Mobilization of Cured Patients to Improve TB Control Programme in Sarlahi District of Nepal

Mobilization of cured patients to improve TB control programme in Sarlahi district of Nepal

By: Raj Nandan Mandal (Master of Public Health) Principal Investigator

Submitted to : Nepal Health Research Council (NHRC) Ramshah Path, P.O. Box: 7626 Kathmandu, Nepal 2007

TABLE OF CONTENTS

Acknowledgement ……………………………………………………………… i Executive Summary……………………………………………………………… ii List of Tables ………………………………………………………………….... iii List of Figures ………………………………………………………………….. iv Abbreviations …………………………………………………………………… v CHAPTER I: INTRODUCTION 1.1 Background of the study ……………………………………………………. 1 1.2 Statement of the problem ………………………………………………… . 2 1.3 Rationale/Justification……………………………………………………… 3 1.4 Research Questions………………………………………………………… 4 CHAPTER II: LITERATURE REVIEW………………………………………. 5 CHAPTER III: METHODOLOGY 3.1 Objective of the study………………………………………………………. 8 3.2 Research hypotheses………………………………………………………... 8 3.3 Research design and methodology…………………………………………… 8 3.4 Study variables ……………………………………………………………… 9 3.5 Conceptual framework…………………………... …………………………. 11 3.6 Selection of cured patients…………………………………………………… 12 3.7 Study site & its justification………………………………………………… 12 3.8 Target Population…………………………………………………………… 12 3.9 sampling Method & Sample Size…………………………………………… 12 3.10 Tools & techniques for data collection…………………………………….. 13 3.11 Validity and Reliability of research………………………………………… 14 3.12 Limitation of the study…………………………………………………….. 14 CHAPTER IV: FINDINGS AND ANALYSES………………………………… 15 CHAPTER V: DISCUSSIONCONCLUSIONS AND RECOMMENDATIONS 35 REFERENCES…………………………………………………………………… 39 ANNEXES ACKNOWLEDGEMENT

I am extremely grateful to all those who have encouraged and supported me to make this thesis become a reality.

First of all I would like to thank NHRC for providing me research grant. Special thanks to Dr. Rajendra Kumar B.C. (Chief Research Officer, NHRC), Mr. Nirbhay Kumar Sharma (Administrative Officer, NHRC), Mr. Subodh Kumar Karn (Account Officer, NHRC), Mr Chandra Bhushan Yaday (Library Incharge, NHRC) and all other staffs of NHRC for their inspiration, cooperation, guidance and support along the way of beginning to end.

At the DPHO Sarlahi, I would like to express my gratitude to Mr. Raj Kishor Pandit-PHA, Md. N.A. Mikrani –DTLA, Mr. Pramod Pandit- A.H.W., Mr. Nageswor Prasad Jaiswal- Public Health Inspector and Rajbir Yadav DTLA for their assistance and support during the period of study.

I would like to thank all data collectors and supervisors for their hard workings and continuous support to me. I will never forget the respondents who respond me to give answer to questions, without thei willingness to answer on questions, this study would not have been accomplished.

And finally, my appreciation to the cured patients who have helped to make people aware and work hard during six months of intervention period.

Raj nandan Mandal Principal Investigator

I EXECUTIVE SUMMARY

The objectives of this study was to find the effect on CFR, CR, SCR and DR after the mobilization of cured patients and it was conducted in randomly selected Sarlahi district of Central region Nepal.

Twelve DOTS centers/Sub centers were randomly selected for intervention and other twelve DOTS centers/Sub centers were selected for control sites. Ten household of the each DOTS center were interviewed to know the knowledge on TB and DOTS and their perception disease. Data was collected using interviews, FGDs, In-depth interviews as well as reviewing the records from the DOTS Centers. Data Collection took place from in Oct. 2006 and in Apr. 2007.

Mobilization of the cured patients was effective in increasing CFR, CR and SCR and in decreasing DR in comparison with control sites. Most of the respondents were illiterate (40.4 %) and 34.2 % were involved in agriculture. On average they had 8 family members and immunized children were 88.8 %.

Ninety three percent of the respondents had heard TB and nearly 2/3rd of them knew it`s symptoms. Fifty nine percent were known to cause and hundred percent of them were known to main mode of transmission. Nearly 3/4 th of them (72.3 %) thought TB is curable and 92 % thought appropriate place for treatment was government health institutions. Seventy two percent knew it’s preventive measures. Thirty eight percent of them got information from neighbors and 85 % knew that TB is communicable disease.

More than half of the respondents (58 %) had heard DOTS and all knew that DOTS can completely cure disease. Almost all cases had been diagnosed by Sputum test and X-ray and most of them were diagnosed in private clinics. Nearly 39 percent knew the treatment course schedule and almost all (97.3 %) knew that medicines were available free of cost in government health institutions. II Similar findings were got from Focus Group Discussions and almost similar results from In-depth interviews. From In-depth interviews they were found very much eager to help to improve TB control program in the rural community and they were found well known to DOTS.

III LIST OF TABLES

Table.1: CFR, CR, SCR and DR of 12 intervention sites before and after intervention..16 Table.2: Difference of Mean, Standard Deviation and `t` value of CFR, CR, SCR and DR of intervention sites…………………………………………………………… 16 Table.3: CFR, CR, SCR and DR of 12 non-intervention sites without intervention….. 17 Table.4: Difference of Mean, Standard Deviation and `t` value of CFR, CR, SCR and DR of non-intervention sites without intervention……………………………….. 17 Table.5: Socio-demographic characteristics of the respondents……………………… 18 Table.6: Tuberculosis related informations…………………………………………… 20 Table.7: DOTS related informations………………………………………………… 22

LIST OF FIGURES

Figure.1: Respondents distribution by their known to TB…………………………..23 Figure.2: Respondents distribution by their knowledge on causes of TB………….. 24 Figure.3: Distribution of respondents by their knowledge on curability of TB……..24 Figure.4: Distribution of respondents by their knowledge on treatment course……. 25 Figure.5: Distribution of respondents by their knowledge on DOTS………………. 25 Figure.6: Distribution of respondents by their knowledge on treatment outcomes… 26 Figure.7: Distribution of respondents by their knowledge on problems having TB... 26 Figure.8: Association between literacy status and knowledge on cause of TB…….. 27 Figure.9: Association between literacy status and known to TB…………………… 27 Figure.10: Association between literacy status and DOTS knowledge…………….. 28

ABBREVIATIONS

AIDS Acquired Immuno Deficiency Syndrome CBS Central Bureau of Statistics CFR Case Finding Rate CR Cure Rate DOTS Directly Observed Treatment Short Course DR Defaulter Rate FCHVs Female Community Health Volunteers HIV Human Immunodefiency Virus PHC Primary health Care Center SCR Sputum conversion Rate TB Tuberculosis TOT Training of Trainers VDC Village Development Committee WHO World Health organization

VII ACKNOWLEDGEMENT

I am extremely grateful to all those who have encouraged and supported me to make this thesis become a reality.

And finally, my appreciation to the cured patients who have helped to make people aware and work hard during six months of intervention period.

