|Year : 2017 | Volume
| Issue : 2 | Page : 4-10
Evaluation of the knowledge of MDR- TB among the Multi-Purpose Workers, under the Revised National Tuberculosis Control Programme, in the mid hills of Himachal Pradesh, India
AK Singh1, B Chawla2, S Chawla2, DK Bhaglani3
1 Ph.D Student, Dr. Yashwant Singh Parmar University of Horticulture and Forestry, Nauni, Solan, Himachal Pradesh, India
2 Assistant Professor, Department Community Medicine, Department Community medicine, MMM college, Kumarhatti, Solan, Himachal Pradesh, India
3 Medical Officer TB, RH Solan, Department of Health and Family Welfare, Solan, Himachal Pradesh, India
|Date of Web Publication||31-Aug-2018|
A K Singh
Ph.D Student, Dr. Yashwant Singh Parmar University of Horticulture and Forestry, Nauni, Solan, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Knowledge of MDR- TB in Multi- Purpose Workers (MPWs) is cornerstone for implementation of RNTCP, so its evaluation is necessary.
Methods: A Cross sectional study in 174 MPWs was conducted. Seven questions about MDR- TB were asked. Answers graded as no answer, incorrect answer and correct answer were allocated zero point, zero and two points respectively. Total score by the MPWs (out of 14), converted to percentage, was used to categorize the knowledge as no knowledge (0%), poor knowledge (> 0 and ≤ 25 %), fair (> 25 and ≤ 50 %), good (>50 and ≤ 75%) and > 75% as excellent knowledge. Comparison was done with the years of job, the training and DOTS provision status. The data was analyzed in SPSS Statistics version 21 and Microsoft Excel 2010 software.
Results: Only 9.2% MPWs had received Modular training. 85.6% had provided DOTS and 86.8% had more than five years of job experience. 9.1% workers had no knowledge about MDR-TB. 16.6%, 53.4% and 20.6% workers had poor, fair and good knowledge respectively. Significant difference of knowledge by gender was found (p-value = 0.02). 15.8% and 52.5% of untrained workers had poor and fair knowledge, respectively. 88.8% of workers having good knowledge were the DOT Providers (p- value of 0.04). 66.7% workers having good knowledge had job experience of more than 20 years (p- value = 0.001).
Conclusion: Knowledge about MDR- TB in MPWs has a significant relation with DOTS provision status and the years of service rendered. Absence of Modular trainings leads to poor knowledge of the worker.
Keywords: Study, knowledge, comparison, gender
|How to cite this article:|
Singh A K, Chawla B, Chawla S, Bhaglani D K. Evaluation of the knowledge of MDR- TB among the Multi-Purpose Workers, under the Revised National Tuberculosis Control Programme, in the mid hills of Himachal Pradesh, India. J Integr Health Sci 2017;5:4-10
|How to cite this URL:|
Singh A K, Chawla B, Chawla S, Bhaglani D K. Evaluation of the knowledge of MDR- TB among the Multi-Purpose Workers, under the Revised National Tuberculosis Control Programme, in the mid hills of Himachal Pradesh, India. J Integr Health Sci [serial online] 2017 [cited 2019 Aug 21];5:4-10. Available from: http://www.jihs.in/text.asp?2017/5/2/4/240244
| Introduction|| |
Tuberculosis is a major public health problem worldwide. The incidence of the disease is especially high in the South East Asia region. In the year 2014, 58% of the total 9.6 million new tubercular cases were detected in this region. With an incidence of about 2.2 million TB cases and a high prevalence of 2.9 million cases reported in the year 2015, India amounts to have a large proportion of infectious pool of the disease. Since the National Tuberculosis Programme (1962) to the evolution of Revised National Tuberculosis Control Programme (RNTCP) in 1992 the targets of cure and diagnosis have been modified form time to time. In 60's only 30% of the patients were diagnosed and of them only 30% got treated successfully. The advent of the RNTCP, based upon the Directly Observed Treatment- Short Course (DOTS), started with the objectives of detecting at least 70% of new sputum positive cases and curing at least 85% of such patients. Globally the incidence of TB has fallen by an average of 1.5% per year since 2000 India also accounted for an increased number of tubercular case finding than any other country since 2000. Millennium Development Goals adopted in 2000 intended to halt and begin to reverse the incidence of TB by 2015 under the target 8 of the MD Goal 6. Presently the Stop TB strategy focuses on its objectives of protecting the vulnerable population from the Multi Drug Resistant (MDR) TB and promotes the use of International Standards for TB care.
