Acceptability of masking and patient separation to control nosocomial Tuberculosis in Uganda: a qualitative study



This study explored the acceptability of cough etiquette, wearing masks and separation by tuberculosis (TB) suspects and TB patients in two districts in Uganda.


The study was conducted in Mukono and Wakiso districts in central Uganda. Eighteen in-depth interviews with patients and eight focus group discussions with health workers were conducted. Patients were asked for their opinions on cough etiquette, patient separation and wearing of masks.


Patients and health workers felt that physical separation was ideal, yet separation and masking were regarded as embarrassing to patients, emphasizing their potential infectiousness. Patients reported greater willingness to cover their mouth with a handkerchief than to wear a mask. Good counseling and health education were suggested to improve patients’ adoption of separation and masking. However patients expressed concerns about equity, coercive and stigmatizing approaches. Universal precautions were more acceptable than targeted ones, with the exception of separating TB patients. Lack of community awareness about airborne transmission of TB was identified as a barrier to accepting and adopting TB infection control measures.


Scaling up effective TB infection control norms and behaviors requires a patient-centered, rights-based, and evidence-based approach. Socially acceptable measures like covering the mouth and nose with a handkerchief should be promoted. We recommend that further studies are needed to explore how community advocacy impacts on acceptability of masking. Furthermore, the efficacy of covering the mouth using a handkerchief or piece of cloth compared to wearing a mask in TB prevention needs to be evaluated.

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  1. Adrian EB, Fardy HJ, Harris PG (2003) Getting it right: why bother with patient-centred care. Med J Australia 179 253–256. Cited 10 October 2011

  2. Aidsmap (2008) Think TB in people with HIV: start routinely screening for TB now. Nam, London, UK. Cited October 2011

  3. Aiello AE, Murray GF, Perez V, Coulborn RM, Davis BM, Uddin M, Shay DK, Waterman SH, Monto AS (2010) Mask use, hand hygiene, and seasonal influenza-like illness among young adults: a randomized intervention trial. J Infect Dis 201:491–498. doi:10.1086/650396

    PubMed  Article  Google Scholar 

  4. Alonso-echanove J, Shah SS, Valenti AJ, Dirrigl SN, Carson LA, Arduino MJ, Jarvis WR (2001) Nosocomial outbreak of Microbacterium species among cancer patients. J Infect Dis 184:754–760. doi:10.1086/323080

    PubMed  Article  CAS  Google Scholar 

  5. Boyce C, Neal P (2006) Conducting in-depth interviews: a guide for designing and conducting in-depth interviews for evaluation input. Cited 10 July 2011

  6. Cowling BJ, Fung RO, Cheng CK, Fang VJ, Chan KH, Seto WH, Yung R, Chiu B, Lee P, Uyeki TM, Houck PM, Peiris JS, Leung GM (2008) Preliminary findings of a randomized trial of non-pharmaceutical interventions to prevent influenza transmission in households. PLoS One 3:e2101. doi:10.1371/journal.pone.0002101

    PubMed  Article  Google Scholar 

  7. Dharmadhikari A (2011) Simple face masks could significantly prevent spread of TB to non-infected patients. American Thoracic Society International Conference. Denver, CO, May 2011. Cited 12 July 2011

  8. Dodor EA, Neal K, Kelly S (2008) An exploration of the causes of tuberculosis stigma in an urban district in Ghana. Int J Tuberc Lung Dis 12:1048–1054. Cited 3 July 2011

  9. Egwaga S, Mkopi A, Range N, Haag-arbenz V, Baraka A, Grewal P, Cobelens F, Mshinda H, Lwilla F, Van Leth F (2009) Patient-centred tuberculosis treatment delivery under programmatic conditions in Tanzania: a cohort study. BioMed Central Med. doi:10.1186/1741-7015-7-80

  10. Ferng YH, Wong-mcloughlin J, Barrett A, Currie L, Larson E (2011) Barriers to mask wearing for influenza-like illnesses among urban Hispanic households. Public Health Nurs 28:13–23. doi:10.1111/j.1525-1446.2010.00918.x