Raj nandan Mandal Principal Investigator

i EXECUTIVE SUMMARY

The objectives of this study was to find the effect on CFR, CR, SCR and DR after the mobilization of cured patients and it was conducted in randomly selected Sarlahi district of Central region Nepal.

ii Similar findings were got from Focus Group Discussions and almost similar results from In-depth interviews. From In-depth interviews they were found very much eager to help to improve TB control program in the rural community and they were found well known to DOTS.

iii LIST OF TABLES

iv LIST OF FIGURES

v ABBREVIATIONS

vi CHAPTER I INTRODUCTION

1.1 Background of the study

Tuberculosis: Tuberculosis, the worlds` one of the most serious public health problem, is an infectious bacterial disease caused by Mycobacterium tuberculosis. It is the most common cause of death due to single organism among persons over 5 years of age in developing countries and 80 % of deaths due to tuberculosis occur in young to middle age men and women. There are about 16 million people living with active tuberculosis, every year 8 million new cases appeared and 2 million deaths occur due to tuberculosis in the world. It has the greatest impact on youth and adults of age group 15 to 59 years and is the most common cause of death among adults. Considering the problem, World Health Organization (WHO) declared tuberculosis as a global emergency in 1993. Nepal is not the exception to this global health problem. About 45 % of the total population is infected with tuberculosis, out of which 60 % is of productive age group (15-49). Every year, approximately 44,000 people develop active TB, among them approximately 20,000 have infectious (smear) positive cases and they are able to spread the disease to others. Directly Observed Treatment Short Course (DOTS) strategy has been adopted in 1995 and implemented since 1996. It has already reduced the number of deaths, however 6,000-7,000 people continue to die every year from this disease. Expansion of this cost effective and highly successful treatment strategy of DOTS, which already has proven its efficacy in Nepal, will have a profound impact on mortality and morbidity. By achieving the global target of diagnosing 70% of new infectious cases and curing 85% of these patients we will save up to 50,000 deaths over the next five years. High cure rate will reduce the transmission of TB and lead to a decline in the incidence of this disease, which will ultimately help us to achieve our objectives of TB control.

1 Study Area :

Sarlahi is one of the Terai district of Central Development Region having the population 635,701. Population growth rate of the district is 2.55%. Total household in the district are 111,076 and average household size in the district is 5.72. The literacy rate of district is 42.13% (male 51.2% and female 33.06%). District headquarter of the district is Malangwa. It has six constitutions and seventeen political ilakas. There are 1 municipality and 99 VDCs. Total area of the district is 1259 sq.km. (CBS 2001). There are 1 district hospital, 1 nursing home, 5 PHC, 10 HP and 84 sub health posts in Sarlahi district. In Sarlahi district DOTS strategy has been implemented since 1998. According to the strategy there are 16 treatment centers and 85 treatment sub centers established and functioning to provide the DOTS (TB) services in the district. On the basis of cohort analysis report 2061/62 of the district (Annual) the Case Finding Rate is 86 %, Sputum Conversion Rate is 82 % and Cure Rate is 85 % (2060/61). The 1 st quarter report of 2062/63 is : CFR 72 %, CR 85 %, DR 3 % and 469 Cases registered by treatment category from 2063 shrawan to 063 Kartik.

1.2 Statement of the Problem

WHO has declared tuberculosis as a global emergency and main stress has been given to improve Case Finding and Cure Rate. Ninety five percent of tuberculosis patients are the inhabitant of developing countries so these countries are main sufferer of the burden of tuberculosis. Tuberculosis is the leading cause of adult death in Nepal. It kills thousands of people in a year but most of the deaths are preventable. Therefore, tuberculosis is a growing problem in Nepal and Case Detection Rate is largely limited by pre-existing social and cultural determinants of patients behavior in tuberculosis. A large number of patients with tuberculosis are inclined to hide that they are suffering from Tuberculosis. Hence, social stigma as well as awareness level, peoples' status, interrelation of society’s members, cultural aspects and community participation plays an important role in the acceptance of disease and adherence to its treatment. These issues also increase the Defaulter Rate. Only epidemiological and clinical aspect of

2 treatment will not be enough to deal with disease. The problem should be viewed in socio-cultural aspect as well. The success of DOTS strategy depends on the changing attitude and behavior toward treatment. So far, we lack information on perception/attitude and awareness level of the patients towards tuberculosis and DOTS. It is assumed that in Sarlahi district CFR, CR and SCR are not satisfactory which may be attributed mainly to socio-cultural factors and due to lack of motivation and knowledge. Therefore, it needs a lot of research and study about the role of cured patients in control of TB. The present study is carried out to find the effect of mobilizing cured patients in control of TB programme.

1.3 Rationale / Justification of the study

Tuberculosis is the biggest infectious killer of youth and adult causing more than one million deaths per month. DOTS is the most effective strategy available today for tuberculosis control (Jai,1998). Population predominantly rural, prevailing superstitions, the social stigma attached to the tuberculosis and low community participation limited the betterment of treatment and control of tuberculosis. Only very limited studies have been conducted yet by focusing on mobilization of cured patients in the respective society. More over, the studies related to DOTS are concentrated mainly on clinical and epidemiological aspect. The present study on revealing the role of cured patients in increasing CFR and CR in local condition will be valuable feedback for finding the effectiveness of DOTS on tuberculosis control. Moreover, it is expected that this would be the basis for the further research works in the subject. Findings of the study could be informative reference for the policy planners and researchers. The following table show why we need research on mobilizing cured patients. Therefore it will be logical to use cured patients or their family members as a source of information to create the community awareness to increase Case Finding Rate and Cure Rate and decrease the Defaulter rate.

3 Fiscal Year CFR(%) CR(%) SCR(%) DR(%) 2058/59 124 81 76 - 2059/60 100 84 78 - 2060/61 100 85 80 - 2061/62 86 85 81 - 2062/63(1 st 72 85 86 3 quat.)

1.4 Research Questions Key Question :

How can we mobilize cured patients to increase Case Finding Rate and Cure Rate in TB? Specific Questions: 1. What roles can cured patients play to create community awareness for DOTS to community people? 2. What are the motivational factors for cured patients to disseminate information on TB ? 3. What are roles of providers and DOTS committee members and FCHVs to motivate the cured patients ? 4. what will be the changes in CFR and CR after mobilization of the cured patients ? 5. How the community people behave with TB patient in the community ?

4 CHAPTER II LITERATURE REVIEW

2.1 Tuberculosis

Tuberculosis is a chronic granulomatous disease, which is recognized as the leading cause of death among the infectious disease. It is caused by Mycobacterium tuberculosis complex which include four closely related organism Mycobacterium tuberculosis, Mycobacterium bovis, Mycobactrium africanum and Mycobacterium micoti . Despite the availability of effective chemotherapy it is still a major public health problem in most of the countries of the world. Because of the serious public health threat posed by Tuberculosis, the WHO declared it a global emergency in 1993 (Cheebrought).

2.2 History of Tuberculosis

In the past tuberculosis has been referred to as the "white plague " and by John Bunyan as "the captain of all these men of death". In ancient Hindu text ,tuberculosis is refared as rograj and Rajayakshma meaning "The king of disease." (Grange et al). Certainly, tuberculosis was well recognized by the time of Hippocrates (377-400BC), who gave an excellent clinical description of the disease called "Pthisis", a greek word which mean " to consume to spit " and " to waste away" ( Grange, 1996;miller,1982). The Dutch Physician, Franciscus Sylvius(1614-1672) deduced from autopsies that tuberculosis characterized by the formation of nodules , which he named "tuberculosis " (Lowell et al ; 1969). Robert Koch discovered the Mycobacterium tuberculosis organism in 24 march 1882 and succeeded in culturing it on inspissated serum. The transmissible nature of tuberculosis was clearly established by Jean Antoine Villemin, a French military doctor in 1868(Webb,1936;Robin ,1995).The word "tuberculosis" which means "a small lump" (Dubos et al 1952) but several names have been used to prefer to tuberculosis in the years. In the past Pulmonary tuberculosis has been refered

5 " tabes Pulmonali" . The acid fast nature of the organism was discovered by Ehrlich in 1885 ( Burke, 1995) and the present method of acid fast staining was developed by Ziehl and subsequently modified by Nielsen and hence the named Ziehl Nielsen Staining technique.

