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Year : 2011  |  Volume : 24  |  Issue : 2  |  Page : 514

Changes in Healthcare Workers' Knowledge about Tuberculosis Following a Tuberculosis Training Programme

1 University of KwaZulu-Natal, Durban, South Africa
2 University of Wisconsin-Whitewater,Whitewater, Wisconsin, USA

Date of Submission13-Jul-2010
Date of Acceptance07-Jul-2011
Date of Web Publication10-Aug-2011

Correspondence Address:
S Naidoo
University of KwaZulu-Natal, Durban
South Africa
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Source of Support: None, Conflict of Interest: None

PMID: 22081655


Background: In resource-limited countries, health policy makers and practitioners need to know whether healthcare workers have sufficient knowledge of tuberculosis and its management.
Objectives: We conducted a study to: (1) measure knowledge changes among healthcare workers who participated in a
tuberculosis training programme; and (2) make recommendations about future tuberculosis training for healthcare workers in the KwaZulu-Natal Department of Health.
Methods: A cross-sectional study conducted in 2007 measured changes in tuberculosis knowledge of doctors, nurses and other healthcare workers after a training programme based on World Health Organization tuberculosis training modules. Data were collected before and after training using a self-administered, 98-item questionnaire covering eight components.
Results: A total of 267 healthcare workers, mean age 40.7 years, answered both pre- and post-training questionnaires. Mean total knowledge scores were low despite significant changes (p<0.001) from a pre-training score of 59.5% to a post-training score of 66.5%. Nurses showed significant improvements in mean total knowledge scores (p<0.001) but had the lowest mean total knowledge score post-training, 63.2%. Doctors had significantly better pre-training (p<0.001) and post-training (p<0.001) mean total knowledge scores compared to nurses.
Conclusions: Improvement in healthcare workers' overall knowledge of tuberculosis during a training programme was not clinically significant. Periodic field training and supervision should be considered to ensure tuberculosis knowledge improvements.

Keywords: Education, evaluation studies, healthcare workers, primary health care, professional competence, training, tuberculosis

How to cite this article:
Naidoo S, Taylo M, Esterhuizen T M, Nordstrom D L, Mohamed O, Knight S E, Jinabha C C. Changes in Healthcare Workers' Knowledge about Tuberculosis Following a Tuberculosis Training Programme. Educ Health 2011;24:514

How to cite this URL:
Naidoo S, Taylo M, Esterhuizen T M, Nordstrom D L, Mohamed O, Knight S E, Jinabha C C. Changes in Healthcare Workers' Knowledge about Tuberculosis Following a Tuberculosis Training Programme. Educ Health [serial online] 2011 [cited 2022 Jan 19];24:514. Available from:


Many National Tuberculosis Programmes (NTPs) lack competent staff and training activities1. While combined political and financial commitment is needed to control the tuberculosis (TB) epidemic, the training of healthcare workers (HCWs) in diagnosis, management and related areas increases NTP success2.

After the outbreak of extensively drug resistant TB in South Africa in 2006, the National Department of Health (DOH) developed a strategic plan to prevent TB and to ensure access to effective and efficient diagnosis, treatment and care3. Consistent with findings from elsewhere that lack of trained staff is a major obstacle to TB control4, the plan identified high staff turnover as a cause of sub-standard practices and recommended strengthening of staff training and supervision3.

In the province where South African extensively drug resistant TB was first identified3, the DOH awarded a tender to the Nelson R. Mandela School of Medicine Department of Public Health Medicine (DPHM) to train HCWs in the diagnosis and management of TB patients5. Receiving the tender based on its public health expertise in TB control, DPHM drew on the experience of clinical subject experts from other departments in the medical school.  

Although our training programme was influenced by experience from Kenya, Vietnam and South Africa6 as well as by studies of knowledge in various HCW cadres involved in TB control7-9, our approach differed because we measured change in TB knowledge in HCWs from pre to post-training10.  


Our cross-sectional study measured changes in TB knowledge pre- and post-training among HCW attendees in 2007 in KwaZulu-Natal (KZN), the largest (2001 census population: 9 426 017) and amongst the poorest of South Africa’s nine provinces. The four of KZN’s 11 health districts with the worst TB treatment outcomes (cure, completion, interruption and death) were chosen for the training. All eligible 818 HCWs working in TB control in hospitals, community health centres, primary health clinics and district offices were advised by the Provincial DOH to participate.

The categories of HCWs in the South African TB Control Programme can be defined and described as:

Nurses: Individuals with a minimum of one year of training in nursing and working in a health facility and in primary health clinics, where nurses diagnose and treat TB;

Nurse trainers/Supervisors: Individuals with nursing qualifications employed to train and supervise facility-based nurses;

Doctors: Doctors in hospitals who diagnose and treat TB;

District managers: Individuals who administer health programmes, including TB control, in areas of a province; and

TB support staff: Individuals who are not doctors or nurses but are involved in parallel functions related to TB control, including lab technicians and contact tracers. 

