INTRODUCTION

Tuberculosis (TB) is an infectious disease of global distribution; its easy transmission, favored by the precarious living conditions of individuals exposed to it, make TB one of the principal diseases of interest in public health, placing it as the second cause of death globally due to infectious diseases ¹. In addition, the goal established to reduce to 50% the prevalence and mortality due to TB globally has not been reached ².

According to the Global Tuberculosis Report 2016, in 2015, 10.4-million people contracted TB and 1.4-million died because of it ¹. In Colombia, for 2015, the National System of Public Health Surveillance (SIVIGILA, for the term in Spanish) was notified, during week 52, of 12,918 cases of TB in all forms, which represented a 2.0% increase in notifications with respect to week 52 for 2014 ³. For epidemiological week 03 of 2016, 577 cases of TB were reported in all its forms, with pulmonary TB having the highest presence, with 85.6% of the total number of cases ⁴. Bogotá, for 2015, reported an incidence of 12.6 TB cases per 100,000 inhabitants ³.

Hence, to achieve compliance with the Sustainable Development Objectives (SDO), which stipulate the eradication of TB by 2030 ⁵, it was established that programmatic actions must continually be strengthened to prevent and control TB globally ⁶ starting with education to enhance knowledge about TB by all the population. Thus, identifying knowledge about TB by health workers, patients, families, and the community is indispensable, given that a high level of knowledge reveals a favorable process in health education that contributes in the global management of the disease, diminishes the disease’s active transmission and favors early and timely diagnosis, as well as early onset of treatment and adherence to such ⁷⁾⁽⁸.

Conversely, scientific literature evidences that lack of knowledge can determine mistaken and wrong behaviors in health care, leading to stigmatizing and isolating the patient, delaying diagnosis and treatment of TB, and favoring poor adherence to treatment ⁹, which is why the disease is still transmitted ¹⁰. Consequently, it is fundamental for the health staff, patients, the community, and families to have adequate knowledge about TB.

Regarding knowledge by the health staff, literature indicates that they must be suitable, adequate ¹¹, and solid ¹²⁾ to ensure success of TB prevention, diagnosis, surveillance, and control. Sufficient knowledge by the health staff guarantees adequate training and guidance to individuals with the disease, their families, and communities, which permits ensuring success of the anti-tuberculosis treatment ¹³.

With respect to knowledge by patients with TB, literature shows that poor knowledge promotes transmission and infection of the disease to their relatives and their community ¹³ because false beliefs are raised about it and because of their fear of being stigmatized. This causes patients with TB to hide their disease, self-medicate, and generate drug-resistant TB due to their abandoning or suspending treatment ¹⁴. Knowledge by families of patients with TB permit placing this disease in the first place in health care and in the most significant microstructure in decision making in relation to the health/disease process of the person with TB, which is why knowledge by the family is indispensable to provide adequate care and acquire prevention measures against the transmission of the disease ¹⁵⁾⁽¹⁶.

Similarly, studies on the community state that it is important to assess its knowledge, given that it is a decisive factor to mitigate TB infection ¹⁷⁾⁽¹⁸. In spite of sufficient scientific evidence on knowledge about TB, Yukselturk & Dinc ¹⁹⁾ highlight the importance of validating measurement instruments to evaluate knowledge about TB, given that in literature no reliable instruments are found that can be replicated and used for other studies. Due to the aforementioned, this study sought to describe the scientific production of instruments and assessment tools on knowledge by patients, health staff, families, and the community on TB, during the period from August 2010 to August 2015, to report the most recent scientific literature on the theme.

It is important to highlight that this study will bear in mind some concepts, like: 1) assessment instruments: those with psychometric characteristics that give them support, reliability, and validity ²⁰, which lets them be culturally relevant, within a given historical place and moment ²¹; 2) assessment tools: those surveys and questionnaires, among others, that permit developing activities like scoring, measuring, correcting, classifying, certifying, and examining the level of appropriation of new knowledge ²².

METHODOLOGY

An integrative review was conducted with the following phases: 1) definition of the objective; 2) definition of inclusion criteria; 3) search for studies in databases and selection of studies according to the inclusion criteria; 4) critical evaluation of the studies; 5) categorization of the studies selected, and 6) data analysis ²³.

The search was conducted in nine databases; however, four providing the highest number of articles were selected: BVS (Virtual Library on Health), Embase, Science Direct, and Redalyc (Figure 1). In the databases mentioned, the study used the Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH) to form the search strategies according to the database: 1) Tuberculosis AND knowledge AND Questionnaires (Embase, Science Direct, and BVS) and 2) Tuberculosis AND knowledge AND Instruments for Management of Scientific Activity (Redalyc).

Source: Elaborated by the authors.

Figure 1 Diagram of the integrative search conducted. 

Article selection was carried out according to the following inclusion criteria: year of publication comprised between August 2010 and August 2015; articles in Spanish, English, and Portuguese; articles from primary research in full text, and studies that included instruments or tools to assess knowledge about TB in any of the four populations object of study (person with TB, family, community, health staff).