2.3 Tuberculosis as a major public health problem and its control

Accordingly to World Health Organization estimates, one- third of the world's human population has been infected by tuberculosis. An estimated 8-10 millions people developed overt tuberculosis annually as a result of primary infection. This proportion of infected persons is similar in developing and developed countries but in the former most infected persons are in productive age (15-45 years) whereas in latter most infected persons are in older age group. Thus in Nepal, for example, 60% of the infected persons are in productive age while in USA and UK very less.Tuberculosis is the cause of 7% of all deaths and in developing countries 1in 4(i.e. 25%) preventable adult deaths, even though it is among the most effective of all adult disease to treat (Murray et al., 1990)

2.4 DOTS .

DOTS (Directly Observed Treatment Short Course) are a strategy for ensuring that every patient stares treatment gets the best chance of being cured. As part of the DOTS strategy, health workers or the trained supervisors counsel and observe their patients swallowing each dose of powerful combination of medicine and health service monitors the patient progress until each is cured. Political and financial commitment and a dependable drug supply are essential parts of the DOTS strategy focuses on the cure of every TB case. Good TB control, which cures patients proven successful in preventing drug resistant in many countries. DOTS are not simply watching a patient take their drugs but it also involves providing motivation, encouragement and follow- ups to the patient. DOTS are also not the solution of poor compliance, but it must include package of activities that will help patients to complete their treatment. Above

6 all DOTS is not easy, it requires a commitment from health workers, patients and community. It is a way of providing the necessary support to the patient that will enable them to complete a full course of treatment. Without such support cure rates will be low and TB control will be not achievable. In Nepal, four pilot sites stated implementing DOTS in 1996 with an expansion to further treatment centers undertaking following the excellent results at the pilot sites .So far there are 111 dots treatment centers in the country. Cure rates in cases treated in 1997/98 at DOTS centers were 86%. Further expansion of DOTS is planned for the year 2000 with the target of covering the whole country. DOTS is the most effective strategies available today for tuberculosis control. It has been suggested that DOTS works better in the certain situation of countries, perhaps not level of public administration, population rural, Prevailing superstitions. The social stigma entailed to the tuberculosis and low community participation limited the betterment of treatment and control of tuberculosis. Only very limited studies have been deduced yet by focusing DOTS and its impacts. Moreover the studies related to DOTS are concentrated mainly on clinical and epidemiological aspects. It is expected that this would be the valuable feedback for finding the effectiveness of DOTS for tuberculosis control. It will also form the basis for further research works in the subject and informative reference for the policy planners and researchers.

7 CHAPTER III METHODOLOGY

3.1Objectives General objectives :

To find the effect on CFR and CR in TB patients after the mobilization of cured patients.

Specific objectives :

1. To identify the motivating factor for satisfied cured patients to disseminate TB information in community. 2. To define the role of satisfied cured patients to create community awareness on TB/DOTS in the community. 3. To identify the support needed by service providers, DOTS committee and FCHVs to motivate the satisfied cured patients to raise the community awareness. 4. To find out the changes in CFR, SCR, CR & DR after the mobilization of satisfied cured patients. 5. To find out the reaction/perception of community people with the TB patients in the society.

3.2. Research Hypotheses The null hypotheses in the present study were stated in the following way:

Ho 1. There is no difference in Case Finding Rate (CFR) before and after intervention. Ho 2. There is no difference in Cure Rate (CR) before and after intervention. Ho 3. There is no difference in Sputum Conversion Rate (SCR) before and after intervention. Ho 4. There is no difference in Defaulter Rate (DR) before and after intervention.

3.3 Research Design and Methodology

Research Method The study design was pre-post comparison with control. The study was conducted in six treatment centers and three sub-centers of each treatment centers and surrounding communities in Sarlahi district. Qualitative ( ), Quantitative ( ), Combined ( √ )

8 3.4 Study Variables

Variables Indicators

1. Cured TB patients Percentage of satisfied cured TB patients having right a. Knowledge knowledge about TB Sign and symptoms Diagnostic methods Availability of drugs Follow up sputum Duration of treatment Disadvantage of irregular treatment Common side effects of Drugs b. attitude Percentage of satisfied cured TB patients having Satisfaction of service provided from HI Perception towards daily DOTS Exposure/recognition of TB patient in the society c. Practice Percentage of satisfied cured TB patients having practice of : Regularity of treatment Regular follow up sputum in time Precaution measure applied Refer suspected family members and neighbors for sputum examination. Cost of drug during treatment of TB(if any) 2. Community Percentage of community people having right knowledge a. Knowledge about TB Sign and symptoms Diagnostic methods Free sputum examination facility Availability of free drugs Duration of treatment Preventive measure About DOTS Disadvantage of irregular treatment b. attitude Percentage of community people having Satisfaction of service provided from HI Perception of TB patients Perception towards daily DOTS c. Practice Percentage of community people having practice of : Treatment of cough more than 2 weeks Precaution measure applied Refer suspected family members and neighbors for sputum examination. Cost of drug during treatment of TB(if any) 3.TB treatment outcome Case Finding Rate

9 Sputum Conversion Rate Defaulter Rate Cure Rate Death Rate Positivity Rate

The brief study design is stated in the figure :

Cured Patients DOTS

committee/HI

Pre Intervention Intervention Post Intervention

B Selection A Intervention Sites and training S for SC Prepare E action plan L Awareness I raising N activities D E Situational Analysis A (DOTS service T S outlets and community) A U R C V O E Non-Intervention Sites L Y L E C T I O N

10 3.5 Conceptual Framework:

The following figure shows the conceptual framework of the study :

Orientation training on Cured Awareness raising TB/DOTS Patients activities

Patients and individuals at households

Support from DHO, DOTS Patients and family committee members at DOTS clinic

DOTS Clinic/ Community HI people

Outcome

Visit to DOTS -CFR service outlets

-CR

-SCR

-DR

Type of study

Descriptive study ( √ ) Analytical study ( √ ) Experimental study ( )

11 3.6 Selection of cured TB patients:

Cured patients were those TB patients who were completely cured and satisfied with TB treatment as well as their family members. Cured patients were primarily mobilized for disseminating/educating community on TB/DOTS.

1. The list of the cured patients prepared with their full address from the selected treatment centers. 2. Meetings were conducted with the satisfied cured patients. 3. Group or individual interactive discussion with the satisfied cured patients. 4. The final list of motivated satisfied cured patients were prepared. 5. Formation of action group (10 to 15 persons). 6. The roles and responsibilities of action group were defined.

Trainings:

1. One day study orientation to District DOTS committee including treatment centers Incharges. 2. 2 days TOT organized for TB focal persons, DOTS committee members/health committee members (20 participants). 3. Two days orientation organized for cured patients action group and a standard protocol was provided to them. 4. Action plan prepared for implementation of intervention at community level.

3.7 Study Site:

Sarlahi district was randomly selected so Sarlahi is the programme district of the study.

3.8 Target Population:

The target population of the study were satisfied cured TB patients of 24 treatment centers/ sub-centers and households of the study area.

3.9 Sampling Methods & Sample Size:

Operational research was carried out in 24-center / sub center (six DOTS centers and 18 DOTS sub centers). 3 DOTS centers and 9 sub centers (3 sub centers per DOTS center) were intervention sites. Like wise 3 DOTS centers and 9 sub centers were

12 control sites of the study. From each site 30 households were randomly selected and one member from all the family were interviewed. Non-Probability Sampling (x) Probability Sampling ( √ ) (Specify : Study district, treatment centers, households and satisfied cured TB patients were randomly selected.)

Sample Size

For descriptive study sample size were 240. For intervention 12 DOTS Centers/ Sub centers and for control also 12 DOTS Centers/Sub centers were randomly selected. Sampling frame (if relevant) and sampling process including criteria for sample selection.

Intervention (12 sites) Control (12 sites)

3 DOTS center 3 DOTS center Randomly selected

3 Sub centers/DOTS center Randomly selected

Data collection (10 H/H randomly selected/VDCx11 VDCs and 1 Municipality) 3 Sub centers/DOTS center

2 satisfied cured patients were mobilized/VDC Data collection (10 H/H randomly (Total 24 satisfied cured selected/VDCx11 VDCs and 1

patients) Municipality)

3.10 Tools and Techniques for Data Collection

13 Data collection Instrument:

The data was collected by the following process :

Cohort report by treatment centers.

Household questionnaire.

Interview with the listed cured patients. Data collection method :

Structured, semi-structured and In-depth interview.

Documentary analysis.

