INTRODUCTION:

Tuberculosis (TB) is recognized as one of the most public health problems in spite of the organism discovered 100 years ago, and the availability of highly effective drugs and vaccine which can prevent and cure the diseases. It was also “estimated that one third of world population is infected asymptomatically with TB of which 5-10% will develop clinical complaint during their life period”¹. The primary goal of tuberculosis (TB) control programs is to minimize transmission within the community and reduce TB incidence by detecting and treating active TB disease as early as possible. A major contributor to ongoing transmission is delay in diagnosis of TB. Diagnostic delays worsen disease prognosis at the individual level and amplify transmission within the community^2,3

Case detection is the vital step in eliminating the tuberculosis; it includes identification, evaluation and receiving the result and reporting with active TB. Usually it is diagnosed when the person is coming with symptoms to the hospital. Thus the health care providers have a major role in detecting the tuberculosis cases. Earlier diagnosis would result in better achievement in treatment, less transmission to contacts, and fewer out breaks of TB⁴. The most significant limitations for upkeep of quality TB services by RNTCP are lack of staff ensuing from its quick extension phase⁵

Hence detecting the cases is a vital component of TB control program which helps to identify the cases, treat them earlier and break the chain of infection. A compact scrutiny of the current case detection situation is mandatory to plan locally suitable approaches and order among possible options. This study attempts to find out the current knowledge and practices of PHC health care workers in TB case finding followed by training as per their needs and evaluate the impact of training on their knowledge and practices in TB case finding.

PRIMARY OBJECTIVES:

1. To find out the difference in proportion of health care workers having adequate knowledge and practice for TB case finding as per RNTCP guideline between pre and post need-oriented training program.

2. To find out the association between healthcare workers knowledge and practice regarding case finding with their demographic variables.

SECONDARY OBJECTIVE:

1. To find out the difference in key case finding indicators between pre and post training program: TB suspect evaluation rate, proportion of suspects diagnosed with TB, ratio of new smear positive to smear negative PTB cases and ratio of new to retreatment PTB cases.

AIMS:

1. To assess the existing situation of TU/DMC/PHC and the level of knowledge and practice of HCWs on TB case finding activities.

2. Find out the current proportion of healthcare workers having adequate knowledge and practice for TB case finding as per RNTCP guidelines.

3. Identify the training needs of the HCWs

4. Conduct the training program as per the needs of HCWs.

5. Find out the proportion of health care workers having adequate knowledge and practice for TB case finding as per RNTCP guidelines after the need oriented training program.

6. Find out changes in key case finding indicators between pre and post training program.

OPERATIONAL DEFINITIONS OF TERMS:

Impact:

It refers to strong effect of need-based training of healthcare workers on knowledge and practice regarding case finding which is measured by post test score.

RNTCP:

Revised National Tuberculosis Control Program is one of the National programs of public health sector started in 1992 with an objective to minimize the TB at the community level that it terminates the public health problem.

RNTCP Guidelines:

It refers to the stepwise authorized activities stated by the government in regard to case finding under RNTCP.

Case Finding:

It refers to identifying the individual with symptoms of pulmonary tuberculosis like cough more than two weeks, fever, night sweats, weight loss and referring for sputum smear microscopic examination.

Knowledge:

It refers to awareness of healthcare workers regarding tuberculosis case finding such as definition, causes, signs and symptoms, diagnostic methods and treatment and is assessed using structured knowledge questionnaire prepared by the researcher which is used as a pre assessment tool to evaluate the needs of the healthcare workers.

Practice:

It includes actual application of RNTCP guidelines to carry out the standard procedure like complete physical examination, sputum collection, sputum examination, health education, recording, reporting and initiating TB treatment for tuberculosis case finding which is observed by researcher using Objective Structured Clinical Examination.

Objective Structured Clinical Examination (OSCE):

It refers to a check list used to observe the practice of healthcare workers on tuberculosis case findings like physical assessment, sputum collection, sputum examination, health education, recording, reporting and initiating TB treatment which is prepared by the researcher.

