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Effectiveness of communication Training program for community volunteers on screening of Tuberculosis patients contacts in Umbada locality Khartoum State

- 2013

Candidate /Majda Alfadel Hamdan MBBS Medicine and Surgery Kassala University

Proposal submitted in Partial Fulfillment of the Requirements for the Medical Doctorate in Community Medicine (2nd September 2013)

Dr. Hashim Suleiman Ahmed Elwagie
MBBS Medicine and Surgery Romania MPH Malaysia FCM Sudan Medical Specialization Board

Tuberculosis is a communicable systemic disease caused by the tubercle bacillus (Mycobacterium tuberculosis). It is one of the leading causes of mortality and morbidity across all age groups throughout the world especially in under developing countries. It is estimated that around eight to nine million new cases of Tuberculosis occurs each year and approximately two three million people die from the disease. More than 90% of Tuberculosis (TB) cases and deaths occur in under developing countries and 75% of these cases are between15 and 54 years old which is economically and reproductive age group. It ranks as the third cause of death, after Human Immune Virus /Acquired Immune Deficiency Syndrome (HIV/AIDSI and Ischemic heart disease. (1) A case with active Tuberculosis may infects an average of 10-15 people annually and on average, 10% of the infected individuals develop the disease during their lifetime (2). Persons living in household of Tuberculosis patient has a high risk of becoming infected and developed Tuberculosis disease themselves, particularly if their immune defences are impaired, therefore their examination carries great importance regarding prevention and control of Tuberculosis.(1) A systematic review of contact investigation found that in low and middle income countries there was an average of 4-5 household contacts per case, and household contacts are at greatest risk of being infected by an index case by 60% (5). The principle of control the tuberculosis disease is treatment of infectious cases in early stages, thereby preventing spread of infection. Each of these control strategies would be enhanced through more efficient and timely diagnosis of Mycobacterium Tuberculosis infection and active disease. Hence World Health Organization (WHO) has been developed a system to trace the contacts in order to break the transmission chain of the disease from smear positive sputum patients who is highly infectious to others by doing proper investigation and treatment (7).

Contact evaluation is considered as an important activity in controlling the disease, both to find persons with previously undetected TB and persons who are candidates for treatment of latent TB infection(7) , thereby contacts screening has a high contribution in increasing TB case notification; there was study carried out in Morocco to report the outcomes of TB contacts investigation activities which was carried out on routine basis by the National TB Control Program (NTP) and it revealed the number of contact investigations exceeded the number of cases notified with Sputum smear positive pulmonary Tuberculosis (SSPPT) , However the proportion of household contacts screened per year remained more or less stable (overall 77.0%, range: 67.8%82.0%). Recently there was analysis has been done to assess the global TB case notification and the data estimated that only 35% of new smear positive cases that arose in 2000 were detected by the current recommended strategy of Direct Observed Treatment for Short course (DOTS) and only 74% were successfully treated. In such situation, it is expected that so many contacts were not detected and treated (3). Care seeking behaviors can affects on the case notification rate through late presentation of the patients as well as their contacts to the health system ,or through diagnosing and treating the patients outside the system of TB control programme.(3) Globally, the estimated new cases of Tuberculosis were 8.7 million and 6.6 million in Eastern Mediterranean Region (EMRO) as has been reported to (WHO) in 2012 whereas Sudan is shouldering (11-16)% of the Tuberculosis burden (EMRO), the case notification rate (CNR) was 52 % in 2011 which is a very low comparing to Global Fund target (90%),(6) and one of the reasons for that is improper implementation of contact tracing system. Sudan as apart of Tuberculosis control strategy, adapted the contacts screening approach and Khartoum state TB Control Program has been pioneer in applying this strategy however, it established the contact tracing system since 2005, to increase the new cases among the contacts of Tuberculosis patients as well as early detection and treatment.

The main objective of the system is to detect new cases among the patients contacts and it targeting all contacts of the Sputum Smear Positive pulmonary Tuberculosis patients (SSPT) with different age including neonate regardless developing disease symptoms or not, in addition to the children with age less than five who got in contact with Sputum Smear Negative pulmonary Tuberculosis patients (SSNPT). The system has clear guidelines in contact evaluation which include the following:.
To ensure the availability of Register book for contacts in TB clinic List the contacts of diagnosed TB patients according the criteria defined by the system in contacts register book. The health worker should asks the patient to bring his/her contacts within seven days from registration date The health worker at Tuberculosis Management Unit (TBMU) with statistical person should prepare a report on contacts that didnt come for examination at the end of every week; this report will be submitted to preventive medicine director of the health area in the locality to identify the reasons of their absence through the patients addresses. The preventive medicine director of the locality should help in the tracing process. The result of contact examination for TB should be register in Contact register book.