Pre-testing of the Data Collection Tools

Pre testing of instruments was done in Mahendranagar VDC/PHC of Dhanusha district.

3.11 Validity and Reliability of the Research (if relevant)

Instruments were used in Nepali Language. Intervention messages were developed in local language Maithili also.

Two shot observations were done.

Pre testing of the questionnaire was done before conducting the study.

Researcher with the help of enumerators was collected data and Supervisor had monitored regularly.

Editing of data was done on the same day of data collection.

3.12 Limitations of the Study (if relevant): This study:

Did not answer the gender and ethnic perspective.

Answers given by cured patients might not be appropriate.

Had taken more time and cost than mentioned.

Could not represent co-infection like HIV/AIDS.

Tried to control biases but might be some confounders.

14 CHAPTER IV FINDINGS AND ANALYSIS

This chapter deals with the analysis and interpretation of the data obtained in terms of semi-structured questionnaire, FGDs and In depth interviews. This was obtained from 24 DOTS Centers/Sub centers in Sarlahi district.

Null Hypotheses

The first step in analysis of data is the statement of null hypothesis. According to Best, a null hypothesis is concerned with a judgment as to whether apparent differences or relationships are true differences or relationships or whether they merely result from sampling error (J. Best 1982). In the view of Bhaduri and Farrel, a null hypothesis is necessary in order to develop a decision procedure for accepting or rejecting a hypothesis (A. Bhaduri and M. Farrel 1981). The null hypotheses in the present study were stated in the following way: Ho1. There is no difference in Case Finding Rate (CFR) before and after intervention. Ho2. There is no difference in Cure Rate (CR) before and after intervention. Ho3. There is no difference in Sputum Conversion Rate (SCR) before and after intervention. Ho4. There is no difference in Defaulter Rate (DR) before and after intervention. According to Best, the rejection or acceptance of a null hypothesis is based upon some level of significance as a criterion. He further says that .01 level of significance is often used as a standard for rejecting or accepting a hypothesis. So the level for accepting or rejecting the null hypothesis was set up .05 level. (i.e. 5 % level of significance)

To test the hypothesis “t” test was selected.

Since it was paired sample, quantitative data and normal distribution paired t test was used and the formula was t= d SD √n

15 Table1: CFR, CR, SCR and DR of 12 intervention sites before and after intervention

CFR (%) CR (%) SCR (%) DR (%) DOTS S. Bef. Aft. Bef. Aft. Bef. Aft. Bef. Aft. Centers/Sub N. Inter Inter Inter Interv Inter Inter Interv Interv centers vention vention ventio ention vention ventio ention ention 1 Salempur 22.5 25 75 79 81 80 4.2 4 2 Sundarpur 36 39.42 73 74 66 72 4 3.9 3 Malangwa 40 33.33 84 80 60 60 3.4 3.2 4 Fulparasi 31 34 69 76 71 76 4 3.5 5 Kaudena 36 40 68 68 82 87 3.4 3.4 6 Sisautiya 32 25 48 50 96 100 4 3.8 7 Barhathwa 55 66.66 85 91 80 82 3.2 3 8 Musaili 40 46 72 78 70 75 3.8 4 9 Simra 32 37.5 76 83 95 100 3.3 3.1 10 Batraul 32 38 75.5 79 66 68 3.7 4 11 Godaita 42.5 43.5 68 69 70 71 4.1 3.9 12 Sakraul 33.5 40 66 68 62 65 4.3 3.8

Table 2: Difference of Mean, Standard Deviation and `t` value of CFR, CR, SCR and DR of intervention sites.

Tests Mean of Std. deviation `t` value Table value of Null differences `t` at .05 level Hypotheses CFR 4.13 5.44 2.62 2.20 Rejected CR 2.96 3.29 3.11 2.20 Rejected SCR 3.08 2.27 4.69 2.20 Rejected DR 1.8 1.67 3.73 2.20 Rejected

The difference of mean in CFR was 4.13 and it’s std. deviation was 5.44. Similarly difference of mean of CR was 2.96 and std. deviation was 3.29 and that of SCR was 3.08 and std. deviation 2.27. The result of the `t` tests on CFR, CR, SCR and DR of the 12 intervention areas showed a significant difference between the outcomes of pre intervention and post intervention. It proves that intervention was effective so the null hypotheses of there is no difference in Case Finding Rate (CFR), Cure Rate (CR), Sputum Conversion Rate (SCR) Defaulter Rate (DR) before and after intervention are rejected at 95 % CI level.

16 Table.3: CFR, CR, SCR and DR of 12 non-intervention sites without intervention.

DOTS CFR (%) CR (%) SCR (%) DR (%) S. Centers/Sub Bef. Aft. Bef. Aft. Bef. Aft. Bef. Aft. N. centers Study Study Study Study Study Study Study Study 1 Ramban 22 21 70 72 82 80 3.5 3.6 2 Grahiya 28 27 72 71 69 72 3.6 3.6 3 Sangrampur 44 47 79 75 70 70 3.7 3.9 4 Parsa 30 29 72 71 68 70 3.4 3.2 5 Haripurwa 32 33 69 70 79 75 3.3 3.4 6 Kabilasi 34 31 64 65 94 94 3.4 3.6 7 Belhi 58 59 88 84 87 84 4 3.8 8 Sahodwa 38 37 70 67 74 72 3.9 4 9 Jamuniya 30 31 79 79 90 89 4 4.2 10 Pipariya 37 38 89 86 72 71 3.5 3.7 11 Sukhchaina 40 38 74 73 76 73 3.6 3.7 12 Chhatauna 38 41 71 71 65 68 3.9 3.6

Table.4: Difference of Mean, Standard Deviation and `t` value of CFR, CR, SCR and DR of non-intervention sites without intervention.

Tests Mean of Std. deviation `t` value Table value Null differences of `t` at .05 Hypotheses level CFR 0.083 1.88 0.15 2.20 Accepted CR -1.08 1.89 -1.98 2.20 Accepted SCR -0.66 2.35 -.97 2.20 Accepted DR .0083 .1919 .1498 2.20 Accepted

The difference of mean in CFR was 0.083 and it`s std. deviation was 1.88. Similarly difference of mean of CR was -1.08 and std. deviation was 1.89 and that of SCR was -0.66 and std. deviation 2.35. The result of the `t` tests on CFR, CR, SCR and DR of the 12 non- intervention areas did not show a significant difference between the outcomes without intervention, so the null hypotheses of there is no difference in Case Finding Rate (CFR), Cure Rate (CR), Sputum Conversion Rate (SCR) Defaulter Rate (DR) before and after intervention are accepted at 95 % CI level.

17 Organization of data

The data for analysis and interpretation was organized in the following manner: - Profile of respondents - TB related informations - DOTS related informations - Findings from FGDs - Findings from In-depth interviews

A. Profile of the respondents

The age of respondents ranged from 15 to 54 years. The majority belonged to the age group 25-30 years. Table 1 presents the age distribution of the teachers.

Table.5: Socio-demographic characteristics of the respondents:

Age of the respondents (n=240) Frequency % 20-29 83 34.6 30-39 123 51.3 40-49 26 10.8 Above 50 8 3.3 Sex of the respondents Male 173 72.1 Female 67 27.9 Total no. of family members Having 4 family members 28 11.7 Having 5 family members 27 11.3 Having 6 family members 30 12.5 Having 7 family members 56 23.3 Having 8 family members 73 30.4 Having 9 family members 13 5.4 Having 10 family members 13 5.4

Caste of respondents Brahmin 28 11.7

18 Yadav 88 36.7 Kuswaha 29 12.1 Mandal 26 10.8 Dalits 41 17.1 Others 28 11.7 Literacy of the respondents Illeterate 97 40.4 Literate 60 25 Class 1-4 13 5.4 Class 5-10 29 12.1 Higher secondary 41 17.1 Occupation of the respondents Agriculture 82 34.2 Service 28 11.7 Business 42 17.5 Housewife 54 22.5 Dailywage labour 34 14.2 Marrital status of the respondents Married 211 87.9 Unmarried 29 12.1 Number of infants Having infant 136 56.7 Not having infant 104 43.3 No. of immunized children Immunized 213 88.8 Non-immunized 27 11.3

From the above table it is found that more than half (51.3 %) of the respondents were in age group 30-39 years followed by 34.6 % in 20-29 years. Nearly three quarter were men and nearly 1/3 rd had 8 family members followed by 23.3 % having 7 family members.