Healthcare workers:

It refers to the healthcare workers who are working in Primary Health Centres of three tuberculosis units of Bangalore urban area and are divided into 3 groups based on their educational qualification, designation and the job description;

Group I:

Medical officers (MO) refers to a doctor who completed MBBS and working at primary health centre.

Group II:

Staff Nurse:

refers to a nurse who has the educational qualification of general nursing and midwifery or B.Sc. Nursing and working in primary health centre.

Health Assistant:

(HA) refers to an assistant who has the educational qualification of ANM or MPHW or PUC and based on their experience and gender they are designated as Junior Health Assistant Male (JHAM), Junior Health Assistant Female (JHAF), Senior Health Assistant Male (SHAM) and Senior Health Assistant Female (SHAF).

Senior Treatment Supervisor (STS):

refers to the staff, who has the educational qualification of any degree and taken training under RNTCP and assigned for one TU.

Tuberculosis Health Visitors (TBHV):

refers to the staff, who has completed the educational qualification of sanitary health Inspector are designated as Tuberculosis Health Visitors (TBHV) for every one lakh population.

Lady Health Visitor (LHV) and Village Health Nurse (VHN):

refers to the field worker, has the qualification of SSLC and working in the primary health centres.

Accredited Social Health Activists (ASHA):

refers to a worker with minimum of 8^th standard qualification assigned for one lakh population.

Group III:

Senior Tuberculosis Laboratory Supervisor (STLS):

refers to the staff, who has the educational qualification of diploma in Laboratory Technician taken training under RNTCP assigned to look after one TU.

Lab technician (LT):

refers to the staff, who has the educational qualification of diploma in Laboratory Technician and posted in designated microscopic centres.

Need-based training

It refers to educating the healthcare workers to the extent to which it is needed after assessing their existing level of knowledge and practice regarding tuberculosis case finding. The content is prepared based on existing knowledge regarding case finding by the researcher in accordance to RNTCP guideline and includes the following essence.

Group I Problem of TB in India, RNTCP goal, objectives, DOTS strategy, STOP TB strategy, ACSM, identification of TB suspects, mode of transmission, diagnosis of TB, diagnostic algorithm of PTB, type of cases, treatment of TB, MDR TB, chemoprophylaxis, HIV co infection among TB patients, intensified TB case finding at ICTC, ART and CCC, determination of TB outcome, and responsibilities of medical officer.

Group II Problem of TB in India, RNTCP, goal, objectives, DOTS strategy, identification of TB suspects, PTB suspects, mode of transmission, diagnosis of TB, type of cases, treatment of TB, determination of TB outcome, and their responsibilities.

Group III Problem of TB in India, RNTCP, goal, objectives, DOTS strategy, identification of TB suspects, PTB suspects, mode of transmission, diagnosis of TB, collecting sputum, preparing and staining slides, examining slides, recording, reporting and verifying results, type of cases, treatment of TB, and determination of TB outcome.

Tuberculosis Unit (TU):

It refers to a TB unit which is established at sub district at the rate of one per 500,000 populations (one per 250,000 populations in tribal and hilly areas).

Designated Microscopic Centre (DMC):

It refers to a centre which covers almost 100,000 populations (50,000 in tribal and mountainous areas) and consists of trained LT, promoted laboratory facilities, binocular microscope and laboratory consumables.

Primary Health Centre (PHC):

It refers to the centre which covers the population of 30,000 populations in plain areas 20,000 population in hilly, tribal and backward areas for more effective coverage.

Research hypothesis:

RH₁ There is a significant difference in the proportion of healthcare workers having adequate knowledge and practice of TB case finding between pre and post need- based training program.

RH₂ There is a significant association between knowledge and practice mean scores of healthcare workers and their selected socio-demographic variables

Delimitations:

The study is delimited to:

· Period of 1 year of data collection

· PHCs of selected Tuberculosis units

· Healthcare workers working at selected PHCs during the time of data collection.

