Preventing tuberculosis transmission in Madura, Indonesia: A health belief model-based approach

Abstract

Pulmonary Tuberculosis (TB) is one of the top 10 causes of death in the world. Various efforts have been made to prevent the transmission of pulmonary tb, but it has not yet had a positive impact, and the success is still low. the health belief model (HBM) is a theory related to health as a form of orientation for health behavior interventions. This study aimed to determine the Lung TB transmission prevention model with the health belief model theory in Sumenep District, Madura, Indonesia. The study design was cross-sectional and implemented in Sumenep District from August to September, 2021. The study population was 152 patients with pulmonary TB, and the authors used a simple random sampling technique of 110 patients. The influence between variables was analyzed using Structural Equation Modeling (SEM) with SmartPLS. Cues to action, perceived susceptibility, perceived barriers, and self- efficacy factors affect the prevention of transmission. Personal factors indirectly affect the transmission prevention through perceived susceptibility, perceived barriers, and self-efficacy. Personal factors have a direct effect on self-efficacy and an indirect effect on self-efficacy through perceived susceptibility. The perceived susceptibility factor indirectly affects the prevention of
transmission through self-efficacy. The cues to action factor has an indirect effect on self-efficacy through perceived benefits. The prevention of pulmonary TB transmission model based on the health belief model is vital in supporting the increased effectiveness of preventing pulmonary TB transmission.

Full text

FULL PAPER
Preventing tuberculosis transmission in Madura,
Indonesia: A health belief model-based approach
Mujib Hannana,* |Emdat Suprayitnoa |Yudhiakuari Sincihub |Cory Nelia Damayantia |
Ristrini Ristrinic
Introduction
Pulmonary Tuberculosis (TB) is one of the top
10 causes of death in the world [1]. It has
received worldwide attention due to the
various efforts to prevent transmission [2].
Pulmonary TB has been infecting one-third of
the world's population [3]. It leads to
deteriorating health in millions of people each
year and is the second leading cause of death
from infectious diseases in the world [4].
According to the World Health
Organization (WHO), by 2022, an estimated
10.6 million people will suffer from
pulmonary TB, and 1.4 million will die.
Indonesia is the second largest contributor of
pulmonary TB cases worldwide after India,
J. Med. Pharm. Chem. Res. 7 (2025) 1617-1627 P a g e | 1617
aFaculty of Health Science, Universitas
Wiraraja, Indonesia
bFaculty of Medicine, Universitas Katolik
Widya Mandala Surabaya, Indonesia
cBadan Riset
Indonesia
dan
Inovasi Nasional,
*Corresponding
Author:
Mujib Hannan
Tel.: +81937304114
KEYWORDS
Pulmonary tuberculosis; health belief model; prevention of
transmission.
Pulmonary Tuberculosis (TB) is one of the top 10 causes of death in
the world. Various efforts have been made to prevent the
transmission of pulmonary tb, but it has not yet had a positive
impact, and the success is still low. the health belief model (HBM) is
a theory related to health as a form of orientation for health
behavior interventions. This study aimed to determine the Lung TB
transmission prevention model with the health belief model theory
in Sumenep District, Madura, Indonesia. The study design was
cross-sectional and implemented in Sumenep District from August
to September, 2021. The study population was 152 patients with
pulmonary TB, and the authors used a simple random sampling
technique of 110 patients. The influence between variables was
analyzed using Structural Equation Modeling (SEM) with SmartPLS.
Cues to action, perceived susceptibility, perceived barriers, and self-
efficacy factors affect the prevention of transmission. Personal
factors indirectly affect the transmission prevention through
perceived susceptibility, perceived barriers, and self-efficacy.
Personal factors have a direct effect on self-efficacy and an indirect
effect on self-efficacy through perceived susceptibility. The
perceived susceptibility factor indirectly affects the prevention of
transmission through self-efficacy. The cues to action factor has an
indirect effect on self-efficacy through perceived benefits. The
prevention of pulmonary TB transmission model based on the
health belief model is vital in supporting the increased effectiveness
of preventing pulmonary TB transmission.
Received: 27 September 2024 Revised: 09 November 2024 Accepted: 18 November 2024
DOI: 10.48309/JMPCR.2025.485382.1475

