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Knowledge about tuberculosis among undergraduate health care students in 15 Italian universities: a cross-sectional study

  • Maria Teresa Montagna1Email author,
  • Christian Napoli1,
  • Silvio Tafuri1,
  • Antonella Agodi2,
  • Francesco Auxilia3,
  • Beatrice Casini4,
  • Maria Franca Coscia5,
  • Marcello Mario D’Errico6,
  • Margherita Ferrante2,
  • Angelo Fortunato7,
  • Cinzia Germinario1,
  • Domenico Martinelli8,
  • Giuseppe Michele Masanotti9,
  • Maria Fatima Massenti10,
  • Gabriele Messina11,
  • Paolo Montuori12,
  • Ida Mura13,
  • Giovanni Battista Orsi14,
  • Alessia Quaranta1,
  • Giovanni Sotgiu15,
  • Armando Stefanati16,
  • Stefano Tardivo17,
  • Maria Valeria Torregrossa10,
  • Anna Maria Tortorano3,
  • Licia Veronesi18,
  • Raffaele Zarrilli12 and
  • Cesira Pasquarella18
BMC Public Health201414:970

https://doi.org/10.1186/1471-2458-14-970

Received: 8 April 2014

Accepted: 11 September 2014

Published: 18 September 2014

Abstract

Background

The Italian Study Group on Hospital Hygiene of the Italian Society of Hygiene, Preventive Medicine and Public Health conducted a multicentre survey aiming to evaluate undergraduate health care students’ knowledge of tuberculosis and tuberculosis control measures in Italy.

Methods

In October 2012–June 2013, a sample of medical and nursing students from 15 Italian universities were enrolled on a voluntary basis and asked to complete an anonymous questionnaire investigating both general knowledge of tuberculosis (aetiology, clinical presentation, outcome, screening methods) and personal experiences and practices related to tuberculosis prevention. Data were analysed through multivariable regression using Stata software.

Results

The sample consisted of 2,220 students in nursing (72.6%) and medicine (27.4%) courses. Our findings clearly showed that medical students had a better knowledge of tuberculosis than did nursing students.

Although the vast majority of the sample (up to 95%) answered questions about tuberculosis aetiology correctly, only 60% of the students gave the correct responses regarding clinical aspects and vaccine details. Overall, 66.9% of the students had been screened for tuberculosis, but less than 20% of those with a negative result on the tuberculin skin test were vaccinated. Multivariable regression analysis showed that age and type of study programme (nursing vs. medical course) were determinants of answering the questions correctly.

Conclusions

Although our data showed sufficient knowledge on tuberculosis, this survey underlines the considerable need for improvement in knowledge about the disease, especially among nursing students. In light of the scientific recommendations concerning tuberculosis knowledge among students, progress of current health care curricula aimed to develop students’ skills in this field is needed.

Keywords

Knowledge Tuberculosis Undergraduate health care students

Background

In the last three decades, the emergence of HIV/AIDS as well as the appearance and spread of drug-resistant forms of tuberculosis (TB) have been associated with an increase in the TB rates in several low-, middle- and high-income countries [1, 2]. Together with HIV/AIDS and malaria, TB is one of the most significant causes of death worldwide, most frequently affecting men in their economically productive age groups [3, 4]. With a TB incidence rate considerably below 10 cases per 100,000 inhabitants over the last 10 years, Italy can be considered a low-burden country. Nevertheless, TB has increasingly become an illness affecting specific population subgroups; approximately 40% of reported TB cases in Italy involve foreign patients resident in Italy. Additionally, regional variation has been reported. Compared with Italy as a whole, TB rates are higher in the large cities of central and northern Italy, most likely because of the larger presence of foreigners or the more extensive commercial activity in these areas [5].

In 1993, the World Health Organization (WHO) declared TB a global public health emergency and supported national and international strategies to improve the care and control of the disease (i.e. Directly Observed Treatment, Short-course (DOTS) and the Stop TB Strategy) [68]. Although the TB mortality rate has decreased by 41% since 1990, Mycobacterium tuberculosis infection and related diseases remain a major global health issue. According to the latest estimates, there were 8.6 million new cases of TB and 1.3 million TB deaths in 2012 [4].

Findings from the global context indicate that a population’s knowledge of TB is crucial to facilitate the seeking of early medical care and avoidance of further M. tuberculosis transmission. Deficient knowledge often results in delays in TB diagnosis and treatment, increasing the risk of M. tuberculosis transmission and the development of multidrug-resistant TB (MDR-TB) across the world [4, 9, 10]. TB knowledge among undergraduate health care students is particularly important, because they may face significant exposure and, consequently, have the highest risk of infection or disease. Moreover, these individuals represent potential future physicians or leaders in the fight against TB, so it is important that they know how to control the disease appropriately [11, 12].

