The Effect of Wechat-Based Training on Improving the Village Doctors’ Knowledge of Tuberculosis Management: A Pre-And-Post Intervention Study from China

Background: In China, village doctors played a crucial role in TB cases referral and management. The current study aimed to evaluate the effect of WeChat-based training program on improving the village doctors’ knowledge on TB management. Methods: A One-year WeChat-based training was conducted by means of releasing original contents (in forms of text, poster, video or cartoon), through WeChat subscription account (WeChat SA) once a week. Pre-and post-training o�ine tests were hold using the same self-administered questionnaire to evaluate the training effect. Results: A total of 467 village doctor were included in the study. During the training, sixty original articles were posted through WeChat SA. With respect to the two tests, the median score increased from 50 (40.0-60.0) to 60 (53.0-70.0) (p<0.001) after training. The median scores were always higher after training no matter what kind of article contents and forms. In addition, the effectiveness of such training was found to be in�uenced by gender and education level. Conclusions: Our results indicated that WeChat-based training could partly improve the knowledge of village doctors on TB management. It is worthy to explore more effective new media-based training methods that might promote TB control work in rural China.


Background
According to the latest Global TB Report released by the World Health Organization (WHO), an estimated 10 million people developed active tuberculosis (TB) in 2018, and 1.45 million died of the disease.TB continues to be a major cause of morbidity and mortality, primarily in low-income and middle-income countries [1].As the high burden country for both TB and latent tuberculosis infection (LTBI), China contributed nearly 10% of the new TB cases to the world and there were 350 million people living with Mycobacterium tuberculosis (MTB) infection [1][2].In addition, around 71% active TB patients were occurred in rural China where with less developed public health infrastructure [3][4].There are around 700 million farmers living in China, most of the healthcare works and primary medical services in rural areas were mainly provided by village doctors [5][6][7].Therefore, village doctors are main forces responsible for TB management in rural China.
It has been reported that 62.6% of Chinese village doctors had contact with suspected pulmonary TB patients [8].Although village doctors are front-line healthcare providers in rural areas and play a crucial responsibility in TB case referral and management, their knowledge and awareness on TB control is relatively poor due to lacking su cient training during work [5,7,9].To improve the village doctors' TB management capability is crucial for strengthening TB control in rural China.For example, improving their capability to early recognize TB-related symptoms and to better trace and manage TB patients have been proved to be helpful for reducing detection delay and irregular treatment [10].Routine in-service trainings were usually given by teachers or experts through lectures, which were always nonsystematic because of venue, time and human resource constraint [11].In recent years, with the development of mobile communication and new media, E-health, a healthcare practice supported by electronic processes came into being.Among them, WeChat is a multi-functional social networking application covering 90% of mobile phones in China [12].WeChat users could obtain information and browse resources from all kinds of WeChat platforms easily.WeChat-based training combining with synchronous communication, video, picture, and article were widely used because of its feasibility, acceptability and e cacy [13][14].The current study aimed to explore the effect of WeChat-based training program on improving the knowledge of TB management for village doctors through a pre-and-post study design.

Demographics survey
For each study participant, socio-demographic information was collected by a standardized questionnaire administered by trained interviewers.The collected information including age, gender, educational level, working year, ever managed TB patients and self-reported history of close contact with TB patients.

Pre-and-post training tests
Two tests were hold before and after the training with a self-administered questionnaire consisting of 30 choice questions (Additional le 1).Each question has ve choices.Nine questions were single choice and the rest 21 questions were multiple choice.The village doctors were asked to circle the most appropriate answer independently without receiving any help.

WeChat-based training
The WeChat-based training lasted for one year from Dec, 2018 to Dec, 2019.A WeChat subscription account (WeChat SA) called "TB control commune of village doctors" was used to post training materials.WeChat SA is a lightweight app on WeChat, which can transmit real-time information to subscribers.In order to ensure all village doctors could access to WeChat SA, all village doctors were taught to subscribe it hand to hand.WeChat SA posted original content, displayed mainly in form of text, once a week with the topics of TB detection, treatment, prevention and patient management.Then a poster summarized the main point of the article would be released later within week.Apart from text and poster, other article types such as video, cartoon and interview were used as well for the need of content expression.

Statistical analysis
The data were double entered in EpiData 3.1 (The EpiData Association, Odense, Denmark).After cleaning, the data were analyzed with SAS 9.4 (SAS Institute Inc., NC, USA) and GraphPad Prism 8 (GraphPad Prism Software Inc., San Diego, California).For each article posted, the amount of reading was recorded.With respect to the pre-and-post-training tests, the 30 questions were divided into four sections according to the contents: seven questions on general knowledge of TB; eight questions on TB detection and treatment; ten questions on TB patients care and management and the rest ve questions on general knowledge of LTBI.Each participant will get a score in the two tests.Each question is assigned with corresponding score based on the number of questions of each subgroup and then normalized to 100 points for direct comparison between subgroups.For multiple-choice questions, only choosing all of the correct answers can get the point.Scores were presented as medians (25% quantile-75% quantile) and compared using Wilcoxon matched-pairs signed rank test for same person pre-and-post the training.Kruskal-Wallis tests were used to compare the distribution of scores among different groups.
Multivariable linear regression was used to explore the possible factors related with score difference before and after the training.P < 0.05 was considered reaching statistical signi cance.