There was study done in Khartoum state 2007-2008 which was about evaluation of contact tracing system ,which showed that the smear positive pulmonary TB case detection rate among the contacts in 2007 was (8.8%),with high detection rate (51.1%) in Khartoum locality and minimum rate in Omdurman locality (13.3%) and zero in Jabl Aulia, Ombada and Karary. It was found that the training of health care providers regarding TB contacts tracing was mostly poor, so they didnt provide information of good quality for contacts ,which has impact on their awareness regarding TB contact tracing in Khartoum state.(6)

Problem statement
Contacts tracing system in Khartoum state had been established since 2005 and the coverage of contacts screening is still below the system target as in 2012 the percentage of smear positive TB contacts who screened was 45%, furthermore there is an analysis was done during the period of 2005- 2012 for contacts screening and it revealed instability of the system ,as there is decreasing and increasing in the percentage of contacts who screened was 55, 50, 44.6 ,38.1,51.7,58.8, 51.7 and 45 respectively (5) ,the system is not working properly and it may related to many reasons, most probably the guidelines are not followed by the health care providers as result, the contacts of TB patients do not come to TB clinic for screening.

To improve the contacts tracing process, the TB program should make use of local Non-governmental Organizations as recommended by STOP TB strategy to use the Onion model to catch up the undetected TB cases in the community in which there are six layers with different approaches, as the first layer is concerned with enhancement of community role in TB control while the sixth one is focused on contacts management and to achieve the two strategies, collaboration with local organization specifically in health education and raising awareness regarding Tuberculosis disease, is essential to detect more TB cases . This intervention study on health education and communication training program will be conducted to the community volunteers in order to communicate effectively and pass precise massages concerning the importance of contacts screening, furthermore to educate the patients about the importance of TB evaluation to their contacts.

Research Question:
Dose the health education and communication training program will effectively improve the contacts screening process?

Research Hypothesis:
The contacts tracing process carried out by community volunteers who received the health education and communication training program is more likely to be improved than the tracing process carried through the routine system.

The objectives:
General: To study the effect of communication training program on community volunteers for contacts screening of pulmonary Tuberculosis patients in Umbada locality Khartoum state 2013. Specific:
1. To conduct an intervention health education and communication training program to the community volunteers towards contacts screening of pulmonary Tuberculosis patients. 2. To measure the proportion of the contacts who are being screened before and post intervention. 3. To identify the reasons of refusing the tuberculosis examination amongst the contacts of Tuberculosis. 4. To measure the proportion of contacts who diagnosed as confirmed Tuberculosis case

List of variables:
1. 2. 3. 4. 5. 6. Demographic and socioeconomic status of the contacts Age Gender Marital status Educational status Occupation Residence

7. The percentage of the contacts of Pulmonary TB patients who screened before the intervention program.
8. The percentage of the contacts of Pulmonary TB patients who screened after the intervention program 9. The reasons that make the contacts not coming for TB examination. 10. The percentage of the contacts diagnosed as confirmed Tuberculosis case

Study design (Community Intervention Trail)
Target population
Contacts of Pulmonary TB patients in TB Clinics TB

Random selection
Sample population

Study population
Contacts of PTB in Um-bada locality

Control population
Contacts PTB in Gabal Awlya locality

Intensive directive H.E & communication program

Routine H.E & communication program

Measurement of proportion
of contacts that screened during study period

Measurement of proportion of contacts that screened during study period

Comparison will be made about the, differences in the contacts proportion noted during study period

Intervention protocol:
Three months intervention study will be conducted as the following steps: Identifying and selecting the community volunteers who will be participate in the study -volunteers of Sudanese TB patients Association-it is local organization working with National Tuberculosis Program in community awareness since 2005. Conducting four days training workshop on Health education and communication program for the community volunteers, specifically in contacts tracing. Listing the pulmonary tuberculosis patients who diagnosed in defined study period. Reviewing the contacts register to list the contacts of diagnosed pulmonary tuberculosis patients. Listing the number of the contacts who attend for TB screening pre intervention. Identifying the contacts who did not attended for TB screening. Conducting first home visit to pass the massages for the patients and their contacts about the importance of TB screening. Conducting second home visit to communicate with contacts who did not come for screening. Developing volunteer home visit register book for contact tracing. Submitting weekly report on contacts tracing process Pretesting the questionnaire which will be used for the contacts Training of volunteers on filling the contacts questionnaire concerning the reasons of refusing the TB screening (attached). Measuring the percentage of the contacts who attend for TB screening post intervention. Each volunteer will be responsible from (5-10) patients according to the patient flow on monthly base to follow up their contacts.

Study area This study will be conducted in Khartoum state, specifically in Umbada locality as study area and Gabal Awlia locality as control one . Um-bada Locality: It has (7) TBMUs, all TBMUs are Primary Health Centers except Um-bada hospital and each Unit run by a team consist of Medical Assistance who is responsible from the case management including all tasks concerning explanation of full picture of disease from infection to the cure stage, lab Technician who is doing the sputum for Acid Fast Bacilli (AFB) microscopic examination and statistician who is responsible from recording and reporting issue. In addition to that a Nurse may be found to be responsible of providing Anti Tuberculosis drugs under Direct Observation Therapy (DOT) Gabal Awlia locality: It has (12) TBMUs with the same criteria of Um bada locality regarding the staff and it has 8 Primary Health Centers and health facilities including two IDPs

Study population
All contacts (as defined in the guidelines) of Pulmonary Tuberculosis patients who diagnosed within defined study period in Tuberculosis Management Units at Um-bada and Gabal awlia localities will be involved in the study.

