Evaluating knowledge gain from TB leaflets for prison and homeless sector staff: the National Knowledge Service TB pilot

Abstract

Background: The National Knowledge Service (NKS) is a National Health Service initiative to make patient and public information available to patients and healthcare professionals. The current study was carried out with a view to determine whether the resources developed by the NKS Tuberculosis Pilot have improved knowledge about tuberculosis among the target group in the short term. Methods: Information resources specifically targeted and developed for homeless sector staff, managers and prison officials were used for this study. Questionnaires were designed to assess a change in the level of knowledge by completing a ‘before’ and ‘after ‘questionnaire. A total of 51 participants took part in the evaluation. McNemar's test for matched pairs was used to determine observed change in knowledge. Results: Staff knowledge on symptoms of tuberculosis (TB) increased significantly after reading the targeted information resources. Knowledge gain for symptoms ranged from 17% (P = 0.007) for weight loss to 45% (P = 0.00001) for persistent fever. Knowledge about general guidelines that are available to this target group also improved, as did knowledge about the potential role of staff in supporting directly observed treatment (by 68% P = 0.00001) and the usual length of TB treatment (by 32% P = 0.0001). Pre-existing knowledge about the infectiousness of TB, risks for transmission and the likely period of hospitalization of patients with TB was high. Conclusions: This study demonstrates that purposefully designed and targeted information leaflets can be used successfully to translate complex information into a simple understandable format and impart knowledge of TB.

Introduction

A National Knowledge Service was set up in England in response to the Kennedy Report¹ into the exceptional mortality rates among children undergoing heart surgery at Bristol Royal Infirmary. This highlighted the need to provide access to best current knowledge wherever and whenever it was needed. The Chief Medical Officer (CMO) published a tuberculosis (TB) action plan for England² in October 2004, which outlines recommended actions that are essential to bring TB under control. A key component of this plan is to reduce risk by increasing awareness among high-risk groups. Following the publication of the CMO's action plan, the National Institute of Health and Clinical Excellence (NICE) published guidelines³ for the management of TB, which included reference to the National Knowledge Service (NKS) as a source of information resources.

The Health Protection Agency (HPA), along with the National Health Service (NHS) and other voluntary organizations, has piloted the NKS for TB. The resources developed by the TB pilot are designed to ensure that evidence based guidelines and quality-assured sources of information on TB are made easily accessible to healthcare professionals, other carers involved in the management of the TB patients and their contacts.

Early diagnosis, particularly of infectious TB, is a major factor in the success of control programmes.³ Diagnostic delays may be reduced by increasing awareness among those at risk of TB and among individuals who care for them. The aim of developing these resources is to (i) increase awareness about the symptoms of TB, so that officials working with the ‘at risk’ groups can direct clients to appropriate services; (ii) provide context-relevant and readily accessible information derived from recent guidelines; and (iii) provide decision support information on topics where guidelines are lacking.

The NKS TB Pilot (TBP) Project Board identified, developed and piloted resources for those working with defined groups at risk of TB, as part of the overall pilot (table 1). In the UK, TB continues to affect particular vulnerable groups disproportionately – including the homeless, illicit drug users and alcoholics.⁴ Staff in the homeless and prison sectors have routine contact with these ‘at risk’ groups without the benefit of healthcare training and therefore require information about the nature of the disease and how they can support their clients. This study was conducted to determine whether the resources produced by the TB pilot increased the knowledge on TB among the Homeless Sector and Prison staff.

Methods

Sample selection

The information resources for the NKS TBP were specifically developed to provide appropriate context specific information to a particular audience and were evaluated by members of the target groups. Staff from a prison and a young offender institution and remand centre in SE England, and staff and managers from hostels who attended a ‘Health Spotlight Event’ organized by Homeless Link, a UK based charity, were invited to participate. All respondents agreed to take part in the survey. Questionnaire surveys were carried out in sessions that had been organized for this purpose.

