FACTORS CONTRIBUTING TO PREVALENCE OF TUBERCULOSIS AMONG

PATIENTS ATTENDING OUT PATIENT DEPARTMENT AT COAST GENERAL

TEACHING AND REFFERAL HOSPITAL.

BY:

OCHIENG MOURICE

COLLEGE NUMBER: D/NURS/20028/1215

A RESEARCH PROJECT SUBMITTED TO THE DEPARTMENT OF NURSING AS A

PARTIAL FULFILLMENT FOR THE AWARD OF DIPLOMA IN COMMUNITY
HEALTH NURSING.

KENYA MEDICAL TRAINING COLLEGE

P.O BOX 711

KITUI

SEPTEMBER 2021

1
DECLARATION
I declare that this research is my original work and has not been presented for a Diploma award
in any other institution.

NAME OF STUDENT: OCHIENG MOURICE

COLLEGE NUMBER: D/NURS/20028/1215

SIGNATURE: …………………………………………….

DATE……………………………………………………….

2
APPROVAL

This proposal has been submitted for review with our approval as college supervisor

INTERNAL SUPERVISOR

NAME: REBECCA MWENGI

DESIGNATION: LECTURER NURSING

SIGNATURE…………………….

DATE…………………………….

3
ACKNOWLEDGEMENT
I would like to give my gratitude to Almighty God for the strength he has granted me and a good
health he has given me during the time of my research work.

I acknowledge my lecturers at Kenya Medical Training College Kitui Campus for their Support
and guidance.

I’m sincerely grateful to my colleagues who supported and encouraged me throughout the study.
I thank and appreciate my immediate supervisor Mrs REBECCA MWENGI

I would like to thank and appreciate my beloved parents for the care and support they gave me
during my time in school and during my time in conducting the study.

4
List of figures

Figure 1:level of education 20

Figure 2:occupation 21
Figure 3:head about tbt 22
Figure 4: mode of transmission 22
Figure 5: mode of transmission 23
Figure 6:signs and symptoms 24
Figure 7:signs and symptoms 24
Figure 8:knowledge about preventive practices. 25
Figure 9:signs and symptoms 26
Figure 10: TB SCREENING 27
Figure 11:screening and medication 28
Figure 12:non-adherence 30
Figure 13:factors contributing to non-adherence 31
Figure 14:treatment period 31
Figure 15:effects of non-adherence to TB medication 32

List of tables

Table 1:age distribution 19

Table 2:gender 20
Table 3: source of health information 22
Table 4:TB screening attendance 27
Table 5:factors that prevents people from accessing TB services 29
Table 6:distance from health facility 29
Table 7:effects of non-adherence 32

5
DEDICATION
This work is dedicated to my beloved parents, brothers and cousins for their moral and financial
support throughout this work.

God bless them.

Table of Contents
DECLARATION ii

APPROVAL iii

ACKNOWLEDGEMENT iv

DEDICATION v

LIST OF ABBREVIATIONS viii

DEFINITION OF TERMS ix

ABSTRACT xi

CHAPTER ONE 1

INTRODUCTION 1

1.1 BACKGROUND OF THE STUDY 1

1.2 PROBLEM STATEMENT 3

1.3 JUSTIFICATION 4

1.4 OBJECTIVES 5

1.4.1 BROAD OBJECTIVE 5

1.4.2 SPECIFIC OBJECTIVES 5

1.5 RESEARCH QUESTIONS 5

1.6 SCOPE AND LIMITATIONS 5

CHAPTER TWO 6

LITERATURE REVIEW 6

Introduction 6

6
 2.2 LEVEL OF KNOWLEDGE ON TB 7

2.3 ACCESSIBILITY OF TB SERVICES BY TB PATIENTS 10

2.4 ADHERENCE TO TB MEDICATION 12

CHAPTER THREE 15

RESEARCH METHODOLOGY 15

3.1 STUDY DESIGN 15

3.2 STUDY AREA 15

3.3 STUDY POPULATION 15

3.3.1 INCLUSION CRITERIA 15

3.3.2 EXCLUSION CRITERIA 15

3.4 STUDY VARIABLES 15

3.4.1 DEPENDENT VARIABLES 15

3.4.2 INDEPENDENT VARIABLES 15

3.5 SAMPLING TECHNIQUE 16

3.6 SAMPLE SIZE DETERMINATION 16

3.7 DATA COLLECTION TOOL 17

3.8 DATA COLLECTION PROCESS 17

3.9 PRE -TESTING 18

3.10 VALIDITY 18

3.11 RELIABILITY 18

3.12 DATA ANALYSIS 18

3.13 ETHICAL CONSIDERATIONS 18

CHAPTER FOUR 19

RESULTS 19

SECTION A: SOCIAL DEMOGRAPHIC DATA 19

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 SECTION B: LEVEL OF KNOWLEDGE 21

SECTION C: ACCESSIBILITY OF TB MEDICATION 26

SECTION D: NON ADHERENCE TO TB MEDICATION 29

CHAPTER FIVE 33

5.0: DISCUSSION, CONCLUSION AND RECOMMENDATIONS 33

5.1: INTRODUCTION 33

5.2: Discussion 33

5.3 Conclusion 34

5.4: Recommendations 35

REFERRENCES 36

APPENDICES 39

APPENDIX1: QUESTINNAIRE 39

INTRODUCTION 39

SECTION A: DEMOGRAPHIC DATA 39

SECTION B: LEVEL OF KNOWLEDGE ON PREVENTIVE PRACTICES ON TB 40

ACCESSIBILITY OF TB MEDICATION 41

NON-ADHERENCE TO TB MEDICATION 42

APPENDIX II: BUDGET 43

APPENDIX III: WORK PLAN 44

8
LIST OF ABBREVIATIONS
DOT Directly Observed Treatment Short Course

TB Tuberculosis

PTB Pulmonary Tuberculosis

WHO World Health Organization

HSC Health Service Coverage

CNR Case Notification Rate

POC Point of Care

GIS Geographic Information System

MDR Multi Drug Resistance

MDR – TB Multi Drug Resistance Tuberculosis

9
DEFINITION OF TERMS

Non- adherence: when a patient does not initiate or continue care that a provider has
recommended
Defaulter: Is a TB patient who has stopped treatment or has failed to attend
Tuberculosis clinic for drugs for more than two months without
knowledge of the service provider.

Defaulter rate: Is the proportion of TB patients defaulting treatment expressed as a

percentage of total TB patients registered for treatment in a given
period of time.

Case detection: Is the identification of new TB patient. It also means case finding.

Cure rate: Is the proportion of smear positive patients whose smear becomes
negative at the end of treatment expressed as a percentage of the
total patients enrolled in a given period of time.

Socio-demographic factors: Are defined in terms of age, sex, marital status, gender, level of
education and place of residence.

Health facility practices: Are defined in terms of systems in place influencing participants’
participation and decision making with regards to treatment
seeking, uptake and retention. That is availability of personnel,
drugs, waiting time for treatment.

Knowledge: Taken in terms of awareness of TB treatment pattern/schedule of

drug, duration of therapy, frequency of medication, importance of
complication on TB treatment and sequence of defaulters, and side
effects of anti-tuberculosis treatment and how it affects defaulters.

Treatment completion: Is the number of patients completing treatment as per schedule

regime.

Re-emerging infection: Any infection caused by recently recognized pathogen.

