Impact of educational intervention on knowledge and awareness of TB among secondary school students in The Gambia
How to cite this article: Owolabi OA, Genekah MD, Njie S, Jallow MK, Jobe A, Tunkara A, et al. Impact of educational intervention on knowledge and awareness of TB among secondary school students in The Gambia. J Pan Afr Thorac Soc 2022;3:25-33.
Health education and awareness campaigns about tuberculosis (TB) can empower adolescents on different aspects of the disease and its management, resulting in early and appropriate care seeking behavior through their advocacy in the community. We assessed the impact of educational intervention on knowledge and awareness about TB among adolescents in the greater Banjul area of The Gambia where approximately 70% of national TB cases are notified.
Materials and Methods:
A school-based, interventional analytical study, and interactive educational workshop was conducted among grade 12 students of the Methodist Academy Secondary School in Bakau, Banjul The Gambia. The workshop activities included illustrative demonstrations using posters, flipcharts, infographics, and games to convey TB messages in six domains: (1) Basic knowledge; (2) symptoms; (3) risk factors (4) modes of transmission; (5) treatment; and (6) care and support. Structured questionnaires were used to assess changes in the student’s knowledge and awareness about TB in the six domains before and after the workshop. Data were analyzed using proportional percentages, mean (95% CI) and differences standard error (SE) and student paired t-test.
Ninety-six students participated in the workshop out of which 92 (96%) students completed both pre- and post-test questionnaires. Sixty-eight percent of the students were females and 58% were from the science stream of the grade 12 students who participated in our workshop. The mean difference and SE between the pre- and post-workshop test scores in the six domains were: basic knowledge: +1.4 (0.2; P < 0.0001); symptoms: +1.5 (0.2; P < 0.0001); risk factors: +3.1 (0.3; P < 0.0001); modes of transmission: +1.2 (0.2; P < 0.0001); treatment: +0.8 (0.1; P < 0.0001); and care and support of TB: +0.5 (0.1; P = 0.0001).
This school-based educational interactive workshop significantly improved the knowledge and awareness of the students especially in understanding the causative agent and risk factors of TB disease. We recommend exposure of students to TB educational activities as part of the school curriculum. The knowledge acquired in this workshop is likely to have impact on the wider community and should be assessed in future follow-up studies to determine if it impacts positively on views held within the wider community.
Tuberculosis (TB) caused by Mycobacterium tuberculosis can affect any part of the human body, especially the lungs. 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. 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. Young people (10–24 years) accounted for a quarter of the world’s population 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. 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. 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. 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
Study design and setting
We used a school-based before and after educative interventional analytical study design to measure the level of impact of educational intervention about TB among high school students in The Gambia.
One hundred and twenty-six students aged between 14 and 19 years, constituted the entire population of students in Grade 12 of the school. They were sensitized for the workshop by our nurses and specialized TB field workers using an information sheet containing the aims, objectives and activities of the project with parental/guardian permission and informed assent from participants. Prior parental/guardian sensitization was performed at the school Parents and Teachers Association meeting.
Questionnaire development and validation process
An adapted questionnaire was developed for this study using the WHO guide for developing knowledge, attitude, and practice surveys tools. We tested the questionnaire among the teaching staff of the school for clarity of the questions to ensure the understanding of the students participating in the workshop. This serves as our internal consistency check rather than using the Cronbach’s alpha to calculate the internal consistency. This is a limitation to our methodology.
TB awareness workshop strategy
A 1-day workshop involving five separate sessions aimed at improving TB-related knowledge in our target population was conducted. The facilitators of this workshop were TB researchers with over 10 years’ experience in TB patients care, trainers of trainee, and community outreach campaigns on World TB day commemoration activities to schools and hard to reach communities.
