing adequate knowledge of TB, and middle-aged (30–40 years) people had a significantly higher likelihood of having adequate knowledge than younger and older people. These two results are coherent with a nationwide study conducted in Bangladesh [39]. Social media users who had higher incomes were more likely to have adequate knowledge about tuberculosis, while social media users who live in rural areas had a considerably lower chance of having an adequate understanding of tuberculosis.

Less than a third (31.19%) of 1,180 study participants demonstrated overall good practices (Table 4). This is an abysmal level of good practices even compared to the estimate of slum dwellers in Nigeria (48.8%) [40] and some other studies in Gambia, and Pakistan [41, 42]. Gender, age, marital status, education, and religion were significantly associated with good practices toward TB with females, married, younger and older, less educated, and Muslim people showing poor practices toward TB. Although poor practices were found among social media users more prevalent in this study than in many others, the risk factors for poor practices discovered in this study are consistent with other studies among different types of populations [41-43].

Fewer than half of the participants expressed a favorable attitude about tuberculosis (44.75%) (Table 5). A lack of proper knowledge about TB might be why this study found such a low level of positive attitudes among social media users toward TB. The estimate of favorable attitude is inconsistent with other identical studies among different populations showing a higher positive attitude toward TB than this study [36, 40–43]. A considerable proportion of respondents wanted to keep it secret if any family member gets TB, were unwilling to work with one previously treated for TB, and had stigmatizing thoughts about TB patients. Like knowledge and practices, favorable attitudes among social media users had similar risk factors. Gender, age, education level, marital status, and region (urban/rural) were significantly associated with favorable attitudes toward TB. Unmarried and undergraduate/graduate level respondents displayed 3 times and 2–6 times higher likelihood of having favorable attitudes toward TB, respectively. Female social media users and rural social media users showed a 95% and 54% lower likelihood of possessing positive attitudes, respectively. Covariates identified for attitudes towards TB are accordant with other studies conducted in developing countries like Bangladesh [1, 13, 44, 45]. However, Luba et al. and some other studies found higher positive attitudes among females and married people, which is inconsistent with this study [1, 13].

Social media websites and platforms can boost professional growth and advancement as well as individual and public health when used properly and sensibly [46]. Since a large number of people in Bangladesh, about 36 million, are using social media platforms such as Facebook, YouTube, Instagram, WhatsApp, IMO, etc., these platforms can be used as a medium to elevate people’s tuberculosis-related knowledge, attitudes, and behaviors. TB prevalence can be lowered in Bangladesh by creating awareness among general people using social media. This is a very attractive and effective platform to convey information regarding TB disease, its signs and symptoms, how to prevent it, and how to detect and treat it along with other public health issues [47]. There is evidence that TB is significantly prevalent among the young population (18–45 years old) in Bangladesh who are mainly active users of social media [13]. If this targeted population can be trained for TB, we can expect a substantial improvement in TB cases and mortality in Bangladesh. It is recommended that Bangladesh Govt., policymakers, and public health experts create and share scientific content on TB and other diseases on social media to educate people.

One of the strengths of our study is that to our knowledge, for the first time in Bangladesh, we conducted a study to assess the knowledge, attitudes, and practices towards TB and their associated factors among a large proportion of general people, who have internet access. Also, our sample size was significantly greater than some other relevant studies. However, this study has some limitations. The low response rate (30%), which is common for voluntary online surveys, may result in sampling bias. Moreover, since the responses were self-reported, information bias may also occur. And since the study participants were only social media/internet users, the findings cannot be generalized to the general population of Bangladesh. However, the findings give an idea of the knowledge, attitudes, and practices among the general population in Bangladesh. Fig 2 shows that mainly men (around 53% of the men) and people who have higher education (70% among those who have completed higher study, 49% of those who have completed secondary education whereas only 6% and 20% of those who have no education and completed primary) dominantly have internet access in Bangladesh [20] which implies that the estimated knowledge, practices, and attitudes may be poorer among the general population compared to this study’s findings.