Programme design was based on TB training material developed by the World Health Organization and the International Union against TB and Lung Disease6, our knowledge of concerns about South African HCW knowledge and practice, consultation with the KZN provincial DOH, and the experiences of other countries6-10.  The training programme and questionnaire covered eight TB components: (1) detection and treatment; (2) advanced treatment; (3) communication and counselling; (4) drug management; (5) continuation of treatment; (6) directly observed treatment; (7) programme management; and (8) monitoring, evaluation, recording and reporting. We included lectures, experiential learning, small group discussions and shared and self-learning.  Each module included a theoretical review and update, followed by presentations based on trainees’ actual experiences. Trainers included facilitators and subject experts who had experience training different cadres of HCWs. Training time averaged 3.5 days per component (range: 2 to 12 days because of variation in module importance and content) and totaled 28 days over a six-month period.

Because our search of bibliographic databases and inquiries to TB researchers and trainers uncovered no questionnaires that were used to assess the effect of training on knowledge, we developed an original, self-administered instrument with 98 questions requiring 'yes' or 'no' answers, covering the eight components of TB. The number of questions (range: 4 to 22) per module was based on the structure of the training programme and prior information on areas of concern with respect to HCW knowledge and practice. This questionnaire was piloted among 30 nurses from a health district that was not included in the training programme. Minor corrections to the questionnaire were made to ensure clarity and ease of understanding. The questionnaire took 30 minutes to complete.

At the start of training, all attendees were informed about the objectives of the study. They signed informed consent and voluntarily completed the questionnaire before training began. At the end of the training programme, participants completed an identical questionnaire. The Biomedical Research Ethics Committee of the University of KZN approved the study, and the KZN DOH granted permission to conduct it.

Descriptive statistics are presented for the demographic data. All test scores were converted from points, with one point per each of the 98 questions, to percentage for analysis. No questions were left blank by respondents to the pre- and post-training tests. For each questionnaire module and each HCW category, total mean percent score before and after training and mean percent score change, with 95% confidence intervals, were calculated. Differences in the mean percent score of the various categories of HCWs were compared using the ANOVA test. The change in percent scores for each category of HCW was compared using the paired samples t-test. The Bonferroni multiple-comparisons procedure was used to compare mean percent scores between each category of HCW before and after training and among districts. The accepted level of statistical significance was α=0.05.  


Of the 818 HCWs who were invited to participate in the training, 585 (71.0%) participated in at least part of the programme. Of these, 267 workers (46.0%) attended the training and answered both pre- and post-training questionnaires. The average age of these participants was 40.7 years (range: 22 to 78 years), with no significant age difference by gender. The majority of participants were women (n=215; 80.5%) and nurses (n=171; 64%).  DOH employment length averaged 6.4 years (range: 1 to 31 years), and 48% (n=127) of participants previously attended a TB training programme. 

For the 267 trainees, the percentage of correct answers to the 98-item questionnaire rose from 59.5% before training to 66.5% after training. Baseline scores were highest for the modules on disease transmission (82%) and disease causation (77%). Knowledge improved the most for monitoring of TB programme (15% increase) and drug management (10% increase). Questions on 'management of TB patients,' 'monitoring of TB programmes' and 'drug management' were generally answered incorrectly at pre-training, and questions on the first two of these three aspects remained incorrectly answered at post-training.

Improvement in total mean knowledge scores ranged from 13.8 percent by TB support staff to 4.7 percent by district managers (Table 1). Nurses had the lowest overall knowledge score at post-training, 63.2%. Nurses (p<0.001), doctors (p=0.01) and TB support staff (p=0.03) showed significant improvements in total mean knowledge scores post-training.  Compared to nurses, doctors had significantly better pre-training (p<0.001) and post-training (p<0.001) overall scores and scores on 'cause of TB,' ‘high risk patients,' 'diagnosis of TB,' 'management of TB patients' and 'monitoring of TB programme'. Doctors also had: significantly better mean scores than TB support staff had at pre-training on 'disease causation,' 'high risk patients' and 'management of TB patients'; and better scores than district managers at post-training with respect to 'high risk patients' and 'monitoring of TB programme'.

Table 1:  Mean percent pre- and post-training knowledge scores by healthcare worker category (n=267)


In an area of South Africa with poor TB treatment outcomes, the overall knowledge of nurses, doctors and other healthcare workers who participated in a 28-day comprehensive training programme improved, but the change was not clinically significant. Of the five participating categories of HCWs, nurses recorded the lowest overall knowledge after the training, achieving their lowest results in the domains of TB patient management and TB programme monitoring.  

Strengths of our study were inclusion of HCWs of all types from the largest province of one of Africa’s largest countries, the use of a questionnaire that covered multiple aspects each by multiple items and an approach to assessment of knowledge change that allowed conclusions about training’s effect.  To ensure that the questionnaire was applicable to all HCWs, we developed questions to test common knowledge among the different categories of HCWs.