Session 1 focused on discussing the cause of TB, the various types of TB disease and TB infection with differences highlighted [Table 1] and the different classification of TB according to drug sensitivity pattern (Drug sensitive TB, multidrug-resistant TB, and extensively drug-resistant TB). How TB is diagnosed was illustrated using audio visual and infographics. Participants were shown materials for collection of sputum, microscope, and slide preparation using illustrative infographics. We illustrated the clinical presentation of TB through posters with common symptoms and signs emphasized, coupled with a snakes and ladder game for identification of the clinical features of TB by participants. This session was concluded with group work during which participants read the questions on the TB snake and ladder game chart and drew lines to the appropriate answers to reinforce knowledge acquired during the workshop.
|1st session||TB: Etiology, Types, Diagnosis and Symptoms||
|2nd session||TB: Transmission, Infection control, and Prevention||
|3rd session||TB: Risk factors, Treatment, Care and Support||
|4th session||TB show room||3 Posters display on workshop materials from sessions 1–3 with facilitators for participants to ask questions and clarify on learning points during the workshop|
|5th session||TB musical shot||3 min TB musical composition with the workshop participants led by local musician|
Session 2 began with an infographic illustration of TB using a glitter game which aimed to demonstrate how aerosolized respiratory droplets are generated during coughing and sneezing and spread as airborne droplets to nearby individuals. Facilitators demonstrated appropriate cough etiquette to reduce such spread. Respiratory waste management in public spaces and at home was also demonstrated by the facilitators. BCG scar identification by the facilitators was performed after taking permission from co-facilitator. Participants were also given the opportunity to assess BCG scarring with their counterpart during the workshop as a mark of having received BCG vaccine during the neonatal period. However, participants were told about the variability of protection against TB conferred by such vaccination from no protection to 80% and that not all who received BCG showed scarring.
Session 3 began with a PowerPoint presentation of risk factors for TB disease such as Diabetes, HIV, smoking, drinking, extremes of ages, and malnutrition. Participants were given an opportunity to advance plausible reasons under the guidance of the facilitators how each of these conditions could predispose to TB disease. TB treatment infographics were displayed showing the process of, patient pre-treatment counseling, and the TB treatment cards.
Session 4 used a TB show room, which was dedicated to displaying all workshop materials in poster format for participants to refresh on the learning materials and activities during the workshop. Opportunities to ask questions were provided by our facilitators standing by the posters with one on one in-depth discussion to enhance participants learning.
Session 5 involved education through music with activities led by a local musician who was cured of TB 18 months before the workshop. The invited local musician composed a song about his experience with TB which lasted 2-min with lyrics: “Find and treat TB, it can happen to you, it can happen to me” all workshop participants were taught to sing this song.
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.
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.
Data were collected using self-administered structured questionnaires to assess (1) general knowledge of TB, (2) symptoms, (3) mode of transmission of the most common form of TB (pulmonary TB), (4) risk factors (5) TB treatment; and (6) care and support for TB patients. Assessment of knowledge was based on dichotomized yes/no, or presence/ absence responses. Independent variables obtained were age, sex, and subjects studied (Science, Commerce or Arts). Parental/guardian permission and participants’ assent were obtained before the workshop day.
All data were analyzed using STATA 16. The statistics are presented as mean (95% CI), differences and standard error (SE) between the pre- and post-workshop test scores in each of the six domains with percentages and frequencies used for all categorical data. Student’s t-test paired analyses were performed comparing pre- and post-workshop tests. P ≤ 0.05 was considered significant.
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].
|Class stream, n=87|
|Gambians, n=88||88 (96.7)|
|Other nationality (Nigerian)||3 (3.3)|
Assessment of students’ basic knowledge of TB
Pre-workshop, 88% of participants identified the cause of TB as a germ, 97% knew that lungs were the most affected part of the body, and 76% identified the sputum as the most common biological sample used for diagnostic tests. After the workshop these increased to 100%, 98.9%, and 89.1%, respectively. The most common misconceptions about the cause of TB by participants pre-workshop included: Drinking bad water (14.1%); evil spirits (3.3%); and mosquito bites (3.3%) [Table 3].
