Expert Consensus on the Essential Preventive Knowledge of Tuberculosis for High School Students, Kathmandu, Nepal

It is qualitative research using three-round Delphi techniques among TB
experts to develop agreement on essential preventive measures to prevent TB and verify
their level of agreement.


Introduction
Tuberculosis (TB) remains a major public health problem. The incidence rate of TB is 152 per 100,000 populations in Nepal and it has not declined as expected [1]. It is fundamental to prevent new infections to shrink the burden of TB. Likewise, essential and adequate knowledge of TB, its services including stigma and discrimination helps to break the barriers for TB diagnosis and treatment services [2][3][4]. Community people including school students need to be aware of preventive measures at all levels of communities which could be essence to lower the burden of the disease [5].

Objectives
The general objective of the study is to develop the consensus on basic and essential information on preventive measures of TB for high school students.

Figure 1:
Steps of the research.

Selection of Experts
A heterogeneous group of twenty-two experts who have knowledge and experience in the field of a TB control program were selected for the surveys. Critical case sampling method is used because the characteristics of the case make them critical [6]. They are more likely to yield the most important information and have the greatest impact on the development of consensus on essential knowledge to prevent TB among high school students.
The expert panel was selected for education and TB sector. The district TB Leprosy officer (DTLOs) of Kathmandu and Bhaktapur district and health workers of the Urban health clinic, school health teachers, and female community health volunteers (FCHVs) of the Kathmandu metropolitan city (KMC) ward 32, 10, 7 were selected purposively. Additionally, schoolteachers 2 from the public schools and 2 from the private schools located and ward 7 and 32 were selected purposively. The experts were selected based on the following characteristics that make the participants a critical case is (Table 1): the filled questionnaire. The first round of data was analyzed using the Jiro Kawakita (KJ) method. To conduct KJ method analysis, the researcher prepares black pens, many pieces of card-sized paper, chart paper [7]. Each statement was written in pieces of paper.
Then, stick in chart paper based on resemblance of meaning of the sentences. The investigator read the statements several times to identify similar and/or close opinions. Each label contains a sentence, which the researcher gets from the data. The KJ method was applied to consolidate similar or connected information to get summarized and categorized groups of items [8]. After that all the investigators reviewed the data, discussed within the team and prepared summarized 46 statements from 154 items. The summary of each group was written down on the business card-sized paper and placed on the top of each group. Lines and comments were written to explain the interrelationship among groups. After that sub-theme was prepared for the statements, based on the summaries of the sub-theme, major theme of the sentences was prepared.
Second Round: In the second round, all the 46 items were sent to all the experts to rank from 1 to 7 based on the importance of each item for the prevention of TB. The first ranked items were given 7 score, 2 ranked was given 6 score. Similarly, the last ranked was given 1 score while for the non-ranked item, no score was given. The total points of each item were calculated. The items will be arranged in the descending order based on the importance.
Third Round: In the third round, the new ranked items based on the total score were redistributed to the experts and asked them, do they agree or disagree with the ranking. If the experts do not agree with the ranking, they were requested to provide new ranking. The numerical value will be given from 1 to 7 based on the importance

Criteria for Consensus Level
The Delphi technique is based on gaining consensus among the selected experts. Though there is variation in opinions and interpretation among the experts and it is quite difficult to gain 100% agreement on all the statements. In fact, no standard methods or guidelines exist for determining appropriate consensus level [9].
The consensus level is 70% of participants scored the item and no consensus: item failed to meet either of the above criteria [10][11][12].

Ethical Consideration
Within the Delphi, participants were allowed to participate voluntarily, and both written and informed consent was taken before the inclusion in the study. The quasi-anonymity was maintained as the participants know each other but their opinions and judgments were strictly anonymous. Along with that the confidentiality of the information, opinions, and judgments was strictly maintained.

Result of the Study
The response rate of the Experts in all the Three Rounds: In all the three rounds of the Delphi technique, all the participants were able to response which is quite good. It is possible for the 100 percent response rate due to timely and frequent follow up with the participants by the research assistant and investigators ( Table 3).

