Vol 2 / Issue 2 / April-June 2012

Journal of Academy of Medical Sciences

Publication of Osmania Medical College
www.e-jams.org

ISSN 2249-4855

ORIGINAL ARTICLE

Awareness of the Revised National Tuberculosis Control Programme and attitude to tuberculosis patients amongst medical undergraduates
Swati M. Baveja, PratibhaJ. Dalal
Department of Microbiology, Terna Medical College, Navi Mumbai, Maharashtra, India

ABSTRACT
Purpose: This study was conducted to assess the knowledge of Revised National Tuberculosis Control Programme (RNTCP) and attitude to tuberculosis(TB) among medical students and interns. Materials and Methods: This crosssectional survey was carried out in a private medical college among 200 medical students. The students were asked to complete a written questionnaire. The answers were statistically analyzed using Statistical Package for the Social Sciences(SPSS) software program, IBM. In addition, item analysis was carried out for each question, wherever applicable. Results: Our analysis revealed that all students were aware of TB. They were also aware of RNTCP. In addition to the didactic lectures, students had gained information from different sources such as textbooks(168), case discussion(155), seminar(95), journals(75), and WHO publications(22). The average number of students with correct response was 122(59.63%). Among the various categories of TB, the correct responses were highest for questions relating to diagnosis(146.25; 73.12%), followed by epidemiology(114; 62.16%), management(130.33; 61.75%), and risk perception(75.33; 28.5%). About 90% students feared the risk of transmission by inhalation from a TB patient with cough. Majority of the students were aware that all smearpositive patients should be isolated and treated. Item analysis of the multiple choice questions(MCQs) showed the areas that required more emphasis. Conclusions: Overall performance of III/I students was better than the rest of the study group. Students performed better in the epidemiology domain compared with the management and preventive aspects of TB. To ensure the successful control of TB and implementation of RNTCP, medical students need to be sensitized by conducting continuous medical education and orientation courses on RNTCP at regular intervals. Key words: Awareness, medical students, Revised National Tuberculosis Control Programme

Address for correspondence: Dr.Swati M. Baveja, 212, Type4, C.G.S. Colony, Wadala(West), Mumbai400031, Maharashtra, India. Email:smbaveja@yahoo.com

Introduction
Tuberculosis(TB) is a serious public health problem in India causing immense morbidity, mortality and distress to individuals, families and communities. TB kills more adults in India than any other infectious disease. The disease incidence peaks in people belonging to the most economically productive age group of 1560years. Every day, more than 5000 Indians develop TB and more than 1000 die of TB(two deaths every 3min).[1] Despite the pathbreaking studies by the Indian medical and scientific community that have contributed to the current diagnostic and therapeutic algorithms, India has the dubious distinction of constituting nearly onethird cases in the world.
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To control this expanding problem, the National Tuberculosis Program(NTP) was reviewed by an expert committee appointed by the World Health Organization(WHO) in 1992. Later, to correct the flaws found therein, the Revised National Tuberculosis Control Programme(RNTCP) was formulated and a pilot project was implemented in 1993.[2] It was based on the fact that patients who are sputum smear positive(SSP) are the major source of disease transmission in the community, and therefore a greater emphasis on detecting these cases is given. The primary objectives of the program are to achieve 80% cure rate in new SSP cases and to detect at least 70% of these. The program has laid down criteria for suspicion, disease diagnosis, categorization, treatment, follow-up and outcome of TB patients. A defining feature of the program has been a shift from hospitalized to outpatient management and supervised treatment. All patients under RNTCP receive drugs under direct supervision called Directly Observed Treatment, Short course(DOTS).[2] In addition to the existing burden of TB, the pandemic of HIV has further aggravated the incidence of TB. HIV infection makes an individual more prone to develop TB and TB is the commonest opportunistic infection amongst HIVinfected
68 Journal of Academy of Medical Sciences