10
Notification rate: Is the estimated number of cases i.e. TB cases arising in a given
period expressed as rate per 100,000 population per year and
reported to a given authority body (WHO).

Multidrug-Resistant Tuberculosis (MDR-TB) : Is defined as TB that is resistant to at least

two drugs, Isoniazid (INH) and Rifampicin (RMP).

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ABSTRACT
The broad objective of this study was to determine factors contributing to prevalence of
tuberculosis among patients attending chest clinic at Coast General Teaching and Refferal
hospital. The specific objectives of this study were; to find out the level of knowledge on
preventive practices contributing to prevalence of TB among patients attending chest clinic, to
establish how accessibility of TB services contribute to prevalence of TB among patients
attending chest clinic and to identify how adherence to TB medication contribute to prevalence
of TB among patients attending Out patient department at Coast General Teaching and Refferall
hospital. A descriptive correctional study design was used, the study area. Coast General
Teaching and Refferall hospital, the study variables that were used were; level of knowledge,
accessibility and adherence to TB services in out patient department and, the study population
were patients attending out patient department at Coast General Teaching and Refferall hospital,
the sampling method that was used was simple random sampling, the sample size of 122 was
used, data collection tool used was a questionnaire, pre-testing of questionnaire was done at
Mariakani sub county hospital, the validity of the instrument was checked in terms of how
questionnaire was constructed and the content of questionnaire, reliability was ensured through
pilot testing to ascertain the suitability of the data collection process to be used in the actual data,
the data were analyzed using descriptive statistics specifically counts, frequencies and
percentages and were presented using tables and charts. For more information on this is found in
chapter three of the research. The permission to carry out the research was granted by National
Commission for Science, Technology and innovation (NACOSTI) and was approved by Medical
superintendent, COAST GENERAL TEACHING AND REFFERAL HOSPITAL. The major
results of this study found that more than two third of the respondents (86%) don’t know the
meaning of non-adherence and less than a third (14%)of the respondents know the meaning of
non-adherence. The study concluded that Poor adherence to treatment results failure of cure
which increases the risk of development of drug resistant strains, spread of TB in the community
and this in turn increases morbidity and mortality. The researcher recommended that TB patients
should be educated to reduce the risk of non-adherence

12
1
CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Globally, more than 1 in 3 individuals is infected with TB according to the WHO, there were 8.8
million incident cases of TB worldwide in 2010, with 1.1 million deaths from TB among
HIV-negative persons and an additional 0.35 million deaths from HIV-associated TB (CDC
2010). In 2009, almost 10 million children were orphaned as a result of parental deaths caused by
TB (WHO 2010)

About one-third of the population of Sub-Saharan Africa is infected with M. tuberculosis in the
year 2010; an estimated 17 million people in Sub-Saharan Africa were infected with both M.
tuberculosis and HIV—70 percent of all people co-infected worldwide. As more people have
become infected and confected with HIV, especially in eastern and southern Africa, the incidence
of TB has been driven upward, as reflected in estimates derived from population-based surveys
and from routine TB surveillance data. In 2013, the incidence rate of TB in the WHO African
region was growing at approximately 3 percent per year , and at 4 percent per year in eastern and
southern Africa (the areas most affected by HIV), faster than on any other continent, and
considerably faster than the 1 percent per year global increase In several African countries,
including those with well-organized control programs annual TB case-notification rates have
risen more than fivefold since the mid-1980s, reaching more than 400 cases per 100,000 people
(WHO 2015).

HIV infection is the most important single predictor of TB incidence across the African
continent. Despite the emphasis placed on finding smear-positive cases under DOTS and the new
WHO Stop TB Strategy (Raviglione and Uplekar, forthcoming), the proportion of cases reported
to be smear-positive has fallen in recent years in several African countries with high rates of
HIV. Although there are uncertainties about diagnosis, these data conform with the expectation
that there will be more smear-negative TB where there is more HIV. Because HIV infection rates
are higher in women than men, more TB cases are also being reported among women, especially

1
those between the ages of 15 and 24 years. TB case reports are typically male-biased., but in
several African countries with high rates of HIV infection, the majority of notified TB cases are
now women (WHO 2015).

e has also been accompanied by a rise in the TB case-fatality rate, and hence the TB death rate in
the general population. One recent estimate put the fraction of AIDS deaths due to TB at 12
percent in the WHO African region in 2000. although this fraction could be higher (Corbett et
al. 2013).

In an autopsy study in Abidjan, Côte d'Ivoire, TB was found to be the cause of death of 54
percent of patients with HIV infection or AIDS. Malawi has reported high early death rates of
HIV-infected TB patients during the first one to two months of treatment Whether this reflects
late presentation and consequently severe TB disease or severe HIV-related illness, such as
bacteremia or Cryptococci meningitis, is not known. The precise cause of death in patients with
HIV-related TB has been difficult to determine because there have been so few autopsy studies.
(Lucas et al. 2015).

Although the ratio of TB incidence rates in HIV-infected and HIV-uninfected individuals is

expected to vary during the course of the HIV epidemic (as the average level of immune
competence declines), recent studies have shown that this incidence-rate ratio takes an average
value of about six Knowing both the incidence-rate ratio and the HIV infection rate in the
general population, we can calculate the proportion of people newly diagnosed with TB who are
infected with HIV. Estimates vary widely between countries, from less than 1 percent on some
African islands (for example, Comoros, Mauritius) to over 50 percent in some countries,
including Botswana, Malawi, South Africa, Zambia, and Zimbabwe. Overall, about one-third (34
percent) of all adults who had TB in Sub-Saharan Africa were infected with HIV in 2013.
(WHO , 2015).

Kenya is listed by the World Health Organization (WHO) among the 30 high burden TB states.
Despite the considerable investment done by the government and partners in TB care and
prevention in the past 20 years, the disease is still the 4th leading cause of death (KNBS 2018).
Finding all people with TB disease and successfully treating them is therefore an important
priority for the country (WHO 2016)

2
1.2 PROBLEM STATEMENT
Globally, more than 1 in 3 individuals is infected with TB according to the WHO, there were 8.8
million incident cases of TB worldwide in 2010, with 1.1 million deaths from TB among
HIV-negative persons and an additional 0.35 million deaths from HIV-associated TB (CDC
2014) . In 2009, almost 10 million children were orphaned as a result of parental deaths caused
by TB (WHO 2017)

About one-third of the population of Sub-Saharan Africa is infected with M. tuberculosis (Dye et
al. 2016). In the year 2010, an estimated 17 million people in Sub-Saharan Africa were infected
with both M. tuberculosis and HIV—70 percent of all people co-infected worldwide (Corbett et
al. 2013).).

Malawi has reported high early death rates of HIV-infected TB patients during the first one to
two months of treatment whether this reflects late presentation and consequently severe TB
disease or severe HIV-related illness, such as bacteremia or cryptococcal meningitis, is not
known. The precise cause of death in patients with HIV-related TB has been difficult to
determine because there have been so few autopsy studies.

