CHAPTER ONE
Introduction
Background to the study
The disease called tuberculosis (TB) existed right from the ancient time and the cause of it was unknown until 1882 when Robert Koch confirmed its’ etiological agent to be tubercle bacillus. TB is a specific infectious disease caused by Mycobacterium tuberculosis, which affects lungs, intestines, meninges, bones and joints, lymph glands, skin and tissues of the body (Park, 2007). In a related definition, the Federal Ministry of Health, FMOH, (1997) stated that it is a communicable, systemic disease caused by tubercle bacillus called mycobacterium tuberculosis. In this study, TB can be defined as a systemic chronic infectious disease caused by mycobacterium tuberculosis, which affects the lungs, intestine, meninges, bone, and joints, lymph glands, skin and other tissues of the body. TB has signs and symptoms.
The signs and symptoms of TB which affects the lungs are persistent cough lasting two weeks or more, weight loss, coughing up blood, chest pain, fever, night sweats, tiredness, shortness of breath, and loss of appetite while the signs and symptoms of TB which affects other organs outside the lungs are back pain, swelling of spine, loss of functions in lower limbs, long standing bone infection, painful joints, with swelling usually affecting one joint, painful urination, blood in urine, frequent urination, hoarseness of voice, pain on swallowing, neck stiffness and long stand ulcer despite antibiotic treatment (AmericanThoracis Society ATS 1999; World Health Organization WHO1996; FMOH, 2010). The signs and symptoms of TB can be used to suspect that someone is having TB. In addition, its’ diagnosis can be made by other means.
Pulmonary Tuberculosis according to WHO (1996) and Park (2007) can be diagnosed by sputum smear microscopy, chest X-ray, tuberculin skin test, clinical features (using signs and symptoms) and sputum culture. The knowledge of diagnosis of TB among the workers involved in TB work is very necessary in the sense that suspects will not be missed out.
There are four different types of tuberculosis, according to Lucas and Gilles (2003), Park (2007), and FMH (1997). Human, bovine, avian and typical strains of mycobacterium are the four different types of tuberculosis. Tuberculosis according to FMOH (1997) can affect the lungs and this is called pulmonary tuberculosis; and when it affects other organs outside the lungs it is called extra-pulmonary tuberculosis. All the four different types of tuberculosis are treated using the treatment regimen for tuberculosis.
The treatment regimen for TB includes rifampicin, isoniazid, pyrazinamide, ethambutol, stroptmycin and thiacetazone. Treatment consist of 2 months (intensive phase) of isoniazid, rifampicin, pyrazinamide, ethombuthol given daily and streptomcyin which is not added in most cases and 6 months (continuation phase) of isoniazed and ethambutol or thiacetazone or 4 months (continuation phase) of Rifampicin and Isoniazid (Lucas & Gilles, 2003; FMOH, 2010). This work intends to ascertain the level of knowledge of treatment regimen among the community health extention workers(CHEWs) involved in the treatment of tuberculosis. These workers use the above mentioned treatment regimen to treat TB patients.
According to FMOH (2008) and (2010), TB patients are persons with proven tuberculosis or with symptoms and signs suggestive of tuberculosis especially cough lasting for 2 weeks or more in Pulmonary tuberculosis. TBCTA (2006) explaining TB as a disease, submitted that a balanced approach emphasized both individual patient care and public health principles of disease control are essential to reduce the suffering and economic losses from tuberculosis. Again, TB as a disease is curable provided patients are detected early and treated promptly with the appropriate treatment regimen (FMOH, 2008).
The mode of transmission of TB is by inhalation of a droplet nuclei generated by sputum positive patients with pulmonary TB, and also by ingestion especially of contaminated milk and infected meant (Cassens, 1987, WHO, 1996, Lucas and Gilles, 2003; park, 2007). It then means that TB spreads when sputum positive patients (contagious people) cough TB bacteria out of their lungs. In this work, the level of knowledge of transmission mode among the CHEWs will be ascertained. It is important that the workers understand the basic principles of preventing this disease.