DOI: 10.4103/2249-4855.118663

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Baveja and Dalal: Awareness of revised national tuberculosis control program amongst medical students

individuals, with WHO estimating that 5% of TB patients are also coinfected with HIV.[2] Therefore, proper knowledge of RNTCP is essential not only for TB control but also to contain HIV epidemic. India has a blend of public and private healthcare delivery systems, with the majority seeking the latter for its perceived confidentiality, convenience of timing, accessibility and personalized management. The private sector is large and mostly unregulated and the care provided has been found to be of inadequate quality. Inappropriate and incomplete prescription and treatment have been identified as major risk factors for the development of the spread of TB and drug resistance. Training of medical students in RNTCP will ensure better future healthcare in the correct diagnosis and treatment of TB. It is against this background that RNTCP has been incorporated as a topic in the undergraduate medical curriculum. Therefore, the present study was conducted to assess awareness of TB, its magnitude, transmission, RNTCP diagnosis, management, risk perception and attitude toward the TB patient.

of evaluating a single MCQ after its MCQ paper correction based on students response to each MCQ. Various indices are determined such as discriminatory index, difficulty index and distracter effectiveness.

Results
This study included 200 medical students68 interns, 62 III/I semester and 70 III/III semester students. Analysis of data revealed that all the students enrolled were aware of TB, had attended a formal lecture on TB during their academic career, and were also aware of RNTCP. In addition to the didactic lecture, students had gained information from different sources, which are shown in Table1. It was found that the main source of information was mainly didactic lecture(187), followed by textbooks(168), case discussion(155), seminar(95), journals(75), and WHO publications(22). There was an overlap between various responses such as academic activities in class, reading and internet surfing. On the internet, the most common website of information was WHO(33), followed by Center for Disease Control(CDC)(7), especially for the interns. Among III/III, there were 22(33.34%) students who scored less than 50%, compared with 6(9.6%) III/I semester students and 12(17.65%) interns, which is very high. Hence, such students required a special training for awareness of TB and RNTCP. Twentyeight students scored more than 70%, III/I students being maximum in this group13(20.96%), followed by 10 interns(40.70%), and 5 III/III students(7.57%). This high achiever group, after basic training, can volunteer to propagate awareness of the program. On comparing the percentage of correct responses both in the various question categories and in different student groups, we found that the average number of students who attempted a correct response was 122(59.63%). Among the various categories of TB, it was found that correct responses were the highest for questions relating to diagnosis 146.25(73.12%), followed by Table1: Source of information of Revised National Tuberculosis Control Programme and tuberculosis
Source of information Lecture Seminar Case discussion Textbook Journal WHO publication Internet WHO website CDC website Other sources III/I 60 28 50 49 30 9 20 9 4 8 III/III 65 34 52 59 21 4 20 8 0 2 Intern 62 33 53 60 24 9 20 16 3 6 Total 187 95 155 168 75 22 60 33 7 16

Materials and Methods

The study was a crosssectional survey, carried out in a private medical college, affiliated to the Maharashtra University of Health Sciences, with an annual intake of 100 students. Medical students from third M.B.B.S. first semester (III/I) and last semester(III/III); and students doing compulsory rotatory internship were asked to complete a written questionnaire comprising 25 questions. Atotal of 200 students from different batches were administered the questionnaire. The questions were based on their curriculum, published literature including that on the RNTCP published by the Central TB Division, Ministry of Health and Family Welfare, Government of India, which currently forms the core curriculum for undergraduates. The questionnaire comprised 25 questions, with majority being multiple choice questions(MCQs). The questions were further subdivided into four different categories: Knowledge about disease(3 questions=Q. No.13); epidemiology (4questions=Q. No.47); diagnosis and management (13questions=Q. No.819, and 21); attitude and risk perception of TB(5 questions=Q. No.20 and 2225). Prior to administering the questionnaire, the Institutional Review Board and Ethics Committee approval were obtained. The individual questionnaire was submitted to students volunteering to participate after explaining the survey purpose and having their informed consent. The identity of the students was not revealed to maintain confidentiality. The answers thus recorded were entered into an excel sheet for scoring. Statistical analysis was carried out using SPSS statistical software program. In addition, item analysis was carried out for questions wherever applicable. Item analysis involves the process
Journal of Academy of Medical Sciences 69

