Impact of educational intervention on knowledge and awareness of TB among secondary school students in The Gambia

INTRODUCTION

Tuberculosis (TB) caused by Mycobacterium tuberculosis can affect any part of the human body, especially the lungs.^[1] TB is the leading single infectious cause of death worldwide with annual global estimate for 2019 of 10 million people developed TB with 1.4 million deaths.^[2] Advocacy and promotional activities were one of the key actions defined by the World Health Organization (WHO), following the United Nations (UN) high-level meeting on TB in 2018 to increase TB awareness and scale up adolescent’s mobilization to end TB.^[3] Young people (10–24 years) accounted for a quarter of the world’s population^[4] and the global burden of TB in young people was estimated at 1.8 million in 2012, which constitutes 17% of all new TB cases globally.^[5] The adolescent period (10–19 years) is well known for its increased susceptibility to TB, due to waning of protection by Bacillus Calmette Guerin (BCG), immunological changes, and social characteristics.^[5,6] Poor knowledge about the signs and symptoms of TB and stigma associated with the disease is known factors leading to delayed diagnosis of TB,^[7,8] poor adherence to treatment and use of traditional healers over the freely available medical care.^[9] This highlights the need for public awareness campaigns among adolescents to raise awareness and improve knowledge about recognition of TB symptoms to enable early health seeking behavior. TB outbreaks have been reported among students in UK, Italy, Ireland, USA^[10-14] India, China, and Ethiopia.^[1,15,16] Therefore, high school students are an important group to be effectively mobilized and empowered with knowledge about TB to involve them as a driver of change.^[9] These are an important group in the community highly mobile and explorative with enthusiasm and keen interest to learn new things. As potential candidate for the wider community of education, commerce, and industry in a growing economy, they are suitable people group component of the society that can be used to take TB messages to both the illiterates and literate in the community when well trained as TB ambassadors.

Therefore, the aim of this study was to educate high school students in The Gambia and to assess the impact of simple educational intervention on the knowledge of the students about TB. This study is the first well-structured TB awareness campaign among school-based adolescents in The Gambia. Our working hypothesis was that improving the knowledge and awareness about TB in high school students will spread awareness to the general community.

MATERIALS AND METHODS

Workshop flow

The preworkshop activities started with registration of students who had been consented and permitted by parents/guardians to attend [Figure 1]. The participants were randomly assigned to one of three groups and given unique identification numbers (for confidentiality) and workshop packs with stickers on all the materials. The facilitators were stationed at each of the stations while the participants rotated from one station to another. The school authority provided access to five large classrooms for the five stations/sessions and to allow easy movement of participants. Sessions 1–4 lasted a maximum of 30 min with 32 participants supported by three facilitators (two group instructors and a group timekeeper). All workshop participants and facilitators came together for the fifth session. In each of the groups, students were assessed using the structured self-administered questionnaire before and after the workshop exercises.

Close

Figure 1:

Described the flow chart of the workshop from participants arrival, briefing, and registration of participants by facilitators of the workshop to knowledge assessment before the workshop activities started, to the different sessions 1–4, the post-workshop test and concluded with musical show on TB song in session 5.

Export to PPT

To ensure quality control during the workshop, the following measures were observed: (1) The facilitators also underwent trainers’ workshop sessions where basic skills on effective workshop facilitation were taught with hands on practice sessions, (2) the facilitators underwent training and practice sessions using the educational materials meant for the workshop by the lead facilitator and facilitated a pilot workshop 2 weeks before the students’ workshop, and (3) the same facilitators were stationed at each session throughout the workshop to ensure consistency.

RESULTS

One hundred and six (84.1%) students submitted consent/ assent forms with parental permission to participate in the workshop. The number of students that ended up participating in the workshop dropped to 96 (76.2%) with 92 (73%) completing both the pre- and post-test questionnaires. Of the ten students who had provided consent but did not participate, 5 came late and 5 had parental permission withdrawn on the day of the workshop for unknown reasons. Our findings are thus based on the 92 participants who completed the pre- and post-test questionnaires. The median age (range) was 17 (14–20) years. Sixty-seven percent of the workshop participants were females and 60% were taking science classes [Table 2].

DISCUSSION

The results of this workshop showed that misinformation exists among adolescents about the cause of TB, the factors that can increase the risk of development of TB, its signs and symptoms, the mode of transmission and duration of treatment of TB among high school students in The Gambia.