Based on this scientific background, the Italian Study Group on Hospital Hygiene (GISIO) of the Italian Society of Hygiene, Preventive Medicine and Public Health (SItI) promoted a multicentre survey that aimed to i) determine the level of knowledge of tuberculosis and its control measures among undergraduate health care students in Italy and ii) investigate personal experiences with practices to prevent M. tuberculosis infection.

Methods

Study design

Those Italian universities that were members of the GISIO group of the SItI and that offered medical and nursing degree courses were consulted. Overall, 15 universities located in urban areas participated in the survey on a voluntary bases. This study, carried out from October 2012 through June 2013, follows the principles of the World Medical Association Declaration of Helsinki and does not report any experiment on humans or human samples, nor research on identifiable human material and data.

All students took part on a voluntary basis and were not remunerated for their contribution. During the recruitment, potential participants were approached and provided with a detailed explanation of the objectives of the study. After participants’ verbal consent was obtained (as required by Italian privacy law), they were asked to complete an anonymous questionnaire.

The questionnaire

The questionnaire consisted of multiple-choice questions divided into two sections comprising 13 and 7 questions, respectively: 1) general knowledge of TB disease, its aetiological agent, vaccine and screening methods and 2) personal experiences with and practices related to TB. The questionnaire also included questions about socio-demographic characteristics (i.e. age, gender, nationality, residence), location of the university and degree course.

To assess the accuracy of the questionnaire, an internal pre-validation procedure was carried out at the University of Bari Aldo Moro involving 20 fifth-year medical students and 10 second-year nursing students (Cronbach’s alpha = 0.83, indicating good internal consistency). This pilot phase allowed the improvement of the quality of several questions. Student participants in the pilot study were invited to complete the questionnaire in a time period of 20 minutes at the end of their lessons on hygiene.

Data analysis

The information collected was entered into a database (File Maker Pro, 11.0v2, 2010) and analysed using Stata MP (11.2 for Mac, 2011). Here, the data are presented as percentages. The percentage distributions of the investigated variables were compared between medical students and nursing students using Chi-square tests. Continuous variables were summarised using means and standard deviations (SD) for variables that were distributed normally. Categorical variables were expressed as proportions. Univariable and multivariable logistic regression analysis was performed to evaluate the association between having correctly answered the questions about the disease, vaccine and screening methods (outcomes) and age, gender, degree course (medical vs. nursing) and tuberculin skin test (TST) result (determinants). The adjusted odds ratio (OR) and 95% confidence interval (CI) were calculated for each outcome. A p-value < 0.05 was regarded as statistically significant.

Results and discussion

The study involved 2,220 Italian students enrolled in nursing (n = 1,611; 72.6%) and medicine (n = 609; 27.4%) courses. All of the participants correctly completed the questionnaire and were considered reliable for the analysis. No data were available with regard to the number of non-participants and how this could have affected the results of the survey. In our sample, the mean age was 22.5 ± 3.7 years, with the majority of the recruited individuals being female (66.4%).

Our findings showed a better knowledge of TB among medical students than among nursing students (Table 1). With regard to general information, the sample reported being aware that TB is an infectious disease caused by various strains of the Mycobacterium genus and more frequently by M. tuberculosis (94.7%), knew of the existence of MDR strains as a consequence of an inadequate therapy (78.5%) and were aware that TB does not affect only the lungs (75.8%). They also stated that the treatment of TB is problematic and requires the intake of a combination of antibiotics over a long period of time (75.1%), that the lethality rate of untreated active forms of TB is > 50% (66.5%) and that the most frequent M. tuberculosis infection outcome is latent infection (59.4%).
Table 1

Percentage of enrolled students who correctly answered the tuberculosis-related questions, stratified by degree course

Chosen answers

All students (n = 2,200)

Medical students (n = 609)

Nursing students (n = 1,611)

p

TB1 is caused by M. tuberculosis

94.7

99

93

<0.0001

MDR2 -isolates are a current problem for TB control

78.5

91.8

73.4

<0.0001

TB does not affect only the lungs

75.8

96

68.1

<0.0001

TB treatment is problematic and several drug must be prescribed for a long period