MATERIALS AND METHODS:

Study setting:

This study was carried out in urban Tuberculosis units’ PHCs in Bangalore, Karnataka. Bangalore urban has got 5 TUs, rural has got 3 TUs and BBMP has got 7 TUs. Based on the operational feasibility and easy access of the researcher Bangalore urban was selected. It has 5 TUs in which 3 consecutive TUs were selected using convenient sampling method based on practicability for the study namely K.R. Puram, Yelanka and Anekal, which covers the population of 18, 65,834 and there are 13, 16 and 15 PHCs under each TU respectively.

Study population:

It consisted of all healthcare workers who fulfilled the inclusion criteria. The healthcare workers posted in PHCs of selected TUs involved in TB case finding: MOs, LT, Staff Nurse, STLS, STS, ANMs, MPHWs, Health Assistants, VHN, LHV and ASHA. These HCWs are divided into three groups based on the qualification and job description.

Group I: Medical officers

Group II: Staff nurse, ANMs, MPHWs, STS, HA, TBHV, LHV/VHN, ASHA

Group III: STLS, Lab technicians

Study Method:

Study proposal was presented in front of Institutional Ethical Committee and approval was taken before the start of the study. Permission was obtained from State Tuberculosis Officer and District Tuberculosis Officer to conduct the study at Primary Health Centres. Convenient sampling method was used to select the 3 TUs and all healthcare workers working in primary health centre of selected TU’s were included. A total of 451 Healthcare workers working in the 44 PHCs of selected 3 TUs were included in study. From them 414 healthcare workers who fulfilled the inclusion criteria and present on the day of data collection had participated on the study. Information regarding TU, DMC and PHCs were collected about the TB case finding activities of the Centres. Written and informed consent was obtained from the respondents after assuring confidentiality. The data collection procedure was explained to study participants. After establishing rapport, brief introduction was given about the study and its purpose.

Questionnaire and OSCE check list was prepared separately for each group. The researcher has collected required data from each healthcare worker independently at a suitable time using a structured knowledge questionnaire. After completing the knowledge questionnaire, the participants were assessed for their practice by OSCE. Assignment with signs and symptoms of tuberculosis in mock patients were given to participants to find out the cases of tuberculosis which was observed by the set of OSCE check list in different stations. Each station was set with necessary equipments and articles to carryout the procedure.

After the pretest, the training needs of different categories of staff were identified and need oriented training program was conducted separately for each group of staff, in collaboration with DTO/THO and MOTCs. The teaching for each group was taken around 45 to 60 minutes. Group teaching for each group was given on different days separately and who were unable to come and attend the teaching was taught individually.

The post test was done by the researcher with the same questionnaire after completion of the three months in which the participants trained.

Dropouts and its analysis:

There were totally 11 dropouts out of 414 healthcare workers. Three HCWs have withdrawn their participation from the study due to retirement and the 8 HCWs the researcher could not access them after three visits of the PHC. For the final analysis 403 samples were taken

Data analysis:

The data was analyzed by using descriptive and inferential statistical methods. Frequency, percentage distribution, mean and standard deviation were used for the assessment of socio-demographic and selected variables, knowledge and practice level. The proportion of knowledge was compared using chi-square test. Differences observed between subjects were analyzed using one-way ANOVA, association of socio-demographic variables with knowledge and practice level was analyzed by paired t test.

RESULTS:

Table 1 Baseline data of Tuberculosis Unit’s

Sl. No.	Information	Remarks of TUs
1	Name of the TB unit	K.R. Puram	Yelanka	Anekal
2	Number of the DMCs	5	6	6
3	Number of PHCs attached	13	16	15
4	Total population covered	7,78,289	4,98,171	5,89,374
5	Nominated MOTC in place and trained by RNTCP	Yes	Yes	yes
6	STS post filled and trained by RNTCP	Yes	Yes	yes
7	STLS post filled and trained by RNTCP	Yes	Yes	yes
8	TB suspect evaluation rate in previous quarter	1151	1114	1063
9	Number of suspects labeled as smear positive in previous quarter:	91	99	69
10	Number of smear positive and smear negative TB cases diagnosed in previous quarter:	106	80	86
11	Total PTB notification rate per 100000 populations	11.69	20.61	12.58
12	Defaulters in previous year	37	45	59

Table 2 Frequency and percentage distribution of HCWs with socio-demographic variables.