|Questions||Expected response||Correct responses (%)||Impact (%)|
|Basic TB knowledge|
|Tuberculosis is caused by germ (bacteria)||Yes||88.0||100.0||12|
|Lung is the most affected organ in TB disease||Yes||96.7||98.9||2.2|
|TB is caused by drinking bad water||No||85.9||96.7||10.8|
|Multidrug-resistant TB is a type of TB||Yes||50.0||90.2||40.2|
|TB is caused by mosquito bite||No||96.7||97.8||1.1|
|Ordinary (drug sensitive) TB is a type of TB||Yes||47.8||73.9||26.1|
|TB is caused by evil spirits||No||96.7||100.0||3.3|
|Extreme drug resistant TB is a type of TB||Yes||55.4||79.3||23.9|
|Sputum test can be used for diagnosis of TB||Yes||76.1||89.1||13.0|
|Mantoux test is used for diagnosis of TB infection||Yes||78.3||82.6||4.3|
|TB symptoms and signs|
|Cough for 2 weeks or more||Yes||96.7||100.0||3.3|
|Feeling tired all the time (Fatigue)||Yes||73.9||79.8||23.9|
|Coughing out blood||Yes||66.3||92.4||26.1|
|Excessive drenching night sweat||Yes||53.3||92.4||39.1|
|Unintended weight loss||Yes||87.0||98.9||11.9|
|Loss of appetite||Yes||83.7||95.7||12.0|
|Risk factor for TB disease|
|Individuals with diabetes||Yes||19.6||73.9||54.3|
|HIV infected persons||Yes||39.1||87.0||47.9|
|Children under 5 years||Yes||44.6||90.2||45.6|
|TB transmission methods|
|By sharing cups, spoon, and cooking pots||No||41.3||82.6||41.3|
|By shaking hands||No||79.3||86.9||7.6|
|By sharing clothing materials||No||88.0||96.7||8.7|
|Through the air from one person to another||Yes||84.8||98.9||14.1|
|Through coughing and sneezing||Yes||97.8||98.9||1.1|
|By drinking bad water||No||83.7||92.4||8.7|
|By using same toilet with TB patients||No||77.2||88.0||10.8|
|TB treatment is free||Yes||77.2||89.1||11.9|
|DOTS refer to a method of TB treatment||Yes||73.9||92.4||18.5|
|TB treatment is for 6 months minimum||Yes||54.3||83.7||29.4|
|TB can be treated by prayers||No||85.9||91.3||5.4|
|There is an effective local TB treatment||No||81.5||84.8||3.3|
|TB care and support|
|BCG vaccine prevents from severe TB in children||Yes||83.7||94.6||10.9|
|TB is a preventable disease||Yes||98.9||97.8||1.1|
|TB cannot kill||No||83.7||81.5||2.2|
|TB is curable||Yes||93.5||96.7||3.2|
|Everybody should run away from TB patient||No||96.7||97.8||1.1|
|TB patients should cover with handkerchief while sneezing/cough||Yes||100.0||100.0||0.0|
|TB patients should be isolated throughout period of treatment||No||96.7||97.8||1.1|
The level of awareness of the participants pre-workshop varied in terms of the response of TB patients to TB medications, with 47.8% aware of drug sensitive TB, 50% of multidrug-resistant TB, and 55.4% of extensively drug resistant TB. Post workshop, the level of awareness improved with 73.9% aware of drug sensitive TB, 90.2% of multidrug-resistant TB, and 79.3% of extensively drug-resistant TB. The mean (95% confidence interval) and mean difference (SE) between pre- and post-workshop on TB basic knowledge were 7.7 (7.4–8.0), 9.1 (8.9–9.3), and +1.4 (0.2), P < 0.0001, respectively [Table 4].
|Educational domain||Mean (95% CI)||Mean difference (Standard Error)||P-value|
|Basic TB knowledge||7.7 (7.4–8.0)||9.1 (8.9–9.3)||+1.4 (0.2)||<0.0001|
|TB symptoms and signs||8.1 (7.8–8.4)||9.6 (9.4–9.8)||+1.5 (0.2)||<0.0001|
|Risk factors for TB disease||4.1 (3.7–4.5)||7.2 (6.8–7.6)||+3.1 (0.3)||<0.0001|
|Methods of TB transmission||8.1 (7.8–8.4)||9.2 (9.0–9.5)||+1.2 (0.2)||<0.0001|
|Treatment of TB||7.6 (7.3–7.9)||8.4 (8.2–8.7)||+0.8 (0.1)||<0.0001|
|TB care and support||6.7 (6.4–6.9)||7.2 (6.9–7.4)||+0.5 (0.1)||0.0001|
Knowledge of symptoms and spread of TB
Most participants knew coughing for 2 weeks or more was a symptom of TB (96.7%) with associated chest pain (92.4%), unintended weight loss (87%), and fever (82.6%) as other symptoms of TB. However, fewer participants knew excessive night sweats (53.3%) and coughing out blood (66.3%) were symptoms of TB [Table 3].