Kenya is one of the countries that bear a high burden of the disease. The country is ranked 13th
out of the 22 countries that bear 80% world’s TB and 5th in Africa. The number of patients
receiving re-treatment has also increased. Of the estimated 2000 cases of multidrug-resistant
(MDR) TB in Kenya in 2009, only 4.1% of these cases were diagnosed and notified Despite the
considerable investment done by the government and partners in TB care and prevention in the
past 20 years, the disease is still the 4th leading cause of death (KNBS 2018). Finding all people
with TB disease and successfully treating them is therefore an important priority for the country.
(WHO2016)

3
1.3 JUSTIFICATION
Tuberculosis (TB) remains one of today’s global health challenges, ranking as the second leading
infectious cause of death and one of the most burden-inflicting diseases in the world. Global
Tuberculosis Report estimated a worldwide incidence of 9.0 million new cases and 1.5 million
deaths in 2013. (2014 WHO)

Better tools are needed to control TB worldwide. Understanding latent TB infection and
persistence of infection after treatment is of the utmost importance. The discovery of new
markers for high and low risk individuals, in terms of development of TB and adequacy of
treatment, would allow evidence-based determination of who to treat, how to treat, and how long
to treat both for prevention and cure.

The findings of this study will help inform the tuberculosis stakeholders and other policy makers
on identifying and designing inexpensive region-specific frameworks on promotion of
compliance to TB treatment. It is hoped that this will reduce the burden of TB in the region and
form a basis for more in-depth research.

4
1.4 OBJECTIVES

1.4.1 BROAD OBJECTIVE

To deterine factors contributing to prevalence of tuberculosis among patients attending
out patient department at Coast General Teaching and Refferall hospital.

1.4.2 SPECIFIC OBJECTIVES

• To find out the level of knowledge on preventive practices contributing to prevalence of
TB among patients attending out patient department

• To establish how the accessibility of TB services contributes to prevalence of TB among

patients attending out patient department

• To identify how adherence to TB medication contributes to prevalence of TB among

patients attending out patient department

1.5 RESEARCH QUESTIONS

• What is the level of knowledge on preventive practices contributing to prevalence of TB
among patients attending out patient department at Coast General Teaching and Refferall
Hospital?

• How does accessibility of TB services contribute to prevalence of TB among patients

attending out patient department at Coast General Teaching and Refferall hospital.

• How adherence to TB medication does contribute to prevalence of TB among patients

attending out patient department at Coast General Teaching and Referral hospital.

1.6 SCOPE AND LIMITATIONS

1. Information from the respondents may be biased.
2. Language barrier.

5
CHAPTER TWO
LITERATURE REVIEW
Introduction
Tuberculosis is a widespread of infectious disease caused by various strains of mycobacterium,
usually mycobacterium tuberculosis. TB usually attacks the lungs (pulmonary TB), but can also
affect other parts of the body (Extra pulmonary TB). Tuberculosis is a public health problem in
many developing countries including Bangladesh. Globally there were 8.8 million incidence
cases of TB in 2010. (WHO,2014).With the rising number of HIV infection and AIDS cases,
there is a threat of resurgence of Baas this is the most common opportunistic infection in them.
TB is the leading cause of death among all infectious diseases. In 2010 there were 1.1 million
deaths among HIV negative people and additional 0.35 deaths from HIV associated tuberculosis
(Kumar et al,2016)

The global burden of TB mainly lies in 22 high burden countries and about 50% of prevalence
occurs in 5 countries of South East Asia, namely, India, Indonesia, Bangladesh and Thailand,
Myanmar. Bangladesh rank sixth among the high burden countries with incident rate of 225 per
g100,000 thousand populations per year and a mortality rate (exclusive of HIV) of 43 per
100,000 thousand populations per year (WHO,2015).

Millennium development goal six implies to halt and begin to reverse the incidence of TB by
2015 and fixed the target (MDG 6 target 6.C) To reduce the prevalence of and death due to TB
by 50% compared with a baseline of 1990 by 2015. The direct observed treatment short course
(DOTS) was launched in 1995 as the main strategy in the control of tuberculosis. The strategy
includes diagnosis through the bacteriology and standardized short – course chemotherapy with
full patient support (Kabra et al.,2013)

The DOTS strategy relies greatly on passive case finding for TB treatment and its success
depends on the patient’s health awareness, ability to recognize early sign symptoms and
accessibility to health services for immediate self-reporting. If a TB infection does not become
active, it most commonly involves the lungs (in about 905 cases). Symptoms may include chest
pain and prolonged cough producing sputum. About 25% of the people may not have any
symptoms. occasionally people may cough up blood in rare cases, the infection may erode into
pulmonary artery, resulting in massive bleeding (Halezeroglus and Okur2014)

6
In 15-20% of active cases, the infection spread outside the lungs causing other kinds of. denoted
as extra pulmonary TB. Extra pulmonary TB occurs more commonly in immune suppressed
persons and children (Jindal,2016). Notable extra pulmonary sites include the pleura, central
nervous system, the genitourinary system and the bones and joints among others (Golden and
Vikram,2013)

A study done in India reported that 73.7% cough. with sputum, weaknesses and breathlessness
40.4% fever 34.3%and hemoptysis 30% were mentioned as symptom of TB. In Pakistan most
commonly, recognized symptom was cough 83.5%, fever 54.7%, chest pain 24.7% and bloody
sputum 24.7% (Gerald et al.,2018).

2.2 LEVEL OF KNOWLEDGE ON TB

It is important that basic knowledge about the disease and the availability of treatment is clear
among community to prevent any undue delay in availing the service. Lack of knowledge makes
TB a serious public health problem. The perceptions of TB prevailing in the community
influence the health seeking behavior of people for their symptoms. While care seeking behavior
chest symptomatic has been explored in different studies, there is death of information on
community perception of TB. A study carried out in Uasin Gishu Kenya, people believed that
physical contact with object like cups, having sexual intercourse with TB patient and mother to
child transmission can cause TB (Fredrick et al.,2018).

According to a study that was carried in India night fever, tiredness, productive cough and cough
more than 3 weeks are signs and symptoms of TB. About mode of transmission of disease 22.9%
were ignorant, 56% thought sneezing and cough, smoking 5.4%, and 2.2% mentioned TB as a
familial disease. Most of them knew that can be cured completely, they opined that the remedial
measures are taking specific drugs given in DOTS center (Shetty et al.,2017).

According to a study conducted in Eastern Amhara region of Ethiopia, a low knowledge score
was more likely to be observed among literate, females, rural residences, low income and
youngest age group. It also showed that less than half of the respondents were aware of diagnosis
and treatment of TB, which could act as a barrier to TB diagnosis and significantly affect the
case notification rate (Thorson et al.,2016)

7
According to the study that was done in Mecha District, Northwest Ethiopia on knowledge of
self-reported attitudes and practices towards TB. It was found out that there is a significant gap
in preventive practice towards TB infection control. It is a well-known fact that knowledge can
influence people’s practices regarding prevention the study revealed the overall knowledge about
TB was 54% (Launiala. et al, 2017)

According to the study that was done in Mongolia in 2012 on KAP on TB more than half of the
population had unsatisfactory level of knowledge towards TB (53.9%). A relationship between
knowledge on TB and educational background, age and gender was observed. The percentage of
the people who are knowledgeable about TB was less among population aged 18-29. The most
effective means of media to distribute TB messages is TV (61%) and 32.4%otherespondents
pointed out IEC materials while 26.2% preferred health professionals (Auer.et al, 2017).

