Abstract Tuberculosis (TB) remains a leading global cause of mortality, with prisons creating high-risk conditions for transmission due to overcrowding and limited access to healthcare. This cross-sectional study assessed the knowledge, attitudes, and TB screening practices of 345 Prison Health Volunteers (PHVs) across three correctional facilities in Chiang Mai, Thailand. Data were collected through questionnaires measuring socio-demographic characteristics, TB knowledge, attitudes, and screening practices from September to December 2023, and were analyzed using descriptive statistics and correlation tests. PHVs demonstrated high levels of TB knowledge (mean = 8.71 ± 1.42/10), positive attitudes (mean = 4.25 ± 0.48/5), and effective screening practices (mean = 4.02 ± 0.56/5). Statistical analysis revealed a significant but modest positive correlation between attitudes and screening practices (rsp = 0.180, P = 0.001). These findings suggest that attitudinal factors are more influential than knowledge alone in determining effective TB screening behaviors. This study demonstrated that Prison Health Volunteers (PHVs) exhibiting more positive attitudes toward TB screening engaged in more effective screening practices, irrespective of their knowledge levels or demographic characteristics. The findings suggest that attitudinal factors serve as a critical determinant of screening behavior, exerting a greater influence than knowledge.

Keywords: Tuberculosis, Knowledge, Attitude, Practices, Prisoner health volunteers

Graphical Abstract:

Citation: Saksaen, P. and Insook, P. 2026. Knowledge, attitude, and practices of the uptake tuberculosis screening among prisoner health volunteers in Chiang Mai, Thailand: A cross sectional study. Natural and Life Sciences Communications. 25(1): e2026016.

INTRODUCTION

Tuberculosis (TB) remains a major global health issue, particularly in low-resource areas of Africa and Asia, as the second leading cause of death from infectious diseases. According to the WHO, 10.6 million people contracted TB in 2021, marking a 4.5% increase from 2020, with 134 cases per 100,000 people. This rise, reversing years of progress, is largely attributed to the impact of the COVID-19 pandemic on TB detection and treatment efforts (Kasznia-Brown, 2023). TB is spread through the air when an infected person coughs or sneezes, releasing bacteria. While it primarily affects the lungs, causing pulmonary tuberculosis, it can also infect other parts of the body, a condition known as extrapulmonary tuberculosis. In 2022, the World Health Organization estimated Thailand’s tuberculosis incidence rate at 143 cases per 100,000 people, or around 103,000 cases. Data from Thailand's tuberculosis program show a steady rise in new and recurrent TB cases over recent years, with 80,160 cases reported in 2017, 85,029 in 2018, and 87,789 in 2019 (World Health Organization, 2022).

For Thailand, according to the National Tuberculosis Information Program (NTIP) report, the tuberculosis incidence rates in the years 2017, 2018, and 2019 were 913.56, 1,067.10, and 1,118.61 per 100,000 population, respectively. These data indicate that the prevalence of tuberculosis in prisons is 6 to 8 times higher than in the general population (Vorasingha et al., 2022). During the fiscal years 2019 to 2022, the number of incarcerated individuals diagnosed with tuberculosis in Chiang Mai province was 86, 138, 67, and 53 cases, respectively (Division of Tuberculosis, Department of Disease Control, 2022). A study by Jareonsri Sae-tung (2017) reported that 557 tuberculosis cases were registered in prisons in the northern region between 2010 and 2014. Additionally, research conducted by Rujira Trakulpua, Rungreung Kitphati, Amornchai Traikunakornwong, and Anurat Song-in examined the prevalence and disability-adjusted life years (DALYs) associated with tuberculosis among inmates in seven correctional facilities in Bangkok in 2017. The findings revealed a tuberculosis prevalence of 6.81 per 1,000 population. Moreover, the study indicated that the burden of tuberculosis in prisons has been rising over time, as evidenced by comparative data from previous years. This trend underscores the urgent need for interventions to address tuberculosis in correctional facilities to prevent further transmission. Accelerated efforts in screening for tuberculosis and multidrug-resistant tuberculosis (MDR-TB) are essential and must be continuously implemented. (Targoolpua et al., 2020)