75.1

92.7

68.4

<0.0001

The lethality rate of untreated active TB is >50%

66.5

62.2

68.3

0.007

Several TB cases are asymptomatic

59.4

82

51.1

<0.0001

TB vaccine is currently available

87.4

90.4

86.3

0.009

TB vaccine is currently available, but it is not 100% effective

66.3

81.6

60.4

<0.0001

TB vaccine is composed by Bacillus Calmette Guerin

44.2

73.4

33.1

<0.0001

TST3 is aimed at detecting asymptomatic M. tuberculosis infection

88.0

90.6

87

0.02

TST is not a drug

69.7

88.3

62.6

<0.0001

TST is not a vaccine

68.6

87.3

61.5

<0.0001

TST is not a laboratory test

50.9

74.5

41.9

<0.0001

1TB = tuberculosis; 2MDR = multi-drug resistant; 3TST = tuberculin skin test.

Regarding knowledge of TB prevention, 87.4% of the student participants stated that they were aware of the existence of a vaccine, and 66.3% declared that this vaccine has a poor effectiveness. The characteristics of the vaccine were known to 44.2% of the sample.

Regarding the tuberculin skin test, the majority of those completing the questionnaires declared that the TST is helpful in diagnosing latent TB infection (88%), that it is not a drug for the treatment of M. tuberculosis infection (69.7%) and that it is not a vaccine (68.6%). However, of all study participants, 50.9% did not identify the TST’s usefulness for the isolation of M. tuberculosis from bronchial secretions.

In terms of personal experiences and practices related to TB, 66.9% of the enrolled students reported to have experienced—in the past—a screening test for the diagnosis of latent TB infection through the Mantoux test (93%), the Tine test (2.9%) or both tests (1.8%). The length of time before the administration of the questionnaire that the TST was performed was < 1 year for 71.7% of the sample, 1–5 years for 19.2% and > 5 years for 8.3%. For 12 students (0.8%), no previous TST was reported. Only 1,445 students reported the TST result; 39 (2.7%) had a positive result according to the guidelines of the Italian Ministry of Health [13], but none presented clinical or radiological evidence of active TB. Of the 1,406 TST-negative students, 281 (19.9%) were immunised with the Bacillus Calmette–Guérin (BCG) vaccine through public hygiene services (50.5%), through preventive medicine services (26.7%), by a general practitioner (6.4%), in anti-TB centres (5.3%) or in other locations (9.3%). For 1.8%, the structure where they were immunised was not reported.

The results of the uni- and multivariable logistic regression analyses performed to evaluate the associations between respondent characteristics and correct answers on the different items are reported in Tables 2 and 3. Regarding the questions concerning TB and its vaccine, providing the correct answers was associated with increasing age. In interpreting the results, it is useful to restate that the questionnaire was distributed at the end of the hygiene lessons. In Italy, the hygiene course is scheduled differently in different degree courses: it can be taught in the first, second or third year of the nursing course and in the fourth, fifth or sixth year of the medicine course. These differences in university planning might have introduced a bias in the results of the survey. The findings of the present study suggest that TB knowledge increases with age, as students develop more focused attitudes and behaviour. This possibility could explain the result from the nursing students but not from the medical students who had attended clinical wards and studied this topic in other subjects (e.g. infectious diseases, microbiology and pneumology).
Table 2

Determinants associated with correct answers, estimated by univariable analysis

Correct answers

Increasing age

Gender

To be a medical student

Previous TST

TB is an infectious disease caused by various strains of Mycobacteria genus, mainly M. tuberculosis

OR = 1.05

OR = 0.91

OR = 3.16

OR = 0.49

95% CI = 0.98-1.12

95% CI = 0.62-1.36

95% CI = 3.28-17.1

95% CI = 0.31-0.77

p = 0.12

p = 0.67

p < 0.0001

p = 0.002

TB does not affect only the lungs

OR = 1.09

OR = 1.15

OR = 2.44

OR = 0.41

95% CI = 1.05-1.13

95% CI = 0.93-1.42

95% CI = 7.46-17.33

95% CI = 0.33-0.52

p < 0.0001

p = 0.178

p < 0.0001

p < 0.0001

The most frequent outcome of the M. tuberculosis infection is the latent TB infection

