CHAPTER ONE
Introduction
Background to the study
The disease called tuberculosis (TB) existed right from the ancient time and the cause of it was unknown until 1882 when Robert Koch confirmed its’ etiological agent to be tubercle bacillus. TB is a specific infectious disease caused by Mycobacterium tuberculosis, which affects lungs, intestines, meninges, bones and joints, lymph glands, skin and tissues of the body (Park, 2007). In a related definition, the Federal Ministry of Health, FMOH, (1997) stated that it is a communicable, systemic disease caused by tubercle bacillus called mycobacterium tuberculosis. In this study, TB can be defined as a systemic chronic infectious disease caused by mycobacterium tuberculosis, which affects the lungs, intestine, meninges, bone, and joints, lymph glands, skin and other tissues of the body. TB has signs and symptoms.
The signs and symptoms of TB which affects the lungs are persistent cough lasting two weeks or more, weight loss, coughing up blood, chest pain, fever, night sweats, tiredness, shortness of breath, and loss of appetite while the signs and symptoms of TB which affects other organs outside the lungs are back pain, swelling of spine, loss of functions in lower limbs, long standing bone infection, painful joints, with swelling usually affecting one joint, painful urination, blood in urine, frequent urination, hoarseness of voice, pain on swallowing, neck stiffness and long stand ulcer despite antibiotic treatment (AmericanThoracis Society ATS 1999; World Health Organization WHO1996; FMOH, 2010). The signs and symptoms of TB can be used to suspect that someone is having TB. In addition, its’ diagnosis can be made by other means.
Pulmonary Tuberculosis according to WHO (1996) and Park (2007) can be diagnosed by sputum smear microscopy, chest X-ray, tuberculin skin test, clinical features (using signs and symptoms) and sputum culture. The knowledge of diagnosis of TB among the workers involved in TB work is very necessary in the sense that suspects will not be missed out.
There are four different types of tuberculosis, according to Lucas and Gilles (2003), Park (2007), and FMH (1997). Human, bovine, avian and typical strains of mycobacterium are the four different types of tuberculosis. Tuberculosis according to FMOH (1997) can affect the lungs and this is called pulmonary tuberculosis; and when it affects other organs outside the lungs it is called extra-pulmonary tuberculosis. All the four different types of tuberculosis are treated using the treatment regimen for tuberculosis.
The treatment regimen for TB includes rifampicin, isoniazid, pyrazinamide, ethambutol, stroptmycin and thiacetazone. Treatment consist of 2 months (intensive phase) of isoniazid, rifampicin, pyrazinamide, ethombuthol given daily and streptomcyin which is not added in most cases and 6 months (continuation phase) of isoniazed and ethambutol or thiacetazone or 4 months (continuation phase) of Rifampicin and Isoniazid (Lucas & Gilles, 2003; FMOH, 2010). This work intends to ascertain the level of knowledge of treatment regimen among the community health extention workers(CHEWs) involved in the treatment of tuberculosis. These workers use the above mentioned treatment regimen to treat TB patients.
According to FMOH (2008) and (2010), TB patients are persons with proven tuberculosis or with symptoms and signs suggestive of tuberculosis especially cough lasting for 2 weeks or more in Pulmonary tuberculosis. TBCTA (2006) explaining TB as a disease, submitted that a balanced approach emphasized both individual patient care and public health principles of disease control are essential to reduce the suffering and economic losses from tuberculosis. Again, TB as a disease is curable provided patients are detected early and treated promptly with the appropriate treatment regimen (FMOH, 2008).
The mode of transmission of TB is by inhalation of a droplet nuclei generated by sputum positive patients with pulmonary TB, and also by ingestion especially of contaminated milk and infected meant (Cassens, 1987, WHO, 1996, Lucas and Gilles, 2003; park, 2007). It then means that TB spreads when sputum positive patients (contagious people) cough TB bacteria out of their lungs. In this work, the level of knowledge of transmission mode among the CHEWs will be ascertained. It is important that the workers understand the basic principles of preventing this disease.
TB can be prevented if appropriate measures are taken. According to WHO (1996) and, Lucas and Gilles, (2003) the preventive measures against TB are effective treatment, environmental control through good or adequate ventilation, educating patients to cover their mouths while coughing, BCG immunization, and six months course of preventive treatment with daily isoniazid. The risk of TB infection transmission from TB suspects and patients is there in TB treatment centres especially among those providing care for people affected by TB. It is equally important to find out through this work the extent the care providers involved in this TB work know about the preventive measures. The CHEWs providing the care for TB patients are in categories.
There are two categories of CHEWs namely senior and junior CHEWs. A senior CHEW (SCHEW) has the responsibility of supervising the junior CHEW, the community health extension workers in training, the volunteer village health workers and traditional birth attendant, while the junior CHEW takes directives from the SCHEW ( FMOH, 2006). In this study, a CHEW who has worked in TB unit for more than five years is assumed to have enough experience while a CHEW who has worked for less than five years in TB unit is assumed to have no sufficient experience. There is need that knowledge of this disease especially among these CHEWs involved in its management is ascertained.