Tuberculosis (TB) in prisons is a major public health concern, with outbreaks reported globally and in Thailand. The prevalence of active TB among prisoners is 3.54% [2.71–4.63] in high-burden countries and 1.43% [0.86–2.37] in low-burden countries, while latent TB reaches 51.61% [39.46–63.58] and 40.24% [23.51–59.61], respectively; active TB prevalence is 3.13% [1.84–5.29] in low- and lower-middle-income countries versus 2.25% [1.70–2.99] in high- and upper-middle-income countries. These high rates reflect environments conducive to TB transmission, exacerbated by overcrowding and limited healthcare access, highlighting the need for targeted TB control interventions, including rapid health assessments and context-specific prevention strategies (Placeres et al., 2023). For instance, a TB outbreak study in central China found 40 cases among 3,459 inmates, with an incidence of 1,156 per 100,000 population (Tong et al., 2019), while Brazilian prisons in 2015 reported 4,712 per 100,000 population (Valença et al., 2015). Methodological studies further indicate that failing to account for clustering in cross-sectional analyses can bias estimates, with odds ratios exceeding prevalence ratios by ~20% when prevalence is >10%, particularly at the courtyard level, emphasizing the importance of cluster-adjusted analyses to accurately assess TB risk factors (Marín et al., 2023).

Prisoners and individuals residing in overcrowded environments are at a heightened risk of tuberculosis (TB) infection and often experience poorer treatment outcomes, placing them in a particularly vulnerable position. Safeguarding their health rights necessitates a collaborative effort between the healthcare and justice sectors (World Health Organization, 2023). Mycobacterium tuberculosis (MTB) spreads readily within prison settings and extends to the broader community through prison staff, visitors, and individuals released from incarceration. TB prevalence, including both latent and active infections, is significantly higher within correctional facilities compared to the general population, regardless of a country's economic status or overall TB burden (Dara et al., 2015).

Several factors contribute to the transmission of MTB in prison environments and present challenges to effective TB control. These include overcrowding, delays in case detection, inadequate contact tracing, insufficient treatment of infectious cases, high inmate turnover, and suboptimal implementation of TB infection control measures (Haeusler et al., 2022; World Health Organization, 2023). The health challenges faced by incarcerated populations are further exacerbated by chronic underfunding, human rights violations, and restricted access to healthcare services, compounded by the absence of justice-based alternatives to incarceration. Structural inadequacies, such as overcrowded facilities, substandard infrastructure, and frequent prisoner movement, further amplify the risk of airborne disease transmission, including TB (Busatto et al., 2022; Rodgerd and Morasert, 2024). Additionally, TB risk factors—including undernutrition, HIV infection, alcohol use disorders, and smoking—are disproportionately prevalent among prison populations (Haeusler et al., 2022; Rakpaitoon et al., 2022; World Health Organization, 2023).

Overcrowding remains a critical challenge both globally and within Thailand's prison system. In Thailand, prison healthcare operates within the primary healthcare framework, emphasizing disease prevention, management, and treatment while promoting the overall well-being of incarcerated individuals. A community-based participatory approach has been implemented in accordance with the Department of Corrections' policy, integrating Prison Health Volunteers (PHVs) into the healthcare system. Given their consistent and close interactions with fellow prisoners, PHVs are well-positioned to identify symptoms and signs of illness more effectively than prison nurses or correctional officers (Waraeitipa et al., 2013; Atirattana and Pawaputanun, 2023).