The Health Worker is the first Public Health Functionary to be in contact with the masses at the village level. The MPW is supposed to suspect a tubercular case, collect sputum for diagnosis and act as a DOT Provider for confirmed tubercular case/cases. The job profile for being a DOT Provider warrants an up to date knowledge about the disease, its progression, spread, diagnosis and cure by treatment. Many evaluation studies in the past have documented that the MPWs are the major DOT Providers in the community, at least at the village level and have a weak knowledge about TB., Untrained status, lack of periodic trainings and poor monitoring / supervision status of the workers has been an area of concern for years together now since 1962. To eliminate TB by the year 2050, the adoption of International Standards of TB care may help to upscale the knowledge of the grass root level MPWs.
Solan, a mid-hill region of Himachal Pradesh has witnessed a fast growth of industrialization and migrant population inhabitations throughout the district. The risk of the import of infection from other states looms the district. The task of MPW DOT Providers is more challenging in the purview of growing cases of MDR, in the district. MPWs are the major proportion of the DOT Providers of the district. The inadequate knowledge of the worker about MDR- TB will lead to wrong perception and this may prove detrimental to the spirit of the TB Programme. The RNTCP protocol and guidelines entail the concept of regular evaluations of the worker performance. In this continuity, the present study was conducted with the aim of evaluating the knowledge of MDR TB in the MPW DOT Providers.
| Methodology|| |
Study area: The study was conducted in the five Health Blocks of the district. These blocks namely Arki, Chandi, Dharampur, Nalagarh and Syri also function as the Tubercular Units under the RNTCP.
Study period: The data was collected from the MPWs in the months of April and May, 2015. It was analyzed during June and the study got completed in July 2015.
Study population: 174 out of 178 MPWs from the five Health Blocks which also function as Tubercular Units of the district, participated in the study.
Study Design: It was a cross sectional study entailing the descriptive epidemiology of the MPWs of the five health blocks (Tubercular Unit)
Study Tools: The instrument for the study was a self-administered questionnaire. The questionnaire was pre-tested in the Government hospital Solan. Thereafter necessary changes were incorporated in it before the commencement of the study. The questionnaire consisted of components such as the training status and the knowledge about MDR TB.
Prior to the commencement of the study an informed written consent from the MPWs was obtained. This being a routine evaluation under the RNTCP, the approval from the Chief Medical Officer of the district and was sought.
Data statistics and analysis: The questionnaire consisted of sections such as the training status of the workers, their DOTS provision status and the knowledge parameters about MDR TB. The data was collected and a comparison was drawn between the DOTS provision / training status and the knowledge about the MDR-TB across the blocks. Seven questions were used to assess the respondent's knowledge about MDR-TB. For knowledge assessment, the answers to the questions were graded as correct and incorrect. Two points for the correct answer and zero points for the incorrect answer were allocated. Thus the maximum point for the knowledge of MDR-TB was 14 and the total score by the respondents was converted to a percentage. This percentage was used to categorize the workers as following: <25% - poor knowledge, 25-50%- fair knowledge, 51-75%- good knowledge and > 75%- excellent knowledge. The analysis also incorporated the respondent's knowledge by their Gender status. The data was analyzed in IBM SPSS Statistics version 21 and Microsoft Excel 2010 software. Pearson's Chi-Square test was used for ascertaining the statistical significance in the output variables. The p- values of lesser than 0.05 were considered significant.
| Results|| |
174 out of 178 (97.7 per cent) Multi -Purpose Workers participated in this study. The [Table 1] shows the general attributes of the study participants from across the five Tubercular units of the district. The mean average age of the study participants was 45.84 years. 84.5 per cent (147) of them were above 35 years of age. Females constituted the major proportion amongst the participants (62.1 per cent). About 87.4 per cent of the workers had undergone only the spot training and that too just prior to the initiation of the DOTS to a patient. 16 (9.2 per cent) of the workers, a very small proportion, had received the modular RNTCP training for MPWs. 149(85.6 per cent) of the study participants had been or were DOT Providers and 25 (14.4 per cent) were Non DOT providers. A large number of MPWs (86.8 per cent) had the experience of more than 5 years of service and the average mean years of service of 17.5 years.