Knowledge, according to Rambo (1984), is an understanding of a subject matter. Hornby (2001) submitted that it is information, understanding and skills that one gains through education or experience. In this study, knowledge is defined as information, understanding and skills that one (this time, CHEW) gains through education or experience. It equally means ideas or facts and abilities a community health extension worker acquires about tuberculosis while doing the job (experience) or through formal training (education). The knowledge of tuberculosis among community health extension workers is very relevant. This is because these groups of workers in health care programme are at the grass root, hence, most accessible government health care providers to members of a community. The knowledge of tuberculosis among this group of health workers will determine to some extent the success of tuberculosis control. Knowledge at times affects attitudes.
Attitude is an expression of how much we like or dislike various things.(Longman, 2006). Attitude in this study is therefore defined as expression of how much we like or dislike different items or objects. This simply means that attitude represents our evaluations towards a wide variety of attitude objects, and this evaluation can either be positive or negative. In which case, those objects towards which we have positive attitude we generally seek out, while those objects towards which we have negative attitude, we typically shun. This definition is relevant to this study judging from the fact that the health workers may have positive or negative attitude to tuberculosis depending on their evaluations.
Community health extension workers, according to FMOH (2006), is a member of the health team for Primary Health Care (PHC), who spends 50% of his time on community based function and 50% in the clinic. Health Resources and Services Administration, HRSA (2001) in her own opinion asserted that community health extension worker is a lay member of a community who work either for pay or as a volunteer in the association with local health system in both urban and rural, and usually shares ethnicity, language, socio-economic status with the community members where he or she serves. In this study, community health extension worker is a member of the health team based at a local or community level who renders both medical and social services to the members of the community voluntarily or by employment of local health care system.
TB, though one of the communicable diseases in the world has a public health implication as many findings indicate hence the need to control it. Park (2007) stated that about 1.7 million people (27 per 100,00) died from tuberculosis in the year 2004. According to the author, TB kills more adults than any other infectious disease and that eight out of ten of all those struck by it are in economically productive age group of 16-49 years. Tuberculosis transmission occurs by airborne spread of infectious droplets from a person with TB of the lung who is coughing. In other words, it is possible to get the disease through inhalation of droplet nuclei. However, the good thing about this disease is that it is controllable and curable too, if adequate mechanism is put in place. Good knowledge of and attitude to tuberculosis among health workers involved in the TB management are some of the mechanisms to be put in place to control the spread of the disease. The aim of short-course chemotherapy in health intervention or treatment of TB is to achieve global targets of 85 per cent cure rate and 70 per cent case detection rate respectively. The success of the intervention or treatment of TB has to start with efficient health care services which can be achieved by providing health workers who have good knowledge of and attitude to tuberculosis especially in treatment regimen as stated earlier. This health intervention or treatment of TB requiring efficient health care services is equally needed in Abia State.
This study was carried out in Abia state of Nigeria. Abia State is one of the states in Nigeria involved in tuberculosis control programme. According to State Ministry of Health, SMOH (2007) Abia State has a population of 3.3 million people in 2004 with annual growth of 3 per cent and a total area of 5803.36 square kilometers and is bounded by the following states; Anambra, Enugu, Ebonyi, Akwa Ibom, Cross River, and Rivers States to the north and north east and south-east, having also a total of seventeen (17) local government areas. Abia State embarked on control of many communicable diseases including TB.
TB is a serious public health problem. The estimate of incidence rate of tuberculosis in Nigeria is put at 290 per 100,000 population, and prevalence rate of 531 per 100, 000 population and these figures place Nigeria 4th among the 22 high burden countries in the world (FMOH, 2006). Statistical record on TB cases as at April 2010, available from Abia State Tuberculosis and Leprosy Control Programme,m (ASTBLCP) showed that the average number of cases of TB registered annually is about 1000. These TB cases (patients) are registered in various local government and private facilities or treatment centres.
According to FMOH (2009) there are 67 TB treatment centers or units in Abia State. Again, records on the health facilities according to SMOH (2007) stand as follows: primary health centers-276, secondary health institution-19, tertiary health institution: federal-1, state-1, registered health institutions (private)-585, registered pharmaceutical services (private)-140, registered mortuaries (private)-7, registered laboratories (private)-39 and patent medicine dealers-3500. Abia State is chosen for this study considering her population, geographical and economic position in Nigeria as well as the health facilities on ground. The state with such a population made up of mainly young people is very much at risk in terms of TB infection. Also the state is linked to other states in which case, tuberculosis in Abia State can spread to other states and vice-versa. Therefore a strong system of TB control has to be put in place to save the inhabitants of Abia State in particular and her sister surrounding states in general. As mentioned earlier, the state has one of the biggest markets in Nigeria called Ariaria International Market and this placed the state in a very important economic position in Nigeria in particular and the world in general.