Prevention of TB:
A total of 154 items from 22 experts were collected. The 154 items were grouped into 46 items using the KJ methods (discussed in the methodology section). Again, these 46 items were divided into the sub-theme and then to major 7 themes such as general introduction of TB, TB screening and diagnosis, risk, treatment of TB, prevention, and control, psychosocial support, and awareness ( Table 4).

Ranking of the Seven Essential Statements in the Second Round:
All the 46 statements were distributed to all the experts to rank on the basis of its importance. Table 5 shows the first important statement is the general introduction of TB (agent and Types) is same across all four groups while after the first ranked statements there are variations in the statements as well as their importance across all the groups ( Table 5).

Prevention of TB in the Third Round:
In the third round, the experts were given the statement to re-rank the statements. Table 6 shows the ranking between FCHVs and health workers is the same, while up to the third rank it resembles schoolteachers too. However, the ranking is quite different among the DTLOs, they are focusing more on the national strategic plan and activities of NTP. It could be due to the reason that they are at district level and perceive it is important to understand national programs at the community level (Table 6).     Table 6: Group-wise ranking of the seven-essential information for the prevention of TB in the third round.   Table 7).

Percentage of the Agreement for 7 Most Important
Information Among the Experts: Among all the experts, nearly 91% of the experts agree that the general introduction of TB is most essential to be communicated at the community level which is followed by message about DOTS and its importance and sign and symptoms of TB. However, the information about methods and tools of TB diagnosis is 6th essential in the ranking but has the lowest percentage of agreement between the experts, which indicates variation in the score given for the statement.
Furthermore, the group theme agreement, most of the statements belong to the group one like general introduction of TB, signs, and symptoms of TB, national strategic plans and activities. However, the 7 statement does not include items from the major them risk as well as prevention and control (Table 8).   behavior and adherence to treatment of tuberculosis [14]. One of the statements that, experts agree is the inclusion of information related to tuberculosis in the Nepali book course. There is inadequate knowledge of TB and its transmission among school students which encourages the change in behaviors among them [15][16][17]. The reasons, maybe due to a paucity in the content of the school curriculum or the availability of information, education, and communication materials [14]. The emphasis needs to be given on increasing the knowledge, attitude, and practice of students about TB and its transmission.
Another interesting finding is that there is quite similarity between the statements of ranking between teachers and health  [18].
In the data analysis, the first round of Delphi used qualitative data analysis techniques using the KJ methods. The information was analyzed with mostly same wording with minor editing and reduced number of items after summarising and grouping of the items. While in the second and third round descriptive statistics were used.
Ascertaining the level of collective opinion often entails the use of descriptive and inferential statistics [19]. One of the aims of the study is to understand the essential knowledge about prevention of TB to communicate school students and develop IEC materials on it. However, the agreed statements on the essentials knowledge on prevention of TB are limited to the aggregate representation of expert's opinions as well as there is no opportunity for participants to elaborate on their opinions and agreement. Therefore, it does not mean that all the agreed statements are most essential information for the prevention of TB. Instead, it can be used for structuring the discussion at the National level and means for raising issues for debate [19].
The participants involved in the study are from the urban areas of the country particularly the Kathmandu. So, the result of the study will be difficult to generalize. There are differences in the level of knowledge and skills among the health workers, teachers, volunteers and DTLOs from rural and urban areas. The knowledge level in TB among health workers was significantly associated with educational status, and TB training and/or orientation received [13]. Furth more, the essential information might vary on the basis of ecological areas of the country. So, it is recommended to conduct more research across different geographical areas in the country.
The response rate is for the survey is excellent despite potential chances of low response rate the survey [20]. Due to multiple feedback processes, along with long items and rounds increases the chances of low response rate in the Delphi survey [20]. A high response rate was achieved because of regular follow up with the participants and sending reminders by research assistant [21,22].

Conclusion
The essential knowledge for prevention of TB among school students should include information about the agent, types of TB, DOTS process and its importance, sign, and symptoms, national strategic plans, including the elements of psychosocial counseling to TB patients. It does not mean, that it should only include this information. The results can be used for developing the IEC materials focusing school students as well as for further research.
There is need for future research with other professional groups like (Doctors, Lab personal). Consequently, the research should be implemented in the various context like urban-rural, ecological distribution.