The participants demonstrated good knowledge about the cause of TB being a germ, but there were some misconceptions on the cause of TB including the role of evil spirits, mosquito bites, and drinking of bad water. Similar confusion about the cause of TB has been reported in the previous studies of high school students in China^[20] and Malawi^[21,22] with the mention of evil spirits, bad luck, drinking bad water, and genetics as causes of TB. This misinformation could be from the communities,^[23] emanating from cultural beliefs of the people passed down over the decades. The understanding of the cause of a disease can influence care seeking behavior of patients, worsening their symptoms with the development of complications that can negatively affect outcome of treatment and continued transmission of TB in the community.^[21] Our workshop did improve the knowledge of these students on the cause of TB although future, longer follow-up studies will need to determine if this impacts on views held within the wider community.

Participants had poor knowledge about important risk factors for the development of TB disease, most especially comorbidities such as HIV/AIDS and Diabetes mellitus, social habits such as alcohol use, and extremes of age. This might by proxy reflect the poor knowledge in the societies and the need to improve on the knowledge and awareness about these conditions in the general population. It can significantly impact on early expanded screening for TB and prompt initiation of prophylaxis treatment for high risk candidates and full TB treatment for active cases of TB that might find and treat missing TB cases.

Participants demonstrated improved knowledge after the workshop on TB symptoms such as coughing blood and excessive night sweats in addition to other common TB symptoms. The recognition of common symptoms of TB is fundamental to seeking diagnosis opportunities by patients and early treatment initiation and curtail spread of TB.^[9] Our study participants demonstrated better awareness and knowledge on the common symptoms of TB than undergraduate health-care students without clinical experience in Malaysia, who had poor knowledge and awareness about common TB symptoms, cough more than 2 weeks (17% vs. 96.7%) and weight loss (10% vs. 87%).^[24] However, their knowledge level on TB being an airborne disease and prevention of TB spread through covering mouth and nose while coughing and sneezing were comparably high as observed in our study.^[24] The ability to recognize presumed TB symptoms is helpful in TB endemic areas where other infectious disease such as malaria, Coronavirus infection (COVID-19), and flu-like syndromes could be confused with TB in the society leading to prolonged delay before presentation, diagnosis, and continued transmission of TB.

The mode of transmission of TB was a major area of misconception among our workshop participants. Few participants could correctly identify the appropriate mode of transmission of TB of the chest before the workshop, being airborne disease spread through coughing and sneezing. More than half responded that TB is spread through sharing of eating utensils and kissing. This was improved by the end of the workshop, but misconceptions still existed indicating that this should be a major focus for future studies. Appropriate knowledge about spread of TB can help avoid risky behaviors that might increase chances of spread of TB^[25] while inappropriate knowledge can foster stigma against TB patients in the society and lead to concealment of TB status by patients from neighbors.

The participant’s knowledge about prevention of TB, infection control, and curability of TB was high and support findings from a study of Malaysian undergraduate health-care students.^[24] However, lower proportion of the participants was aware of the duration of treatment to be a minimum of 6 months for simple uncomplicated drug sensitive TB before the workshop activities. A similar study conducted in India reported a lower level of awareness (28%) about the duration of TB treatment,^[25] and much lower (12.6%) in another study in a slum community of Delhi, India.^[26] This knowledge gap among our participants was not surprising because studies done in Malawi on both adults and children with TB showed lack of knowledge about the duration of TB treatment.^[21,27] However, poor understanding about the duration of treatment could result into abrupt stoppage of treatment which potentially results in drug-resistant TB and continued spread of TB.

The high level of awareness about TB by the students in some of the domains explored through our workshop activities could reflect their exposure from other sources such as radio, television, social and print media, and friends/neighbors. Another important source could be information transfer to the participants from the teaching staff of the school that participated in our TB pilot workshop. However, we did not explore sources of TB information during the workshop from the participants. Our study is the first to explore TB disease risk factors among students, using workshop methodology in TB endemic setting to our knowledge.

After the workshop the students and teachers pledged their willingness to take the messages learnt from the workshop to their immediate environment, hopefully influencing health-seeking behaviors of their contacts. However, further studies need to be performed to ascertain how much (if any) information was disseminated. It would also be important to set up social media avenues such as WhatsApp or Facebook groups to ensure accurate dissemination of information.

The school authority has started to engage other students in the school through peer education method, utilizing participants trained at the workshop as peer educators in the school.

CONCLUSION

TB awareness workshop in schools as part of TB control in the communities is needful. Advocacy communication and social mobilization strategy deployed in schools to inform students who ultimately shall serve as agent of change, influencing their colleagues at schools and the communities at large. We, therefore, recommend inclusion of TB education in school curriculum starting from the elementary to high schools in TB endemic and high burden countries as it applies in high income settings in Europe.