The fact that TB constitutes a major public health problem in the world in general and Nigeria in particular cannot be over emphasized. Abia State is not an exemption, being one of the states in Nigeria. According to, FMOH (2004), it has been estimated that about 250,000 new TB cases occur yearly in Nigeria. In Abia State, it is estimated that the number of new TB cases is about 1000 yearly on the average. The author further stated that cases of tuberculosis have been on the increase all over the world resulting into high morbidity and mortality, and that the situation has been worsened by the pandemic of HIV/AIDS, hence the cure rate of TB is expected to be very low unless concrete steps are taken to control both TB and HIV/AIDS. This is because TB is a major killer of HIV victims while HIV infection is a major predisposing factor of TB. The above sources indicating incidence of tuberculosis in Nigeria and Abia state in particular therefore, show that the disease is still existing and equally spreading among the populace hence the need for this study. When the present targets of cure and case detection rates of Abia state tuberculosis and leprosy control programme (ASTBLCP) are compared with the global targets, the difference is still very much especially the case detection rate. The difference in cure rate between ASTBLCP and that of the global target is 11 per cent while the difference between case detection rate of Abia state and WHO’s target for case detection rate is 59 per cent (Abia State TB and leprosy control programme 2010 annual statistics). There is actually a big gap between global targets and what Abia state has achieved as targets which is a problem. For cure rate, it means that about 11 per cent of cases registered for treatments are not cured (i.e. only 74% are cured) hence spread of the disease continues.
The global target for cure rate is 85% but Abia State has achieved only 74 per cent cure rate according to ASTBLCP (2010) statistics. The 85 per cent global target for cure rate minus 74 per cent cure rate of Abia State gives a difference of 11 per cent which is the gap or problem. In the same vein, the global target for case detection rate is 70 per cent but Abia State has only 11 per cent as case detection rate. The 70 per cent of global target for case detection rate minus 11 per cent case detection rate of Abia State will give 59 per cent differences, which is equally a gap or problem. The difference in case detection rate indicates that 59 per cent of people suffering from tuberculosis who are expected to be detected and placed on treatment are not yet detected thereby increasing the number of sources of infection in the communities of Abia state.
There are some demographic factors which may be associated with knowledge and attitude to TB. They include marital status, age, sex (gender), religion, education (level of education), disease status, rank, job experience and occupation. However, in this study only four demographic factors namely, gender, job experience, education (level of education) and rank will be examined. Gender in this work means male or female folk of the CHEWs (respondents). The knowledge level as well as attitude towards TB among these folks will be ascertained or determined. Education on the other hand has to do with level of education of CHEWs who equally are the respondents in this study. This variable will reveal the impact of educational level on knowledge of and attitude to TB among the CHEWs. Concerning rank in this work, it has to do with the professional position of the CHEWs in relation to their work. The rank is made up of Senior and Junior CHEWs (SCHEWs & JCHEWs) respectively. There is need to find out through this work if position or rank can affect knowledge of and attitude to TB among the CHEWs. Similarly, job experience in this study implies length of service put in the TB work by the CHEWs. A CHEW who has worked for more than five years in TB unit is assumed to have enough experience while a CHEW who has worked for less than five years in Tb unit is assumed to have not enough experience. This work attempts to find out if job experience i.e length of service can affect the knowledge of and attitude to TB among the CHEWs.
Theories related to this work include knowledge and attitude theories. The knowledge theory comprises Aristotle’s epistemology and empiricism theories while attitude theory comprises social-judgement and consistency theories.
Abia state having about 1000 cases of tuberculosis registered for treatment according to ASTBLCP (2010) annual statistics is a serious threat to the economy of the state. This is not yet the expected figure to be detected going by WHO’s target. Therefore, there is need to find out through this study the knowledge of and attitude to tuberculosis among the health workers attending to the cases of this disease in Abia State.
Statement of the Problem
According to FMOH (2010) the targets for tuberculosis control are to cure eighty-five per cent of TB cases registered for treatment and detect seventy per cent of a given population expected to suffer from tuberculosis. These targets have not been achieved in Abia State. Presently, the cure and detection rates of Abia State are 74 per cent and 11 per cent respectively .
The non-achievement of these targets (85% and 70% case detection rate) is actually a big gap and problem too judging from the above mentioned figures. Furthermore, the study intends to find out whether these workers (CHEWs) have the knowledge and attitude to TB or not. Since knowledge and attitude could be the contributing factors why these targets have not been met, the present study attempts to determine the status of knowledge and attitude of CHEWs. The knowledge of and attitude to TB among the community health extension workers in Abia state had not been ascertained. The knowledge and attitude to TB studies carried out among health workers in Nigeria did not include community health extension workers and were not in Abia State in particular.
Having looked at some possibilities that can cause this problem of not achieving the targets for cure and detection rates respectively, this study therefore sought to find out whether the workers (CHEWs) had the expected knowledge and attitude to TB or not.
Purpose of the Study
The purpose of the study was to find out the knowledge of and attitude to TB among community health extension workers (CHEWs) in Abia state. Specifically, the study intends to:
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