Questionnaire design and administration

The questionnaires were designed to assess a change in the level of knowledge of the target users following the distribution of information leaflets. All staff members were given leaflets appropriate to their posts (table 1). Specific questions about knowledge of TB and possible methods/actions the officials could take if a client in their care is diagnosed with TB were asked. The questionnaires examined the following areas:

• Background information on TB

• Awareness about symptoms of TB

• Guidance and options available for supporting clients

• Areas of knowledge/practice where guidelines are lacking

All participants were asked to complete a pre-designed questionnaire before and after reading the relevant information resources during their survey sessions. Both the questionnaires asked the same questions and were based on information provided in the information resources.

The respondents were required to choose from a list of pre-determined options and, where appropriate more than one answer to a particular question was allowed. A limited number of control questions on symptoms not associated with TB were also included in the options. Respondents provided comments where they felt clarification was required. Gain in knowledge was calculated based on correct answers provided ‘after’ reading the leaflet, where a wrong answer or no answer was provided in the ‘before’ questionnaire by the same respondent.

Data analysis

Statistical analyses were performed using Stata version 9.2. McNemar's test for matched pairs was used to determine the statistical significance of any change in knowledge observed.

Results

A total of 51 staff participated in the study. Twenty-eight (55%) were prison staff and 23 (45%) were from the homeless sector. Prison staff who participated in the study were those who responded to a call for volunteers, while homeless sector staff who participated comprised all attendees at a ‘Health Spotlight Event’ on an unrelated topic. Eight (28%) staff in the prison sector had worked in a healthcare setting. In contrast, two staff members working in the homeless sector had limited previous clinical exposure (4%).

Increasing awareness of symptoms of TB

The first section of all three leaflets included a list of six common symptoms of TB, persistent fever, ‘cough for a long period of time’, heavy sweating, unusual tiredness, weight loss and coughing blood, plus a few symptoms not relevant to pulmonary TB.

Our results (table 2) indicate that the leaflets significantly increased respondents' knowledge of the symptoms of TB. There was a significant gain in knowledge of 45%, 33%, 27%, 23% and 17% for persistent fever (P = 0.00001), heavy sweating (P = 0.0003), unusual tiredness (P = 0.0018), weight loss (P = 0.007) and coughing blood (P = 0.05) as symptoms of TB, respectively.

Most participants appeared to know that ‘coughing for a long period of time’ is a symptom of TB. After reading the resources all users were aware that this was a symptom of TB, however, this increase in correct responses (9%) was not statistically significant (P = 0.2).

There was no significant change in the incorrect attribution of symptoms unrelated to pulmonary TB (from 1.9% to 4%).

Supporting clients—where guidelines are available

The proportion of participants correctly identifying the duration of treatment for TB as 6–9 months increased by 32% (P = 0.0001). Similarly, there was a 68% increase in the proportion of staff acknowledging their potential role in the direct observation of TB treatment (P = 0.00001). There was also a 13% increase in respondents who correctly identified the need to support contact tracing, however, this was not statistically significant (P = 0.34).

A 48% increase in the respondents' knowledge of the appropriateness of BCG vaccination in this population was observed (P = 0.0018).

Addressing areas where guidelines are lacking

Knowledge regarding risks and precautions to prevent the spread of disease was not improved significantly after reading the information resources. Nearly 80% of participants, however, identified the correct answers at baseline suggesting high levels of knowledge.

General background and immediate action

Levels of knowledge regarding the infectiousness of TB, the fact that it is a curable disease, and appropriate referral processes were not significantly improved after reading the leaflets, but were already high among participants beforehand. Knowledge about the likely length of hospitalization was not significantly different after reading the leaflets, although the beforehand level of knowledge (at 77%) was lower than for the other topics in this section.

Discussion

Increasing awareness of TB is an international priority. General lack of knowledge and several misconceptions about TB have been reported from various countries.^5–7 In order to assess the effectiveness of knowledge dissemination, a gap in knowledge about TB was identified among carers of the homeless and those in prisons. The users were provided with information from guidelines^3,8,9 in a simple format, developed in consultation with the relevant stakeholders, which aimed to increase knowledge on TB and provision of support to clients in their care.