with an estimated 969,000 cases [5]. East Java
Province is in the top three with the number
of Lung TB cases out of 34 provinces in
Indonesia, and Sumenep Regency 2021 is the
district with the highest number of Lung TB in
East Java [6]. Based on data from the Sumenep
District Health Office in 2023, several health
center areas have a high incidence of
pulmonary TB, namely Puskesmas Bluto,
Puskesmas Pamolokan, and Puskesmas
Gapura.
Pulmonary TB is hazardous because of its
rapid transmission through airborne droplets
when coughing and sneezing [7]. The
transmission of lung TB germs is due to the
lack of awareness of sufferers, families, and
the environment to prevent transmission of
Lung TB [8]. Various efforts to overcome the
transmission of lung TB have been optimized
in various countries since 1995 [9]. However,
Pulmonary TB still causes health problems in
the community that cause sickness, disability,
and a very high mortality rate [10].
The World Health Organization (WHO)
developed
a
strategy
to
end
the
global
pulmonary TB epidemic by 2035 by reducing
the incidence and mortality rates by 90% and
95%, respectively [11]. DOTS strategy
recommendations (Directly Observed
Treatment Shortcourse) from WHO as an
effort to control Lung TB have not had a
positive impact, and its success is still low
[12]. especially the transmission of Lung TB in
the Sumenep community is still very high [13].
Therefore, a model is needed to prevent
the transmission of Lung TB in the Sumenep
district so that the incidence rate decreases
each year [14]. The health belief model (HBM)
is proven potentially effective because this
theory is used from a behavioral science
perspective to prevent disease transmission
[15]. The health belief model theory has been
used since the early 1950s to maintain health-
related behavior as a health behavior
intervention orientation [16]. Based on the
background above, the researcher needs to
use the theory in this study on the prevention
model of Pulmonary TB transmission with the
health belief model. This study aims to
determine the prevention model of pulmonary
TB transmission based on the health belief
model in Madura, Indonesia.
Experimental
The design in this study was cross-sectional.
This study was conducted at three health
centers in the Sumenep district, namely
Puskesmas Bluto, Puskesmas Gapura, and
Puskesmas Pamolokan, and was conducted
from August to September, 2024. The
population in this study were all patients with
pulmonary TB in three health centers in the
Sumenep district, namely Puskesmas Bluto,
Puskesmas Gapura, and Puskesmas
Pamolokan, with as many as 152 patients.
This study used a simple random sampling
technique with a sample size of 110
pulmonary TB patients. At this stage,
preliminary studies, research permits, and
research instruments with questionnaires
about demographic and respondent
characteristic data were collected and
analyzed. The authors collected the data by
administering questionnaires tested for
validity and reliability. Questionnaire
measurements on the perceived susceptibility
construct are categorized into low-risk,
moderate-risk, and high-risk. The severity,
perceived benefit, and self-efficacy are
categorized into high, moderate, and low. The
perceived barriers are categorized into low,
moderate, and high. The classification of cues
to action with indicators of health worker
support, family support, and media
information construct is categorized into high,
moderate, and low. The classification of
prevention of transmission of pulmonary
tuberculosis (prevention of transmission) is
categorized into good, sufficient, and deficient.
Personal constructs with indicators of age,
gender, education, occupation, income, and
length of illness-data analysis using Structural
Equation Modeling (SEM) Smart PLS.
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M. Hannan et al.

