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THE NON-COMPLIANCE TO TUBERCULOSIS TREATMENT AMONG PATIENTS SUFFERING TUBERCULOSIS

CHAPTER ONE

INTRODUCTION

1.1     Background of the Study

Tuberculosis is an air-borne infectious disease caused by bacteria of the genus Mycobacterium. Tuberculosis often called TB primarily affects the lungs causing what is referred to as pulmonary tuberculosis (PTB). It can also affect other parts of the body apart from the lungs leading to what is referred to as extra-pulmonary tuberculosis (EPTB). Extensive dissemination of the tubercle bacilli via the blood stream and lymphatic system leads to military tuberculosis. The World Health Organization declared Tuberculosis a global emergency in 1993 and it remains one of the world’s major causes of illness and death. TB is both preventable and curable. One third of the world’s population (two billion people) carry the TB bacteria. More than nine million of these become sick each year with active TB that can be spread to others.

Latent TB disease cannot be spread. TB disproportionately affects people in resource-poor settings, particularly in Africa and Asia. It poses a significant challenge to developing economies as it primarily affects people during their most productive years. More than 90% of new TB cases and deaths occur in developing countries. In Nigeria it is one of the diseases for routine notification to the Federal Ministry of Health via the Integrated Disease Surveillance and Response mechanism. Both diagnosis and treatment are free, the WHO, government and donor agencies finance the services. The global fund to fight Aids, Tuberculosis and malaria (GFATM) is an organ of the WHO that support TB control programs.

TB is one of the top ten leading causes of hospital admissions and one of the leading causes of morbidity and mortality in adults. TB is a disease associated with poverty and invariably occurs among the urban slum dwellers where there is often over-crowding. The fact that TB is a serious public health problem in Nigeria cannot be over emphasized.

Before 2012, the exact burden of TB in Nigeria was not known, the WHO in 2007 estimated the incidence rate for all forms of TB at 311 per 100,000 population, incidence of smear positive pulmonary tuberculosis at 131 per 100,000 population, and prevalence at 546 per 100,000 population (WHO report, 2009). These figures place Nigeria 4th among the 22 high burden countries in the world and second in Africa. (Federal Ministry of Health, 2015)

However, WHO report for 2012 estimates show that Nigeria is still one of the 22 countries that contribute 80% of the global Tuberculosis burden, but the estimated incidence and prevalence of Tuberculosis for the country stands at 108/100,000 and 161/100,000 populations respectively. (WHO, 2012). The NTBLCP conducted a national TB prevalence survey in the country between March and November 2012. Estimated adult TB prevalence rates per 100,000 population based on findings from the national prevalence survey is 318 (95% CI, 225-412) smear positive and 524 (95% CI, 378-670) bacteriologically confirmed (smear positive and/or culture positive) cases.

According to the survey report, the highest prevalence of TB cases appears among males and when disaggregated by age, individuals (both males and females) aged 35-54 years have the highest prevalence. Children < 15 years were not included in the survey. Quoting from the survey report, the prevalence of smear-positive TB among men is higher (484, 95% CI: 333-635) than in females (198, 95% CI: 108-289). A similar situation was found in the bacteriologically positive cases, with 751 (95% CI: 538-965) and 359 (95% CI:213-505) per 100,000 males and females respectively.

When survey report became available early 2014, the reported prevalence of 524 (95% CI, 378-670) cases per 100,000 population was found to be far higher than the earlier estimated prevalence for 2012 put at 161 per 100,000 population (WHO, 2013). With estimated population of 174 million in 2013, TB prevalence in absolute numbers was 570, 000 (includes HIV+TB) cases (430,000-730,000) and incidence was 590,000 (340,000-880,000) cases.

In 2013, the estimated incidence and prevalence of Tuberculosis for the country was 338/100,000 (194-506) and 326/100,000 (246-418) populations respectively. These estimates changed when the survey reports were published early 2014. Multi-drug resistance (MDR) According to WHO global TB report, there was an estimated 3.5% (95% C.I.: 2.2-4.7%) of new cases and 20.5% (95% C.I.: 13.6-27.5%) of previously treated cases with MDRTB worldwide in 2013. For Nigeria, the WHO estimated MDRTB prevalence of 3.1% and 10.1% among new and retreatment cases respectively in 2012 (WHO, 2010).

Based on report of the first national drug resistant TB prevalence survey conducted in Nigeria by the FMoH/NTP between October 2009 and November 2010, there was a prevalence of 2.9% {weighted (95% CI: 2.1 – 4.0%)} among new smear positive TB cases and 14.3% (95% CI: 10.2 – 19.3%) among retreatment smear positive TB cases. The report of the survey was published late 2012.