According to the study that was done in south west Ethiopia cross sectional study on community
KAP on 422 study participants (58.5% males and 41.5% females) only 3.3% mentioned
bacteria/germ as a cause of pulmonary TB (PTB) and 9.9% mentioned cough for at least two
weeks as the sign of TB, 57.6% of the study participants had good level of knowledge about TB,
40.8% had favorable attitude towards TB and 45.9% had good practices. Female participants
were less likely to have good level of knowledge less likely to have favorable attitude and less
likely to have good practices compared to male participants (Majrooh.et al, 2013).

According to the study conducted in Shinile town, Somali regional state overall knowledge mean
score about TB was 10.67. One hundred and eighty-seven participants (45.6%) had low overall
TB knowledge and 223 (54.4%) had high over- all knowledge about TB. High level of overall
knowledge about TB was reported among individuals with educational status of grade 8 up to
grade 12 compared to illiterate individuals. Mean know- ledge score about attitude towards TB
was 3.76. One hundred and seventy-six (42.9%) had poor attitude and two hundred and
thirty-one (57.1%) had good attitude towards TB and those affected by the disease (Medhin.et
al, 2015).

According to the study that was conducted in Nigeria indicated that (77.2%) of patients had
knowledge about the transmission TB through air during coughing. This shows that the
association of transmission through air with TB is considerable that might affect the level of

8
ventilation required to prevent TB transmission. The result of the study showed that favorable
knowledge (66.9%) of residents about tuberculosis disease was satisfactory knowledge on TB
(Tobisn.et al, 2013)

According to the study that was conducted in Ethiopia, Tuberculosis was the common cause of
mortality and morbidity. Ethiopia as multi- cultural country, the knowledge of TB has been
mentioned to demonstrate considerable spatial changes. Moreover, through the electronic media
and health education campaigns, information about healthcare can attain many public rapidly and
boost the knowledge level among individuals (Baker.et al, 2013).

A study carried out in Addis Ababa, Majority of the respondents believed that TB is a curable
disease and others were at risk of acquiring the disease. Similarly, 65.5% of the respondents
stated that the disease is curable with modern therapy but 22.5% of the respondents did not know
how it is cured. Only 43.1% of the respondents knew the current free service of diagnosis and
treatment of TB and 50% did not know it as free services (Denissie et al.,2017)

According to a study conducted in India regarding prevention of TB,87% of respondents told

modern treatment that, followed by covering mouth while coughing and proper disposal of
sputum were other responses. Many respondents stated more than one precaution. A study
among general population of showed somewhat higher results where 95.5% respondents told
about treatment and 30% about cough hygiene. Croatia reported early diagnosis and treatment by
90.7% of respondents, followed by hygiene 53.9% and better nutrition, 43.5% reported that
treatment, covering mouth while coughing and proper disposal of sputum were known to
73.7%,446.6% and 38.9% individuals, respectively, while in Bihar study, it was very lower
where only 33% were aware about modern treatment. It was very alarming that even today there
was tendency to discriminate TB patients, which was quite evident from the study and from other
studies also (Delhi et al.,2015).

Tuberculosis prevention and control efforts primarily rely on the vaccination of infants and the
detection and appropriate treatment of active cases. Other prevention measures include, people
with tuberculosis infection should always cover their mouths when they cough or noses when
they sneeze. People with latent TB infection should take medication to prevent it from becoming

9
active TB disease. Also, people at risk for or who have been in contact with people with TB
infection should be tested (Lawn et al.,2017).

2.3 ACCESSIBILITY OF TB SERVICES BY TB PATIENTS

Health service coverage (HSC) and access are commonly used indicators in health policy
planning and management. Different studies describe the HSC (‘potential coverage’) as the
ability of a healthcare facility to provide services for a target population and categorize access to
health services as availability, accessibility, accommodation, affordability, and acceptability
(Higgs, 2013).

According to a study that was conducted in Ethiopia, which focused on the physical accessibility
and availability of tuberculosis (TB) control services. Spatial accessibility, the physical closeness
to or distance from a healthcare facility, was one of the factors that affect the utilization of
available health services. The use of residential locations to measure physical accessibility to
health facilities helps identify the disparities and inequity in health service provision in terms of
geographic distribution and accessibility (Christie.et al, 2014).

Geographic information systems (GIS) can be used to assess the accessibility to healthcare
services healthcare providers and for planning appropriate locations for health facilities. Few
studies from Africa have also used GIS to assess accessibility to TB control facilities and
provided important information for TB control programs (Brabyn .et al, 2015),

In Ethiopia, the incidence of TB was 224 per 100,000 people in 2013 (having declined from 342
in 2005). TB case notification rates (CNRs) and treatment outcomes are used to measure the
performance of a TB control programme. The CNR is the number of TB cases recorded per
100,000 people for a given year. In 2013, 131,677 cases (140 cases per 100,000 people) of all
forms of TB and 43,860 smear-positive pulmonary TB cases were recorded in Ethiopia. In the
same year, about 30,000 deaths were reported in HIV-negative TB cases. Following the
expansion of DOTS services, the CNRs and treatment outcomes improved. Thus, the proportion
of new smear-positive TB cases who were successfully treated (having completed treatment or
been cured) increased from 80% in 2000 to 89% in 2011, while the proportions of loss to
follow-up and mortality declined (WHO, 2014).

10
In a study that was carried in Ghana, unique spatial data was assembled on health facilities
providing TB testing services, population, and topographic landscape, as well as supporting
survey to assess realistic levels of geographic accessibility to public health facilities providing
TB testing services at POC in the UER. The study results showed majority (62%) of the
population travel beyond 10 km to access TB diagnostic testing in the region. It also revealed
that TB diagnostic service was available in only ten health facilities in the UER which translates
to approximately 125,000 people per facility considering the region’s current total population of
1,244,983. (Gething.et al 2017).

Although geographic accessibility is not the only determinant of access to health care, where
service provision is sparse, and the population is predominantly rural, it plays a critical role for
healthcare outcomes. Poor geographic accessibility to public health facilities providing TB
testing services at POC revealed by the study implies patients in referred from PHC clinics in
rural areas have to walk for hours or pay exorbitant transport fares to access TB diagnostic
services (Dangisso.et al, 2015)

According to a study done in Ethiopia, Evidence shows that physical distance is one of the
factors that affect utilization of different health services. Studies report various factors such as
socio-economics, health seeking behavior, individuals’ preference for service, service quality,
affordability or indirect costs, stigma, and low level of awareness about a disease that could
affect the utilization of existing facilities. (Ford.et al, 2011)

On the other hand, TB CNRs depend on variations in the burden of TB in different geographic
areas and the association between distance and the CNRs could be masked by differences in the
burden and transmission of TB. The performance of the TB control programme could have been
influenced by low coverage or supply of microscopy and basic facilities. In the data, the number
of facilities offering smear microscopy for 100,000 people was 2.3, consistent with the national
report. (WHO,2014).

Studies from other countries report the relationship between altitude and TB incidence and
suggest that the oxygen pressure in different altitudes may affect or favor the proliferation and
survival of Mycobacterium, which might contribute to low CNRs or a lower disease burden in
areas with high altitudes. (Vargas.et al,2014)

11
Poor access to TB control facilities could also contribute to low CNRs; nonetheless, we found a
significant association between altitude and TB CNRs after adjusting for distance and for
population density. however, areas with poor accessibility to health facilities had low TB CNRs.
This could partly explain how poor access to diagnostic facilities might contribute to low CNRs
despite the active case-finding intervention. The study also found an increased CNR among older
age groups and improved treatment outcomes during the active case-finding period. These data
implied that improved accessibility and the active case-finding approach detected more cases
among older age groups and contributed to an increase in CNRs. (Datiko.et al, 2013).