OR = 1.11

OR = 1.27

OR = 4.36

OR = 0.79

95% CI = 1.08-1.15

95% CI = 1.06-1.52

95% CI = 3.47-5.50

95% CI = 0.66-0.95

p < 0.0001

p = 0.011

p < 0.0001

p = 0.013

Most of 50% of patients affected by active tuberculosis died

OR = 1.00

OR = 0.86

OR = 0.76

OR = 0.97

95% CI = 0.98-1.02

95% CI = 0.71-1-03

95% CI = 0.63-0.93

95% CI = 0.81-1.17

p = 0.92

p = 0.108

p = 0.007

p = 0.77

The treatment of the tuberculosis need the long-time use of antibiotics

OR = 1.13

OR = 1.46

OR = 5.87

OR = 0.40

95% CI = 1.09-1.18

95% CI = 1.18-1.80

95% CI = 4.24-8.12

95% CI = 0.32-0.51

p < 0.0001

p < 0.0001

p < 0.0001

p < 0.0001

The multidrug resistence of some strains of M. tuberculosis is an emergent concern

OR = 1.05

OR = 1.21

OR = 4.04

OR = 0.49

95% CI = 1.01-1.08

95% CI = 0.97-1.50

95% CI = 2.96-5.51

95% CI = 0.39-0.62

p = 0.005

p = 0.088

p < 0.0001

p < 0.0001

A vaccine against tuberculosis is available

OR = 1.00

OR = 1.04

OR = 1.50

OR = 1.20

95% CI = 0.97-1.04

95% CI = 0.79-1.35

95% CI = 1.10-2.03

95% CI = 0.92-1.56

p = 0.78

p = 0.79

p = 0.009

p = 0.171

The effectiveness of anti-tuberculosis vaccine is quite low

OR = 1.04

OR = 1.19

OR = 2.91

OR = 0.52

95% CI = 1.01-1.06

95% CI = 0.98-1.43

95% CI = 2.31-3.66

95% CI = 0.43-0.63

p = 0.007

p = 0.078

p < 0.0001

p < 0.0001

The TB vaccine is prepared with the Bacillus Calmette-Guérin

OR = 1.07

OR = 1.47

OR = 5.59

OR = 0.62

95% CI = 1.94-1.09

95% CI = 1-24-1.77

95% CI = 4.54-6.89

95% CI = 0.52-0.75

p < 0.0001

p < 0.0001

p < 0.0001

p < 0.0001

TST is not a vaccine

OR = 1.04

OR = 1.09

OR = 1.44

OR = 1.42

95% CI = 1.01-1.09

95% CI = 0.82-1.42

95% CI = 1.06-1.96

95% CI = 1.09-1.85

p = 0.04

p = 0.558

p = 0.021

p = 0.009

TST is not a laboratory test to detect M. tuberculosis in the sputum

OR = 1.07

OR = 1.14

OR = 4.32

OR = 0.66

95% CI = 1.04-1.10

95% CI = 0.94-1.38

95% CI = 3.32-5.60

95% CI = 0.54-0.80

p < 0.0001

p = 0.189

p < 0.0001

p < 0.0001

TST is not a drug for M. tuberculosis infection

OR = 1.05

OR = 1.22

OR = 4.05

OR = 0.71

95% CI = 1.03-1.08

95% CI = 1.02-1.45

95% CI = 3.39-4.99

95% CI = 0.59-0.85

p < 0.0001

p = 0.028

p < 0.0001

p < 0.0001

Table 3

Determinants 1 associated with correct answers, estimated by multivariable regression

Correct answers

Determinants

OR (95% CI)

p-value

TB is an infectious disease caused by various strains of Mycobacteria genus, mainly M. tuberculosis

Increasing age

1.50 (1.08 - 2.09)

0.02

TB does not affect only the lungs

To be a medical student

21.81 (2.89-164.38)

0.003

The most frequent outcome of the M. tuberculosis infection is the latent TB infection

To be a medical student

4.70 (1.83-12.04)

0.001

The TB vaccine is prepared with the Bacillus Calmette-Guérin

To be a medical student

13.43 (4.84-37.22)

0.001

TST is not a vaccine

Increasing age

1.10 (1.02-1.20)

0.02

TST is not a laboratory test to detect M. tuberculosis in the sputum

To be a medical student

2.19 (1.01-4.75)

0.047

TST is not a drug for M. tuberculosis infection

To be a medical student

2.90 (1.11-7.59)

0.03

1The investigated determinants are: age, gender, degree course (medical vs. nursing) and tuberculin skin test (TST).

Overall, our data highlight two main features: i) TB knowledge is sufficient among health care students (>60% of the enrolled students replied correctly to the questions asked) and ii) the level of knowledge is significantly higher among medical students than among nursing students. Regarding the first major finding, most student participants (up to 95%) chose the right answer to questions gauging general information on TB (aetiological agent, clinical forms, lethality and antibiotic resistance). Here, our data are not consistent with the results of other surveys, which have demonstrated different levels of TB knowledge [1417]. Moreover, other studies have reported that only one-third of the participants provided correct answers to questions about disease transmission [17], and misconceptions among health professionals concerning TB transmission and therapy have been described [18, 19].