The students demonstrated varied knowledge about the spread of TB. The majority knew TB was an airborne disease (84.8%) spreading through coughing and sneezing (97.8%) for pulmonary TB. However, there were a relatively high % who had incorrect assumptions on how TB was spread including sharing utensils (58.7%), shaking hands (20.7%), sharing clothing (12%), drinking bad water (16.3%), using the same toilet (22.8%), kissing (68.5%), and sex (15.2%). At the end of the workshop, these assumptions were still shared by a high proportion of participants including sharing utensils (17.4%), shaking of hands (13.1%), kissing (13.1%), and use of same toilet (12%) [Table 3].
The mean (95% confidence interval) and mean difference (SE) pre- and post-workshop on the symptoms were 8.1 (7.8– 8.4), 9.6 (9.4–9.8), +1.5 (0.2), P < 0.0001 and spread of TB 8.1 (7.8–8.4), 9.2 (9.0–9.5), +1.2 (0.2), P < 0.0001, respectively [Table 4].
Knowledge of factors influencing development of TB disease
The knowledge of participants on the risk factors for development of TB disease was grossly deficient in relation to HIV infection and diabetes mellitus as potent risk factor for the rapid development of TB disease TB exposed individuals. After the workshop, there was marked improvement in knowledge acquired by the students on risk factors diabetes (19.6% pre to 73.9% post) and HIV infection (39.1% pre to 87% post) [Table 3]. The mean (95% confidence interval) and mean difference (SE) pre- and post-workshop on the risk factors for the development of TB were 4.1 (3.7–4.5), 7.2 (6.8– 7.6), and + 3.1 (0.3), P < 0.0001, respectively [Table 4].
Knowledge of TB prevention, treatment, care, and support
Eighty-four percent of participants knew that BCG vaccine could offer protection against disseminated TB disease in children, 93.5% responded that TB is curable and 74% with the use of TB medications (DOTS strategy). All the participants recognized covering your mouth and nose when you cough and sneeze as an infection control measure to reduce spread of TB. Seventy-seven percent of respondents knew that there is free treatment for TB in The Gambia before the onset of the workshop [Table 3].
However, <60% of the participants knew the duration of TB treatment to be 6 months minimum for drug sensitive TB, and 18.5% indicated there are local treatments for TB in the community. After the workshop, there were improvements in knowledge [Table 3].
The mean (95% confidence interval) and mean difference (SE) pre- and post-workshop on TB prevention, treatment, care, and support were 7.6 (7.3–7.9), 8.4 (8.2–8.7), +0.8 (0.1), P < 0.0001 and 6.7 (6.4–6.9), 7.2 (6.9–7.4), +0.5 (0.1), P = 0.0001, respectively [Table 4].
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 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, 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. 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. 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%). 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. 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 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. 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, and much lower (12.6%) in another study in a slum community of Delhi, India. 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.
Due to limited resources and time, we could not conduct a follow-up survey of the longer-term impacts of our workshop on the participants. The generalizability of our findings in the greater Banjul area is limited by the sample size, sampling method, and inability to apply the Cronbach’s alpha coefficient calculation for the internal consistency of our adapted questionnaires. However, it provides pilot data for further research into this subject amongst the general populace of The Gambia. We could not delve into the aspects of TB stigma under the structure of this workshop meant to raise awareness about TB in the adolescents. This is meant for further studies in the future among this population.
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.
The authors are grateful to the MRCG at LSHTM field and clinic teams (Nurses/field assistants, Nurse coordinators, field workers and supervisors, etc.) who facilitated the sensitization, recruitment, facilitation of the study participants; the National TB and Leprosy programme managers; and the authority of Methodist Academy school, Parents and Teachers Association of the school, study participants and their families who participated in the workshop project.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
This work was supported by the LSHTM Public Engagement small Grants and UK Medical Research Council and the UK Department for International Development (DFID, London, UK) under the MRC/DFID Concordant agreement. The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Conflicts of interest
There are no conflicts of interest.
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