The [Table 2] indicates the assessment of the knowledge by Gender distribution across the five blocks. The parameters included for the scoring of knowledge were as following: (1) Full name of the disease which is resistant to tubercular drugs, (2) how does this disease occur, (3) what is the duration of treatment of this disease, (4) how many drugs are used for treatment, (5) name of the most important drug which is resistant, (6) name of the category of patients falling under this disease and (7) relationship of immunity and this disease. The composite score showed that about 9.1% (16) MPWs scored zero for all the seven questions. They had no knowledge about the MDR-TB. 16.6% (29) had poor knowledge of the disease. A large proportion i.e. 53.4% (93) had a fair knowledge about MDR-TB and only about 20.6% (36) had a good knowledge about the MDR-TB. No worker was assessed to have an excellent knowledge of the disease i.e. knowledge of more than 75% about the disease.
Further analysis revealed that there was a significant difference (p- value = 0.02) of knowledge by Gender across the five Tubercular Units and for most of the parameters, the knowledge component of the Females was higher.
The knowledge of MDR-TB varied across the blocks as per the modular training status of the MPWs. The [Table 3] depicts that a major proportion of the MPWs i.e. about 90.8 % (158) had never undergone the RNTCP Modular training on Tuberculosis. Only 9.1% (16) workers had at one time or the other during their job tenure, had undertaken the training though by contrast even in this group, despite of having training under RNTCP, there was a single person who had no knowledge about the drug resistant TB. Although the relationship between the knowledge of the workers with their training status was found statistically not significant, a large proportion i.e. 25 out of 158 (15.8%) untrained personnel did have a poor knowledge base and another 15 out of the total untrained 158(52.5%) workers, had only a fair knowledge about the MDR- TB.
The [Table 4] depicts that the knowledge of the MDR- TB was significantly associated with the DOTS Provision status of the worker (p- value = 0.04). Out of 36 workers who had a good knowledge of the disease 32 (88.8%) had provided the DOTS during their respective jobs.
Another large proportion i.e. 90.3% of the persons having the fair knowledge of the MDR- TB, were the DOT Providers. Only about 7.3% (11 out of 149) MPWs who were DOT Providers, had no knowledge of the disease at all. By contrast, only 16 % (4 out of 25) of the Non DOT Providers had a good knowledge about the drug resistant TB.
The [Table 5] clarifies that there is a significant relation between the years of service put up by the MPWs and the knowledge outcome about the MDR- TB (p- value = 0.001). Out of 36 workers having a good knowledge of the disease, 24 (66.7%) were the ones who had put up more than 20 years of service. Similarly the ones having the fair knowledge of the disease were those who had rendered more than 10 years (48.4% having > 10 to ≤ 20 years and 36.6% having >20 years) of service. On the other hand, out of those who had poor knowledge of the disease, a large proportion (41.4) were those who had less than 10 years of experience of work as health personnel in the Health Sub Centre.
| Discussion|| |
The knowledge of the first line health workers determines the quantum of awareness levels in the masses. The present study has revealed that a large proportion of MPWs were untrained and that they had a poor knowledge base about the drug resistant TB. The level of knowledge was significantly associated with gender. Jain et al. (2012) has also reported poor knowledge amongst the DOT Providers in a study conducted in Ujjain, India.
Even in the ones who had undergone Modular training, the knowledge about MDR-TB was lacking. The tuberculosis review report of 2013 revealed workers with less experience and no trainings. The report also emphasized that quality of the trainings are not being assessed, trainings and supervision are not linked and that trainings and refresher courses are needed for up scaling the knowledge of RNTCP field staff. Our study has also mentioned the need of assessment of the workers, in the view of growing industrialization leading to a massive influx of migrant population. Such population dynamics are associated with the problems of unplanned slum inhabitations, environmental sanitation problems and a high default rate of treatment due to the fear of loss of working hours from the industries/ factories. This has led to the increase in the numbers of MDR- TB cases. In similar findings Mahato et al. (2015) showed that the tuberculosis was found more in lower socio economic class, migrant population and refugees. A study by Kamineni et al. (2011) in Odisha, India revealed that the trainings of the health workers lead to an increased awareness about the disease, in the community. In another similar finding by Jaiswal et al. in 2003, it was highlighted that the poor knowledge base of the workers leads to a high default rate in Tuberculosis. Similarly in another review report of DOTS Programme (WHO-GTP, 1997) it was suggested that advanced training of the field workers under RNTCP was needed for the proper implementation of the programme.