In a study conducted in Nigeria, inaccessibility of TB services was linked to distance, time,

money and knowledge about where to obtain services free of charge. There have been reports of
clients travelling a distance of 40km everyday within a state to receive treatment. In this study
accessibility is further limited by the centralization of TB control activity with less activity in
rural areas. Many Nigerians who reside in rural areas are at a disadvantage (WHO 2016).

2.4 ADHERENCE TO TB MEDICATION

Adherence of TB patients describes to which a patient correctly follows medical advice. The
various definitions found throughout literature provide an opportunity for patients to be
accurately or inappropriately classified as non-adherent, thus creating a greater need for a
standardized definition of what is and is not medication adherence. One of the pitfalls of the
generic definitions of medication adherence is that medication adherence can be defined from a
process-oriented perspective or an outcome-oriented perspective. A process-oriented definition
of adherence considers the act of patient seeking medical care to develop, define and follow the
advice agreed upon with the provider. Ultimately, adherence include taking medication as
prescribed including the time of each daily dose, frequency of each dose, and the correct
dosage.an outcome-oriented definition of adherence focuses on a specific clinical outcome, with
subsequent measurements to assess adherence (Vermeire et al.,2018).

In developing countries, particularly, there are many factors affecting adherence to TB treatment
as evidenced from a variety of literatures. Age, lack of treatment support from family, extreme
illness, far distance, lack of access to formal health services, traditional beliefs leading to
self-treatment, low income, lack of social support, drug side effects, pill burden, lack of food,

12
stigma with lack of disclosure, and lack of adequate communication with health professionals
were some of the documented factors (Bagchi.et al, 2013).

Worldwide, the implementation of Directly Observed Treatment (DOT) has been related to
decreased rate of treatment failure, relapse and drug resistance. However, its influence on
decreasing TB incidence has been inadequate by non-compliance to DOT, which happens when
patients do not turn up for treatment at health facility or community DOT points (Chani, 2015).

According to the WHO’s report on worldwide plan to halt TB, poor treatment has been caused
by evolution of Mycobacterium tuberculosis strains that do not respond to treatment with
standard first line combination of anti-TB medicines, resulting in the emergence of multi drug
resistance TB (MDR-TB) in almost every country of the world (WHO, 2014).

In a study that was conducted in Pakistan, majority of the respondents lacked adequate
knowledge about TB. Most of the respondents did not know the actual cause, mode of
transmission and treatment length. Some patients believed TB as a hereditary and deadly disease
which has no cure. A number of respondents did not know the conventional treatment period is
6 months and the risk they face if they stop the medication. (Khan J. et al, 2016).

One of the overarching dilemmas and challenges facing most TB program’s is a patient that does
not complete TB treatment for one reason or another. There is an unfavorable magnitude of poor
adherence to treatment of chronic diseases including TB in the world. However, greater than
90% of patients with TB are expected to adhere the treatment in order to facilitate cure. Poor
adherence to treatment results failure of cure which increases the risk of development of drug
resistant strains, spread of TB in the community and this in turn increases morbidity and
mortality, although many national and international efforts have been implemented against TB
prevention and control, still patients are failing to complete their treatment to declare cure even
with execution of globally recommended strategy (DOT) in almost all parts of the WHO regions
(Harries.et al, 2019).

Studies have found that educating a TB patient significantly reduces the risk of treatment
non-adherence). Hence, health care providers should be trained and encouraged to provide a
more personalized health education within the context of the patient’s background and local
customs. (Dick.et al 2017).

13
Most of the respondents were encouraged to take their treatment properly because distance to
health facility was relatively manageable. The Ministry of Health addresses distance barriers by
training TB promoters from the community to provide medication to those who are unable to
reach the clinic. Similar studies report that distances from patients’ homes to the health facilities
and financial burdens contribute to diagnostic delay and treatment non-adherence which
discourage patients for treatment initiation and compliance (Tadesse.et al 2015).

Assessing medication adherence can vary from based on process or outcome, where both
perspectives fail to incorporate persistence of therapy as a key component of adherence. Ideally,
when establishing a regimen, the patients and provider will be defining the duration of the time a
specific therapy is inspired. Thus, medication persistence refers to continuing a therapy as
prescribed by the provider, from the initial prescription until the time the provider discontinues
encof pills left at a specific time is divided by the total number of pills for the given time, also
known as the proportion of days covered model or the medication possession ratio. For instances,
previous studies have required a rate of at least 80% for some disease process in order for a
patient to be considered adherent whereas other studies required a rate of 95% to be considered
adherent. By calculating a specific percentage to define adherence, the results allow researchers
to dichotomize and measure adherence (Otersberg and Blaschke, 2020).

14
CHAPTER THREE

RESEARCH METHODOLOGY

3.1 STUDY DESIGN

A cross-sectional descriptive study design was used to determine factors contributing to
prevalence of TB among patients attending out patient department at Coast Genera Teaching and
Refferal l hospital. This method was used since it is not costly and simple to conduct in a short
period of time given for data collection.

3.2 STUDY AREA

The study was conducted at Coast General hospital.

3.3 STUDY POPULATION

Patients attending out patient department at Coast General Teaching and Refferal

3.3.1 INCLUSION CRITERIA

The study included all patients attending out patient department at Coast General Teaching and
Referral hospital.

3.3.2 EXCLUSION CRITERIA

The study excluded all patients who did not attendout patient department at Coast General
Teaching and Refferal hospital.

3.4 STUDY VARIABLES

3.4.1 DEPENDENT VARIABLES

Prevalence of TB

3.4.2 INDEPENDENT VARIABLES

● Level of knowledge
● Accessibility
● Adherence

15
3.5 SAMPLING TECHNIQUE
The sampling method that was used was simple random sampling where every member of the
population had an equal chance of being selected. Random numbers were written on pieces of
papers after which the researcher placed them in a box and the respondents were requested to
pick the papers randomly. Those who picked yes were selected to participate in the study and
those who picked no were not selected to participate in the study.

3.6 SAMPLE SIZE DETERMINATION

The standard statistical formula (Fischer’s et al, 2018) will be used to obtain the sample size.

Where when the population is more than 10,000

n= Z2Pq

d2

Where n= Desired sample size

Z = the standard normal deviation usually set at 1.96

P= the proportion of the target population estimated to have particular Characteristics, usually
measured at 0.5

q = 1-p

d = degree of accuracy desired, usually set at 0.05

n. = 1.96 2 x 0.5 x 0.5

(0.05)

= 384.16

16
= 384

Since the study population is less than 10,000 the sample size was calculated as follow

Nf = n

1+n / N

Where by:-

Nf = desired sample size for population less than 10,000

n= constant of 384

N= estimated population size (180)

Therefore,

Nf = 384

1 +384/180

Nf = 384/3.13

Nf = 122

= 122 respondents

3.7 DATA COLLECTION TOOL

The data was collected using questionnaire tool whereby questionnaire form was structured with
closed ended questions and the researcher issued questionnaire to the respondents to fill by
choosing relatively best answers from a set of given options.

3.8 DATA COLLECTION PROCESS

Data was collected through structured self-administered questionnaires. Questionnaires was
issued to the respondent. The respondents were required to fill the questionnaire and appropriate
responses was indicated where necessary and then data was be analyzed.