Results and discussion
Almost half of the respondents were aged ≥ 58
(31.8%). Gender was mostly (55.5%) male.
Education almost half (40.0%) graduated
from high school. Almost half (47.3%) were
self-employed. Economic status was mostly
(57.3%) ≥UMR. Length of illness was (61.8%)
1-2 years (Tables 1-3).
TABLE 1 Distribution of personal factors for patients with pulmonary TB in Sumenep District, Madura,
Indonesia, in 2024
Indicator
F
Percentage
(%)
Age (years old)
≤ 15-25
17
15.5
Min: 13
Max: 83
Mean: 46.67
SD: 17.444
26-
36
22
20.0
37-
47
13
11.8
48-
57
23
20.9
≥ 58
135
31.8
Total
110
100
Sex
Male
61
55.5
Female
49
44.5
Total
110
100
Education
Uneducated
12
10.9
Elementary graduates
33
30.0
Junior high school
graduates
21
19.1
Senior high school
graduates
44
40.0
Total
110
100
Occupation
Unemployed
12
10.9
Farmers/fishers
32
29.1
Self-
employed
52
47.3
Employee
14
12.7
Total
110
100
Income
< minimum wage
47
42.7
≥ minimum wage
63
57.3
Total
110
100
Illness duration
<1 year
27
24.5
Min: 0.16
Max: 9
Mean: 1.6670
SD: 1.67422
1-2 years
68
61.8
> 2 years
15
13.6
Total
110
100
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TABLE 2 Distribution of perceived susceptibility of lung TB in Sumenep District, Madura Indonesia, in
2024
No.
Category
Frequency
Percentage
(%)
1
Low risk
28
25.5
2
Moderate risk
55
50.0
3
High risk
27
24.5
Total
110
100
TABLE 3 Distribution of perceived severity of lung TB in Sumenep District Madura, Indonesia, in 2024
No.
Category
Frequency
Percentage(%)
1
High
49
44.5
2
Moderate
47
42.7
3
Low
14
12.7
Total
110
100
TABLE 4 Distribution of perceived benefit of lung TB in Sumenep District Madura, Indonesia, in 2024
No.
Category
Frequency
Percentage
(%)
1
High
19
17.3
2
Moderate
67
60.9
3
Low
24
21.8
Total
110
100
Table 4 reveals that most patients with
pulmonary TB (60.9%) have moderate
perceived
benefits.
Patients
with
Lung
TB
have perceived barriers almost entirely
(78.2%) moderate barriers (Table 5).
TABLE 5 Distribution of perceived barrier of lung TB in Sumenep District Madura, Indonesia, in 2024
No.
Category
Frequency
Percentage(%)
1
Low barrier
8
7.3
2
Moderate barrier
86
78.2
3
High barrier
16
14.5
Total
110
100
TABLE 6 Distribution of lung TB cues to action in Sumenep District Madura, Indonesia, in 2024
Indicator
Category
Total
High
Moderate
Low
F
(%)
F
(%)
F
(%)
∑
(%)
Health worker support
20
18.2
66
60.0
24
21.8
110
100
Family support
64
58.2
45
40.9
1
0.9
110
100
Media information
8
7.3
34
30.9
68
61.8
110
100
Table 6 indicates that patients with Lung
TB have cues to action with indicators of
health worker support mostly (60.0%)
moderate, indicators of family support mostly
(58.2%) high, and indicators of media
information mostly (61.8%) low.
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M. Hannan et al.