Regarding knowledge of asymptomatic cases of TB infection, our study yielded less positive results: only 60% of the total sample provided the correct answer. Considering the role of asymptomatic cases in the epidemiology of TB disease, these data are cause for concern. Moreover, only 44.2% of participants in this study knew the TB vaccine composition, and only two-thirds of the sample were aware that the current vaccine is not 100% effective. Given that the TB vaccine is a key preventive measure against some of the most severe manifestations of the primary infection, such as hematogenous dissemination and meningoencephalitis, and that there is no strong evidence of the vaccine’s efficacy against the pulmonary form of TB, these data appear critical.

Concerning the TST, the frequency of correct answers was high only for those questions about the detection of asymptomatic infected individuals. For other questions (i.e. TST is a vaccine, laboratory test or drug), more than 30% of the participants answered incorrectly. These data are consistent with the results that have been reported from some other authors [16].

Regarding the second main finding, the medical students in our sample provided correct answers in most cases (from 62.2% to 99%), and their level of knowledge was significantly higher than that of the nursing students. Although this result is consistent with the different level of knowledge required in these degree courses, poor knowledge of TB may raise crucial questions for health care workers employed in high-risk clinical areas in terms of perceptions of occupational risk and patient safety. Health care workers, especially nurses, can be exposed to M. tuberculosis during their routine clinical activities. Additionally, they can play an important role in patients’ symptom identification, education of patients and families about TB diagnosis and treatment, supporting patients’ adherence to their therapeutic regimens, the effective utilisation of health care services and the adequate management of adverse drug events [20]. Therefore, when these members of the health care system exhibit poor knowledge of TB, the outcomes of TB treatment and of preventive programmes may be at risk of failure. Thus, it is crucial to plan and implement strategies and policies to improve the knowledge of health care team members towards TB, including the capacity to integrate knowledge and good practices [21, 22].

Conclusions

Our study found sufficient TB knowledge in a sample of Italian health care students. Nevertheless, we consider it is necessary to improve knowledge about TB, especially among nursing students. TB knowledge among health care undergraduates is important, because these students could be exposed to the Mycobacterium strains during their training activities or when they are employed in private and public health care settings. Consequently, consistent with the conclusions of other authors [16, 23, 24], we suggest upgrading the current health care curricula. The training provided through courses of study should provide the scientific basis necessary to achieve an appropriate level of professional autonomy. Students’ skills in this field can be developed by promoting an integrated, multidisciplinary study programme focused on problem-oriented learning and active learning strategies (e.g. seminars, computer simulations, etc.).

Declarations

Acknowledgements

The authors wish to thank the Italian Society of Hygiene (SItI) for the scientific support provided and also all of the students who filled in the questionnaire.

Authors’ Affiliations

(1)
Department of Biomedical Science and Human Oncology—Hygiene Section, University of Bari Aldo Moro
(2)
Department GF Ingrassia, University of Catania
(3)
Department of Biomedical Sciences for Health, Università degli Studi di Milano
(4)
Department of Translational Research, N.T.M.S., University of Pisa
(5)
Department of Basic Medical Sciences, Neuroscience and Sense Organs—Hygiene Section, University of Bari Aldo Moro
(6)
Department of Biomedical Science and Public Health, Politecnica delle Marche
(7)
Department of Interdisciplinary Medicine, University of Bari Aldo Moro
(8)
Department of Medical and Surgical Sciences—Hygiene Section, University of Foggia
(9)
Department of Experimental Medicine, University of Perugia
(10)
Department of Health Promotion and Child Sciences ‘G. D’Alessandro’, University of Palermo
(11)
Department of Molecular and Developmental Medicine, University of Siena
(12)
Department of Public Health, University of Napoli Federico II
(13)
Department of Biomedical Science—Hygiene Section, University of Sassari
(14)
Department of Public Health, Sapienza University of Rome
(15)
Department of Biomedical Sciences—Epidemiology and Medical Statistics Unit, University of Sassari—Research, Medical Education and Professional Development Unit
(16)
Department of Medical Sciences, University of Ferrara
(17)
Department of Public Health, University of Verona
(18)
Department of Biomedical, Biotechnological and Translational Sciences, University of Parma

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  25. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/970/prepub

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© Montagna et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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