Upon identifying and selecting the articles, these were subjected to evaluation, a phase that used the Scottish Intercollegiate Guidelines Network (SIGN) evidence levels of classification in independent manner to determine the methodological quality of the articles ²⁴.

After the critical evaluation of the articles, a second reading was performed to categorize the dimensions assessed on knowledge in the instruments or tools found in relatives, health staff, patients, or community. For this purpose, a database was constructed in Microsoft Excel for each study population, which permitted the respective description of the scientific production of instruments or assessment tools of knowledge about TB by each of them.

RESULTS

The search in nine databases produced 57 articles, which were reduced to 42 after excluding 15 articles that did not comply with the inclusion criteria: one had no exact description of an instrument or tool to assess knowledge, another was not within the period stipulated, and 13 were in two databases at the same time. Figure 1 presents the results of the search in the number of articles found (Figure 1).

The Integrative Review included 42 articles, which are listed in Table 4, Table 5, Table 6, and Table 7, grouping the principal data of the studies: name of the article, year, authors, type of study, country, instrument or tool used to assess knowledge, variables of the instrument or too, and type of validity and reliability in each of the articles.

Table 4 Scientific production of instruments and assessment tools on knowledge of TB by patients 

Source: Elaborated by the authors

Table 5 Scientific production of instruments and assessment tools on knowledge of TB by the health staff 

Source: Elaborated by the authors

The following show the most significant percentages in the characterization of the scientific production found:

Table 1 evidences that the highest scientific production was found in the health staff on the assessment of knowledge about TB through instruments or assessment tools.

Table 2 identifies Latin America as the continent with the most scientific production on knowledge about TB.

Table 3 shows that of the Latin American countries, Brazil is the country with the most scientific production on assessment of knowledge about TB.

With respect to the type of study used in the research reviewed, 90.5% is quantitative-type research (92.1% are cross-sectional descriptive studies, 5.3% are prospective studies, and 2.6% are quantitative studies of cases and controls), 7.1% are mixed studies, given their qualitative and quantitative characteristics, and only 2.3% are qualitative studies.

With regard to the strategies to assess the reliability of the instruments used to measure the level of knowledge, these are divided into three parameters: articles that base their reliability on a pilot test (26.2%), articles using expert evaluation to test their reliability (9.5%), and research that apply Cronbach’s alpha coefficient (7.1%). Some of the scientific research used more than one parameter to provide reliability to the instrument or method; 2.4% used the pilot test and expert evaluation, 2.4% were based on the three parameters (expert evaluation, pilot test, and Cronbach’s alpha coefficient), and 4.8% did so through expert evaluation and Cronbach’s alpha coefficient. Finally, it is worth highlighting that 47.6% of the studies do not specify the development of the methodological procedures of reliability used in the instruments or assessment tools.

Another important aspect was the type of validity assigned to the instruments and assessment tools. For this purpose, two forms of validation were used ²⁰: the first is the construct validation, seen in 33.3% of the articles; the second is the content validity, which corresponds to 40.5% of the articles. In 28.2%, no validity of any type is noted.

The dimensions of the instruments or tools in common in the scientific production selected are sociodemographic characteristics of the study population (age of participants, gender, occupation, etc.), causes, diagnosis, signs and symptoms, prevention, treatment, and transmission of the disease.

The following present information compiled with respect to the instruments and tools used to assess knowledge on tuberculosis, discriminated by the different categories of patients, family, health staff, and communities.

Instruments and assessment tools on knowledge of TB by patients

Quantitative-type studies are prevalent in the patient category with an evidence level of 3, according to the SIGN classification ²⁴. Most studies had no strategy to measure reliability and content validity is the most-often used in all the articles found. Finally, among the dimensions used in the instruments or tools to assess knowledge, there is the mode of TB transmission, and most consider that knowledge about TB by patients is low (Table 4).

Instruments and assessment tools on knowledge of TB in the health staff

The health staff had the highest scientific production, with mostly quantitative-type studies and 2+ level of evidence prevailing, according to the SIGN classification ²⁴. To evaluate reliability, it was found that the majority of the studies (18 of 22) do not use any strategy to measure such; however, it must be highlighted that four of the instruments used Cronbach’s alpha coefficient and content validity content, which is the type of validity used in most studies from this category. With respect to the dimensions used in the instruments or tools to assess knowledge, we find the treatment. It was noted that the level of knowledge by the health staff about TB was low (Table 5).

Instruments and assessment tools on knowledge of TB by the community

For this category, the results revealed that all the studies are quantitative type with 2+ level of evidence prevailing, according to the SIGN classification ²⁴. Only one article, conducted in Colombia in Zenú communities, had an instrument with content validity and Cronbach’s alpha coefficient as reliability method. Even so, construct validation prevailed in most of the articles using the pilot test and expert evaluation as reliability method. Mode of transmission was found as the most-assessed dimension, and it is noted that the level of knowledge about TB by this population is low (Table 6).