Study limitations were limited generalizability due to nonparticipation by a majority of eligible HCWs and the combination of nurses with different years of experience into one group.  Limited human resources for health services is a major constraint in South Africa11.  Most HCWs deliver not only TB services but also comprehensive preventive and curative services. The high workload of HCWs may explain the low attendance and completion of our voluntary training programme.

Overall, we are concerned about nurses having the least knowledge before and after training because they are in the forefront of TB service delivery in South Africa and many parts of the world. This unfortunate situation exists despite the fact that between 2000 and 2003, about 70 to 80% of district and facility-level staff in South Africa were trained using material developed by the World Health Organization and the International Union against TB and Lung Disease10. Equally concerning is the poor TB knowledge among the district managers, including even a decrease in three aspects of knowledge post-training.  

The benefit of our TB training programme to HCWs may have been limited by its funding, which did not allow us to monitor study participants in the field after training ended. Primary healthcare services improve when health workers receive decentralised district and facility-based training, supervision and follow-up12,13.  

The failure of the training programme to attract more than a minority of eligible HCWs to participate indicates a need to review and adapt TB training methods and policy. Perhaps a focus group of frontline HCWs can inform designers of future evaluations of TB training programmes. Our study findings highlight the inadequacies of current HCW training for TB. Future training initiatives require a long-term approach to human resource development within the NTP.  Experiences in Kyrgyzstan14 and the Democratic Republic of Congo15 show that periodic training and supervision in the field can improve healthcare workers’ TB knowledge and skills.


1Global Tuberculosis Control: Surveillance, Planning, Financing. WHO Report 2006. (WHO/HTM/TB/2006.362). Geneva: World Health Organization; 2006.

2Fanning A. The importance of education, training and supervision in global TB control. The International Journal of Tuberculosis and Lung Disease. 2000; 4(12 Suppl 2):S208-214.

3National Department of Health (NDOH). Tuberculosis Strategic Plan for South Africa 2007-2011. South Africa Pretoria; 2007.

4Harries AD, Zachariah R, Bergström K, Blanc L, Salaniponi FM, Elzinga G. Human resources for control of tuberculosis and HIV-associated tuberculosis. The International Journal of Tuberculosis and Lung Disease. 2005; 9(2):128-137.

5Naidoo S, Taylor M, Mohamed O, Knight SE, Jinabhai CC. Monitoring and Evaluation of Tuberculosis Training: KwaZulu-Natal. Departmental Report. University of KwaZulu-Natal: Durban, KwaZulu-Natal; 2007.

6World Health Organization. Management of Tuberculosis Training for Health Facility Staff. (WHO/CDS/TB/2003.314a). Geneva: World Health Organization; 2003.

7Hashim DS, Al Kubaisy W, Al Dulayme A. Knowledge, attitudes and practices survey among health care workers and tuberculosis patients in Iraq. Eastern Mediterranean Health Journal. 2003; 9(4):718-731.

8Maciel EL, Vieira Rda C , Milani EC, Brasil M, Fregona G, Dietze R. Community health workers and tuberculosis control: Knowledge and perceptions. Cadernos De Saúde Pública. 2008; 24(6):1377-1386. In Portuguese.

9Lewin S, Dick J, Zwarenstein M, Lombard CJ, Staff training and ambulatory tuberculosis treatment outcomes: A cluster randomized controlled trial in South Africa. Bulletin of the World Health Organization. 2005; 83(4):250-259.

10Figueroa-Munoz J, Palmer K, Poz MR, Blanc L, Bergström K, Raviglione M. The health workforce crisis in TB control: A report from high-burden countries. Human Resources for Health. 2005; 3(1):2. doi: 10.1186/1478-4491-3-2.

11Hall EJ. Nursing attrition and the work environment in South African health facilities. Curationis. 2004; 27(4):28-36.

12Teasdale K, Brocklehurst N, Thom N. Clinical supervision and support for nurses: An evaluation study. Journal of Advanced Nursing. 2001; 33(2):216-224.

13Loevinsohn BP, Guerrero ET, Gregorio SP. Improving primary health care through systematic supervision: A controlled field trial. Health Policy and Planning. 1995: 10(2):144-153.

14Awofeso N, Schelokova I, Dalhatu A. Training of front-line health workers for tuberculosis control: Lessons from Nigeria and Kyrgyzstan. Human Resources for Health. 2008; 6:20. doi: 10.1186/1478-4491-6-20.

15Vanden Driessche K, Sabue M, Dufour W, Behets F, Van Rie A. Training health care workers to promote HIV services for patients with tuberculosis in the Democratic Republic of Congo. Human Resources for Health. 2009; 7:23. doi:10.1186/1478-4491-7-23.


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