Majority (36.7 %) were from Yadav community followed by dalits 17.1 % and kuswaha 12.1 %. Majority of the respondents (40.4 %) were found totally illiterate while 25 % were literate and only 17.1 % had got higher education. More than 1/3 rd (34.2 %) were involved in agriculture, 17.5 % were doing business and almost women were housewives.

Nearly 88 % were married and 56.7 % had infant in the family during data collection. Higher majority of children (89 %) were found immunized.

B. TB related informations. Table.6: Tuberculosis related informations. Communicability of TB (n=224) Frequency % Communicable 190 84.8 Non communicable 6 2.7 Don’t know 28 12.5 Mode of Transmission (n=190) By coughing/Sneezing 190 100 Sitting Together 150 78.9 Eating Together 126 66.3 * Multiple response Sources of information (n=224) Radio/TV 44 19.6 Health Personnel 77 34.4 Magzines/Poster/Pamphlet 13 5.8 Peer 4 1.8 Neighbors 85 37.9 Other 1 .4 Main symptoms of TB (n=224) Chronic Cough 168 75 Eveningrise Fever 159 71

20 Hemoptysis 224 100 Chest pain 97 43.3 Anorexia/Loss of Weight 84 37.5 Weakness 162 72.3 * Multiple response Proper place for TB treatment (n=224) Government Health Institutions 190 84.8 Dhami Jhankri 0 0 Private Clinics 6 2.7 Medical Shops 28 12.5 Availability of medicines (n=224) Available 218 97.3 Not available 0 0 Don’t know 6 2.7 Cost of TB medicines in health institutions (n=224) Free of cost 224 100 To buy 0 0 Preventive measures of TB (n=224) Immediate health check up on suspicion 125 55.8 Covering mouth during sneezing/coughing 37 16.5 Don`t know 62 27.7 Action taken for chronic cough Visit health institutions 221 92.1 Visit medical shops 110 45.8 Visit Private Clinics 199 82.9 Call Dhamijhankri 69 28.8 Eat domestic herbs 15 6.3 * Multiple response

21 The result of the above table shows that among them who had heard TB, more than ¾ th of the respondents knew that TB is communicable disease and 12.5 % had no ideas about communicability. Among the respondents known to TB, all of them told that TB is transmitted by coughing and sneezing (Droplet infection). A high proportion (38 %) had got information from neighbors followed by 34.4 % from health personnel and nearly 20 % by Radio/TV.

Hundred percent of the respondents explained hemoptysis as major symptom of TB, 75 % chronic cough and 71 % eveningrise fever as symptom of TB. Nearly 85 % had suggested health institution as best place for TB treatment while 12.5 % medical shops and 2.7 % private clinics. Almost all (97.3 %) of the respondents told that medicines were found in government health institutions and 100 % knew that medicines were distributed free of cost. More than half of the respondents (55.8 %) answered that when we had suspicion of TB, we had to visit health institution for health check ups while 16.5 % informed that by covering mouth during coughing and sneezing we can prevent TB from transmission. More than 92 % of the respondents visited health institutions when any family member had cough more than 15 days while 83 % were interested to visit private clinics but very few 28.8 % called Dhamijhankri for the treatment.

C. DOTS related informations Table.7: DOTS related informations. Necessity of DOTS (n = 139) Frequency % To complete cure of TB 139 100 To prevent from transmission 139 100 To prevent from being chronic 98 57.9 * Multiple response Diagnosis of TB (n= 29) By Sputum Test 29 100 X-Ray 27 93.1 Physical examination 22 75.9

22 Place of diagnosis (n= 29) Government Health Institutions 9 31 Private Clinics 20 69 Place of treatment (n= 240) Government Health Institutions 221 92.1 Private Clinics 191 79.6 Dhami Jhankri 69 28.8 Don’t know 6 2.5 * Multiple response

The above given table revealed that among them who had heard DOTS, 100 % of them told that DOTS is necessary for complete cure and to prevent from transmiossion. The respondents who had patient of TB were diagnosed by sputum test (100 %) and by X-Ray 93.1 %. For the diagnosis of TB majority (69 %) were visited private clinics while for the treatment 92 % were contacted government health institutions and only 79.6 % were contacted private clinics for the treatment.

Fig:1. Respondents distribution by their known to TB

No 7%

Yes 93%

A high proportion of the respondents (93 %) had heard TB while only 7 % were unknown to TB.

23 Fig:2. Respondents disribution by their knowledge on cause of TB 0% 0%

15% 0% Spirits Microorganisms

13% Malnutrition Wastes 59% Smoking/Alcoholism 13% Don`t know Other

More than half (59 %) of the respondents were known to cause of TB while 15 % thought that smoking/alcoholism is the main cause of TB. Thirteen percent of each were in the favor of malnutrition and wastes as the cause of TB.

Fig:3. Distribution of respondents by their knowledge on curability of TB

80 72.3 70 60 50 40 30 25

Percentage 20 10 2.7 0 Yes No Don`t know Curable

Nearly ¾ th of the respondents thought that Tb is curable while only 2.7 % told that Tb is not curable and one quarter had no idea about curability of TB.

24 Fig:4. Percentage distribution of respondents by their knowledge on treatment course

45 38.8 40 35 30.8 30.4 30 25 20 15 Percentage 10 5 0 0 0 0 0 6 months 8 months 12 18 24 Don`t Other months months months know Treatment Course

Majority (38.8 %) of the respondents were unknown to course duration of TB treatment however 30.8 % were known to course duration but 30.4 % had misinformation regarding course duration of TB treatment.

Fig:5. Percentage distribution of respondents by their knowledge on DOTS

No 42%

Yes 58%

More than half of the respondents (58 %) had heard DOTS while 42 % were unknown to DOTS strategy.

25 Fig:6. Percentage distribution of respondents by their treatment outcome

100 89.7 80 60 40

Percentage 20 6.9 3.4 0 0 Completely Relapse Death Other cured Treatment Outcomes

A high proportion (89.7 %) of the patients had been cured from DOTS while 6.9 % become relapse and 3.4 were died due to TB.

Fig:7. Percentage distribution of respondents by their problems after having TB 120

100 0 No

29.9 Yes 80 40.4 59.2 60 100 100 100 40 72.1 59.6 20 40.8

0 0 0

n s in n w r e m a e o e rd e p d n th u l . r k b b y u t O . o h b ` o r P t. n c p n o E c. e D o S M Problems after having TB in family member

This graph shows that if anybody of the family member suffer from TB then there is economic burden (100 %) in each case while physical pain explained by 72.1 % and social problems by nearly 60%.

26 Fig:8 Association between literacy status and knowledge on cause of TB

100% 95.70% 100% Know 90% Do not know 80% 70% 60% 50% 40%

Percentage 30% 20% 0% 4.30% 10% 0% Illiterate Literate Literacy Status

Literacy status of the respondents is significantly (p = <0.01) associated with knowledge on causes of Tuberculosis.

Fig:9 Association between literacy status and known to TB

120 97.9 100 86.6 80 Heard 60 Do not heard 40 Percentage 13.4 20 2.1 0 Illeterate Literate Literacy Status

Literacy status of the respondents is significantly (p = <0.01) associated with knowledge on Tuberculosis i.e. the people who are illiterate are less known to TB than literate.

27 Fig:10 Association between Literacy status and DOTS knowledge

100

60 Heard DOTS 40 Do not heard

Percentage 20

0 Illeterate Literate Literacy status

Literacy status of the respondents is significantly (p = <0.01) associated with knowledge on DOTS. Literate people were well known to word DOTS than illiterate people.