Fig 2

The distribution of internet users and non-users in Bangladesh across sex and education levels (Source: Bangladesh National ICT Household Survey [20]).

Conclusion

This study revealed poor knowledge, attitudes, and practices toward TB among social media users in Bangladesh. Less than half of the study participants showed sufficient knowledge, good practices, and favorable attitudes toward TB. These findings are poorer than most other study findings conducted in developing country settings. Females, older, illiterate/less educated, married, and rural people were more vulnerable to having poor knowledge, attitudes, and practices toward TB. Bangladesh government and policymakers should design internet-based programs and interventions to improve knowledge, attitudes, and practices about TB among social media users in a bid to achieve the End TB goals, including a 95% reduction in TB mortality and a 90% reduction in TB incidence by 2035 compared to 2015 levels. In this study, participants had internet/social media access and are supposed to have better knowledge, attitudes, and practices toward TB. Hence, the findings should be interpreted and generalized with caution. Future studies should be more representative of the general population of Bangladesh.

(DOCX)

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29 Jun 2022

Knowledge, Attitude, Practices, and Determinants of Them towards Tuberculosis in Bangladesh: A Cross-sectional Study

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Reviewer #1: This manuscript describes an online survey on the Knowledge, Attitude and Practices related to Tb in Bangladesh. The topic is important since Knowledge and attitude play a key role in the process of disease control. The authors have described the study methodology well and the topic is of utmost importance. I have a few queries and concerns regarding the study as mentioned below:

Major concerns

1. Representativeness of the study – Online surveys may not be representative of the general population. This is especially true in some areas where internet connectivity and social media usage may be very low.

Representativeness is best achieved through probability sampling and two key components are required for probability sampling. I) Known non-zero chance of selecting any member of the target population. II)Random selection of members

Both these factors are not present in this study. Hence the results cannot be projected to the general population. Several methods have been evolved to address representativeness in online surveys such as probability or open online panels, weighting, quota or river sampling, sample matching etc. If any such methods were used in this study please mention that.

Some statistics on the usage of social media, the proportion of the population with access to the internet and social media etc may help judge the representativeness to an extent. A comparison of the sociodemographic factor distribution of this study sample with that of the general population may reveal insights regarding the representativeness of the study population.

2. Bias- In Section 4.1: Strengths and Limitations of the study- only information bias due to self-reporting is addressed.

The study also has several factors for selection/sampling bias, specifically volunteer bias and low response rates. Social media users with some knowledge about Tb may have been more likely to click the link for the survey. If any methods were used to improve this as mentioned in Question 1 please mention that. The lower the response rate the higher the risk of sampling bias.

3. Development and Validation of the questionnaire – Is this an existing questionnaire or an adapted version of an existing questionnaire. Otherwise, the process of development and validation of the questionnaire has to be mentioned in more detail. The methods section only mentions that the “questionnaire was validated by several experts and pilot surveys”. How the questionnaire was developed and validated is important if it is a new questionnaire.

4. The Discussion needs to include an assessment on the representativeness of this study for the general population of Bangladesh as mentioned before. Additionally, while there are very few KAP studies on the topic among the general population in Bangladesh, several studies are available on specific subgroups such as students, industrial workers etc. Comparison with these studies may give further insights.

Minor

5. The sample size of the study is much higher than the calculated sample size. If sample size calculation was done retrospectively, then power calculation may be a better option.

6. The introduction can be written with more clarity.

Eg On Page 2, paragraph 2 it is mentioned that “There are also a lot of misconceptions concerning the aetiology and mode of transmission in Bangladesh [13]. TB is thought to be inherited in some locations [14-16].” The juxtaposition of the two sentences suggests that the misconception that Tb is inherited exists in Bangladesh. However, all the studies referenced are from the African continent.

Paragraphs 1 and 2 on Page 1 (introduction) are slightly confusing and repetitive with Tb statistics from different years mentioned in different places. The first paragraph mentions statistics from Global Tb Report 2014 and 2015, while the second paragraph uses the Global Tb report 2021 statistics. If the intention is to show the change in Tb incidence or mortality that is not conveyed here.

