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 first test. While for the second test, 127 village doctors quit. The demographic distribution between those who took tests and those who only took first test was showed in additional file 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 final 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.
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 stratified 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. 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.
Subgroup analyses on testing pre-and-post the training
The distribution of scores for each village doctor pre-and-post the training were described using histogram shown in Figure 1. 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).
The 30 questions were divided into four sections according to the contents. Significantly 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 qualified smear sample for microscopy, common first 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 definition 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 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), significantly increased scores were observed after training for both types. (Figure 2B) (p<0.001). For core point for training in form of text on WeChat SA, the median score increased from 50.0 (40.0-60.0) to 60.0 (40.0-70.0). For core point for training in combined types on WeChat SA, the median score increased from 52.6 (36.8-63.1) to 63.1 (52.6-73.6).
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 significant (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).