D. Findings from FGD 5.1 Work schedule for nowadays: We asked the respondents what they do nowadays. Overall, the most frequent answers were farming (Sugarcane and Wheat). Some people were involved in small business of fertilizers. From this it is clear that most of them were illiterate people depending upon agriculture. 5.2 Expenditure of leisure time: We asked the respondents how they were spending their leisure time. The respondents gave a wide range of options for spending leisure time. Majority were spending their leisure time by talking with their friends and neighbors. Some of them were enjoying by playing cards. It was also revealed during the group discussion with females that they used to sleep during daytimes as they had no work to do. 5.3 Major diseases found in the community: Respondents were asked about the common health problems found in the community. We received a wide variety of answers. Majority informed that pneumonia and diarrhea were the main health problems. From females we got Leucorrhoea as the major problem. Some

28 of them told that Skin diseases and TB were also the major problems of the community. 5.4 Heard about TB: The groups and individuals were asked about the familiarity of the TB in the community. Almost all of the respondents informed that they had heard TB from different sources. It seems that TB is familiar even among illiterate people. 5.5 Communicability of TB: The groups and individuals were asked if all of you had heard about TB then told which type of disease TB is. More than half of the respondents replied that TB is communicable disease and about 25 % were unknown about it and 20 % told TB is non communicable disease. 5.6 Mode of transmission: The persons answering TB as communicable disease were asked that how TB transmits from one person to another. Droplet infection was the main mode of transmission in the view of more than 2/3 rd of participants. About 15 % were informed that polluted air is the main cause while 10 % were in favor of drinking contaminated water. Two of them were totally unknown about mode of transmission. 5.7 Causes of TB: Respondents were asked about the cause of TB. Nearly forty percent of the respondents replied that microorganisms were the main cause of TB. About 30 % informed that smoking and alcoholism are the main cause while rest were in favor of hard labour as the main cause of the TB. 5.8 Symptoms of TB: We asked the respondents about the symptoms of TB. Majority of the respondents answered fever, cough, hemoptysis, loss of appetite and loss of weight as the major symptoms of TB. Two of them told melaena (blood in stool) is also the symptom of TB. 5.9 What will you do if somebody in your family suffers from chronic cough: We asked the respondents individually that what will you do if somebody in your family suffers from chronic cough. We got variety of answers. Majorities were in favor of health check ups in government health institutions but around 1/3 rd replied that they will visit private clinics for better treatment. It indicates that 1/3 rd people were not satisfied with health service providers.

29 5.10 Which tests and where to test: We asked the respondents about the type of tests and available places of tests for the diagnosis of TB. More than half of the respondents replied that sputum test and X-Ray are the tests available for the diagnosis of TB. About 25 % told skin test is also for TB and four people told blood test is also done for the diagnosis of TB. Among them one is unknown about tests of TB. 5.11 Cost for sputum test in government health institution: Participants were asked about the cost bearing for sputum test in government health institution. Almost all of the respondents informed that sputum test is done free of cost in government health institution. Some 3 people were never visited for any test in government health institution so they were not known about cost of test. It revealed that people were not bearing any cost for sputum test in government health institution. 5.12 Cost for medicines in government health institution: Participants were asked about the cost bearing for medicines available for the treatment of TB in government health institution. All of the respondents informed that medicines of TB is distributed free of cost in government health institution. However some of them informed that sometimes medicines were not available on time. 5.13 Duration of taking medicines for TB: We asked the respondents about the duration of taking medicines for the treatment of TB. A little over 1/3 rd of the respondents replied that they had to take medicines for 8 months to cure TB completely. About 30 % told 12 months and 20 % told 6 months. Among them five were not given any answer about the duration of TB treatment. 5.14 Do you have heard DOTS? If yes what is DOTS? The groups and individuals were asked about the meaning of DOTS. Only 1/3 rd of the respondents informed that they had heard DOTS from different sources. But more than half of the respondents were not known about DOTS. Six people were not in a position to reply anything about DOTS. It explores that DOTS is not familiar among illiterate people. Among people who had heard DOTS did not give answer completely the meaning of DOTS. Some said new and best treatment system of TB and some said regular follow ups were the key component of DOTS.

30 5.15 Concept of people on TB patients: Participants were asked about the thinking of people for the TB patients. Nearly half of the respondents answered that TB patients were taken as normal patients but about 1/3 rd participants shared their experience with us that many of rural people try to isolate them. It revealed that people’s attitude were not positive on TB patients. So they always try to keep their problems unknown to family and community. 5.16 Preventive measures for TB: We asked the respondents about the preventive measures needed for TB. More than half of the respondents thought that BCG vaccination in childhood is the best preventive measure for TB. Similarly covering mouth during sneezing and coughing is the other important preventive measure for the prevention of TB. Some argued that avoiding crowd can also prevent TB transmission. Among them two were unknown about the mode of transmission of TB. So they could not suggest any preventive measure for TB. 5.17 Role of cured patients to make people aware in the community: The groups and individuals were asked about the role of cured patients to make people aware in the community. The respondents gave a wide range of opinions for cured patients to make community aware. About 1/3 rd of the respondents suggested that they had to keep close watch over community people specially when somebody suffers from chronic fever and cough. Some people argued that they had to start awareness campaign in the community. Some suggested to work as social volunteer for early diagnosis and complete treatment. 5.18 What should be done for further improvement of TB control program: In the question of what should be done for further improvement of TB control program, they had suggested that the laboratory facilities should be extended up to community level. Some of them requested for regularity of service providers and regular supply of medicines.

31 E. Findings from In-depth Interviews 5.1 Work schedule of individual cured patients for nowadays: Fourteen of the twenty four cured patients told that they were involved in the managing of paddy. Some people (8) were involved in farming of potatoes, sugarcane and wheat. Two of them were involved in their small business. 5.2 Utilization of leisure time by cured patients: Majority (17) were spending their leisure time by talking with their friends and neighbors which were similar with the FGDs. Some of them (6) were enjoying by playing cards. One of them was happy to spend his leisure time with his family. 5.3 Symptoms before the diagnosis of TB: Fifteen of them informed that they had noticed chronic fever with chest pain, loss of appetite and weight. Six of them told that they had long fever, cough with hemoptysis and weakness. Three of them had suffered with irregular mild fever, weakness, lethargy and exertion dyspnoea. 5.4 Time taken for the diagnosis of TB: Eleven of them had been diagnosed after 18 days of the symptoms, five after 21 days, another five after 22 days and three after 28 days. 5.5 From where and how TB was diagnosed: Fifteen of them informed that they had been noticed from health institution by sputum tests. Nine of them told that they had been diagnosed from private clinics by chest x-ray, blood test and by montoux test. 5.6 Which places did you take treatment for TB: Fifteen of them informed that they had started health check ups and treatment from health institution and completed there. Nine of them told that they had started health check ups and treatment from private clinics then shifted to the health institution and completed there. 5.7 Duration of TB medicines: All of them had taken medicines for 8 months as they had followed DOTS strategy. They had completed course according to health service provider’s suggestion.