Eg. Paragraph 1 mentions “ Globally, 10.4 million people were reported to have contracted tuberculosis in 2015, with 1.8 million people dying from the disease”

While in paragraph 2 it is mentioned “Globally, 10 million individuals were infected with tuberculosis in 2019, with 79% of those infected living in the 30 high-burden countries and 1.2 million people dying from the disease”.

7. In Section 2.3, subsections 2.3.2 and 2.3.3 mention all the questions that were part of the questionnaire. This is redundant considering that Table 3 has all the questions and answers along with the proportion of responses. A brief description of the questionnaire along with any methods used to reduce duplicates etc should be sufficient.

8. In section 2.5 the second paragraph describes the statistical analysis. While the term 'multivariate logistic regression' is used interchangeably with 'multivariate analysis' in some publications, the term “multivariate logistic regression” is usually used for models with multiple outcome/dependent variables. In this manuscript, the term multiple or multivariable logistic regression may be more appropriate. (Please see Ref: Hidalgo B, Goodman M. Multivariate or Multivariable Regression? Am J Public Health. 2013 Jan 1;103(1):39–40.)

9. Section 2.6 is repetitive. All the points have already been mentioned in sections 2.1 and 2.4.

10. Some minor grammatical errors need correction. Please use editing software. Eg. The term “general people” should be replaced with “the general population”.

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Reviewer #1: Yes: Martina Shalini Arul Joseph

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6 Jul 2022

Response to Editor/ Reviewer:

Reviewer point #1: “Representativeness of the study – Online surveys may not be representative of the general population. This is especially true in some areas where internet connectivity and social media usage may be very low.

Representativeness is best achieved through probability sampling and two key components are required for probability sampling. I) Known non-zero chance of selecting any member of the target population. II)Random selection of members

Both these factors are not present in this study. Hence the results cannot be projected to the general population. Several methods have been evolved to address representativeness in online surveys such as probability or open online panels, weighting, quota or river sampling, sample matching etc. If any such methods were used in this study please mention that.

Some statistics on the usage of social media, the proportion of the population with access to the internet and social media etc may help judge the representativeness to an extent. A comparison of the sociodemographic factor distribution of this study sample with that of the general population may reveal insights regarding the representativeness of the study population.”

Author response #1: Thank you so much for catching the issue. We completely agree with you that the results of our study can not be generalized to the general population of Bangladesh. However, we have interpreted our findings for the people who have internet access in the revised manuscript. Hence, we have replaced the word “general population/ general people” with people who have internet access. In addition, we have added a comparative distribution across gender and education levels (Figure 5) of internet users and non-users in Discussion Section to get an idea about knowledge, attitudes, and practices toward TB among the general population.

Reviewer point #2: “Bias- In Section 4.1: Strengths and Limitations of the study- only information bias due to self-reporting is addressed.

The study also has several factors for selection/sampling bias, specifically volunteer bias and low response rates. Social media users with some knowledge about Tb may have been more likely to click the link for the survey. If any methods were used to improve this as mentioned in Question 1 please mention that. The lower the response rate the higher the risk of sampling bias.”

Author response #2: Thank you for the legit suggestion. We have updated Strengths and Limitations accordingly.

Reviewer point #3: “Development and Validation of the questionnaire – Is this an existing questionnaire or an adapted version of an existing questionnaire. Otherwise, the process of development and validation of the questionnaire has to be mentioned in more detail. The methods section only mentions that the “questionnaire was validated by several experts and pilot surveys”. How the questionnaire was developed and validated is important if it is a new questionnaire.”

Author response #3: Thank you for the comment. Yes, we have used an adapted version of existing questionnaires. We have mentioned it in subsection 2.1 in the revised manuscript.