Among all TB cases, the global average of isoniazid resistance without concurrent rifampicin resistance was 9.5% (95%CI: 8.0–11.0%) in 2013. In new and previously treated TB cases respectively, the global averages were 8.1% (95%CI: 6.5–9.7%) and 14% (95%CI: 11.6–16.3%) (WHO, 2010). In the Nigerian survey report, any resistance to Isoniazid (not considering concomitant resistance to Rifampicin or to any other drug) was found among all cases(generally) in 139 (9.6%; 95% CI: 8.1 – 11.3% of) respondents tested by Line Probe Assay. Stratified by treatment category there were a prevalence rate of 7.2% (95% CI: 6.0 – 8.8%) among new TB cases and 20.0% (95% CI: 15.2 – 25.6%) among retreatment TB cases (Federal Ministry of Health, 2013).

Any resistance to Rifampicin (not considering concomitant resistance to Isoniazid or to any other drug) was found in 115 (7.9%; 95% CI: 6.6 – 9.5%) among all cases (generally) tested by Line Probe Assay. Stratified by treatment category there were a prevalence rate of 4.4% (95% CI: 3.4 – 5.6%) among new TB cases and 24.9% (95% CI: 19.6 – 30.9%) among retreatment TB cases (Federal Ministry of Health, 2013).

Statement of the Problem

The treatment of tuberculosis requires the use of multiple drug combinations to minimize the development of drug resistance. Multi-drug-resistant Mycobacterium tuberculosis (MDRTB) strains, defined as strains resistant to at least Rifampicin (RIF) and Isoniazid (INH), are emerging as major global public health problem. WHO estimated MDRTB rate of 3.1% among new cases and 10% among re-treatment cases in Nigeria as at 2011. (WHO Report, 2012). The emergence of HIV/AIDS has increased the incidence of TB worldwide and made both clinical management and laboratory diagnosis more complicated and difficult. Majority of victims are people of reproductive age bracket and this has devastating impact on the economy of Nigeria. Young men and women who ought to be contributing to the growth of the economy is instead a burden on the economy. The national DR-TB survey also confirms the known fact that TB disease is prevalent among the economically active age group. In that survey, these groups encompass about 70% of the respondents.

1.3       Objectives of the Study

The main objective of this study is to assess the factors that influences non-compliance to tuberculosis treatment among patients suffering from tuberculosis. Specific objectives include;

i.  To determine factors influencing non-compliance to tuberculosis treatment among patients suffering from tuberculosis.

ii.  To determine impact of non-compliance to tuberculosis treatment on patients suffering from tuberculosis.

iii.  To find out challenges facing the TB control in Usiomu, Eku, Delta state.

1.4       Research Questions

1.  What are the factors influencing non-compliance to tuberculosis treatment among patients suffering from tuberculosis?

2.  Is there a significant impact of non-compliance to tuberculosis treatment on patients suffering from tuberculosis?

3.  What are the challenges facing the TB Control Program in Usiomu, Eku, Delta state?

1.5       Research Hypotheses

Hypothesis I

H0: There are no significant factors influencing non-compliance to tuberculosis treatment among patients suffering from tuberculosis.

Hi: There are significant factors influencing non-compliance to tuberculosis treatment among patients suffering from tuberculosis.

Hypothesis II

H0: There is no significant impact of non-compliance to tuberculosis treatment on patients suffering from tuberculosis.

Hi: There a significant impact of non-compliance to tuberculosis treatment on patients suffering from tuberculosis.

1.6       Significance of the Study

This study will be of immense benefit to other researchers who intend to know more on this study and can also be used by non-researchers to build more on their research work. This study contributes to knowledge and could serve as a guide for other study.

1.7     Scope of the Study

This study is on assessing the factors that influence non-compliance to TB among patients suffering from Tuberculosis in Usiomu Eku Delta State. The research study will cover the entire patients of General Hospitals Usiomu. All departments of the hospital will be sampled in the collection of data for the study. The study will cover a fair balance of male and female patients of the hospitals.

1.8     Limitations of the study

The demanding schedule of respondents made it very difficult getting the respondents to participate in the survey. As a result, retrieving copies of questionnaire in timely fashion was very challenging. Also, the researcher is a student and therefore has limited time as well as resources in covering extensive literature available in conducting this research. Information provided by the researcher may not hold true for all research under this study but is restricted to the selected respondents used as a study in this research especially in the locality where this study is being conducted. Finally, the researcher is restricted only to the evidence provided by the participants in the research and therefore cannot determine the reliability and accuracy of the information provided. Other limitations include;

Financial constraint: Insufficient fund tends to impede the efficiency of the researcher in sourcing for the relevant materials, literature or information and in the process of data collection (internet, questionnaire and interview).

Time constraint: The researcher will simultaneously engage in this study with other academic work. This consequently will cut down on the time devoted for the research work.

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