32 5.8 Why DOTS is necessary for the complete cure of TB: We asked the cured patients to give their opinion about the necessity of DOTS for TB treatment. Except one of the respondents, all of them told that DOTS is necessary for the complete cure of TB because in DOTS there is direct observation by health service providers. There is regular follow ups and medicines are available everywhere and at free of cost in the health institutions. One of them told that due to transportation and absence of health service providers it is exertious and time consuming. According to him we should get full course medicines at a time. 5.9 What are the disadvantages of irregularity of taking medicines: Fourteen of them informed that if medicines are not taken regularly then it can not be cured. Six of them told that relapse and defaulter would happen if medicines are not taken regularly. And rest four told that it will take more time and money than usual course. 5.10 How can TB be prevented: More than half (16) of the respondents suggested that BCG vaccination in childhood is the best preventive measure for TB. Similarly four of them argued that covering mouth during sneezing and coughing is the other important preventive measure for the prevention of TB. Three of them told that avoiding crowd can also prevent TB transmission. One of them replied that balance diet and good personal hygiene can prevent TB. 5.11 Can we prevent TB by making people aware: All of them supported this argument but they had focused on comprehensive awareness campaign especially for the illiterate people. They had suggested street drama, role play and female oriented awareness activities to make people aware about TB. 5.12 What will be the role of you people (cured patients) to make community people aware about TB: A little below half (10) of the respondents suggested that we have to play the role of social worker to make people aware regarding TB. We have to help people in timely diagnosis. Similarly nine of them argued that cured patients should be mobilized to find new case of TB. Rest five suggested to make TB control committee with the active participation of cured patients. 5. 13 Which type of role you can play in this work: Sixteen of them were ready for any type of responsibility to help TB control program. Six

33 of them told that they will help as social committee member of TB control program. Rests two were also ready to help but they had demanded some incentives for this work. 5.14 Which type of help have you expected for this work: Majority (17) of them had expected a lot from DOTS committee and also from health service providers. They had expected immediate response whenever they needed. Rest of them had expected social prestige as a leader and demanded to take part in such types of meeting. 5. 15 How community people behaved with you during your treatment: Nearly half (11) of the respondents answered that we were taken as normal patients but 1/3 rd of the cured patients (8) replied that many of rural people tried to isolate them from social fair and festivals. Rests were received warm cooperation from the community people. It revealed that some people’s attitude were not positive on TB patients. 5.16 In your opinion how can we minimize negative attitudes of people about TB: Majority (16) of them had given their view that negative attitudes of people about TB can be minimized by frequent awareness campaign in which leaders and health workers were involved. Rest of them suggested that Community people should be informed that TB is curable and can be easily prevented by using simple measures. 5.17 What should be done to make TB control program more effective: In the question of what should be done for further improvement of TB control program, half of them suggested that the cured patients should be mobilized to improve CFR, CR etc. Seven of them focused on laboratory facilities extending up to community level. Some of them (five) requested for regularity of service providers and regular supply of medicines

34 DISCUSSION

Tuberculosis is an old disease, which continues to pose major public health challenges to developing countries. Though it is possible to cure and control TB, it still affects and kills millions of people every year in developing countries. While industrialized countries managed to control TB, the picture in Asia and Africa is grim. DOTS is a strategy for ensuring that every patient who starts TB treatment gets the best chance of being cured. However it is not achieved 100 % success. So another new strategy of mobilizing cured TB patients to control TB was suggested.

In this chapter the findings of this study will be critically analyzed in relation to the objectives of study and pre-existing knowledge in this area. First, the findings from pre and post intervention will be discussed. This will be followed by the general profile discussion, TB related information’s and DOTS related information’s. Finally, the findings from FGDs and In-depth interview will be discussed.

Mobilization of the cured patients was effective in increasing CFR, CR and SCR and in decreasing DR in comparison with control sites. It has become possible due to the regular monitoring of cured patients in the community. While in non-intervention sites those rates were not improved because of lack of awareness. The study findings are not so highly significant due to Madhes Andolan and strikes of paramedics during intervention period.

More than 1/3rd of the respondents were illiterate (40.4 %) which is probably due to rural study areas and 34.2 % were involved in agriculture as it is the main earnings of the Terain people. On average they had 8 family members which is a little bit higher than the national figure (CBS 2001). Immunized children were 88.8 % which is also lower than the national immunization coverage may be due to high illiteracy and poverty.

More than 4/5th of the respondents (93 %) had heard TB as this disease is widely prevalent in the community. Nearly 2/3rd of the respondents knew one or more symptoms of TB as it is old disease and also easy to suspect. Fifty nine percent were known to cause and all of

35 them were known to mode of transmission as it is very popular in the community. Nearly 3/4th of them (72.3 %) thought TB is curable and 92 % thought appropriate place for treatment was government health institutions. It has become possible due to electronic medias and Audio Visual aids. Seventy two percent knew its preventive measures by the help of health personnel and DOTS committee. Thirty eight percent of them got information from neighbors followed by health personnel (34.4 %) and 85 % knew that TB is communicable disease. From ancient times it is thought that TB is disease of Chhut i.e. if somebody is touched with the patients then transmitted

More than half of the respondents (58 %) had heard DOTS. It might be due to the trend of talking about any disease happened in any person in the rural community. All knew that DOTS can completely cure disease and can prevent from transmission to other people. Almost all cases had been diagnosed by Sputum test and X-ray as these two test are common in TB diagnosis and also due to availability of everywhere. Most of them were diagnosed in private clinics because they thought government health institutions lab reports are not so reliable and also lacking skilled manpower. Nearly 39 percent knew the treatment course schedule and almost all (97.3 %) knew that medicines were available free of cost in government health institutions. There is a long process to get anti tubercular drugs in the government health institutions and drugs are also limited only for the card holder patients. So they thought that these drugs are available free of cost in government health institutions.

Similar findings were got from Focus Group Discussions and almost similar results from In-depth interviews. From In-depth interviews they were found very much eager to help to improve TB control program in the rural community and they were found well known to DOTS.

36 CONCLUSION

The research findings show that large number of family size and unimmunized children were very much related with social, cultural and literacy factors.

On the basis of above findings we can conclude that: 1. Mobilization of cured patients seems to be effective in increasing CFR, CR and SCR in the study area when we compare intervention sites results with non-intervention sites results. It may also be due to increase in educational status and increase in conscious level of the people. 2. Mobilization of cured patients also seems effective to control TB in Sarlahi district as it had decreased the DR. It might be associated with the success of DOTS program. 3. Mobilization of cured patients can increase awareness level on TB in the community people. 4. Some children were not found immunized which is not satisfactory. 5. Almost all respondents had heard TB but DOTS was unknown to many illiterate people. 6. Cause of TB was not known to every people which affected the use of preventive measures. 7. Laboratory service seems to be less satisfactory in government health institution so for the diagnosis many people were visiting private clinics however for the treatment they had taken medicines from the government health institutions.

37 RECOMMENDATIONS

1. Cured patients should be mobilized as social volunteer by the government to make TB control program effective. 2. Expand laboratory services to grass root level and strengthen referral system to the government hospital. 3. Enhance and expand specific activities to deal with TB through capacity building, provision of adequate and timely drugs supply in DOTS Centers and adequate number of equipments in the laboratory. 4. Skilled health manpower like VHW, FCHVs, MCHWs etc. should be mobilized more effectively to achieve 100 % vaccination. 5. Importance of taking medicines regularly should be emphasized on every visit of the patient. For this local cured patients can be mobilized to monitor his/her regularity. 6. Visiting private clinics for both diagnosis and treatment should be discouraged with the help of cured patients explaining them about the reliability and effectiveness of DOTS. 7. Employ all appropriate means to improve information, education and communication (IEC) activities, including such strategies as mass media and interpersonal health education like peer group education, health education through health facility staff at schools, and communities.