The present study clarifies that the more the years of job of the worker, the more is the knowledge about the drug resistant TB. Despite of this there were many workers who had poor knowledge of the concept. Similarly Nath et al. (2006) in a study amongst the DOT Providers at Delhi recommended that all the DOT Providers required the re- trainings irrespective of their experience in RNTCP. Isara et al. (2015) in a study conducted in Nigeria, has also reported about the need of restructuring the training programme for greater gains of knowledge of the drug resistant TB. Our study also highlights the need for re trainings for knowledge enhancement.
| Conclusion|| |
The knowledge about MDR- TB was more in the Females, the DOTS Providers, the workers having more years of experience of job and the ones who had undergone modular trainings. However, even in the trained workers, a large proportion had poor knowledge about the drug resistant TB. Hence it is recommended that regular modular and refresher trainings should be conducted for the grass root level workers, to strengthen the RNTCP.
| References|| |
World Health Organization. Global Tuberculosis report 2015 Geneva: WHO;2015.
Khatri GR. DOTS progress in India: 1995–2002. Tuberculosis. 2003 Feb 1;83(1):30-4.
Central TB Division. TB India 2005 RNTCP status report. Frontline TB care Providers working towards freedom from TB New Delhi: CTD;2005.
Singh N, Gupta D. Revised national tuberculosis control programme (RNTCP) in India; current status and challenges. Lung India. 2005 Oct 1;22(4):107.
World Health Organization. Millennium Development Goals 2000. [cited 2017 May 20]. Available from: www.who.int/topics/millennium_development_goals/en/
World Health Organization. The Stop TB Strategy. [cited 2017 May 4]. Available from: www.who.int/tb/strategy/stop_tb_strategy/en/
Mohanan Nair V. Multipurpose Health Workers in Primary Health Care (An Inter-District Subcentre-based Study from Kerala: S. India) (Doctoral dissertation 1998, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerela, India).
Nirupa C, Sudha G, Santha T, Ponnuraja C, Fathima R, Chandrasekaran V, Jaggarajamma K, Thomas A, Gopi PG, Narayanan PR. Evaluation of directly observed treatment providers in the Revised National Tuberculosis Control Programme. Indian Journal of Tuberculosis. 2005;52(2):73-7.
Swami PGN, Shilpa PM. A study to evaluate the effectiveness of Self Instructional Module on knowledge regarding Revised National Tuberculosis Control Programme for the Female Health Workers of selected Primary Health Centres of Tumkur district, Karnataka. IOSR Journal of Nursing and Health Sciences 2014;3(5):51-6.
Jain M, Chakole SV, Pawaiya AS, Mehta SC. Knowledge, Attitude and Practice of DOTS providers under RNTCP in Ujjain, Madhya Pradesh. Natl J community Med. 2012;3(4):670-4.
World Health Organization. Joint Tuberculosis Review report India2003 Regional office for South East Asia New Delhi: WHO;2004.
Mahato RK, LaohaSiRiWong W, VaeteeWootaChaRn K, Koju R, BhattaRai R. Major delays in the diagnosis and management of tuberculosis patients in Nepal. Journal of clinical and diagnostic research: JCDR. 2015 Oct;9(10):LC05--LC09.
Kamineni VV, Turk T, Wilson N, Satyanarayana S, Chauhan LS. A rapid assessment and response approach to review and enhance advocacy, communication and social mobilisation for tuberculosis control in Odisha state, India. BMC public health. 2011 Jun 10;11(1):463.
Jaiswal A, Singh V, Ogden JA, Porter JD, Sharma PP, Sarin R, Arora VK, Jain RC. Adherence to tuberculosis treatment: lessons from the urban setting of Delhi, India. Tropical Medicine & International Health. 2003 Jul 1;8(7):625-33.
Pio A, Luelmo F, Kumareasan J, Spinaci S. National Tuberculosis Programme Review: Experience over the Period 1990-1995. Bulletin, World Health Organization 75;6:569-81.
Nath A, Sharma N, Kumar R, Ingle GK. Assessment of In- service re- training needs of paramedical health workers of Revised National Tuberculosis Control Programme (RNTCP) in Delhi. Health and Population: perspectives and issues 2006;29:77-89.
Isara AR, Akpodiete A. Concerns about the knowledge and attitude of multidrug - resistant tuberculosis among health care workers and patients in Delta State, Nigeria. Nigerian journal of clinical practice. 2015;18(5):664-9.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]