Knowledge and Perception of Youths Towards the Use of Directly Observed Therapy in Pulmonary Tuberculosis Therapy in Nnamdi Azikiwe University Teaching Hospital Nnewi
CHAPTER ONE
Research purpose
Knowledge and perception of youths towards the use of DOTS strategy and propose a model that supports the DOTS strategy in Nnamdi Azikiwe University Teaching Hospital Nnewi, Anambra state, Nigeria.
Research objectives
The research objectives were to
- determine level of patient centeredness’ of DOTS
- determine level of satisfaction of TB patients’ with DOTS service
- describefactors related to TB patient centeredness and satisfaction with DOTS
- exploreTB experts and defaulted TB patients’ perception about DOTS strategy patient centeredness and satisfaction level of TB
- exploredefaulted TB patients’ driving factors to default from TB
- proposea descriptive model that will support the DOTS strategy with regards to patient centeredness and satisfaction.
CHAPTER TWO
LITERATURE REVIEW
INTRODUCTION
This chapter deals with literature, which involves thorough reading of different studies and scientific material. Literature review includes a critique of studies related to the topic. The relevant documents were accessed online through Medline, EMBAS, Pub med and Google scholar database using key words such as PCC, TB care, TB patient satisfaction, risk factors separatly and jointly.
TUBERCULOSIS
As described in Chapter One TB is a chronic infectious disease caused by a type of bacteria referred to as M tb. Although TB affects almost all organs of the body, mainly affects the lung. TB transmission is airborne from a person who has TB of the lung during coughing, speaking and sneezing of infectious droplets (Tiemersma et al 2011:2). Once an individual acquires M tb infection remains infected for many years, probably for life. Under normal circumstances only 10% of the infected persons will develop TB disease at some point in their life (Young, Perkins, Duncan & Barry 2008:1255-1265).
TB risk factors
Although any person can get TB infection, review of the risk factors to acquire and transmit TB indicates that there are many factors which could change the probability of transmission and prognosis of TB. The risk factors can be categorised as factors related to TB index cases (TB suspected or confirmed), individual, institutional, socioeconomic, behavioural, demographic and health system issues (Narasimehan, Wood, MacIntyre & Mathai 2013:3).
TBindex cases
A person who presents for assessment as a confirmed or suspected case of TB is known as an index case for TB. The degree of risk is dependent upon the duration and frequency of exposure of an individual with index case and is influenced by the degree of infectiousness of the index case (Narasimehan et al 2013:2).
Bacillary load in the sputum and proximity to an infectious case are positively correlated with the infectivity of the TB patient. Smear positive TB cases are more infectious than other types of TB cases due to the presence of increased number of bacilli. An untreated sputum positive patient can infect approximately 10 individuals per year and each smear positive case can lead to two new infections. Hospital employee, prisoners, inner city residents and care givers are at high risk to be infected with M tb and develop primary active TB at a higher probability than those people far away from index cases (Narasimehan et al 2013:2). Nearly, 20% of household contacts with active TB cases develop an infection (Gabriel & Mercado 2011:2170).
CHAPTER THREE
RESEARCH METHODOLOGY
Research design
Bhattacherjee (2012:35) describes that a research design as the arrangement of conditions for collection and analysis of data in a manner that aims to combine relevance to the research purpose with economy in procedure and control over the hindering factors. A good research design facilitates research operations by yielding maximum information with minimal expenditure of resources. Qualitative research enables the researcher to explore attitudes, behaviour experiences and in-depth opinion from participants. On the other hand, quantitative research generates statistics by which
the sample characteristics can be inference to the total study population (Oliver 2010:77). Therefore, this study used mixed method to take advantage of both approaches.
Study site selection
At the time of data collection, the list of health facilities which implement DOTS strategy in Nnamdi Azikiwe University Teaching Hospital Nnewi, Anambra state was requested from TB department. Then it was categorised based on the ownership of the facilities, namely: private for profit, government, non government and non government for not profit. A total of 30 health facilities were randomly selected from the categories. The determined sample size was allocated to 30 randomly selected health facilities proportionally based on their TB case load.