38 REFERENCES

1. Nepal Tuberculosis Center. Annual Report of Tuberculosis Control Program : Bhaktpur, Nepal; 2001/02 2. Nepal Tuberculosis Center. Tuberculosis in Nepal : Bhaktpur, Nepal; 2003 3. District Development Committee. District Profile of Sarlahi : Nepal; 2062 4. Central Bureau of Statistics. National Census 2001 : Nepal; 2001 5. District Health Office/Public Health Branch. First Quarter Report : Sarlahi, Nepal; 2062 6. SAARC Tuberculosis Center. Tuberculosis in the SAARC Region an update : Kathmandu, Nepal; 2004 7. Subedi LP, Khanal A, Sharma B, Rana P, Raut RK, Subedi IP. Socio-economic impact of DOTS Stategy in combating Tuberculosis in the Bhaktpur district of Nepal. Journal of Nepal Health Research Council 2004 : 2, (1): 43 8. Dhungana GP. Prevalence of Tuberculosis among HIV infected persons of Kathmandu . Tribhuban University Kirtipur; 2005 9. Rashid, Kabir, Hyder. Textbook of Community Medicine and Public Health. 4 th edition. Dhaka: RHM publisher; 2004 10. Park K. Park`s Textbook of Preventive and Social Medicine. 19 th Edition, India: Banarsidas Bhannott Publisher; 2006

39 ANNEXES A. Questionnaire for household survey

Namaste, we have come here to discuss about Tuberculosis problems, attitudes of community people and local efforts to cure Tuberculosis. Your valuable information will be helpful to conduct anti-tubercular programs in this area. Your information will be kept confidential. Data Collector`s Name: ….. Collection Date: ….. Supervisor`s Name: ……… Supervision Date: …. Questionnaire about knowledge, attitude and practices on Tuberculosis among community people (above 15 years old)

A. Basic Questions:

1. Guardian’s Name: ….. 2. Respondent’s Name: … 3. Address: … 4. Age:… 5. Sex: … 6. Total members in the family: …… Male: … Female: …. 7. Caste: … 8. Literacy Status of the respondents a) Illiterate b) Literate c) Primary d) Secondary e) Higher secondary 9. Occupation of the respondents a) Agriculture b) Service c) Business d) Housewife e) Daily wage Labors f) Others 10. Marital Status of the respondents a) Married b) Unmarried 11. Number of Infants in the family: … 12. Number of U5 children in the family: … Male: … Female: …. 13. Number of immunized children in the family:…. Male: … Female: …. B. Questions about Tuberculosis:

1. Do you have heard Tuberculosis (TB)? a) Yes b) No (Go to question no. 13) 2. What type of TB disease is? (Communicable/Non- Communicable) a) Communicable b) Non- Communicable c) Other d) Don’t know 3. How TB is transmitted from one person to another? (Multiple choice) a) Coughing/Sneezing b) Living together c) Eating together d) Don’t know e) Other 4. From where you have come to know about TB? a) Radio/TV b) Health worker c) Magazines/Poster/Pamphlet d) Peer e) Neighbors f) Others 5. In your opinion, what is the cause of TB? a) Spirit b) Micro-organism c) Malnutrition d) Waste e) Smoking/Alcoholism f) Don’t know g) Other 6. What are the main sign and symptoms TB? (Multiple choice) a) Continuous cough from 15 days b) Evening fever c) Hemoptysis d) Chest pain e) Anorexia/Wt. loss f) Weakness g) Don’t know h) Other 7. Is TB curable? a) Yes b) No c) Don’t know 8. In your opinion, which is the best place for the treatment of the TB? a) Health Institutions b) Traditional healers c) Private clinic d) Vaidya e) Medical shop f) Other 9. How much time necessary to take medicine for complete cure of TB? a) 6 months b) 8 months c) 12 months d) 18 months e) 24 months f) Other g) Don’t know 10. Is medicine available in your nearest health institution? a) Yes b) No c) Don’t know 11. Is medicine freely available or have to buy in health institution? a) Free of cost b) Have to buy

12. How can we prevent from TB? a) Immediate test on suspicion b) Not spitting unnecessarily c) Cover mouth on coughing/sneezing d) Not eating together e) Don’t know f) Other 13. What will you do if somebody have cough from 15 days in your family? (M.C.) a) Check up in health institution b) Visit medical shop c) Visit private clinic d) Visit traditional healer e) Use of domestic herbs f) Other e) Don’t know 14. Do you have heard DOTS? a) Yes b) No ( If no go to question no. 16) If yes, what is DOTS? …………………………………… 15. Why DOTS is necessary for the treatment of TB? (Multiple choice) a) For complete cure b) To prevent from transmission c) To prevent from chronic d) Other e) Don’t know 16. Did anybody in this family have TB since 2 years? a) Yes b) No ( If no go to question no. 19) If yes, how it was diagnosed? (Multiple choice) a) By sputum test b) By X-Ray c) By physical examination d) Don’t know e) Other 17. Where it was diagnosed as TB? a) In health institution b) In private clinic c) By traditional healer d) Don’t know e) Other 18. How was patient after the treatment of TB? a) Completely cured b) Relapse c) Death d) Other 19. Where do you visit for the treatment of TB? (Multiple choice) a) In health institution b) In private clinic c) To traditional healer d) Don’t know e) Other 20. What type of problems come when somebody in the family suffer from TB? (Multiple choice) a) Economic burden b) Social problems c) Physical problems d) Mental burden e) Don’t know f) Other Thanks! B. In-depth Interview guide Cured Patients Target Group: Cured Patients of 20-45 years of age. Participant : Two (2) person per V.D.C. Facilator : One (1) person Note-taker : One (1) person Creating Environment: Namaste, we have come here to discuss about Tuberculosis problems, attitudes of community people and local efforts to cure Tuberculosis. Your valuable information will be helpful to conduct anti-tubercular programs in this area. Your information will be kept confidential. 1. In which work you are buzy nowadays? 2. How are you spending your leisure time? 3. What were the sign/symptoms before the diagnosis of TB? 4. How many days after illness TB was diagnosed? 5. From where and how TB was diagnosed? 6. From where you had taken treatment for TB? 7. How many days you had taken medicines for TB? 8. Why DOTS is necessary for curing TB? 9. What are the demerits of taking irregular medicines for TB? 10. What should be done to prevent TB? 11. Is there possibility to prevent TB by increasing awareness in the community? 12. What type of role you people can play in making community people aware? 13. Which type of role you can play in this work? 14. Which type of help you have expected for this work? (DOTS Committee/Local Health Worker) 15. Which type of behavior community people had shown when you were taking treatment for TB? 16. In your opinion, how can negative attitude of community people can be minimized? 17. What should be done to make TB control program more effective?

C. Focus Group Discussion guide Community People Target Group: Community people (2 Male group/2 Female group) Place : Health Post Building Participant : 6-12 persons Facilator : One (1) person Note-taker : One (1) person Helper : One (1) person Creating Environment: Namaste, we have come here to discuss about Tuberculosis problems, attitudes of community people and local efforts to cure Tuberculosis. Your valuable information will be helpful to conduct anti-tubercular programs in this area. Your information will be kept confidential. 1. In which work you are buzy nowadays? 2. How are you spending your leisure time? 3. Which diseases are affecting the people in this village? 4. Have you heard about TB? 5. If you have heard then which type of disease TB is? (Communicable/Non-communic.) 6. If TB is communicable then by which mode it transmits from person to person? 7. In your opinion, what are the causes of TB? 8. What are the main symptoms of TB? 9. What will you do if someone suffer from continuous cough (15 days) in your family? 10. Which tests need for the diagnosis of TB and from where those tests can be done? 11. Is money needed to pay for sputum test to diagnose TB in the health institution? 12. Do you need to pay money for the medicines of TB in the health institution? 13. How much time needed to take medicines to cure TB completely? 14. Have you heard about DOTS? If yes then what is DOTS? 15. How community people behave with TB patients in your community? (Good/Bad) 16. What are the preventive measures for the TB? 17. Which type of role cured TB patients can play for making community people aware? 18. At last, what should be done to make TB control program more effective? 33. Work Plan (should include duration of study, tentative date of starting the project and work schedule / Gantt chart) Activities/Time Sep Oct Nov Dec Jan Feb Mar Apr May Jun Pre intervention & preparation Sharing meeting with DPHO & planning Tool development & testing Tool finalizing Enumerator selection Training/Orientation/Wor kshop for data collection Baseline survey Intervention Phase Data collection Data coding & compilation Data analyzing, interpretation & Reporting Dissemination of findings

Intervention Sites: Non-intervention Sites: 1. Salempur 5. Sisautiya 9. Fulparasi 1. Ramban 5. Haripurwa 9. Jamanuya 2. Sundarpur 6. Batraul 10. Kaudena 2. Grahiya 6. Kabilasi 10.Sukhchain 3. Barhathwa 7. Malangwa 11. Sakraul 3. Parsa 7. Belhi 11.Pipariya 4. Musaili 8. Simra 12. Godaita 4. Sangrampur 8. Sahodwa 12.Chhatauna