PHVs act as a crucial role in health promotion, disease prevention, knowledge dissemination, and the provision of basic healthcare services, aligning with the principles of primary healthcare. Selection criteria for PHVs include demonstrating good behavior, having at least two years of imprisonment remaining, completing primary education or higher, and exhibiting a willingness to serve as health advocates. Following their selection, PHVs undergo comprehensive healthcare leadership training (Atirattana and Pawaputanun, 2023; Pansakun et al., 2024), including a primary healthcare course provided by the Department of Health Service Support, Ministry of Public Health, Thailand. Upon successful completion, they receive certification, equipping them to fulfill their responsibilities effectively within the prison healthcare system. The researcher is therefore interested in studying the knowledge, attitude and practices in identifying individuals with suspected tuberculosis among PHVs in Chiang Mai province, as well as the relationship between knowledge, attitude, and practices in tuberculosis case finding among PHV. This study aims to examine the knowledge, attitude and practices of prison health volunteers in Chiang Mai province in identifying individuals with suspected tuberculosis based on the Knowledge-Attitude-Practice (KAP) model (Green and Kreuter, 2005). Understanding their level of knowledge and the effectiveness of their current practices is crucial for enhancing early detection and intervention strategies within correctional facilities. Furthermore, this study seeks to analyze the relationship between knowledge and practice in tuberculosis identification among these volunteers. Investigating this correlation will provide valuable insights into whether greater knowledge leads to more effective case identification. The findings will help inform the development of targeted training programs and policy improvements to strengthen tuberculosis control efforts in prison settings.

MATERIALS AND METHODS

Study design and procedure

A cross-sectional study was conducted to determine the relationship between knowledge (K), attitude (A), and practice (P) regarding tuberculosis (TB) screening among Prison Health Volunteers (PHVs) in Chiang Mai Province from September to December 2023. This study used the Knowledge-Attitude-Practice (KAP) model outlined by Green and Kreuter (2005) that states that knowledge can determine attitudes, and based on the two, health practice can be determined. The researchers hypothesized that when PHVs possess correct knowledge about tuberculosis (including risk populations and symptoms), they develop positive attitudes toward TB screening in prisons, which enables them to perform effective screening procedures and reporting, ultimately ensuring that infected prisoners receive quality treatment. Participants were required to meet several inclusion criteria: being 18 years of age or older, having completed at least lower secondary education, being able to understand and communicate in Thai, and expressing willingness to participate in the study. The Human Research Ethics Committee of Chiang Mai Provincial Public Health Office approved this research (CM 11/2566).

Sample size

The sample size calculation was based on Cochran's finite proportion formula (Cochran, 1977). Assuming a 50% prevalence of the attribute of interest, with a 95% confidence level, a 5% margin of error, and a population of 1,700, the required sample was 314. To accommodate possible incomplete questionnaires (given the self-administered format), a 10% non-response allowance was applied, yielding a final target of 345 participants.

The subjects were 345 Prison Health Volunteers (PHVs) who were recruited in three correction facilities located in Chiang Mai: Chiang Mai Central Prison (n = 200), Chiang Mai Female Correctional Institution (n = 100) and Fang District Prison (n = 45). PHVs are convicted prisoners (minimum of good-conduct level) given training based on the health-volunteer program of the Department of Corrections to provide health promotion, TB screening and basic care to other inmates. Stratified simple random sampling technique was employed to make the sample representative as the PHV population proportionate to each site. It was done on 360 eligible PHVs, 345 of whom agreed to take the survey (response rate 95.8%).

The possible selection bias was reduced by randomly drawing names using the current PHV rosters as provided by the prison health staff. Volunteers who served less than six months or those set to be released in less than three months were eliminated.

Data collection

The researcher submitted an official request for approval to collect data from the supervising authority, specifically to the Director-General of the Department of Corrections and the Prison Warden. This request included detailed explanations of the research objectives, procedures, and data collection processes, along with a request for cooperation. Upon receiving approval, the researcher coordinated with prison nurses to facilitate data collection. This involved scheduling meetings, explaining research procedures, and requesting permission for external personnel to enter the prison. The researcher provided an overview of the participant selection process and sought assistance from prison nurses to arrange appointments with participants. Once scheduled, participants were briefed on the research objectives and organized into groups of ten at designated venues within the prison. During data collection, the researcher explained the study's objectives and procedures, allowing participants to ask questions. The researcher emphasized that participation would not adversely affect the PHV and assured them of their anonymity. After gaining consent, the researcher distributed a questionnaire on infection surveillance among prison health volunteers, ensuring confidentiality in the process. Participants signed informed consent forms and completed the questionnaires independently. The researcher reviewed responses for accuracy, requested additional information if needed, and collected the completed questionnaires while keeping the consent forms separate to maintain confidentiality.

Instrument

The information was collected with the help of a socio-demographic questionnaire created by the main researcher and referred to the gender, age, educational level, years of working as a prison health volunteer (PHV), and the frequency of PHV training.