17
3.9 PRE -TESTING
The data collection tool was pre-tested/piloted to determine the faults and weaknesses of the tool
in order to validate whether the tool was effective and the pilot area was Machakos county
referral hospital.

3.10 VALIDITY
The validity of the instrument was checked in terms of how questionnaire was constructed and
the content of questionnaire. The validity was ensured by making sure that the research questions
were in order and easy to follow and information was scrutinized for accuracy.

3.11 RELIABILITY
The reliability was ensured through pilot testing to ascertain the suitability of the data collection
process that was used in the actual data. The results of the piloting were used to enhance
structuring of the questionnaire and the clarity of the data collection tool.

3.12 DATA ANALYSIS

The data that was obtained were analyzed using descriptive statistics such as counts, frequencies
and percentage frequencies and was presented inform of tables and charts e.g. bar charts, pie
charts.

3.13 ETHICAL CONSIDERATIONS

The permission to carry out the research was granted by National Commission for Science,
Technology and Innovation (NACOSTI) and was approved by Mombasa Hospital Medical
superintendent. Dignity was maintained to the clients and the researcher to ensure that there was
no physical or physiological harassment. Information from the clients was treated as confidential.

18
CHAPTER FOUR

RESULTS
This chapter entails data analysis, presentation and interpretation of findings from 122
respondents who participated in the study. The findings are presented in form of tables and
charts (figures).

SECTION A: SOCIAL DEMOGRAPHIC DATA

Table 4.1: Age distribution (n=122)

AGE FRIQUENCY % FREQUENCY
15-20 10 13
20-25 38 41
25-35 54 31
35-49 20 15
TOTAL 122 100
Table 1:age distribution

More than a third of the respondents (41%) were age between 20-25 years as the highest, (31%)
were aged between 25-35 years, (15%) were aged between 35-49 years and (13%) respondents
were only age between 15-20 years.

Table 4.2: Gender (n=122)

GENDER FREQUENCY %FREQUENCY

Male 40 33

19
 Female 82 67
TOTAL 122 100
Table 2:gender

Slightly above two thirds of the respondents (67%) were female and (33%) were male

Figure 4.1: Level of Education (n=122)

Figure 1:level of education

Slightly above half of the respondents (53%) had gone up to secondary level, (39%) had gone up
to tertiary level, (6%) of the respondents had reached primary school while (2%) said that they
did not attend any school.

20
Figure 4.2: Occupation (n=122)

Figure 2:occupation

Two thirds of the respondents (66%) were unemployed, (13%) were self-employed, (12%) of the
respondents were employed and (9%) said that they were casual workers.

SECTION B: LEVEL OF KNOWLEDGE

Figure 4.3: Heard about TB (n=122)

21
Figure 3:head about tbt

More than three quarter of the respondents (88%) said that they have heard about TB and
(12%)of the respondents said that they have never heard about TB.

Table 4.3: Source of Health Information (n=122)

SOURCE OF HEALTH INFORMATION FREQUENCY %FREQUENC
Y
Health Professionals 85 20

MEDIA (Radio, TV, Newspapers) 25 70

Hospital 12 10

TOTAL 122 100

Table 3: source of health information

Majority of the respondents (70%) said that they received information from Media such as
Radio, TV, Newspapers etc. (20%) said that they received from Health professionals and (10%)
said they get information about TB from Hospitals.

Figure 4.4: Do you know any mode of TB transmission (N=122)

22
Figure 4: mode of transmission

More than three quarter of the respondents (86%) said that they know the mode TB transmission
and (14%)of the respondents said that they don’t know the mode of TB transmission.

Figure 4.5: If yes which one (n=122)

Figure 5: mode of transmission

Less than a half of the respondents (48%) reported that it is through droplet spread, (39%) of the
respondent said that it is through sleeping with a person infected with TB while (13%) said it is
through blood transfusion.

23
Figure 4.6: Do you know Signs and symptoms’ of TB (n=122)

Figure 6:signs and symptoms

More than two third of the respondents (84%) said that they know signs and symptoms of TB
while (16%)of the respondents said that they don’t know sighs and symptoms of TB.

Figure 4.7:If yes which one (n=122)

Figure 7:signs and symptoms

24
Majority of the respondents (62%) said persistent cough of more than two weeks, (25%) said
sneezing while (13%) said tiredness.

Figure 4.8: Knowledge about preventive practices of TB (n=122)

Figure 8:knowledge about preventive practices.

More than a half of the respondents (59%) knew preventive practices of TB while (41%) did not
know.

25
Figure 4.9: If yes which one (n=122)

Figure 9:signs and symptoms

Less than a half of the respondents (48%) said proper coughing etiquette, (39%) said
overcrowding while (19%) of the respondents said avoid speaking with someone face to face.

26
SECTION C: ACCESSIBILITY OF TB MEDICATION
Figure 5.0: Heard about TB screening? (n=122)

Figure 10: TB SCREENING

Majority of the respondents (64%) said that they know screening while (36%) said that they
don’t know TB screening.

Table 4.4: TB screening attendance (n=122)

TB SCREENING ATTENDANCE FREQUENCY %FREQUENC
Y
Once a year. 12 10
Twice a year 8 7
When sick 52 43
Never 50 40
TOTAL 122 100

27
Table 4:TB screening attendance

Less than a half of the respondents (43%) attend TB screening when sick, (40%) of the
respondents reported that they never attend TB screening, (10%) said they attend once a year
while (7%) attend at least twice a year.

Figure 5.1: About screening and medication. (n=122)

Figure 11:screening and medication

More than two third of the respondents (94%) said that TB screening and medication is
affordable, (3%) said it is expensive and (3%) said it is very expensive.

28
Figure 5.2: Factors that prevent people from accessing TB services (n=122)

FACTORS PREVENTING PEOPLE FROM FREQUENC %FREQUENCY

ACCESSING TB SERVICES Y
Socio economic 34 27
Individual preference 52 43
Cost 6 5
Lack of awareness 25 25
Total 122 100

More than a third of the respondents (43%) said individual preference, (27%) said socio

Table 5:factors that prevents people from accessing TB services

economic factors, (25%) said lack of awareness while (5%) said cost.

Table 4.6: Distance from Health Facility (n=122)

DISTANCE FREQUENCY %FREQUENCY

UPTO 1 KM 52 43

1-5KM 36 30

5-10KM 20 16

10-15KM 14 11

TOTAL 122 100

29
Table 6:distance from health facility

More than a third of the respondents (43%) travel less than a kilometer to access TB services,
(30%) said they travel one to five kilometers, (16%) said they travel five to ten kilometers and
(11%) said they travel ten to fifteen kilometers.

SECTION D: NON ADHERENCE TO TB MEDICATION

Figure 5.2: Meaning of non-adherence(n=122)

Figure 12:non-adherence

Majority of the respondents (62%) said that they don’t know the meaning of non-adherence and
(38%) said they know the meaning of non-adherence.

30
Figure 5.2: Factors contributing to non-adherence(n=122)

Figure 13:factors contributing to non-adherence

Majority of the respondents (61%) said distance is the main factor that contribute to
non-adherence, a third of the respondents (31%) said stigma while (8%) said extreme illnesses.

