Russian healthcare workers’ knowledge of tuberculosis and infection control

Summary

Background

Lack of knowledge may contribute to a higher risk of nosocomial tuberculosis (TB) among Russian TB healthcare workers (HCWs).

Design

Community-based participatory study. Russian TB HCWs at five TB facilities (n=96) surveyed to assess knowledge specific to TB/infection control.

Results

Scores overall were low. Analysis of variance showed a significant difference in knowledge by job category. Physicians scored significantly higher than nurses, lab staff and support staff. Nurses and laboratorians scored significantly higher than support staff. The biggest area of knowledge deficit was infection control.

Conclusion

Knowledge level of TB HCWs could influence the prevalence of nosocomial TB infection.

Introduction

Russian HCWs have a 10–20 times higher risk of developing nosocomial tuberculosis (TB) than the general population^1,2. Previous research with HCWs in other countries has documented that TB HCWs often lack knowledge about TB and infection control, which contributes to an increased risk³. However, infection control measures are not always implemented even when HCWs are well informed^4,5,6. No studies were found that examine the level of Russian HCWs’ knowledge about TB. The purpose of this study was to examine TB HCWs’ knowledge of TB and infection control in two regions of the Russian Federation.

Study Population and Methods

We conducted a community-based participatory study of Russian TB HCWs, examining current knowledge of TB/infection control measures. We defined community to include all levels of Russian HCWs in TB care facilities. The study protocol was approved by Institutional Review Boards in the United States, and the Chief Physicians of participating TB programs.

Setting and Sample

The study was conducted in five TB care facilities in the Leningrad and Vladimir regions of Russia in October, 2008; three TB hospitals and two outpatient TB clinics. The convenience sample was composed of 96 physicians, nurses, laboratorians, and support staff. Subjects were 18 years or older and employed in one of five TB care facilities. Following informed consent, subjects completed the self-administered questionnaire in approximately 25 minutes.

Measures/Instruments

Basic knowledge of TB was measured using the Knowledge Assessment Questionnaire (KAQ) developed specifically for this study because we were unable to find an instrument that captured all relevant content. This 20 item instrument was theoretically derived from standards of TB treatment, TB infection control, and education/training programs for HCWs^3,7,8,9. The KAQ is constructed of 16 multiple multiple-choice questions and four true/false questions. Each multiple-choice question has a correct answer that includes more than one response and subjects must select all of the correct responses in order for the question to be scored as correct. Russians are familiar with this test format.

The KAQ was drafted in English by an English speaking author and a bilingual Russian TB physician who translated it into Russian. The Community Project Team, comprised of 12 TB HCWs, developed the final Russian questionnaire, ensuring accuracy and relevance to TB treatment in Russia. Initial KR20 reliability was 0.618; two items with low inter-item reliability were deleted leaving the final 18 item KAQ with a reliability of 0.70. The final KAQ included three areas: disease process (five questions), treatment (six questions), and infection control (seven questions).

Data Analysis

Data were analyzed with descriptive statistics and group differences were examined with analysis of variance and post hoc comparisons using Tukey’s HSD statistics (SPSS 17.0).

Results

Eighty-five percent of subjects were 35 or older and had worked in TB care for more than 10 years; 51% worked at the same facility for 10 years or longer. Subjects’ work settings are described in Table 1. The percentage of correct responses is reported by job category (Table 2). There was a significant difference in knowledge by job category (F(3,92)=25.922, p<.001). Post hoc comparisons showed that physicians scored significantly higher than nurses (p=0.011), laboratorians (p=.021), and support staff (p<.001). Nurses and laboratorians scored significantly higher than support staff (p<.001).

Table 1.

Health Care Workers by Study Locations

	Physician (M/W)	Nurse (M/W)	Lab (M/W)	Support Staff (M/W)	Totals
Region 1: Hospital 1	3 (1/2)	8 (0/8)	6 (0/6)	6 (3/3)	23
Region 2: Hospital 2	10 (0/10)	8 (0/8)	6 (0/6)	8 (0/8)	32
Region 2: Hospital 3	2 (2/0)	7 (0/7)	0	7 (0/7)	16
Region 2: Clinic 1	5 (0/5)	8 (0/8)	0	0	13
Region 2: Clinic 2	6 (1/5)	6 (0/6)	0	0	12
Totals	26	37	12	21	96

*89 subjects were women, 7 were men.