CDC Centre for Disease Control; WHO World Health Organization

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Baveja and Dalal: Awareness of revised national tuberculosis control program amongst medical students

epidemiology 114(62.16%), management 130.33(61.75%), and risk perception 75.33(28.5%)[Figure 1]. Groupwise comparison of students for correct response revealed that risk perception awareness of TB was less among all three groups, with the least among the III/I subjects. However, there were more correct respondents among the III/I semester students compared with III/III semester students and interns in areas such as epidemiology, diagnosis and management[Figure 2]. We also observed that 180(90%) students feared the risk of transmission by inhalation from TB patients with cough, amongst them 47% completely agreed and 43% partially agreed. There were 20(10%) students who were unaware of such a

risk. About 95% students agreed with the need for personal protective equipment while interviewing and examining patients with TB(79.5% completely agreed and 15.5% partially agreed), whereas 10(5%) did not agree[Table2]. Majority(90%) of the students were aware that all smearpositive patients should be isolated and treated. Groupwise distribution of these students showed 56/62(90.32%) to be in III/I semester, 59/70(84.28%) in III/III semester, and 65/68(95.58%) to be interns[Figure 3]. Students found it difficult to answer questions related to the management and prevention aspect of TB; hence, more emphasis should be given on these aspects of RNTCP while teaching. However, students also felt that the questions related to epidemiology and diagnosis were easy. Following item analysis of the MCQs[Table3], it was evident how well students have understood RNTCP, which topics need more emphasis, what are the common mistakes and which areas are confusing. The teaching/learning methods can be modified based on these results.

Discussion
During the analysis on the knowledge about epidemiology, we found that majority of the subjects(63%) were aware about the aims of RNTCP but only 41.5% of students knew that one smearpositive patient could infect 1015 people. Only 19.35% of students knew that TB is a marker disease for HIV and that alto patients should be screened for HIV and vice versa. These findings are consistent with other similar surveys. Jackson etal.[3] observed deficiencies in the knowledge, attitude,

Figure 1: Performance of students in different question categories

Table2: Comparison of correct response (%) of different groups and question categories
MCQ no. Q4 Q5 Q6 Q7 Q8 Q11 Q12 Q14 Q09 Q10 Q13 Q15 Q16 Q17 Q18 Q19 Q21 Q20 Q24 Q25 Topic Epidemiology Questions Extent of problem in India Aim of RNTCP Age group affected maximum Rate of infectivity by smear positive patients Commonest symptom Most specific test Most appropriate sample Concentration of NaHCl for disinfecting TB bacilli One sputum specimen positive out of three Treatment in smearnegative cases Followup of CAT1patients Relapse Treatment of extra pulmonary TB patients Dosage of INH Indication of stoppage of TB t/t Continuation phase of CAT1 DOTS Transmission of infection PPE Isolation precautions All students 55 63 68.5 41.5 92 89.5 77 34 57 20.5 67 95 64 30.5 86 74 92.5 17 6 62.5 III/I 19.35 79.0 72.58 48.38 91.93 85.48 83.87 32.25 75.80 16.12 64.51 93.54 62.90 40.32 87.0 75.80 91.93 11.29 6.45 90.32 III/III 19.35 55.71 58.57 35.71 94.28 95.71 78.57 31.42 50 18.57 64.28 98.57 58.57 32.85 81.42 72.85 90 12.85 1.428 84.28 Interns 19.35 55.88 75 41.17 89.70 86.76 69.11 38.23 47.0 26.47 72.0 92.64 70.58 19.11 89.70 73.52 95.58 26.47 10.29 95.58

Diagnosis

Management

Risk perception

RNTCP Revised National Tuberculosis Control Programme; TB Tuberculosis; DOTS Directly observed treatment, Short course; MCQ Multiple choice questions; CAT1Category 1; INH Isoniazid; PPE Personal protective equipments