Figure 5.3: Conventional treatment period of TB(n=122)

Figure 14:treatment period

31
More than two third of the respondents (86%) said they don’t know the conventional treatment
period for TB and (14%) said they know the conventional treatment period for TB

Figure 5.2: Effect of non-adherence to TB medication(n=122)

Figure 15:effects of non-adherence to TB medication

Majority of the respondents (59%) said they know effect of non-adherence and more than a third
(31%) said they don’t know

Table 4.4: If yes which one (n=122)

EFFECT OF NON ADHERENCE FREQUENCY %FREQUENC
Y
Extreme illness 27 22
Death 27 22
All of the above 68 56
TOTAL 122 100
Table 7:effects of non-adherence

More than a half of the respondents (56%) said both death and extreme illnesses are the effects of
non-adherence to TB medication (22%) said extreme illnesses and (22%) said death.

32
CHAPTER FIVE

5.0: DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1: INTRODUCTION
This chapter presents the discussion of the findings of the study, conclusions and
recommendations. These are aimed at providing answers to the main research questions and
making recommendations on factors contributing to prevalence of TB among patients attending
chest clinic at Coast General Teaching and Refferal hospital.

5.2: Discussion
The results of this study showed that majority of the respondents 67% were female while 33%
were male. The study disagrees with study done by Majrooh.et al,(2017) in south west Ethiopia
which stated that males were 58.5% and 41.5% females. The study continued to reveal that More
than two third of the respondents (88%) have knowledge about TB and less than a third (12%)of
the respondents don’t know about TB. This study agrees with the study done in Shinile town,
Somali region by Medhin.et al (2015) which stated that overall knowledge mean score about TB
was 10.67. One hundred and eighty-seven participants (45.6%) had low overall TB knowledge
and 223 (54.4%) had high over- all knowledge about TB.

The study revealed that majority of the respondents (70%) receive information from Media such
as Radio, TV, Newspapers etc. (20%) receive from Health professionals and (10%) get
information about TB from Hospitals. This study agrees with the study done in Mongolia by
Auer.et,al(2017) which stated that the most effective means of media to distribute TB messages
was TV (61%) and 32.4%otherespondents pointed out IEC materials while 26.2% preferred
health professionals

The study results further revealed that More than two third of the respondents (86%) know the
mode of TB transmission and less than a third (14%) don’t know the mode of TB transmission.
This study agrees with the study that was conducted in Nigeria by Tobisin.et al,(2014). which
sated that (77.2%) of patients had knowledge about the transmission TB through air during
coughing. This shows that the association of transmission through air with TB is considerable
that might affect the level of ventilation required to prevent TB transmission. The result of the

33
study showed that favorable knowledge (66.9%) of residents about tuberculosis disease was
satisfactory knowledge on TB

The study results showed that More than a third of the respondents (43%) travel less than a
kilometer to access TB services, (30%) travel one to five kilometers, (16%) travel five to ten
kilometers and (11%) travel ten to fifteen kilometers. This study is against the study that was
carried in Ghana by Gething.et al (2016). The study results showed majority (62%) of the
population travel beyond 10 km to access TB diagnostic testing in the region. It also revealed
that TB diagnostic service was available in only ten health facilities in the UER which translates
to approximately 125,000 people per facility considering the region’s current total population of
1,244,983.

The study results further revealed that Majority of the respondents (62%) stated that persistent
cough of more than two weeks as the signs and symptoms of TB , (25%) sneezing while (13%)
said tiredness. This study agrees with the study done in India by Shetty et al,(2018). which
stated that night fever, tiredness, productive cough and cough more than 3 weeks are signs and
symptoms of TB.

The study results further revealed that More than two third of the respondents (86%) did not
know the conventional treatment period for TB and (14%) knew the conventional treatment
period for TB. This study agrees with the study that was done in Pakistan by Khan J. et
al,(2018) which sated that majority of the respondents lacked adequate knowledge about TB, a
number of respondents did not know the conventional treatment period is 6 months and the risk
they face if they stop the medication

5.3 Conclusion
The researcher concluded as the following:

⮚ People who have adequate knowledge on T.B prevention protect themselves, friends and

their families from TB than those who do not have adequate knowledge on TB.

⮚ Majority of the respondents know the signs and symptoms of TB compared to those who

don’t know.

34
 ⮚ It is very important for TB patients to adhere to treatment since non adherence results to

treatment failure which increases the risk of development of drug resistant strains which
in turn increases morbidity and mortality.

⮚ Majority of the respondents get health information about TB through media and few from

hospitals and health professionals.

5.4: Recommendations
Based on the results researcher recommends the following:

⮚ The researcher recommended patients to attend TB screening regularly.

⮚ The researcher recommended the utilization of TB services since it is affordable.

⮚ The researcher recommended health care providers to be trained and encouraged to

provide a more personalized health education within the context of patient’s background
and local custom in so as to prevent non-adherence.

⮚ The Nairobi county government in partnership with the hospital to organize a healthy

education training to inform patients attending chest clinic on the importance of utilizing
the available TB services.

35
APPENDICES

APPENDIX1: QUESTIONNAIRE

INTRODUCTION
I am a student in KMTC Kitui campus carrying out a study on factors contributing to prevalence
of TB among patients attending chest clinics at Coast General Teaching and Referral Hospital.

TOPIC: FACTORS CONTRIBUTING TO PREVALENCE OF TB AMONG PATIENTS

ATTENDING CHEST CLINIC AT COAST GENERAL TEACHING AND REFERRAL
HOSPITAL .

INTRODUCTION

● Do not write your name on the questionnaire.

● Answer the questions by ticking in the boxes provided according to your view.
● Each and every question should have one answer.
● Confidentiality is maintained to the information given.

● Your response and co-operation will be highly appreciated.

SECTION A: DEMOGRAPHIC DATA

1. Age?
a) (15-20) years. [ ]
b) (20-25) years. [ ]
c) (26-35) years. [ ]
2. Gender?
a) Male. [ ]
b) Female. [ ]

36
 3. Educational level?
a) Primary. [ ]
b) Secondary. [ ]
c) University/ college. [ ]
d) None. [ ]
4. Occupation
a) Employed [ ]
b) Unemployed [ ]
c) Self-employed [ ]
d) Casual worker [ ]

e) No [ ]
5. If yes, where did you hear it from?
a) Media [ ]
b) Health professionals [ ]
c) Hospital [ ]
d) Other specify…………………………………………………………………
6. Do you know any mode of TB transmission?
a) Yes [ ]
b) No [ ]
7. If yes which one do you know?
a) Droplet spread [ ]
b) Blood transfusion [ ]
c) Sleeping a person infected with TB [ ]
d) Other specify…………………………………………………………………..
8. Do you know any signs and symptoms of TB?
a) Yes

SECTION B: LEVEL OF KNOWLEDGE ON PREVENTIVE PRACTICES ON TB

9. Have you ever heard about TB?
f) Yes
g) No [ ]

37
 10. If yes which one?
a) Persistent cough of more than two weeks [ ]
b) Loss of appetite [ ]
c) Weight loss [ ]
d) Other specify………………………………………………………………………
11. Do you know any preventive practices of TB?
a) Yes [ ]
b) No [ ]
12. If yes which one?
a) Proper coughing etiquette [ ]
b) Avoiding overcrowding [ ]
c) Avoid speaking with someone face to face [ ]
d) Other specify………………………………………………………………………