CHAPTER FOUR
DATA PRESENTATION AND ANALYSIS
INTRODUCTION
The previous chapter, Chapter 4, described the research approach, methods of data collection and analyses to achieve the stated objectives and rigor of the study. This chapter presents the data analysis outcome of quantitative and qualitative findings in the form of text, tables and graphs in two sections.
CHAPTER FIVE
DISCUSSION, CONCLUSION AND RECOMMENDATIONS
DISCUSSION OF THE RESEARCH FINDINGS
Although the main interest of this study was to evaluate DOTS to the perspective of patient centeredness and satisfaction of TB patients, it is useful to understand the respondents’ general characteristics.
The response rate for questionnaires was 99.3%. Among all the respondents, the male respondents constituted 56% (336), significantly higher than the female study participants (p=0.009). Similarly, the gender disproportion was reported in other studies and report conducted in Nigeria (Nezenega, Gacho & Tafere 2013:3; EHNRI 2011:45; WHO 2014a:58). The disproportionate of gender related to different TB prevalence proportion between genders, high proportion of TB occur with men. The epidemiologic difference is related to differences in social roles, risk behaviours and activities which are conducive to transmission of TB, such as more social contacts and engagement in professions associated with a higher risk for TB for men (Nhamoyebonde & Leslie 2014:102-103).
Similar with other studies conducted on TB in Nigeria (Getahun et al 2013:524; Nezenega, Gacho & Tafere 2013:3) the majority, 494 (82%) of the respondents of this study were in productive age groups (18-44 years).
The MDR-TB proportion among all TB patients reported in this study is 32 (5.3%). Of which 8 (1.6%) were among new TB patients, and this is similar to WHO’s (2014a:73) report and 24 (3.7%) were among retreatment TB patients. However, the proportion of MDR-TB patients in retreatment category was by far lower than WHO (2014a:73) estimated report for Nigeria and globally, 12%.
DOTS strategy implementation
Otu’s (2013:229) review reflected that DOTS strategy is remaining as a cornerstone of TB control in developing countries and globally. Similarly, the DOTS strategy is a main approach to control TB at public and private health facilities in Anambra state, Nigeria (EFMOH 2013:36). Both government and non-government health facilities provide standardised TB treatment service by trained HCPs on the guidelines for clinical and programmatic management of TB, TB/HIV and Leprosy in Nigeria. Gebrekidan et al (2014:5) asserted that non-governmental health facilities usage of the stated guideline. Abiding and implementing this guideline standardised TB treatment provision reduced dissimilarity of treatment provision across the region and enables to monitor individual TB patients. Similarly, though with provision of flexibility, most TB treatment guideline supports the use of direct observation to monitor TB patient’s treatment adherence (Horsburgh, Barry & Lange 2015:2157).
The TB patients are observed daily for the first two months of treatments and then after will collect their drugs weekly. However, different times studies report that the number of travel frequencies to be observed and collect the drugs exposes the TB patients for different costs and exhaustion in Nigeria and elsewhere in Africa (Vassall, Seme Compernolle & Meheu 2010:608; Tadesse Demissie Berhane Kebede & Abebe 2013:6; Fiseha & Demissie 2015:6).
Even if DOTS is criticised (Otu 2013:230), different scholars described that implementation of DOTS strategy has brought better treatment outcome and contributed for reduction of TB prevalence (Marais 2013:89; Moonan et al 2011:1; Yen et al 2012:178-180; Chien, Lai, Tan, Chien, Yu & Hsueh 2013:1916; Hamusse, Demissie & Lindtjorn 2014b:1). Similarly, the study demonstrates that DOTS strategy improved treatment outcome of TB patients and contributed to reduction of TB prevalence compared to before it was not in place. However, Horsburgh et al (2015:2152) in their review raised the criticism that though direct observation is important to TB treatment, it is deficient to solve cause of non-adherent with TB treatments entirely and related with number of limitations.
Challenges related with DOTS
As evidenced by Gebrekidan et al (2014:7) and Gebreegziabher, Yimer and Bjune (2016:3), the study pointed out a number of challenges with DOTS strategy. Among the challenges inconsistent supply of laboratory reagents and drugs are major, as reported elsewhere in Nigeria. In cognisant of this challenge particularly related to TB drugs logistics problem kit system has been started and reached to 70% of national geographic coverage (EFMOH 2015a:63). However, the kits also criticised for having short expiry date.