Reviewer point #4: “The Discussion needs to include an assessment on the representativeness of this study for the general population of Bangladesh as mentioned before. Additionally, while there are very few KAP studies on the topic among the general population in Bangladesh, several studies are available on specific subgroups such as students, industrial workers, etc. Comparison with these studies may give further insights.”

Author response #4: As we mentioned above, we are not generalizing our findings to the general population without any caution in the revised manuscript. we have also added some statistics regarding our study participants, people who have internet access. Moreover, we have added some comparative views for our findings with existing studies in the Discussion Section.

Reviewer point #5: “The sample size of the study is much higher than the calculated sample size. If sample size calculation was done retrospectively, then power calculation may be a better option.”

Author response #5: Thank you for your comments. The main purpose of our study was to make inferences about the level of knowledge, attitudes, and practices based on the sample information. As we don’t intend to reject some null hypothesis (if it happens to be false), we are concerned about the precision of any estimate from the sample but not about the statistical power. However, we found that the absolute precision for the sample we collected is 5.2%. This has been added in 3.1 subsections.

Reviewer point #6: “The introduction can be written with more clarity.

Eg On Page 2, paragraph 2 it is mentioned that “There are also a lot of misconceptions concerning the aetiology and mode of transmission in Bangladesh [13]. TB is thought to be inherited in some locations [14-16].” The juxtaposition of the two sentences suggests that the misconception that Tb is inherited exists in Bangladesh. However, all the studies referenced are from the African continent.

Paragraphs 1 and 2 on Page 1 (introduction) are slightly confusing and repetitive with Tb statistics from different years mentioned in different places. The first paragraph mentions statistics from Global Tb Report 2014 and 2015, while the second paragraph uses the Global Tb report 2021 statistics. If the intention is to show the change in Tb incidence or mortality that is not conveyed here.

Eg. Paragraph 1 mentions “ Globally, 10.4 million people were reported to have contracted tuberculosis in 2015, with 1.8 million people dying from the disease”

While in paragraph 2 it is mentioned “Globally, 10 million individuals were infected with tuberculosis in 2019, with 79% of those infected living in the 30 high-burden countries and 1.2 million people dying from the disease”.”

Author response #6: We agree with you that there were some ambiguities in the introduction section. Thank you very much for identifying them. We have removed the sentence “TB is thought to be inherited in some locations [14-16]”, because the references are based in African countries and we didn’t find such references based in Bangladesh.

You can see that we revised the write-up to reduce the redundancy of similar statistics. However, there are still few stats from the different years to show that unsatisfactory progress has been made in controlling TB in the last few years.

Reviewer point #7: “In Section 2.3, subsections 2.3.2 and 2.3.3 mention all the questions that were part of the questionnaire. This is redundant considering that Table 3 has all the questions and answers along with the proportion of responses. A brief description of the questionnaire along with any methods used to reduce duplicates etc should be sufficient.”

Author response #7: Thank you for raising this point. As you suggested, we have removed subsections 2.3.2 and 2.3.3 from Section 2.3 and added subsection 2.5, which described in detail the data management process.

Reviewer point #8: “In section 2.5 the second paragraph describes the statistical analysis. While the term 'multivariate logistic regression' is used interchangeably with 'multivariate analysis' in some publications, the term “multivariate logistic regression” is usually used for models with multiple outcome/dependent variables. In this manuscript, the term multiple or multivariable logistic regression may be more appropriate. (Please see Ref: Hidalgo B, Goodman M. Multivariate or Multivariable Regression? Am J Public Health. 2013 Jan 1;103(1):39–40.)”

Author response #8: I would like to thank you for catching this issue. This was a serious typo. We have corrected it in the revised manuscript.

Reviewer point #9: “Section 2.6 is repetitive. All the points have already been mentioned in sections 2.1 and 2.4.”

Author response #9: Section 2.6 has been deleted.

Reviewer point #10: “Some minor grammatical errors need correction. Please use editing software. Eg. The term “general people” should be replaced with “the general population””

Author response #10: Thank you for your suggestion. The manuscript has been checked for grammatical issues with Grammarly Premium services. The corrections have been made.