We found that although the targeted staff groups had basic knowledge about TB before the intervention, this was unlikely to be enough to support or guide the clients in their care through the process of ‘early’ diagnosis and treatment of TB. This study has shown that following an intervention that consisted of reading context-specific, short, tailored, easily accessible information leaflets, knowledge among prison and homeless sector staff about symptoms of TB, the duration of treatment, and their role in supporting treatment was significantly improved. This improvement can contribute to early diagnosis, prompt treatment and limit further spread. The resources did not, however, improve knowledge in all areas that they addressed, although this was primarily on topics for which participants already had a high level of knowledge.

Previous studies have indicated that the rate of TB among the homeless and prisoners is higher than the general population.¹⁰ Prior to this pilot, no targeted information resources were available for carers for these groups of people. Previous studies have shown that information leaflets can be used to increase knowledge e.g. of breast cancer screening.¹¹ Leaflets have also been shown to influence understanding and provide reassurance about genetic testing, but additional strategies may also be required.¹²

The key contribution of this study is that it has added value to available guidance by mobilizing and delivering accessible knowledge to specific user groups, for instance:

• There is evidence of a significant increase in knowledge about symptoms among the users.

• This study has shown that these resources have significantly increased the awareness among the staff to support their clients suspected or diagnosed with TB, including the role of the officials in supporting directly observed therapy (DOT). The NICE guidelines³ strongly recommend DOT for street or shelter dwelling homeless people with active TB, and patients with likely poor adherence such as individuals in prisons.

All participants indicated that these resources were important and useful to them. This project did not, however, develop any new guidance. In other areas, the leaflets were not as effective: This survey was undertaken on a relatively small sample of the target population, however, we have identified highly statistically significant gains in knowledge in specific user groups. These staff groups, most of whom are not from a medical background, work closely with clients at a higher risk of developing TB.

• The increase in knowledge in areas where guidelines are lacking was limited, particularly on the subject of sharing of common facilities. This has identified the need for further work in this area.

The survey sessions were conducted in an artificial setting, as the respondents were aware that they would need to answer a questionnaire based on the leaflets. Whether the respondents would read the leaflet with as much care in a normal setting is not known. There was the possibility of some participation bias among prison officials who volunteered to take part, in contrast to the homeless sector respondents, where all members who attended a forum that was on an unrelated topic completed the questionnaire.

In this study we have not investigated whether the increased knowledge is retained in the long term or if it has led to a behaviour change. Behaviour change is an important measure of effectiveness, however it is also a process measure. The ultimate outcome measure of any intervention is a change in health status. This will be difficult to determine in any study.¹³ Other limitations include the role of unmeasured confounders which could be addressed with a randomized controlled design. Future assessments of such leaflets should utilize such an approach.

Further awareness raising strategies include training sessions such as lectures aimed at improving knowledge,¹⁴ the use of television, radio, billboards,⁵ posters and, where appropriate, web based education.¹⁵ These have all been shown to be effective methods of increasing knowledge.

This study has demonstrated that purposefully designed and targeted information leaflets can be used successfully to increase awareness about TB among staff groups who work with those ‘at risk’ of TB, namely the homeless and prison sector staff, but do not have any clinical training.

Funding

Department of Health in England (to the NKS TB).

Conflicts of interest: None declared.

Acknowledgements

We are very grateful to all those who contributed to this study, and all members of the NKS TB Project Board—James Freed, Julius Weinberg, Lynn Altass, Neil Ferguson, Patricia Young, Patty Kostkova and Tina Harrison. Linda Briheim-Crookall, Beth Coyne and Gail Emerson from Homeless Link for their continued support during the development and evaluation of the resources on Homeless Sector group. Autilia Newton, Adrienne Testa, Eamonn O’Moore, Marion Bond, Mary Piper, Noel Gill, Ruth Gelletlie, Samantha Perkins and Stephen Conaty for their contributions during the development and evaluation of the Prison Official resources.

References