Table 2.

Knowledge Assessment Questionnaire Responses

Reliability .70	All N=96 % correct	Physicians N=26 % correct	Nurses N=37 % correct	Lab N=12 % correct	Support N=21 % correct
Mean Scores (SD)	9.31 (2.77)	11.38 (1.96)	9.70 (2.44)	9.25 (1.76)	6.10 (1.61)
Questions
Disease Process
1) Tuberculosis is caused by	90%	96%	87%	100%	76%
3) Tuberculosis infection is the same as tuberculosis disease.	73%	88%	76%	83%	38%
4) What are the most common symptoms of pulmonary tuberculosis?	74%	77%	79%	92%	48%
5) What are the general symptoms of tuberculosis?	75%	81%	87%	83%	38%
6) How does the immune system respond to try to control the organism?	50%	62%	53%	50%	29%
Treatment
9) Why is drug sensitivity testing done?	43%	50%	53%	50%	10%
10) Why must tuberculosis be treated for at least 6 months?	31%	31%	24%	58%	29%
11) What adverse reactions may be caused by isoniazid?	43%	81%	50%	0%	5%
12) Why should at least four drugs be used to treat tuberculosis?	58%	81%	65%	25%	38%
17) TB can be cured.	92%	96%	89%	92%	86%
18) MDR-TB can be cured.	59%	77%	66%	33%	38%
Infection Control
2) How is tuberculosis spread?	89%	96%	82%	100%	81%
7) What does a positive smear indicate about a patient’s infectiousness?	57%	77%	55%	67%	29%
8) Why is a culture necessary?	51%	73%	50%	33%	33%
13) Circle the factors that affect infectiousness of a TB patient.	9%	15%	11%	8%	0%
14) What three types of controls should a TB program include?	17%	35%	16%	8%	0%
15) When should personal respirators be used?	43%	58%	42%	50%	19%
16) What methods can help decrease the presence of the TB organism in the air?	30%	58%	34%	8%	0%

Tuberculosis disease was generally well understood with the exceptions that some thought TB was caused by a virus, protozoa, or fungus and others incorrectly identified difficulty swallowing, eye pain, joint pain, or muscle pain as symptoms of TB. Knowledge of treatment was lower than knowledge of disease process. Most importantly, approximately half of all physicians, nurses, and laboratorians knew the purpose of drug sensitivity testing. Only one-third were able to identify why TB should be treated for at least six months and fewer than one-fourth of physicians and nurses understood the importance of a four-drug regimen. One-third did not believe MDR-TB could be cured.

Infection control knowledge was lowest. Six subjects believed TB was transmitted by sharing needles. Healthcare workers in rural settings (55%) were more likely to respond that TB was transmitted via ingesting contaminated meat and liquid than were HCWs in urban settings (16%); this was the only question where there were differences by setting. Fifty-seven percent understood the relationship of a positive sputum smear to infectiousness, and 9% identified all factors that affect infectiousness. Thirty-nine subjects knew to wear respirators in units with infectious patients, but many did not know respirators should also be worn where cough-inducing procedures are done or in homes of infectious patients. Some elected to wear respirators in units with noninfectious patients or when taking care of patients who have been on drug therapy more than four weeks.

Discussion

The observed gaps in knowledge increase the risk of nosocomial infection for TB HCWs and the gaps exist despite institutionally-based educational requirements for staff. Both regions provide education for TB HCWs when they are oriented to the facility, and continuing education is required; only one region conducts written exams following educational offerings. It appears that new strategies are needed to maintain current knowledge, especially related to infection control.

Knowledge deficits varied by job category, which has important implications for educational programs. The education of support staff is challenging because of their educational background and special attention may be required to prepare them to safely work in high risk settings such as TB care. Educational materials (posters and fliers) are widely used in Russian hospitals and similar strategies could be employed to educate both staff and patients about TB transmission.

A well-educated workforce is essential to decreasing nosocomial infection. Educational needs should be determined according to job categories and programs designed to eliminate misperceptions which could be identified during training sessions via pretesting or in small group discussion.

Generalizability was improved by conducting the study in two regions and different types of facilities. Borderline reliability could reflect random error but could also result from guessing.

Conclusions

Knowledge is foundational to any intervention. This study demonstrates that knowledge about TB and infection control could be improved. Review and revision of curriculum and teaching methodologies is suggested.