ACCESSIBILITY OF TB MEDICATION
13. Have you ever heard about TB screening?
a) Yes [ ]
b) No [ ]
14. If above YES how often do you attend it?
a) Once a year [ ]
b) Twice a year [ ]
c) When sick [ ]
d) Never [ ]
e) Other specify………………………………………………………………………..
15. How is screening and medication?
a) Affordable [ ]
b) Expensive [ ]
c) Very expensive [ ]
16. In your opinion what could be the main factor that prevent people from accessing TB
services?
a) Socio economic [ ]
d) Individual preference [ ]
38
 e) Cost [ ]
f) Lack of awareness [ ]
g) Other specify…………………………………………………………………..
17. What is the distance from your home to the health facility?
a) Up to 1 KM [ ]
b) 1-5KM [ ]
h) 5-10KM [ ]
i) 10-15KM [ ]

NON-ADHERENCE TO TB MEDICATION
18. Do you know the meaning of non-adherence?
a) Yes [ ]
b) No [ ]
19. If yes what is it about?
a) Not following medication as recommended by health care provider [ ]
b) Following medication as recommended [ ]
c) Other specify………………………………………………………………………
20. What is the main factor that contributes to non-adherence to TB medication?
a) Distance [ ]
b) Stigma [ ]
c) Extreme illness [ ]
d) Other specify……………………………………………………………………..
e) Do you know the conventional treatment period of TB?
a) Yes [ ]
b) No [ ]
f) If yes which one?
a) One week [ ]
b) One month [ ]
c) Six months [ ]
d) No idea [ ]
g) Do you know any effect of non-adherence to TB medication?
a) Yes [ ]
39
 b) No [ ]
c) Extreme illness [ ]
d) Death []
e) All of the above [ ]
f) Other specify…………………………………………………………………

21. If yes which one?

APPENDIX II: BUDGET

DESCRIPTION UNIT QUANTITY UNIT COST TOTAL COST

REAM DUPLICATIN 2 500 1000

G PAPERS
FILE No 1 100 100
RUBBER No 1 20 20
BIRO PENS No 4 25 100
TYPING/PRINTIN Copies 150 30 4500
G
BINDING Booklet 3 100 300
TRANSPORT Days 20 100 200
LUNCH Days 20 100 200
FLASH DISC No 1 1500 1500
TOTAL 7920

APPENDIX III: WORK PLAN

YEAR 2021 2022

40
ACTIVITY S O N D J F M A M J J A S
Problem
identification
Literature
review
Proposal
writing
Data
collection
Data
collection
Report
writing

41
REFERRENCES
Kumar V, Abbas AK, Fausto N, Mitchell RN(2012).Robbins Basic pathology (8th Ed).
Saunders Elsevier.Vol.32;516-522.

Kabra, Vimlesh Seth, SK.(2009).Essential of tuberculosis in children (3rd Ed.) New

Delhi:Jaycee Bros M, Medical Publisher.57(6).249-453

Golden MP, Vikram HR, (2008). Extra pulmonary tuberculosis on overview, America Family
Physcal Vol.9: 176-189.

Gerald L Mandell, John E Bonnett, Mandell, Douglas and Bonnett’s.(2010). Principles and
practice of infectious diseases(7thEd.) Philadelphia, PA: Churchil Livingstone/
Elseevier.pp.chapter. Vol.4 250-322.

Fredrick H,Russel J,(2009). Assessment of factors contributing to treatment adherence and

knowledge on TB transmission among patients on TB treatment. Journal of epidemiology.
Vol.2,7:92-98.

Shetty N, Shemko M, Abbas A.(2010). Knowledge and practices regarding tubeeerculosis. Vol
7:77-82

Osterberg, L, and Blaschke, T. (2009). Drug therapy: Adherence to TB medication.New

England journal of Medicine, Vol. 353(5), 487-497.

Launiala A, Honkasalo ML. (2017) Ethnographic study of factors influencing compliance to

intermittent preventive treatment of malaria during pregnancy among Yao women in rural
Malawi.

Auer C, Sarol JJ, Tanner M, Weiss M (2012). Health seeking and perceived causes of
tuberculosis among patients in Mongolia J Trop Med Int Health 5: 648-565.

Majrooh MA, Mushtaq MU, Ahmad W, Rizwan M, Luqman MQ, (2012). KAP regarding
tuberculosis. Int J Tuberc Lung Dis

Baker L, Wagner TH, Singer S, Bundorf MK (2013). Use of the Internet and e-mail for health
care information ;national survey.

42
Higgs G. (2013) A literature review of the use of GIS-based measures of access to health care
services. Health Serv Outcomes Res Methodol; 5: 11939.

Christie S, Fone D. (2012) .Equity of access to tertiary hospitals in Wales: a travel time analysis.
J Public Health Med

Brabyn L, Skelly C (2011). Modeling population access to New Zealand public hospitals. Int J
Health Geogr 2011

WHO (2014). Global tuberculosis report . Geneva: World Health Organization.

Gething PW, Johnson FA, Frempong-Ainguah F, Nyarko P, Baschieri A, Aboagye P (2012)

Geographical access to care at birth in Ghana: a barrier to safe motherhood. BMC Public Health.

Dangisso MH, Datiko DG, Lindtjorn B. (2015). Accessibility to tuberculosis control services
and tuberculosis programme performance in southern Ethiopia.Glob Health Action.

Ford CM, Bayer AM, Gilman RH, Onifade D, Acosta C, Cabrera L,(2011). Factors
associated with delayed tuberculosis;

WHO (2014). Global tuberculosis report . Geneva: World Health Organization

Vargas MH, Furuya ME, Perez-Guzman C. (2014). Effect of altitude on the frequency of
pulmonary tuberculosis.Int J Tuberc Lung Dis;

Datiko DG, Lindtjorn B.(2015) Health extension workers improve tuberculosis case detection
and treatment success in southern Ethiopia: a community randomized trial. PLoS One;

Bagchi S, Ambe G, Sathiakumar N. (2013). Determinants of poor adherence to

anti-tuberculosis treatment in Mumbai, India. International journal of preventive medicine.;

Chani K.(2010). Factors affecting compliance to tuberculosis treatment in AndaraKavango

region Namibia.

Khan J, Irfan M, Zaki A, Beg M, Hussain SF, Rizvi N. (2011) Knowledge, attitude and
misconceptions regarding tuberculosis in Pakistani patients. J Pak Med Assoc

Harries AD, Maher D, Graham S. (2011) TB/HIV: a clinical manual: World Health
Organization;.

43
Dick J, Lombard C. (2011). Shared vision a health education project designed to enhance
adherence to anti tuberculosis treatment. Int J Tuberc Lung Dis. Demissie M, Lindtjor B,
Berhane Y. (2012) Patient and health service delay in the diagnosis of pulmonary
tuberculosis. Ethiopia: BMC Public Health

Tadesse T, Demissie M, Berhane Y, Kebede Y, Abebe M. (2013). Long distance travelling and
financial burdens discourage tuberculosis DOTs treatment initiation and compliance in Ethiopia:
a qualitative study. BMC Public Health

Medhin G, Tolossa D,Legesse M (2015) Community knowledge, attitude, and practices towards
tuberculosis in Shinile town, Somali regional state, Eastern Ethiopia a cross-sectional study.
BMC Public Health.

Denissie M, Lindtjor B, Berhane Y. (2012) .Patient and health service delay in the diagnosis of
pulmonary tuberculosis. Ethiopia: BMC Public Health

22.

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45
46
47
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