Variables

Numbers (N= 403)

Percentage (%)

Age in years

1. < =30

2. 31 – 40

3. 41 – 50

4. 51 – 60

127

106

20.3

31.5

21.8

26.3

Gender

1. Male

2. Female

121

282

30.0

70.0

Educational qualification

1. MBBS

2. DMLT

3. BSC N

4. GNM

5. ANM

6. Secondary school

7. Others (B.sc, B.com, DME, BA, HI, DEE)

180

14.8

8.6

1.0

10.6

7.6

45.0

12.4

Work experience

1. < 1 years

2. 1 – 9 years

3. 10- 19 years

4. More than 20 years

153

116

130

1.0

38.0

28.7

32.2

Designation

1. Medical officer

2. Lab technician

3. STLS

4. Staff Nurse

5. JHA

6. SHA

7. TBHV

8. LHV/VHN

9. ASHA

10. Others (BHEO, SHI, JHI)

11. STS

193

14.8

7.9

0.7

11.7

47.8

5.7

1.7

5.0

2.7

1.0

0.7

Training under RNTCP

1. Trained

2. Not trained

324

80.4

19.6

Table 3 Overall Percentage of knowledge level of HCWs

Test	Percentage of Knowledge			Total N(%)	c2 value	‘p’ value
	Inadequate <50%) N (%)	Moderately adequate (50-70%) N (%)	Adequate (>70%) N (%)
Pre	173(42.9)	187 (46.6)	43 (10.7)	403(100)	120.174	0.001***
Post	47 (11.7)	225 (55.8)	131 (32.5)	403 (100)

Table 4 The difference in mean percentage of pre and post test knowledge score of HCWs among groups

Groups	Test	N	Mean	SD	Min	Max	MeanDiff	SE Diff	‘t’ value	‘p’ value
Group 1	Pre	60	57.4	15.425	17.5	87.5	13.8	2.57	5.364	0.001^***
Group 1	Post	60	71.2	12.601	30.0	92.5	13.8	2.57	5.364	0.001^***
Group 2	Pre	308	49.8	15.427	7.7	92.3	12.1	1.17	10.366	0.001^***
Group 2	Post	308	61.9	13.568	15.4	92.3	12.1	1.17	10.366	0.001^***
Group 3	Pre	35	53.4	13.848	28.6	77.1	17.4	3.20	5.417	0.001^***
Group 3	Post	35	70.8	12.984	31.4	94.3	17.4	3.20	5.417	0.001^***

*** very high significance at P≤0.001

Table 5 Overall percentage of practice level of HCWs

Test	Percentage of Practice			Total N (%)	c2 value	‘p’ value
	Inadequate (<50%) N (%)	Moderately adequate (50-69%) N (%)	Adequate (>=70%) N (%)
Pre	103(25.6)	183(45.4)	117(29)	403(100)	134.949	0.001^***
Post	4(1)	160(39.7)	239(59.3)	403(100)

Table 6 The difference in mean percentage and standard deviation of pre and post test practice HCWs

Groups	Test	N	Mean	SD	Min	Max.	Mean Diff	SE Diff	‘t’ value	‘p’ value
Group 1	Pre	60	68.6	17.014	36.4	100.0	13.8	2.67	5.153	0.001^***
Group 1	Post	60	82.4	11.831	54.5	100.0	13.8	2.67	5.153	0.001^***
Group 2	Pre	308	55.5	13.826	22.2	88.9	14.9	1.07	13.872	0.001^***
Group 2	Post	308	70.4	12.829	38.9	127.8	14.9	1.07	13.872	0.001^***
Group 3	Pre	35	74.5	9.495	46.7	90.0	12.2	1.80	6.767	0.001^***
Group 3	Post	35	86.7	4.847	73.3	93.3	12.2	1.80	6.767	0.001^***

^***very high significance at P ≤0.001

Table 7 Quarterly report of key case finding indicators for 2013 and 2014.