Inclusion criteria:
All contacts of Smear-positive TB patients who are on treatment during defined study period. Under five contacts of Smear negative TB patients who are on treatment during defined study period.

Exclusion criteria:
Contacts of pulmonary tuberculosis Patient who complete the treatment Contacts Pulmonary tuberculosis patients who transferred out Contacts Pulmonary tuberculosis patients who died

Data collection:
The data will be collected using the following tools:
Contacts Register : Reviewing the register before and after the intervention Questionnaire: a structured, pre-coded, pre tested questionnaire for contacts of pulmonary TB patients who did not come for TB examination.

Sample size &sampling technique

Sample frame:

The sample frame will be the contacts of Pulmonary Tuberculosis patients who diagnosed at TBMUs in um bada locality, within defined period of the study which will be three months.
Sample size:

The sample size will be the total number of the contacts of Pulmonary Tuberculosis patients diagnosed with in the period of the study and the mean TB patients monthly flow is 72.
Sampling technique:

Total coverage for the contacts of pulmonary Tuberculosis patients who defined to be included in the study within defined period for study.

Data Analysis:

The contacts report will be analyzed manually to measure the percentage of contacts attendance pre and post intervention. Analyzing contacts register to measure the percentage of confirmed TB cases in the contacts Computerized methods by spectrum program (SPSS) will be used to analyze the reasons of refusing the TB screening.

Ethical Consideration
Approval will be taken from Sudan Medical Specialization Board and Research Committee Khartoum state Minstery of Health . Permission letter from Khartoum state Minister of Health will be taken to the TB management Units in Umbda Locality. Verbal agreement, for participation in the study will be obtained. Confidentiality will be considered for the participants.

Timeframe 2013- (Gantt chart)


Timeline (2013 )
September October November December

Submission of final proposal and getting ethical approval Training program Pre intervention data collection Starting the intervention program Intervention program data collection after the intervention

W4 W1 W1 W2 W2 W3 W 4 W2 W2

Post assessment data analysis Overall Data analysis Draft report Final report submission

W3 W3 W3 W4

Budget lines:
Data collectors Statistical person Training Travel cost Communication cost Report writing Supplies (stationary ) Other cost (5%of above) Total cost

No. of person
8 3 12 8 8 1 10

60(2months) 7 4 7 7 1 1 -

100 100 35 10 20 1500 1620 465 -

Cost in SDG
1600 2100 1680 560 1120 1500 1620 465 9765 SDG

1. Rodrigues LA, Diwan VK, Wheeler JG, 1993. Protective effect of BCG against tuberculous meningitis and miliary tuberculosis: a meta-analysis. Int J Epidemiol 22: 11541158. 2. Asbroek A H A, Bijlsma M W , Malla P , Shrestha B , Delnoij D M 2008, " The road to tuberculosis treatment in rural Nepal: a qualitative assessment of 26" BMC Health Services Research, vol. 8 3. Abu Rumman K, Abu Sabra N , Bakri F, Seita A, and Bassili A, 2008 Prevalence of Tuberculosis Suspects and Their Healthcare-seeking Behavior in Urban and Rural Jordan, A Journal of Tropical Medicine and hygiene, vol. 79, pp. 545551 4. Care Seeking Behavior of Pulmonary Tuberculosis Patients and Their household Contacts in Khartoum State: Delay, Pattern and Determinants 2008 5. Khartoum state annual report 2011-2012 6. [Reference: Morrison J et al. Tuberculosis and latent tuberculosis infection in close contacts of persons with pulmonary tuberculosis: a systematic review and met analysis of yield of contact investigation in low and middle income countries. Lancet ID 2008;8(6):359-68] 7. WHO annual country report 2011-2012 8. Guidelines for the Investigation of Contacts of Persons with Infectious Tuberculosis Recommendations from the National Tuberculosis Controllers Association and CDC, December 2005. 9. National TB Control Program Annual report 2011 10. Global tuberculosis control: surveillance, planning, financing: WHO report 2010 11. Census report 2010 -2011 12. Health Research Methodology, A guide for training in Research Methods , WHO Regional Office for the Western Pacific ,Manila, 2001


(Annex 1) Educational and Communication Training Program components:

Time frame
8:30-3:30 Day one

The object
Introduction to Tuberculosis disease and importance of contacts tracing Communication skills and how to communicate with TB contacts Group work :Role plays Part 1: Group work :Role plays Part11: specific recommendations on how to use the communication skills in contacts tracing

Day two

Day three Day four


(Annex 2) The contacts questionnaire


(Annex 3) Khartoum State Map