The level of knowledge regarding tuberculosis (TB) was evaluated through a 13-item questionnaire based on three main points: (1) provision of TB information prisoners, (2) search of suspected TB patients, and (3) monitoring and advising of the prisoners. The items included TB transmission, symptoms, diagnosis and treatment, screening, sputum collection, health education and infection-control measures. The items were in multiple choice format (yes / no) with a score of 1 or 0. The overall score (0-13) was translated into a percentage and the cut-off used by Bloom (Bloom, 1968)  was used: low ≤60% (≤7.8), moderate 61–80% (7.81–10.4), and high >80% (≥10.41).

The TB attitude scale was an 11-item scale that was created based on literature. The items were rated using four-point Likert-scale (4 = strongly agree to 1 = strongly disagree); all the negatively worded items were reverse-scored such that the higher the score, the more positive attitude the person had. The overall score was between 11–44, classified as poor (≤26), moderate (27–35), and high (≥36) according to Bloom’s cut-off.

TB screening practice was assessed with a 14-item questionnaire covering: (1) systematic search for suspected TB cases in dormitories, (2) documentation and reporting of findings, (3) sputum collection, (4) follow-up and communication of results, and (5) infection-prevention and health education. Responses were in a binary format (perform / not perform). The total practice score ranged from 0 to 14, and Bloom’s cut-off was applied: poor ≤8, moderate 9–11, and high ≥12.

The KAP questionnaire was created as a whole based on the PHV training curriculum of the National TB Control Division and then modified based on the validated TB KAP instruments. Six experts (two physicians with preventive medicine and prison experience, three nursing lecturers and one senior nurse practitioner) were used to review content validity with CVI values ranging between 0.89 and 0.97. The reliability was also high (KR-20 = 0.83-1.0 knowledge and practice, Cronbachs 9 = 0.81-0.99 attitude). Special factor loading of 0.42 to 0.78 proved the construct validity of the instrument with an exploratory factor analysis (principal axis factoring, varimax rotation) indicating the presence of the three conceptual domains.

Statistical analyses

Data cleaning and verification were conducted before analysis. SPSS version 30.0, licensed from Maejo University (SPSS Inc., Chicago, IL, USA), was used to conduct statistical analysis. Individuals with incomplete data were excluded from the analysis. Prior to statistical testing, preliminary assumption testing was conducted to check for normality, linearity, and homoscedasticity. The Kolmogorov-Smirnov test was used to assess normality of distribution for continuous variables. Because several distributions were non-normal, non-parametric tests were selected for correlation analyses.

Descriptive statistics—frequencies, percentages, means, standard deviations, medians, and interquartile ranges (IQR)—were used to summarize socio-demographic characteristics, knowledge levels, attitudes, and practices regarding TB screening among Prison Health Volunteers.

Spearman's rank correlation coefficient (r_sp) was employed to examine relationships between continuous variables (age, knowledge scores, attitude scores) and practice scores, whereas the point-biserial correlation coefficient (r_pb) was calculated for associations between dichotomous variables (gender, education level, years of PHV experience, previous PHV training) and practice scores. Correlation strength was interpreted using conventional thresholds (0.10–0.29 = small, 0.30–0.49 = moderate, ≥0.50 = large). A P-value <0.05 was considered statistically significant.

Correlations among Knowledge, Attitude, and Practice were also examined using Spearman’s rho, and the previously unreported Knowledge–Attitude association was included to complete the KAP framework. Effect sizes were interpreted following Cohen (1988) benchmarks (small = 0.10, medium = 0.30, large = 0.50).

To further identify determinants of higher Practice while adjusting for socio-demographic covariates, an ordinal logistic regression model (proportional odds) was fitted, with Knowledge, Attitude, age, education, and training frequency entered as predictors.

RESULTS

Socio-demographic characteristics

A total of 345 PHV participated in this study, with 66.38% male PHV, ages ranging from 19 – 81 years, 43.77% belonging to the 30-39 age group. The majority, 45.80% had a lower secondary education level, 57.39% had a one-year experience for PHV working, and 52.75% had been PHV training one time (Table 1).