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Baveja and Dalal: Awareness of revised national tuberculosis control program amongst medical students

Table3: Results of item analysis

MCQ no. Q4 Q5 Q6 Q7 Q8 Q11 Q12 Q14 Q9 Q10 Q13 Q16 Q17 Q18 Q19 Q21 Q20 Q24
MCQ Multiple choice questions

Topic Epidemiology

Difficulty index 54 62 68 40.5 92 89 76.5 32.5 55.5 20.5 65.5 62.5 29 85 72.5 90 17 5.5

Interpretation Acceptable(ideal) Acceptable Acceptable Less difficult Easy Easy Easy Difficult Acceptable(ideal) Extremely difficult Acceptable Acceptable Difficult Easy Easy Very easy Very difficult Very difficult

Discrimination index 0.24 0.1 0.34 0.25 0.08 0.12 0.25 0.21 0.33 0.09 0.21 0.15 0.02 0.08 0.35 0.1 0.12 0.03

Interpretation Good Not discriminative Acceptable Good discriminator Not discriminative Not discriminative Good discriminator Acceptable Acceptable Not discriminative Acceptable Not discriminative Not discriminative Not discriminative Excellent Not discriminative Not discriminative Not discriminative

Effective distracter 4.5 9 8 2.5 0 8.5 5 1 2 6 15 0.5 10.5 2.5 5 3 0.5 0

Interpretation Good Good Good Poor poor Good Good Poor Poor Good Good Poor Good Poor Good Poor Poor Poor

Diagnosis

Management

Risk perception

Figure 2: Response of different categories of students

differences in undergraduate exposure to TB, total knowledge, and practice competency at three medical schools in Canada, India and Uganda. Survey on the diagnostic and management aspect showed that most(92%) of the students knew that cough is the commonest symptom of TB and sputum microscopy is the most specific test for diagnosing infection. However, very few knew that one requires minimum 5% sodium hypochlorite to kill Mycobacterium tuberculosis bacilli. Majority of students knew about DOTS but only 20.5% of students knew how to manage a smearnegative TB patient. Most of the students were not updated about the dosage of antituberculous drugs. Only 30.5% mentioned the correct dose of INH. Various studies have shown that the knowledge of diagnosis and treatment of TB has lacunae. In an article[5] from NewDelhi
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Figure 3: Response of students for isolation of sputum positive patients

and confidence about TB in students in the medical profession. Moreover, TB patients are socially discriminated, though the level of discrimination is much less compared with leprosy and HIV. A survey of finalyear medical students from Canada, India and Uganda by Emili etal.[4] demonstrated significant
Journal of Academy of Medical Sciences

Baveja and Dalal: Awareness of revised national tuberculosis control program amongst medical students

TB center, 141 different treatment regimens were mentioned in the responses and of them only 11(7.8%) were therapeutically rational. Asurvey conducted of 460 interns from five Pakistani teaching hospitals showed only 22% correctly identified the estimated number of new TB cases in Pakistan.[6] Only 38% considered sputum smears for acid fast bacilli as the optimal test for diagnosis of pulmonary TB and 43.5% for followup during TB treatment. Most interns(82%) were unable to identify a single component of the DOTS strategy. The study reflected poor awareness of and low compliance to the WHO/NTP guidelines amongst interns. In 2005, Jackson etal.[3] found that onethird medical students did not know the method of administering tuberculin, or that Bacillus Calmette Guerin(BCG) vaccine was not a contraindication for the tuberculin skin test. Our analysis on the risk perception and attitude toward TB patients revealed surprising results. Only 17% of students knew intubation has one of highest risks of transmission and that the N95 respiratory mask provides protection against TB(6%). Responses of various students among different categories reveal that risk perception awareness was less among all the three groups; however, compared with the 3rd year students, the interns had a marginally better risk perception. The reason could be that the interns do much more of clinical and practical work compared with students. Rao etal.[7] reported an overall risk of 11.2cases per 1000 interns working in Post Graduate Institute, Chandigarh. The risk was higher(17.3cases per 1000) in the interns within 1styear of joining the hospital, hence reinforcing the need to implement simple, effective, and affordable TB infection control measures in healthcare facilities. Item analysis of the MCQs revealed that the level of difficulty for most of the items/questions was higher in III/I semester students compared with III/III semester students and interns. This indicates that for the III/I semester students, the exam was easier and that they have better knowledge about RNTCP than the III/III semester students and interns. The reason could be related to recently acquired knowledge, as III/I semester students have fresh knowledge about the subject. However, for interns, the difficulty index for most of the questions was very low, indicating the interns felt the questions were difficult; this could be because recall of past memory is poor, busy schedule of interns and the stress of preparation of entrance exams for postgraduation. Topicwise comparison of the difficulty index revealed that all three groups had less knowledge of risk perception of TB. This might explain the increasing trend of TB infection among the medical personnel, thereby emphasizing the importance of universal safety precautions and personal protective equipment.