Demographic information
There were 653 registered village doctors in study site.Among them, 594 village doctors met the inclusion and exclusion criteria and participated in the rst test.While for the second test, 127 village doctors quit.
The demographic distribution between those who took tests and those who only took rst test was showed in additional le 2. Female and those without a history of close contact with TB patients were more likely to refuse the second test.Finally, 467 village doctors were included in the nal analyses.As shown in Table 1, most of the subjects were males (342/467, 73.23%) and more than half of them (275/467, 58.86%) aged 40-60 years old.Most of the study participants (340/467, 72.81%) were only with a high school education.As approximately two thirds of village doctors had ever managed TB patients, thus most of them had close contact history.Nearly all of the subjects had subscribed the WeChat SA and 57.01%(248/467) of subscribers would read the WeChat SA once new article was updated.The 30 questions were divided into four sections according to the contents.Signi cantly increased scores were observed after training for each section as described in Figure 2A (p<0.001).For "General knowledge of TB" section, the core knowledge mainly focused on symptoms and mode of transmission, the median score increased from 71.4 (57.1-85.7) to 85.7 (71.4-99.9).For "TB detection and treatment" section, the core knowledge mainly focused on quali ed smear sample for microscopy, common rst line anti-TB drugs, regimens and possible adverse events, the median score increased from 50.0 (25.0-62.5) to 62.5 (37.5-75.0).For "TB patients care and management" section, the core knowledge mainly focused on detailed obligation of village doctors on management of TB patients, free policy for TB treatment and detection and location and services provided by local dispensaries, the median score increased from 50.0 (40.0-60.0) to 60.0 (50.0-70.0).For "General knowledge of LTBI" section, the core knowledge mainly focused on the de nition of LTBI, Bacillus Calmette -Guerin vaccination and tuberculin skin test, the median score increased from 20.0 (0-60.0) to 40.0 (20.0-60.0). Among

Potential demographics factors related with score
Further analyses were conducted to describe the distribution of score pre-and-post training among different subgroups (Figure 3).No difference for the scores before the training were found for gender, but after training, female got a higher improvement.Individuals with less working year (≤ 25 years) had higher scores for both tests compared to those with working year > 25 years (p<0.001).Greater educational levels were associated with higher scores regardless of training (p<0.001).To our surprise, individuals never management of TB patients got higher scores compared with those ever management of TB patients before training (p=0.01).Differences in the distribution of education levels might be a confounder as nearly half of individuals who had never management of TB patients had an education level >12 years while the proportion was only 10% for those who had ever management of TB patients.While after training, the difference was no longer signi cant (p=0.179).Multivariable linear regression was used to explore the possible factors related with testing score difference before and after the training.Gender was the only factors related with improved TB knowledge level after training (p=0.041).