Instruments and assessment tools on knowledge of TB by the family

In this case, we found the lowest scientific production, given that only one qualitative-type article was found, which has no validated evaluation instrument, but does have an evaluation tool. The dimensions assessed in this case are the mode of transmission, treatment, and control of the disease, and knowledge was considered high in this study for this population (Table 7).

DISCUSSION AND APPLICATIONS IN HEALTH

This study evidenced the existence of a large amount of scientific production in Latin America and Africa, which agrees with the presence of the high prevalence and incidence of TB in these parts of the world. In light of the aforementioned, the WHO ²⁵⁾ mentions the need to conduct studies regarding knowledge about TB to achieve control of the disease through educational actions.

The vast majority of the studies found are from the health staff category, representing 52.3% of the total; nevertheless, it became important to detail the results reported by research, given that although this population mostly evaluates knowledge, these prove to be deficient to identify the pathology. This same result was evidenced by Laurenti et al.,²⁶ by mentioning that low levels of knowledge by the health staff exist due to the poor academic preparation on TB ⁽²⁷. This permits reflecting upon the importance of continuing to enhance knowledge in the health staff ²⁸⁾⁽²⁹ with constant training processes in health care institutions and undergraduate academic formation about TB ³⁰.

Assessment of knowledge in the community occupies an intermediate level in scientific production; however, scientific evidence states that communities (especially indigenous and rural communities) are not populations of interest in research on TB, although they are highly vulnerable groups for continuous and early transmission of the disease ³¹.

Although most studies are related to the health staff, it is worth emphasizing another aspect noted, given that it was found that not many research works encompass knowledge about TB assessed in patients and families, representing 19.4% and 2.3%, respectively, of the total number of articles. Due to the scarce research knowledge by patients and families, it is possible to overlook the importance of correct knowledge they have about TB, to generate adherence to treatment and control transmission of the disease in the family and the community ^32)(33)). Added to the poor scientific production to assess knowledge about TB in patients, the articles revealed a low level of knowledge in this population, which generates a factor that negatively affects health interventions aimed at controlling TB³⁴. The aforementioned poses a challenge for the different health disciplines to carry out new research that permit creating health care interventions that raise awareness in patients about their disease ²⁸, and implementing educational processes as important aspects to prevent and control the disease ³⁵.

Measuring knowledge about TB through instruments or assessment tools sets big challenges, given that not many of the studies found clearly reveal the validation processes of the instruments or the psychometric parameters assessed, and very few evidence some type of validation. Much lower still is the number of instruments (5 instruments) with Cronbach’s alpha coefficient as reliability test, as a test that provides the instrument with greater reliability upon evaluating the correlations existing between each of the items ³⁶⁾ and, hence, Cronbach’s alpha coefficient must be a tool that offers precision to the instruments ³⁷. Thereby, lack of validation and of psychometric parameters are aspects that question the reliability of the results, given that it is indispensable that these be validated instruments to truly test the hypotheses proposed ³⁸, measure what needs to be measured with trustworthy results ³⁹ and without probability of bias ⁴⁰⁾⁽⁴¹.

The lack of clarity of the validation process of the instruments is because the studies found assessed knowledge about TB, but none introduced the design of a completely validated and reliable instrument that complies with all the psychometric parameters, as stated by Yukselturk et al.,¹⁹ who indicated that no validated instruments exist that permit replicability of the instrument to other research.

With respect to the level of evidence of the scientific production found, it was noted that most of the studies belong to a level of evidence of 2+ and 3, according to the SIGN scale ²⁴. This showed that, although these are investigations that contribute to the development of knowledge about TB, studies with greater reach are needed that permit unveiling the creation and design of a validated instrument to assess knowledge about TB that provides reliable results verifiable with other studies⁴². The design of instruments aimed at the four study populations creates a challenge for future researchers, especially instruments for patients and families, given that they are the two populations with the least scientific production found and with no instrument validated.

Finally, the instruments must be validated and reliable for the results obtained, after the assessment of knowledge from the population, to guide in decision making in health and, thus, permit enhancing strategies and actions to improve the health conditions of patients and of the global population, managing to end TB, to be in agreement with the new SDO ⁵.

FINAL CONCLUSIONS

Tuberculosis is an easily transmitted disease associated to the precarious living conditions of people exposed to it and to poor knowledge about it. The comprehensive review evidenced the wealth of scientific production on TB, with knowledge being one of the most important themes to investigate. However, a rigorous search of the instruments and assessment tools on knowledge patients, health staff, the community, and families of patients have about TB indicated scarce scientific production, given that most studies on knowledge about TB have no type of instrument used or developed, and those that have it do not clearly evidence a validation process with psychometric parameters. The most frequently evaluated dimensions in the instruments were cause, prevention, mode of transmission, signs and symptoms, and treatment, which are themes that must be further enhanced in educational interventions.

Scientific production on instruments and assessment tools on knowledge of TB is mostly found among the health staff; thereby, identifying the need to carry out subsequent research that design an evaluation instrument on knowledge about TB to apply with patients and families. Lastly, research must be continually enhanced to assess knowledge about TB that permits making decisions in health to prevent, control, and eradicate TB.