Year	Quarter	Name of TUs	Key case finding indicators
Year	Quarter	Name of TUs	TB suspect evaluation rate	Proportion of suspects diagnosed with TB	Ratio of new smear positive to smear negative	Total number of sputum positive cat II retreatment cases
2013	Q1	K R Puram	1147	77	68	27
		Yelanka	1096	79	42	20
		Anekal	1020	72	55	23
	Q2	K R P	1151	91	56	25
		Yelanka	1114	93	45	26
		Anekal	1005	77	62	18
	Q3	K R Puram	1287	103	58	30
		Yelanka	1229	109	52	18
		Anekal	1063	69	67	24
	Q4	K R Puram	1227	84	72	32
		Yelanka	1077	87	52	19
		Anekal	836	58	62	32
2014	Q1	K R Puram	1102	79	63	22
		Yelanka	1034	71	53	18
		Anekal	860	53	51	16
	Q2	K R Puram	1195	102	70	23
		Yelanka	949	83	43	31
		Anekal	802	67	46	17
	Q3	K R Puram	1362	101	74	25
		Yelanka	1087	88	50	19
		Anekal	947	77	59	19
	Q4	K R Puram	1375	108	80	25
		Yelanka	1009	80	49	24
		Anekal	886	69	63	18

The above table-7 reveals the key case finding indicators before and after teaching. The total TB suspect evaluation rate in K.R. Puram TU in the year of 2013 was 4812 whereas in 2014 it was 5034 which show the TB suspect evaluation rate is higher than the previous year. In Yelanka and Anekal TUs it was 4516 and 3924 in the year 2013 and 4079 and 3495 in the year 2014 respectively, which indicates that the TB suspect evaluation rate has come down. Regarding the proportion of suspects diagnosed with TB, it was increased in K.R Puram TU from 355 in 2013 to 390 in 2014, whereas in Yelanka and Anekal TUs it has declined from 368 to 322 and 276 to 266 respectively.

About the ratio of new smear positive to smear negative cases in K.R. Puram and Yelanka TUs 254, 191 in the year of 2013 and 287, 195 in the year of 2014 respectively which is increased comparing to the previous year. The other hand, in Anekal TU it was declined from 246 to 219 comparing to previous year. Concerning the total number of sputum positive cat II retreatment patients, in K.R. Puram and Anekal TUs it was 114 and 97 in the year of 2013 and 95 and 70 in the year of 2014 respectively which shows there was a reduction in the total number of sputum positive cat II retreatment patients. Whereas in Yelanka TU it was 83 in 2013, 92 in 2014 which show marginal increase in cases.

DISCUSSION:

The findings of the study are based on its objectives and are discussed in the following headings.

Primary Objective 1: To find out the difference in proportion of health care workers having adequate knowledge and practice for TB case finding as per RNTCP guideline between pre and post need-oriented training program

The difference in mean percentage of pre and post test knowledge level of HCWs, in which group 1 had highest mean percentage (57.4, 71.2) in pre and post test among all groups. The difference observed in all groups were statistically significant at p<0.001. The difference mean percentage of pre and post test practice level of HCWs, in which group 3 had highest mean percentage (74.5, 86.7) in pre and post test among all groups. The difference observed in all groups were statistically significant (p<0.001)

The findings are consistent with the study done by Jain R.C. to assess the effectiveness of multi module training for health care professions at tuberculosis education and training centre at Bangalore. Around 32 health care professionals were selected randomly. A self administered questionnaire was used. Healthcare professionals showed marginal improvements in clinical practice behavior when they attended more than one training. The result showed significant improvement (32%) in the knowledge of healthcare professionals regarding tuberculosis and its treatment (DOTS) after attending training program. Thus, the study reported, great levels of satisfaction, information, enhancement and intent to change after each training experience⁶.

Hence the RH₁ stated that ‘’There is a significant difference in the proportion of healthcare workers having adequate knowledge and practice of TB case finding between pre and post need- based training program’’ was accepted.

Objective 2: To find out the association between healthcare workers knowledge and practice regarding case finding with their demographic variables.

Regarding the association between HCWs knowledge and selected socio-demographic variables reveals that, there was a statistically significant difference observed between pre and post test of HCWs with gender, age (other than 41-50 years in group 1), work experience (other than <1 year in group 1 and >20 years in group 3), and RNTCP training.