TABLE 7 Distribution of lung TB self-efficacy in Sumenep District Madura, Indonesia, in 2024
No.
Category
Frequency
Percentage (%)
1
High
36
32.7
2
Moderate
58
52.7
3
Low
16
14.5
Total
110
100
Table 7 shows that most patients with
pulmonary TB have moderate self-efficacy
(52.7%). Patients with pulmonary TB have
behavior to prevent the transmission of
pulmonary TB. Most of them (58.2%) are
sufficient (Table 8).
TABLE 8 Distribution of prevention of lung TB transmission in Sumenep District Madura, Indonesia, in
2024
No.
Category
Frequency
Percentage
(%)
1
Good
17
15.5
2
Sufficient
64
58.2
3
Deficient
29
26.4
Total
110
100
This study uses SEM analysis to determine
the prevention model of pulmonary TB
transmission based on the health belief model
in Madura, Indonesia. Based on the results of
the convergent validity test output, six
indicators have a factor loading value below
0.5, namely indicators of age, gender,
education, and occupation on personal
constructs, as well as indicators of family
support and media information on cues to
action constructs removed from the model
(Figure
1).
The
results
of
the
Average
Variance Extracted (AVE) test obtained the
value of all constructs> 0.5, indicating that the
indicators can explain their factors, and the
reliability test of all constructs obtained a
composite reliability value>0.6, which means
that
the
described
constructs
are
reliable
(Table 9).
FIGURE 1 Factor loading model fit analysis
Preventing tuberculosis transmission in madura…
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TABLE 9 Average Variants Extracted (AVE) and composite reliability values
Composite
Reliability
AVE
Cues to Action
1.0000
1.0000
Perceived Barriers
1.0000
1.0000
Perceived Benefit
1.0000
1.0000
Perceived Severity
1.0000
1.0000
Perceived Susceptibility
1.0000
1.0000
Personal
0.6949
0.5324
Prevention of Transmission
1.0000
1.0000
Self-
Efficacy
1.0000
1.0000
FIGURE 2 P-value model fit analysis
Figure 2 demonstrates that personal Lung
TB on perceived susceptibility has a p-value of
0.262 (>0.05), so personal lung TB affects
perceived susceptibility. Personal Lung TB on
perceived barriers has a p-value of 3.191 The
analysis for personal Lung TB on perceived
barriers showed P-value = 0.191, which is
significant (P < 0.05), so personal lung TB
affects perceived barriers. Personal Lung TB
on self-efficacy has a p-value of 3.160 (>0.05),
so personal lung TB affects self-efficacy.
Perceived susceptibility of lung TB to the
prevention of transmission has a p-value of
3.184 (>0.05), so that perceived susceptibility
of Lung TB affects the prevention of
transmission. Perceived susceptibility of lung
TB to self-efficacy has a p-value of 3.164
(>0.05), so perceived susceptibility of Lung TB
affects self-efficacy. Lung TB cues to action on
perceived benefit has a p-value of 3.504
(>0.05), so lung TB cues to action affect
perceived benefit. Lung TB cues to action on
the prevention of transmission have a p-value
of 0.549 (>0.05), so lung TB cues to action
affect the prevention of transmission. Lung TB
self-efficacy in the prevention of transmission
has a p-value of 3.125 (>0.05), so lung TB self-
efficacy affects the prevention of transmission.
Perceived benefits of lung TB on self-efficacy
has a p-value of 0.597 (>0.05), so the
perceived benefits of lung TB affect self-
efficacy. Perceived barriers of Lung TB to the
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M. Hannan et al.

prevention of transmission have a p-value of
0.104 (>0.05), so perceived barriers to lung
TB affect the prevention of transmission. Two
pathways are not significant, namely personal
lung TB to perceived severity and perceived
severity to the prevention of transmission,
because they have a p-value <0.05, so they are
removed from the pathway.
Discussion
The health belief model theory explains that
perceived susceptibility, perceived severity,
perceived benefits, perceived barriers, cues to
action, and self-efficacy influence the
prevention of transmission [17].
Cues to action is a cue for someone to take
action or behave in the form of behavior [17].
Cues can be in the form of external and
internal factors, such as support from health
workers, messages from the mass media, and
advice or recommendations from friends or
other family members. Cues to action on
indicators of health worker support have a
direct effect on the prevention of transmission
behavior (prevention of transmission) of
pulmonary tuberculosis and have an indirect
effect by increasing health knowledge and
skills through health system support that
makes one aware of the benefits of an action
taken by a person so that it forms a person's
belief to continue to behave healthily and
ultimately make a proper prevention of
transmission behavior [18].
Self-efficacy is a belief in one's ability to
organize and carry out the expected actions to
achieve goals [19]. Self-efficacy can influence
his decisions about actions to achieve his
goals, including his evaluation of various
events encountered [20]. Self-efficacy affects
one's personal goals in action. The higher a
person's level of self-efficacy, the better the
prevention of transmission behavior of
pulmonary tuberculosis [21]. Personal factors
such as economic level affect the formation of
good self-efficacy. Personal factors in the form
of
a
good
economy
are
in
line
with
high
knowledge. Therefore, it is easy to have
confidence in behavior in preventing
pulmonary TB [22]. Besides personal
economic factors, the length of illness affects
the self-efficacy of patients and families with
pulmonary TB. The length of illness a person
suffers will make them try to find treatment
information and carry out all kinds of
treatment to recover and prevent
transmission [23].
Perceived susceptibility is a person's
subjective perception of the risk of their
health condition, including acceptance of
diagnostic results and personal estimates
[19]. Perceived susceptibility affects a
person's behavior. The higher the perceived
susceptibility of a person, the better the
prevention of transmission behavior
(prevention of transmission) of Lung TB [24].
Personal factors in the form of a good
economy align with high knowledge to
understand low feelings of vulnerability and
obedient behavior in preventing good
Pulmonary TB [25]. Bsides personal economic
factors, the length of illness affects the feelings
of vulnerability of people with pulmonary TB.
The length of illness a person suffers will
make them feel highly vulnerable to infecting
others [26].
Perceived barriers or perceived barriers to
change, if individuals face obstacles found in
carrying out a health behavior such as
uncertainty, perceived side effects,
nervousness, and something that might act as
an obstacle for someone to behave healthily
[17]. Perceived barriers affect a person's
healthy behavior. The lower a person's
perceived barriers, the better the prevention
of transmission behavior of Pulmonary TB
[27]. Personal factors in the form of
economics affect feelings of barriers to
healthy behavior, such as difficulty getting to
health services, low health knowledge, and
excessive worry [28]. Besides personal
economic factors, the length of illness affects
feelings of obstacles for patients and families
with
pulmonary
TB.
The
length
of
illness
Preventing tuberculosis transmission in madura…
P a g e | 1623

