Tuberculosis-related knowledge, attitude, and preventive practice among university students in Bali, Indonesia: a mixed methods study

Technical Summary: Tuberculosis-related Knowledge, Attitudes, and Preventive Practice among University Students in Bali, Indonesia

Problem Statement
Despite decades of global initiatives, Tuberculosis (TB) remains a persistent public health challenge, with Indonesia ranking as the second-largest contributor to global TB incidence. University students represent a large, vulnerable demographic (aged 10–24) that is often overlooked in prevention strategies, despite spending significant time in crowded settings like dormitories and classrooms which facilitate transmission. While previous Knowledge, Attitude, and Practices (KAP) surveys exist globally, findings are context-dependent and vary widely. In Indonesia, existing data is limited, often restricted to specific regions (e.g., West Java), conducted during the pandemic, or focused on general populations rather than university students. There is a critical need for recent, context-specific evidence to guide targeted interventions in Indonesian higher education settings.

Methodology
This study employed a sequential mixed-methods design conducted between March and August 2025 at a large public university in Bali, Indonesia. The research was guided by the Health Belief Model (HBM) to interpret findings.

• Quantitative Phase: A cross-sectional online survey was administered to 425 university students (aged ≥18) selected via non-probability convenience sampling. The instrument included demographic questions and validated sections on TB Knowledge (11 items), Attitude (13 items), and Preventive Practices (11 items). KAP levels were categorized using Bloom's cut-off scores (Good: ≥80%, Moderate: 60–79%, Poor: <60%). Data were analyzed using descriptive statistics, independent t-tests, one-way ANOVA, Pearson correlation, and multivariable linear regression.
• Qualitative Phase: Four Focus Group Interviews (FGIs) were conducted with 19 participants (purposively sampled for diversity in gender, age, and major) to explore quantitative findings in depth. Qualitative data were analyzed using summative content analysis.
• Integration: Findings from both phases were integrated during the interpretation stage to identify convergence, divergence, expansion, and complementarity.

Key Results

• KAP Levels: Participants demonstrated poor knowledge (44.2%), good attitudes (73.9%), and moderate preventive practices (54.8%).
  • Knowledge: Students performed well on items regarding transmission (airborne) and treatment duration but struggled with misconceptions about BCG vaccine longevity and the use of chest X-rays for diagnosis.
  • Attitude: High willingness to disclose diagnosis to family/lecturers and adhere to treatment was observed. However, interest in learning more about TB and perceived accessibility of screening services were lower.
  • Practice: Common behaviors included covering the mouth when coughing and ventilation. Routine annual chest X-ray screening was notably low (11.1% agreed to do so).
• Statistical Associations:
  • KAP scores were significantly correlated (p < 0.001).
  • Knowledge was significantly lower among non-health faculty students and those with limited TB information exposure.
  • Attitude scores were higher among students with a personal or family history of TB.
  • Preventive Practice scores were higher among students whose mothers had education beyond high school.
  • Exposure to TB information was the strongest consistent predictor across all three domains.
• Qualitative Themes:
  • Enablers: Prior exposure to information, existing basic knowledge, high perceived risk (driven by national burden), and a desire for future initiatives.
  • Barriers: Fear of negative impacts (stigma, academic disruption), significant knowledge gaps (screening, symptoms), low perceived personal risk (due to lack of local cases), and lifestyle factors (academic pressure, unhealthy routines).

Key Contributions

1. Contextual Evidence: This is the first study to assess TB-related KAP specifically among university students in Bali Province, providing data for a region with lower reported TB cases but high student density.
2. Methodological Innovation: It is the first study in Indonesia to apply a mixed-methods design to this specific population, allowing for the triangulation of statistical trends with nuanced behavioral insights.
3. HBM Application: The study successfully mapped student behaviors to HBM constructs, revealing that while students perceive high severity and have strong self-efficacy for treatment adherence, they suffer from low perceived susceptibility, unclear perceived benefits of prevention, strong perceived barriers (confusion about screening), and a scarcity of cues to action within the university environment.

Significance and Claims
The authors claim that the integration of findings reveals critical gaps in risk perception, symptom recognition, and the practical application of screening, despite generally positive attitudes. The study posits that universities serve as critical settings for targeted, evidence-based interventions.

Specifically, the paper argues that:

• Interventions must address the underestimation of personal risk among students.
• There is a need to clarify early symptom profiles and provide step-by-step guidance for screening to bridge the gap between intention and action.
• Institutional cues to action (e.g., reminders, integrated campaigns, supportive campus environments) are necessary to reduce delays in help-seeking.
• The findings highlight the necessity of moving beyond episodic, project-based TB initiatives toward continuous, institutionalized strategies within higher education.

The authors maintain a modest tone, acknowledging limitations such as the non-probability sampling (limiting generalizability), potential social desirability bias in self-reported data, and the cross-sectional nature of the study. They conclude that while this study provides important preliminary evidence, future research with larger, representative samples and longitudinal designs is required to strengthen reliability and applicability across Indonesian higher education.