TB can be prevented if appropriate measures are taken. According to WHO (1996) and, Lucas and Gilles, (2003) the preventive measures against TB are effective treatment, environmental control through good or adequate ventilation, educating patients to cover their mouths while coughing, BCG immunization, and six months course of preventive treatment with daily isoniazid. The risk of TB infection transmission from TB suspects and patients is there in TB treatment centres especially among those providing care for people affected by TB. It is equally important to find out through this work the extent the care providers involved in this TB work know about the preventive measures. The CHEWs providing the care for TB patients are in categories.
There are two categories of CHEWs namely senior and junior CHEWs. A senior CHEW (SCHEW) has the responsibility of supervising the junior CHEW, the community health extension workers in training, the volunteer village health workers and traditional birth attendant, while the junior CHEW takes directives from the SCHEW ( FMOH, 2006). In this study, a CHEW who has worked in TB unit for more than five years is assumed to have enough experience while a CHEW who has worked for less than five years in TB unit is assumed to have no sufficient experience. There is need that knowledge of this disease especially among these CHEWs involved in its management is ascertained.
Knowledge, according to Rambo (1984), is an understanding of a subject matter. Hornby (2001) submitted that it is information, understanding and skills that one gains through education or experience. In this study, knowledge is defined as information, understanding and skills that one (this time, CHEW) gains through education or experience. It equally means ideas or facts and abilities a community health extension worker acquires about tuberculosis while doing the job (experience) or through formal training (education). The knowledge of tuberculosis among community health extension workers is very relevant. This is because these groups of workers in health care programme are at the grass root, hence, most accessible government health care providers to members of a community. The knowledge of tuberculosis among this group of health workers will determine to some extent the success of tuberculosis control. Knowledge at times affects attitudes.
Attitude is an expression of how much we like or dislike various things.(Longman, 2006). Attitude in this study is therefore defined as expression of how much we like or dislike different items or objects. This simply means that attitude represents our evaluations towards a wide variety of attitude objects, and this evaluation can either be positive or negative. In which case, those objects towards which we have positive attitude we generally seek out, while those objects towards which we have negative attitude, we typically shun. This definition is relevant to this study judging from the fact that the health workers may have positive or negative attitude to tuberculosis depending on their evaluations.
Community health extension workers, according to FMOH (2006), is a member of the health team for Primary Health Care (PHC), who spends 50% of his time on community based function and 50% in the clinic. Health Resources and Services Administration, HRSA (2001) in her own opinion asserted that community health extension worker is a lay member of a community who work either for pay or as a volunteer in the association with local health system in both urban and rural, and usually shares ethnicity, language, socio-economic status with the community members where he or she serves. In this study, community health extension worker is a member of the health team based at a local or community level who renders both medical and social services to the members of the community voluntarily or by employment of local health care system.
TB, though one of the communicable diseases in the world has a public health implication as many findings indicate hence the need to control it. Park (2007) stated that about 1.7 million people (27 per 100,00) died from tuberculosis in the year 2004. According to the author, TB kills more adults than any other infectious disease and that eight out of ten of all those struck by it are in economically productive age group of 16-49 years. Tuberculosis transmission occurs by airborne spread of infectious droplets from a person with TB of the lung who is coughing. In other words, it is possible to get the disease through inhalation of droplet nuclei. However, the good thing about this disease is that it is controllable and curable too, if adequate mechanism is put in place. Good knowledge of and attitude to tuberculosis among health workers involved in the TB management are some of the mechanisms to be put in place to control the spread of the disease. The aim of short-course chemotherapy in health intervention or treatment of TB is to achieve global targets of 85 per cent cure rate and 70 per cent case detection rate respectively. The success of the intervention or treatment of TB has to start with efficient health care services which can be achieved by providing health workers who have good knowledge of and attitude to tuberculosis especially in treatment regimen as stated earlier. This health intervention or treatment of TB requiring efficient health care services is equally needed in Abia State.
This study was carried out in Abia state of Nigeria. Abia State is one of the states in Nigeria involved in tuberculosis control programme. According to State Ministry of Health, SMOH (2007) Abia State has a population of 3.3 million people in 2004 with annual growth of 3 per cent and a total area of 5803.36 square kilometers and is bounded by the following states; Anambra, Enugu, Ebonyi, Akwa Ibom, Cross River, and Rivers States to the north and north east and south-east, having also a total of seventeen (17) local government areas. Abia State embarked on control of many communicable diseases including TB.