The daily observation of TB patients while they take-in their drugs is indicated as the DOTS delivery system related challenge since it demands effort from TB patients. The efforts are the ability of TB patients to pay daily for transportation fee, undesired implications on their work and social lives disturbance (Fiseha & Demissie 2015:1; Gabriel & Mercado 2011:2178). Consequently, this may lead to non-adherent to full course of the treatment (Tanimura et al 2014:1770). This has been reported as a cause to default from the treatment elsewhere in Nigeria (Tesfahuneygn, Medihin & Legesse 2015:8).
Alike Wynne, Richter, Banura and Kipp (2014:8) inflexibility of TB patients referral system, once after they started the follow-up at a given health facility, is another reported weakness related to TB care delivery system.
As Fiseha and Demissie (2015:9) and Behzadifar, Mirzaei, Behzadifar, Keshavarzi, Behzadifar and Saran (2015:3) indicate, incentive inquiry and having less interest to work with TB particularly with MDR-TB of HCPs and trained staff turnover are challenges related to human resource of TB control programme.
The study explains that the need of treatment supporter is mandatory to start TB treatment. The treatment supporter could be anybody who is living in close relationship with the TB patients alike Soomro et al (2012:16) stated. However, the study highlight that bringing the right treatment supporter is difficult to some of TB patients particularly for TB patients who are living alone and came from outskirt of the city.
A review made by Otu (2013:229) indicates that different types of treatment supporter or observers do not have significant difference on treatment outcome of TB patients. In addition, a study conducted in Botswana affirmed that TB patients who got their treatment by direct observation did not show better treatment outcome than those who took their treatment at the community health care centre (Mugisha et al 2013:93).
The study identified weak PPP in the TB control activities particularly participation of private for profit health facilities. Despite provision training for free for HCPs who work in private health sector, drugs and laboratory reagents; less than 10% of non- government health facilities is providing TB treatment. Limited number of private health facilities involvement in TB control activities are stated in Nigeria (EFMOH 2015:65).
Patient-centeredness of DOTS
Although components of PCC were not boldly put in DOTS, the concept of PCC as a component was started at the introduction of DOTS (Grant 2013:3). In stop TB strategy and end TB strategy, the PCC is a required component and a core pillar for TB control, respectively (WHO 2013c:10).
Nevertheless, the PCC focuses on considering patient’s point of view, situations in the PCC decision-making process goes far beyond simply setting target with the patient (Locatelli et al 2015:24). Empowering people with TB and communities, social support programmes, communication and partnership between health sectors are components of the stop TB strategy that reflects patient centeredness of TB care (WHO 2012:4).
The study used overarched framework to determine patient centeredness of DOTS as pioneer work to the researcher’s knowledge level. As a result, the study shows that, although feeling of the respondents was not similar across dimensions, overall perceived PCC was 60% among TB patients who were on follow-up of their treatment. However, none of the defaulted TB patients was in a position to feel as they received the PC-TB care. TB experts also agreed that the current TB treatment provision is not entirely PCC.
Among PCC dimensions, the lowest mean score was reported on HCO’s particularly with regard to establishing and strengthening multidisciplinary care teams to TB care. However, evidences (Pulvirenti, McMillan & Lawn 2014:306; Carver & Jessie 2011:4) stated that coordinated health care services are starting position for PCC. Subsequently, coordinated health care service help to avail the health care service in reduced cost. Allied health care services such availing transport, food, spiritual and social support to TB patients are limited, however, the availability of these services is imperative for TB patients not only to avail PCC but also to provide health care services with affordable cost (Berhe et al 2012:7).
The perceived PCC received is significantly different between gender; males are less likely to feel as they received PCC (AOR= 0.45, 95%CI 0.3, 0.7) while level of education did not show significant difference with perceived PCC. The level of perceived PC-TB care received did not show any significant difference among the patients’ type of TB, and TB patients expectation.
PCC determined by quality of interaction between HCPs and patient (Epstein, Fiscella, Lesser & Stange 2010:1490). Pre-service and in-service training that focus on good communication skill provision for the HCPs can improve the ability to interact with TB patients (Otero et al 2015:30). In the study perceived to have good communication with HCPs and experience on using health care services show significant association with perceive alike Jayadevappa & Chhatre (2011:21) stated in their review.