Table 1. Socio-demographic characteristics. (n = 345).

This study revealed that only 73.0% of respondents had high knowledge, approximately 24.9% had moderate knowledge, and 2% low knowledge. The mean knowledge score was 11.02 ± 1.35 points, range 7 to 13 score. The majority, 99.13% of respondents had high level of attitude for screening prisoner with suspected TB, and 93.91% had a high range score of practices of the uptake tb screening (Table 2).

Table 2. Frequency, percentage, score range, median (IQR), level of KAP (n=345).

The statistical analysis examined the relationship between various demographic and knowledge-based variables and the practices of Prison Health Volunteers (PHVs). Spearman's rank correlation coefficient (r_sp) and point-biserial correlation coefficient (r_pb) were employed as appropriate for the variable types under investigation. The findings reveal that most variables demonstrated no statistically significant correlation with PHV practices. Age (r_sp = 0.004, P = 0.945), gender (r_pb = 0.097, P = 0.072), education level (r_pb = 0.063, P = 0.240), years of experience in PHV work (r_pb = -0.56, P = 0.301), previous PHV training (r_pb = -0.045, P = 0.407), and knowledge (r_sp = 0.025, P = 0.644) all failed to reach statistical significance at the conventional threshold (P < 0.05) (Table 3).

Attitude was the only variable that had a significant correlation with PHV practices (r_sp = 0.180, P = 0.001). The association with the Knowledge and Attitude was also small but significant, positive (r_sp = 0.22, P = 0.003; small effect, Cohen, 1988) (Table 3). This statistically significant correlation is a weak relationship by the accepted effect size standards.

These findings indicate that attitudinal variables could be more significant in defining PHV practices than demographic variables or levels of knowledge. Therefore, it is possible that training activities which focus on the attitudinal aspects - motivation, self-efficacy, and perceived barriers- help to enhance the performance in the practice more than the training activities aimed at the increase of the knowledge are effective.

Table 3. Correlation coefficient between factors, knowledge, and attitude with practice of the uptake tb screening among PHV (n=345).

Note: r_sp = Spearman’s Rank Correlation Coefficients, r_pb = Point Biserial Correlation Coefficients, * P < 0.01

DISCUSSION

This study investigated knowledge, attitudes, and practices regarding tuberculosis screening among Prison Health Volunteers (PHVs) in Chiang Mai, Thailand. Our findings revealed a statistically significant relationship between positive attitudes and effective tuberculosis screening practices (r_sp = 0.180, P = 0.001), while knowledge levels and demographic variables showed no significant correlation with practice behaviors. We also observed an interesting negative correlation between years of experience as a PHV and their screening practices, suggesting that longer tenure may be associated with decreased vigilance in tuberculosis detection activities.

Even though there was a significant relationship between Attitude and Practice, the effect size was low (r_sp = 0.18), which indicates that attitudes do not significantly influence screening practices. The workload, supervision, environmental constraints structural conditions are likely to mediate the capacity of PHVs to act, as was the case with previous work on prison TB control. Attitude enhancement, institutional help, refresher training, and sufficient resources should be included in the future interventions.

The absence of correlation between knowledge and practices (r_sp = 0.025, P = 0.644) represents a notable knowledge-practice gap that has been observed in other correctional healthcare studies. Winetsky et al. (2020) noted that even when prison healthcare workers possess adequate knowledge about TB symptoms and screening protocols, implementation can be hindered by environmental constraints, competing priorities, and systemic barriers specific to correctional settings. Dolan et al. (2016) identified similar discrepancies in their global review of prison TB programs, suggesting that knowledge alone is insufficient to drive appropriate case-finding behaviors.

This knowledge-practice gap represents a recognized challenge in prison TB control efforts globally. Moller et al. (2024) described this phenomenon as the "implementation barrier" where correctional healthcare providers possess the necessary information but face structural and operational obstacles to applying that knowledge. The prison environment introduces unique challenges including resource limitations, security priorities that may compete with health concerns, and high inmate turnover (Dara et al., 2015; WHO, 2022). As Biadglegne et al. (2015) emphasized, knowledge without supportive systems for implementation often fails to translate into effective practice in correctional settings.