The association between HCWs practice and selected socio-demographic variables reveals that, there was statistically significant difference observed between pre and post test of HCWs with gender, age (other than <=30 and 51-60 years in group 1), work experience (other than <1 year and >=20 years in group 1 and >=20 years in group 2), and RNTCP training (other than group 1 who had not taken training).

Hence RH₂ stated that, ‘‘There is a significant association between knowledge and practice of healthcare workers and their selected socio-demographic variables’’ was accepted.

The secondary objective was to find out the difference in key case finding indicators between pre and post training program: TB suspect evaluation rate, proportion of suspects diagnosed with TB, ratio of new smear positive to smear negative PTB cases and ratio of new to retreatment PTB cases.

With respect to the key case finding indicators before and after teaching, the total TB suspect evaluation rate in K.R. Puram TU in the year of 2013 was 4812 whereas in 2014 it was 5034 which show the TB suspect evaluation rate is higher than the previous year. In Yelanka and Anekal TUs it was 4516 and 3924 in the year 2013 and 4079 and 3495 in the year 2014 respectively, which indicates that the TB suspect evaluation rate has come down. Regarding the proportion of suspects diagnosed with TB, it was increased in K.R Puram TU from 355 in 2013 to 390 in 2014, whereas in Yelanka and Anekal TUs it has declined from 368 to 322 and 276 to 266 respectively.

The quarterly report reflects that the K.R Puram TU had shown significant improvement in all key case finding indicators comparing with other TUs.

CONCLUSION:

The above discussed study findings clearly represent that, there has been high statistical significant impact on need based training of healthcare workers on their knowledge and practice regarding case findings. This draws the conclusion for the study that, teaching was effective and it should be done with regular interval. Sensitizing the HCWs with knowledge and practice of case finding with regular intervals, would improve their level of knowledge and practice in case finding. The most significant limitations for up keeping the quality TB services by RNTCP are lack of staff ensuing from its quick extension phase. Till the recruitment of required staff, the available staff needs to be distributed in understaffed areas and proper training should be given to them.

RECOMMENDATIONS:

· District public health nurse can be included in the activities of RNTCP

· The similar research study can be conducted in all tuberculosis units. The same study can be replicated for better generalization.

· Effectiveness of OSCE can be studied further.

· An explorative study can be done to assess the barriers of healthcare workers in early case detection

· To assess the attitude of healthcare workers towards case detection, additional studies are required.

· Up gradation of current TB laboratories and formation of new microscopic centres and appointment of required laboratory technician to enhance case detection is essential.

· Involving nursing faculty for supervision and arranging for reinforcement teaching on regular interval.

· OSCE can be included in RNTCP training for healthcare workers.

ACKNOWLEDGEMENT:

The authors are grateful to Dr. V K Chadha for his proficient guidance and support throughout the study period and Mr. Jaganathan, Statistician for critical analysis of data, expert guidance and direction rendered during the study.

REFERENCES:

1. Park k. Preventive and Social Medicine, 22^nd edi. Jabalpur, Banarsidas Bhanot Publishers. 2013. p 166-183.

2. Dye C, Scheele S, Dolin P, Pathania V, Raviglione M.C. Consensus statement. Global burden of tuberculosis: estimated incidence, prevalence and mortality by country. WHO Global Surveillance and Monitoring Project. JAMA. 1999; 282:677–686.

3. Bjune G. Tuberculosis in the 21st century: an emerging pandemic? Norsk Epidemiologi.2005;15:133–139.

4. Washington State dept of Health, DOIt 343-071, July 2011.

5. Naveent Singh, Dheeraj Gupta. Revised National Tuberculosis Control Program (RNTCP) in India; current status and challenges. URL from htt://www.lungindia.com

6. Jain R.C., Tuberculosis – challenges and opportunities, Indian J Tuberc 2011; 58:148-154 Available from: URL:http://Irsitbrd.nic.in/IJTB/IJT_14.pdf

Received on 31.07.2019 Modified on 10.09.2019

Asian J. Nursing Education and Research. 2020; 10(2):145-153.

DOI: 10.5958/2349-2996.2020.00032.4