    PubMed  Article  Google Scholar 

  11. Flick U (1992) Triangulation revisited: strategy of validation or alternative? J Theory Soc Behav 22:175–197. doi:10.1111/j.1468-5914.1992.tb00215.x

    Article  Google Scholar 

  12. Forman J, Creswell WJ, Damschroder L, Kowalski CP, Krein SL (2008) Qualitative research methods: key features and insights gained from use in infection prevention research. AJIC Pract Forum. doi:10.1016/j.ajic.2008.03.010

  13. Gandhi NR, Moll A, Sturm AW, Pawinski R, Govender T, Lalloo U, Zeller K, Andrews J, Friedland G (2006) Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. Lancet 368:1575–1580. doi:10.1016/S0140-6736(06)69573-1

    PubMed  Article  Google Scholar 

  14. Graneheim UH, Lundman B (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 24:105–112. doi:10.1016/j.nedt.2003.10.001

    PubMed  Article  CAS  Google Scholar 

  15. Harries AD, Hargreaves NJ, Gausi F, Kwanjana JH, Salaniponi FM (2002) Preventing tuberculosis among health workers in Malawi. Bull World Health Organ 80:526–531

    PubMed  CAS  Google Scholar 

  16. Joshi R, Reingold AL, Menzies DPAIM (2006) Tuberculosis among health-care workers in low- and middle-income countries: a systematic review. PloS Med 3:e494. doi:10.1371/journal.pmed.0030494

    PubMed  Article  Google Scholar 

  17. Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, Ferrier K, Payne S (2001) Preferences of patients for patient centred approach to consultation in primary care: observational study. BMJ 322:468–472. doi:10.1136/bmj.322.7284.468

    PubMed  Article  CAS  Google Scholar 

  18. Macintyre CR, Cauchemez S, Dwyer DE, Seale H, Cheung P, Browne G, Fasher M, Wood J, Gao Z, Booy R, Ferguson N (2009) Face mask use and control of respiratory virus transmission in households. Emerg Infect Dis 15:233–241. doi:10.3201/eid1502.081167

    PubMed  Article  Google Scholar 

  19. MOH (2006) Uganda HIV/AIDS sero-behavioural survey: ORC macro. Ministry of Health, Kampala, Uganda. Cited 23 October 2011

  20. Stewart M (2001) Towards a global definition of patient centred care: the patient should be the judge of patient centred care. Br Med J 322:444–445

    Article  CAS  Google Scholar 

  21. Stewart MA (1995) Effective physician-patient communication and health outcomes: a review. CMAJ 152:1423–1433. Cited 4 September 2011

    Google Scholar 

  22. Syed Q, Sopwith W, Regan M, Bellis MA (2003) Behind the mask: journey through an epidemic—some observations of contrasting public health responses to SARS. J Epidemiol Commun Health 57:855–856. doi:10.1136/jech.57.11.855

    Article  CAS  Google Scholar 

  23. UBOS (Uganda Bureau of Statistics) (2006) Cited 16 August 2011

  24. UBOS (Uganda Bureau of Statistics) (2007) Uganda Demographic and Health Survey 2006. UBOS, KampalaUganda

    Google Scholar 

  25. UBOS (Uganda Bureau of Statistics) (2009–2010) Uganda national household survey: socio-economic module. UBOS, Kampala,Uganda. Cited 15 August 2011

  26. WHO (2007) People at the centre of health care: harmonizing mind and body, people and systems. WHO, Geneva. Cited 9 August 2011

  27. WHO (2008a) Three I’s meeting: Intensified Case Finding (ICF), Isoniazid Preventive Therapy (IPT) and TB Infection Control (IC) for people living with HIV. WHO, Geneva. Cited 21 July 2011