Communication and prioritising patients’ concerns are stated factors to increase patient centeredness of a given health care (Ahmad et al 2011:185; Constand et al 2014:6). The highest mean score reported by the TB patients with HCPs’ perspective was prioritising patients concern and communication of HCPs with patients.
RECOMMENDATIONS
As it is well known one of the research outcomes is to provide recommendations based on the findings. Therefore, in this section recommendations are provided.
These are provided at different levels that the researcher thought the most relevant to use and implement the specific recommendations: health care policymaker and leaders of health programmes, researchers and HCPs.
To health care providers
- HCPs should improve their communication skills and interaction to convey theinformation to the TB patients and the patients’ A good relationship can be built by listening carefully to the patient.
- It is important at the beginning of treatment to create a time to counsel patientsregarding the disease, the prescribed treatment, and how the diagnosis and treatment may affect their
- Ongoingpatient education needs to be provided
- The health care worker should discuss expectations of the treatment period,identify potential barriers to completing treatment, give a sense of emotional support, and identify if the patient needs to take his or her medicine in a “TB treatment facility” other than the management unit
- A plan of care need to be participatory and agreed between the HCP and thepatient based on the patient’s individual needs and
- Mustprovide a TB care service with using standard precautions for all TB patients without discrimination of either MDR-TB or susceptible TB
- The capacity of HCPs also needs to be enhanced with regards to provision of psychological support to TB patients that could support better treatment
To health care policy makers and leaders of TB care services
The policy makers at National, Regional, Zone and Woreda levels, health bureaus need to continue playing a significant role in ensuring and improving the TB patient centeredness of TB care delivery at public and private health institutions. In addition, they have to gear or support the TB care delivery system policy to give attention for patients’ right to receive a service focused on their need, value, respect and preference.
One of the ways to improve patient centeredness and satisfaction level of TB patients is endorsing fully or partially the proposed PC-TB care model of this study at policy level and then support the HCOs to implement progressively from few numbers of health organisations to all health organisations both at public and private health care organisations.
Support the proposed PC-TB care model implementation through provision of guidance, training, supportive supervision and monitoring and evaluation of its effectiveness.
Design an effective survey mechanism that can reflect the TB patients feeling whether they feel that they are receiving a care focused on their need and satisfaction with the TB care delivery system in the nation. So as to able amend when there is a gap in the TB care delivery system.
The National, Regional, Zone and Woreda health bureaus need to facilitate the training that increases the HCPs communication skill, attitude and reinforce programmed community education that give emphasis on route of transmission prevention and treatment of TB and the importance of the communities role in improvement of health care services in the nation and regions as well. In addition, monitor the happening of ongoing patient education by HCPs at service delivery point during refill of the treatment is important.
The health care organisation’s capacity has to be built and reinforced to provide integrated TB care service with nutritional support, HIV/AIDS services, psychological support, mental health care and social support for TB patients. Moreover, the HCOs’ premise comfortableness must be improved and should encourage to TB patients to sit and listen the health education.
It is essential not to overlook the importance of reliable laboratory reagents and drug supply lines and buffer stock management with contingency planning in case of failure of supply lines.
The health care policy makers and leaders of TB care services also need to have regular supportive supervision schedule by skilled professionals in discussion with the supervisees. The supportive supervision should aim to hold-up observed improvements and identify gaps that may need intervention.
To researchers
As Cobelens et al (2012:14) pointed out there are numerous areas of TB that need research particularly programmatic activities of TB control. In addition, research and innovation is one of the pillars to end TB in combination with integrated PCC of TB (WHO 2015:7). Therefore, the following research agendas are forwarded:
- Pilot the proposed PC-TB care model whether support TB control strategy interms of the patient centeredness of TB care, TB treatment outcome, TB patients’ satisfaction and cost effectiveness in community trial design.
- Assess the quality of TB care service provision across government and non-government TB care service rendering health
CONCLUSION
This chapter discussed the study’s finding in comparison with other literatures, how far the study’s objectives have been met, contribution and limitation. Furthermore, the recommendations for health care policymaker, leaders of health programmes, researchers and HCPs are provided.
The following final chapter, Chapter 7 will present the descriptive model development process and the proposed model that would enhance TB patient centeredness of the TB-care.
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