The correlation between Attitude and Practice was significant though with a low effect size (r_sp = 0.18), meaning that the attitudinal factors are only slightly effective in explaining the screening behaviours. The data might also support the existence of the indirect effect of knowledge on practice through the attitudes in accordance with the original KAP model, yet this route was not completely examined in our data. The mediation or path models could help understand the use of attitude as an intermediary between knowledge and practice in future analysis.

In addition to the personal factors, structural conditions, including workload, supervision, and environmental limitations, are also likely to influence the capacity of PHVs to undertake screening activities. The positive attitudes are likely to be reinforced by institutional support, role definition, and regular refresher training to enhance successful practice. The following system level enablers will be required in case the attitudinal interventions will translate into long term TB screening performance in the correctional facilities.

Our findings align with previous Knowledge, Attitude, and Practice (KAP) studies in correctional settings. Topp et al. (2016) similarly found that attitudes toward TB control were more predictive of screening behaviors than knowledge levels among prison healthcare workers in Zambia. The importance of attitudinal factors in determining TB screening practices has been consistently documented across different prison contexts (Adane et al., 2017; Noé et al., 2017).

The significant correlation between attitude and practices highlights the importance of psychological and motivational factors in TB control efforts. According to the Health Belief Model applied to correctional healthcare by Niveau (2018), healthcare providers' perceived benefits of screening, barriers to implementation, and belief in their ability to make a difference all influence screening behaviors. Telisinghe et al. (2016) demonstrates that healthcare workers who maintain favorable attitudes toward tuberculosis control are more likely to advocate effectively for inmates' healthcare needs within systems that typically prioritize security concerns over health issues.

The lack of significant associations between demographic variables and practices contradicts some previous findings. This discrepancy might reflect differences in training standardization, supervision practices, or organizational factors between study settings.

Although demographic variables including gender, age, education level, years of experience as a PHV, and previous PHV training contribute to the statistical relationship model, our findings reveal that only the positive attitudes of PHVs significantly influence their tuberculosis screening practices among prisoners. The established screening pathway allows PHVs to report identified cases to prison nurses, who then facilitate comprehensive care including laboratory testing, chest radiography, specialist medical assessment, and appropriate treatment interventions.

This research provides crucial foundational data for improving tuberculosis management in correctional facilities by highlighting the importance of strengthening motivation, self-efficacy, and confidence among PHVs in identifying suspected tuberculosis cases. These components should be prioritized in future training and support programs to maximize TB case detection in prison settings.

LIMITATIONS

This study has several limitations. The cross-sectional design presents inherent constraints on establishing causality. Although a stratified random sampling method was employed, access to participants depended on coordination with prison health staff, which may have introduced minor selection bias. This may limit the broader applicability of results beyond the three participating correctional facilities. Further studies should examine causal pathways within the KAP model of TB screening among PHVs across diverse prison settings.

CONCLUSION

This study provides important insights into the knowledge, attitudes, and practices (KAP) related to tuberculosis (TB) screening among Prison Health Volunteers (PHVs) in Chiang Mai Province, Thailand. The findings reveal that although PHVs demonstrate relatively high levels of knowledge, attitudes, and practices, notable inconsistencies persist across these domains. Attitude emerged as a significant predictor of TB screening behavior, whereas knowledge of TB did not substantially influence participation in screening activities. Future studies should develop context-specific TB literacy and screening strategies tailored to prison environments, taking into account institutional characteristics, regional disparities, and resource limitations.

ACKNOWLEDGEMENTS

The authors thank the Chiang Mai Central Prison, Chiang Mai Women's Correctional Institution, Fang District Prison, and the Department of Corrections under the Thai Ministry of Justice for their support in data collection.

AUTHOR CONTRIBUTIONS

Conceptualization and design: Porramat Saksaen, Poramate Insook.

Methodology: Porramat Saksaen, Poramate Insook.

Data analysis: Porramat Saksaen.

Writing—original draft: Porramat Saksaen, Poramate Insook.

Writing—review and editing: Porramat Saksaen, Poramate Insook.

Project administration: Porramat Saksaen.

All authors have read and agreed to the published version of the manuscript.

CONFLICT OF INTEREST

The authors declare that they hold no competing interests.

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