  28. WHO (2008b) Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Available: Cited 10 September 2011

  29. WHO (2009a) A framework to plan, implement and scale-up TB infection control activities at country, facility and community level. Implementing the WHO policy on TB infection control in health-care facilities, congregate settings and households. WHO, Geneva. Cited 5 July 2011

  30. WHO (2009b) WHO policy on TB infection control in health-care facilities, congregate settings and households. WHO, Geneva. Cited 2 July 2011

  31. WHO (2009c) Global tuberculosis control. WHO, Geneva. Cited 4 Feb 2012

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We thank the study participants, research assistants and the district health officials from both districts. We recognize the contribution of Suzanne Verver (KNCV TB Foundation, Netherlands), Richard Mugambe and Lynn Atuyambe (Makerere University School of Public Health).

Declaration of conflicting interest

The authors declare no potential conflict of interest with respect to the research, authorship, and publication of the article.


The authors received funding for carrying out the research, but no financial support to authorship and publication of this article. The funding was provided by KNCV TB Foundation and Belgium Technical Corporation (BTC).

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Corresponding author

Correspondence to Esther Buregyeya.

Appendix 1: An example of some of the questions asked in the focus group discussion and in-depth interview guide

Appendix 1: An example of some of the questions asked in the focus group discussion and in-depth interview guide

An example of some questions in the in-depth interview guide

  1. 1.

    Think about your community, what are the main health problems in this community? (Probe for TB if not mentioned) What is TB? (Probe for people’s opinions on TB, e.g., When you think about TB, what comes to your mind? (Encourage participants to reflect on the general opinion of TB in the community).(Probe: causes, signs and symptoms, transmission, disease associated, risk of getting TB in the community).

  2. 2.

    Tell me about the waiting area (outpatient department) and what happens there. (Probe if they received any verbal health info, and if TB was mentioned, what was mentioned about TB)

  3. 3.

    (If there was a talk) what kinds of information were they given in these talks? What kinds of requests did the health workers make of you?

  4. 4.

    4. What kinds of instructions did you receive about how you were expected to wait? Were you asked to wear or do anything specific?

  5. 5.

    How did you feel about these requests/instructions or how would feel if you were asked to;

    1. a.

      What did it feel like to be told to cover your mouth while coughing/how would you feel to be told to cover your mouth while coughing?

    2. b.

      What did it feel like to wear the mask/how would you feel if you were asked to wear a mask? (Hint: Show the patients the picture of a patient wearing a mask. Explain to them that wearing a mask by a TB suspect or TB patient helps in reducing transmission of TB).

    3. c.

      How did you feel when you were separated/how would feel if you were separated from the other OPD attendees/patients because you were coughing/TB suspect?

  6. 6.

    How do/would you feel being seen by a health-care worker wearing a mask? Please explain.

  7. 7.

    Please tell me what can be done by TB suspects/patients to reduce their chances of transmitting their infection to other TB patients? (probe for patients understanding of cough hygiene or cough etiquette.)

  8. 7.

    Suggest ways on how best TB suspects (patients with cough for 2 weeks or more) and patients can be handled in order to reduce chances of transmitting TB infection to other patients but without stigmatizing them?

An example of some questions in the focus group discussion guide

  1. 1.

    How common is TB in this health facility?

  2. 2.

    Which TB infection control measures is this facility implementing? Please tell me which administrative measures are implemented in the patient’s waiting area?

  3. 3.

    What are patients’ attitudes towards the following?

  4. a.

    Separating of patients suspected of having TB (cough for 2 weeks and above) from the other patients in the waiting area (OPD)

  5. b.

    Cough etiquette/covering their mouth when coughing and sneezing

  6. c.

    Wearing of surgical masks in the waiting area by those patients suspected of having TB or with confirmed TB

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Buregyeya, E., Mitchell, E.M.H., Rutebemberwa, E. et al. Acceptability of masking and patient separation to control nosocomial Tuberculosis in Uganda: a qualitative study. J Public Health 20, 599–606 (2012).

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  • Attitudes
  • Surgical masks
  • Tuberculosis prevention
  • Stigma
  • Uganda