someone suffers will make sufferers saturated
with trying to find treatment information and
carry out all kinds of treatment [29].
Conclusion
Cues to action, perceived susceptibility,
perceived barriers, and self-efficacy factors
affect the prevention of transmission.
Personal factors indirectly affect the
prevention of transmission through perceived
susceptibility, perceived barriers, and self-
efficacy. Personal factors have a direct effect
on self-efficacy and an indirect effect on self-
efficacy through perceived susceptibility. The
perceived susceptibility factor indirectly
affects the prevention of transmission through
self-efficacy. The cues to action factor
indirectly affects self-efficacy through
perceived benefits. The model of prevention of
pulmonary TB transmission based on the
health belief model has a vital role in
supporting the increase in the effectiveness of
preventing pulmonary TB transmission.
Acknowledgments
The authors would like to thank the Ministry
of Education, Culture, Research, and
Technology of Indonesia (Kemendikbud-
Ristek) for providing a research grant to carry
out the scheme PKDN research with grant
number:062/E5/PG.02.00/PL.BATCH.2/2024;
08/SP2H/PTBATCH.2/LL7/2024;028/LPPM/
PP-04/E.01/UNIJA/VIII/2024.
Funding
This research was funded by the Ministry of
Education, Culture, Research, and Technology
of Indonesia (Kemendikbud-Ristek).
Authors' Contributions
Mujib Hannan: substantial contribution to the
conception and design, analysis and
interpretation of data.
Emdat Suprayitno: Creating research
discussion, conducting data analysis, assisting
in collecting research data, assisting in
publication.
Yudhiakuari Sincihu: Drafting the concept of
module material, coordination and Focus
group discussion with a team of health
experts, drafting research instruments,
validity and reliability tests.
Cory Nelia Damayanti: data collection process,
drafting the final report, drafting the KI
submission, conducting the RAB report,
coordinating with health experts
Ristrini: Drafting the Concept of the TB
Transmission Prevention Model, Data Analysis
and Assisting in Publication.
Conflict of Interest
The authors declare no conflict of interest.
Orcid:
Mujib Hannan*:
https://orcid.org/0000-0002-9405-6819
Emdat Suprayitno:
https://orcid.org/0000-0002-3438-5506
Yudhiakuari Sincihu:
https://orcid.org/0000-0003-0609-8996
Cory Nelia Damayanti:
https://orcid.org/0000-0003-3654-7211
Ristrini Ristrini:
https://orcid.org/0000-0003-1294-9013
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Preventing tuberculosis transmission in madura…
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How to cite this article: Mujib Hannan,
Emdat Suprayitno, Yudhiakuari Sincihu,
Cory Nelia Damayanti, Ristrini, Preventing
tuberculosis transmission in Madura,
Indonesia: A health belief model-based
approach. Journal of Medicinal and
Pharmaceutical Chemistry Research, 2025,
7(8), 1617-1627. Link:
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