In addition, we went through the whole article for similar types of typos and editing mistakes. We believe that the changes have improved the revised manuscript, which you will find updated.

11 Aug 2022

16 Aug 2022

Responses to reviewers:

Reviewer point#1: Section 2.1 line 6 mentions that participants "were requested to help those who do not have access to the internet or social media". What kind of help was suggested? If these "others" had no access to internet, that would imply that devices with internet access had to be shared. However, in section 2.5 it is mentioned that duplicate submissions were identified and dropped based on the device ids.

Author response#1: Thank you for identifying this significant discrepancy. Actually, our initial plan was to request participants to help others who don’t have internet/smart device access. However, later, we decided to survey only those who have internet/social media access. The sentence was taken from our initial study plan doc, and regrettably, we kept this sentence by mistake. The statement in section 2.5 about removing duplicate submissions based on device id is correct.

Reviewer point#2: There are still some grammatical and typographical errors. Eg. device is spelled devise in section 2.5.

Author response#2: We are sorry for the grammatical and typographical errors. We have gone through the entire manuscript with extensive care and corrected all the errors we identified.

Reviewer point#3: References: Some references are not in the correct format. Please check the correct format for reports and websites

Author response#3: Thank you so much for identifying the discrepancies in the references. We have corrected the discrepancies in the revised manuscript.

Reviewer additional point: Rather than attempt to extrapolate the results to the general population, the authors can focus on the interpretation of these results among social media users and their implications. The discussion can be rewritten with focus on the interpretation of this study's results and how they can inform future targeted health education using social media.

Author response: Thank you for your insightful comment, we really appreciate it. We have rewritten the discussion section following your instructions.

Submitted filename: Response to reviewers_R2.docx

Click here for additional data file.

30 Aug 2022

5 Sep 2022

Responses to reviewers:

Reviewer point#1: The authors have made all suggested changes. I have a few suggestions.

The title may be better if including the term internet users or social media users.

Author response#1: Thank you for your suggestion. The title now includes social media users to specify the study participants.

Reviewer point#2: In socio-demographic characteristics(Section3.1)- is there a need to include calculated precision?

Author response#2: Yes, you are absolutely right. We have removed it.

Reviewer point#3: In Table 1 - no need to include Consent as a variable.

Author response#3: This variable from Table 1 has been removed.

Reviewer point #4: The article can be further shortened, figures 2,3,4 are not necessary. Similarly, the data in table 2 can be included in tables 4,5,6 instead of a separate table.

Author response #4: The article has been shortened significantly following the above suggestions. Thank you for the suggestions.

Reviewer point#5: In the discussion section comparing the demographic characteristics of the general population with that of this study may be useful. The Discussion can be streamlined further. In the Discussion Paragraph 5 on Pg14 states TB is significantly prevalent among the young population in Bangladesh who are mainly active users of social media. This statement is abrupt and requires either reference or further explanation. Or this statement can be included in the first paragraph where the importance of the 18-45 years age group is mentioned.

Author response #5: We agree with you that the sentence was abrupt without any references. We have revised the wording to make it coherent and also added a reference. We think the discussion section is good overall.

Reviewer point#6: Please check format for references for reports and databases. Reports as references year of publication has to be mentioned (eg. Ref no. 24). For databases references should be according to ICJME guidelines(e.g. Ref: 22).

Author response #6: Thank you for identifying the issue and also for sharing the guidelines. We have modified them following the guidelines.

Submitted filename: Response to Reviewers_R3.docx

Click here for additional data file.

14 Sep 2022

Knowledge, Attitude, Practices, and Determinants of them toward Tuberculosis among Social Media Users in Bangladesh: A Cross-sectional Study

PONE-D-22-04571R3

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Reviewers' comments:

2 Oct 2022

PONE-D-22-04571R3

Knowledge, Attitude, Practices, and Determinants of them toward Tuberculosis among Social Media Users in Bangladesh: A Cross-sectional Study

Dear Dr. Mohsin:

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