TB, emphasizing the fact that these aspects of TB should be considered. The average correct response in the different groups ranged from 28% to 62%, which is far from acceptable, as TB is a serious public health concern in India. Training should be imparted to the students covering all aspects of TB by conducting continuous medical education programs every year. In Second MBBS, a course on pathogenesis and diagnosis of TB, including RNTCP; in Third MBBS on the DOTS and DOTS+strategies; and also an orientation course at the beginning of internship will definitely help the students to improve their knowledge on TB. Therefore, we recommend that to ensure the successful control of TB and successful implementation of RNTCP, we need to sensitize medical students and future healthcare providers on a regular basis. Extremely drug resistant(XDR) TB has been reported from Mumbai in 2012. Moreover, multidrug resistant(MDR) TB has become a burning problem today. Therefore, new researches should be started on XDR TB along with intensification of research activities on MDR TB.

ACKNOWLEDGMENT
The study was conducted as an ICMR shortterm research studentship project(STS), 2008. No.21/556/08BMS.

References
1. RothschildBM, MartinLD, LevG, BercovierH, BarGalGK, GreenblattC, etal. Mycobacterium tuberculosis complex DNA from an extinct bison dated 17,000years before the present. Clin Infect Dis 2001;33:30511. 2. Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare. Managing the Revised National Tuberculosis Control Programme in your area. Atraining course. Modules 14 and 59. April 2005; p.1182 and 1248. 3. JacksonM, HarrityS, HoffmanH, CatanzaroA. Asurvey of health professions students for knowledge, attitudes, and confidence about tuberculosis, 2005. BMC Public Health 2007;7:219. Available at: http://www.biomedcentral. com/14712458/7/219.[Last accessed November 2010]. 4. EmiliJ, ScottF, UpshurRE, SchmuckML, JohnKR. Attitudes toward tuberculosis of final year medical students from Canada, India, and Uganda. Teach Learn Med 2002;14:16874. 5. RajpalS, MittalA, DhingraVK, MalhotraR, GuptaR, MalhotraC, etal. Knowledge, attitude and practices regarding tuberculosis and DOTS among interns in Delhi, India. JColl Physicians Surg Pak 2007;17:45761. 6. KhanJA, ZahidS, KhanR, HussainSF, RizviN, RabA, etal. Medical interns knowledge of TB in Pakistan. Trop Doct 2005;35:1447. 7. RaoKG, AggarwalAN, BeheraD. Tuberculosis among physicians in training. Int J Tuberc Lung Dis 2004;8:13924. How to cite this article: Baveja SM, Dalal PJ. Awareness of the revised national tuberculosis control programme and attitude to tuberculosis patients amongst medical undergraduates. J Acad Med Sci 2012;2:68-72. Source of Support: Nil, Conflict of Interest: None declared.

Conclusions
All students were aware of RNTCP. The overall performance of III/I students was better than the rest of the study group. Students performed better in the epidemiology domain as compared to the management and preventive aspects of
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Journal of Academy of Medical Sciences