Discussion
As far as we know, this is the rst study to explore the effect of WeChat-based training on improving the knowledge of TB management for village doctors in China.O ine tests before and after the training were hold to evaluate the effect of the training.We found the studied village doctors showed relatively poor knowledge on TB management with a median score of 50 in the pre-training test.To a certain extent, oneyear WeChat-based training improved the capability of the village doctors and the median score increased to 60 after training (p for difference < 0.001).The effectiveness of information transmission by means of the new media was found to be in uenced by multiple factors including gender and education level.
As one of the TB high burden countries, China has launched a series of projects to tackle the epidemic.However, there was a huge gap between the o cial requirements and actual practices [15].A metaanalysis including 12 studies evaluated the performance of TB control services in China.The summarized results showed that around halves of TB patients were treated by self-administration (52%) and that only 20% actually had their treatment observed by healthcare workers [16].Another metaanalysis showed that self-administered therapy was associated with lower rates of treatment success, adherence, and sputum smear conversion as well as higher rates of development of drug resistance when compared with directly observed treatment short-course (DOTS).TB treatment outcomes improved when patient education, healthcare provider education, reminders and tracers, or mobile digital technologies were employed [17].Village doctors are responsible for implementing health education, referring symptomatic TB patients, managing TB patients during treatment, reporting inappropriate discontinuation and side effects occurring under the DOTS strategy [18].It was reported that village doctors need to manage 0.7 million current TB cases in China.Despite their crucial responsibility in TB management, their knowledge and awareness on TB level is generally lacking.Thus, it was essential to improve their capability through enhancing systematic training.
Although several studies had investigated the awareness of different populations on TB knowledge previously in China, few were conducted in village doctors.A study published in Chinese reported that the awareness rate of TB knowledge improved obviously from 46.8-87.1% for 205 village doctors after training [19].However, only eight questions were used for testing and evaluation in this study, the core points covered are limited.A cross-sectional study were performed among 1088 medical students using self-administered questionnaire to evaluate their TB knowledge level.Similar to our research, 32 multiplechoice questions were used and each question had ve possible answers.The total mean percentage of correct answers for TB knowledge was 44.4% [20].Another study conducted among medical students as well found only 24.1%, 27.2% and 34.1% of the students had knowledge of TB symptoms of cough/ blood-tinged sputum, their local TB dispensaries and free TB treatment policy, respectively [21].Although the questions designed in above study were not exactly the same and the rate of awareness could not be compared directly, it still indicated that no matter for village doctors or medical students with higher level of education, their TB knowledge were inadequate, and necessary education are needed to promote TB knowledge and practices in healthcare workers.
It is well known that exposure to health education was signi cantly associated with increased knowledge.
A study from India showed community training including community radio, wall painting and street plays might contribute to increase in knowledge of TB [22].As has been observed in our study, the median score increased by 20% after one-year WeChat SA-based training.Female doctors got a better improvement after adjusting other covariate such as education level, working year and reading frequency (increased by 20.0% vs 26.4%).Biological, learning ability or memory performance between female and male might partly result in the difference.In addition, a positive relation was found between education level and the performance of learning.Recruiting medical students with undergraduate or graduate degree to rural areas to be a village doctors might be an important step to ll in the gap.While the fact is, it is di cult to attract new blood to work in rural areas due to identity recognition, career development and low income [8].Therefore, for most village doctors with lower education level, apart from routine inservice trainings, instant training that had good feasibility and accessibility and was not subjects to venue and time constraint needs to be enhanced.A number of studies had explored the effect of WeChatbased training on others health disorders, such as mental health or chronic cardiovascular and cerebrovascular diseases [13,23].Our research took TB as an entry point, which may be a good attempt to provide new insights for further improving rural doctors' knowledge of other infectious diseases.
Several limitations of this study should be kept in mind.First, only a 20% increase in median score was observed in self-controlled testing.Low average reading times might at least partly explain such a limited improvement.The e cacy of such designed training was essentially depended on self-learning willingness.Therefore, how to improve village doctors' engagement through enriching the article content or controlling article length should be considered in further practice.Second, parts of the village doctors in our study were mainly responsible for general medical care but not disease prevention, thus they might lack interests in the content of this WeChat SA speci cally on TB.Expanding WeChat SA among more village doctors especially responsible for disease control might achieve more sound effect.Third, currently, there is no standard testing questionnaires for evaluating the level of TB knowledge for healthcare workers.Most studies using self-designed questionnaire only set two options (Yes/No) for choice question.In our study, the set of multiple choices increased the di culty of the test.In the future, establishing evaluation method that can be widely used will be important for improving the consistency and generalizability of such studies.Fourth, follow-up bias was inescapable as one fth of village doctors did not participate in the post-training test, but it might not signi cantly in uence the current results as no difference (p = 0.244) was found between them and those included in nal analyses.

Conclusions
Our study indicated that TB management knowledge level of village doctors needs to be greatly improved and new media-based training could be an effective tool.Along with the popularity of mobile telecommunication, further studies are needed to explore effective and innovative ways to optimize the training of village doctors.
A one-year WeChat-based training program was conducted among village doctors of Zhongmu County, Henan Province, which locates in middle China with a national average TB epidemic level.Two o ine tests pre-and-post the training were hold to evaluate the effect of the program.All of the village doctors registered in Zhongmu County were included in the study with the following inclusion criteria: licensed doctor worked in the local village clinic or community health center; voluntarily sign the informed consent form and willing to participate in the training and tests during the study duration.Those without mobile phone or WeChat account were excluded.
Subgroup analyses on testing pre-and-post the trainingThe distribution of scores for each village doctor pre-and-post the training were described using histogram shown in Figure1.The median score before the training was 50 (40.0-60.0).A remark right shift was observed and the median score after training was 60 (53.0-70.0)(p<0.001).

Table 1
Characteristics of the study population The average reading for each article were 245, 38 and 199 respectively with respect to these 3 types.General knowledge of TB was mainly displayed in forms of video and general knowledge of LTBI were displayed in forms of text.
Abbreviation: TB, tuberculosis; WeChat SA: WeChat subscription account * Sum might not always equal to total due to missing data Abbreviation: TB, tuberculosis; WeChat SA: WeChat subscription account * Sum might not always equal to total due to missing data Summary of released original content in WeChat SA As shown in Table 2, a total of 70 original articles were posted in WeChat SA during the training.Apart form 10 extension articles focusing on HIV/TB, diabetes/TB or non-mycobacteria tuberculosis, the contents of the rest 60 articles were closely connected to the main points on the test paper.The average reading for each article was 144.When further strati ed by contents and types, there are 19, 26 and 15 were displayed in the form of text, poster and other types (such as video or cartoon), respectively.Abbreviation: LTBI: latent tuberculosis infection; TB, tuberculosis; WeChat SA: WeChat subscription account the 30 questions on test paper, apart from one question about which type of facial mask should be chose were not covered by contents in WeChat SA, the core points of the rest 29 questions were all covered by WeChat SA.According to the article types being displayed, the 29 questions were divided into two subgroups: 10 were published in the form of text and the rest 19 were released with combined types (text + other), signi cantly increased scores were observed after training for both types.(Figure2B)