Tuberculosis education and prevention among social networks in Awutu Senya East Municipal, GhanaElana I. Desrivieres MS, MPH

January 2014Kasoa Polyclinic and Cheerful Hearts Foundation collaboration

Background

Objectives

Acknowledgments

The contagious nature of the Tuberculosis disease and the life cycle of the bacteria makes the need for education and prevention vital. The social network of the infected individual is at great risk for contracting the disease. Contact testing does not guarantee that all individuals who are in close contact with the infected will be brought to the clinic for testing. There is no guarantee that this is the only group of individuals the TB patient may have infected. That is why this program first identified communities where high numbers of infected individuals resided and extended outreach to the entire community. Adding the referral component to the program, created the bridge to care for anyone with TB like symptoms.

The education piece of this program was very effective based on the reviews received from community members. The TB skit given at schools, in addition to the use of the TB visual education flip chart, coupled with the organized format of talks influenced the positive feedback from audience members.

One oversight of this project lay in the area of sputum testing for young children. Normally young children are unable to provide a sputum sample, so this method of testing for TB is inappropriate. As a result two parents who reported to clinic for testing were given referrals by the Disease Control unit to visit another medical facility for a chest x-ray. This is something to consider for future activities of this program.

TB activities picture summary

Selection of communities for community sensitization: Four communities were selected with the aid of Kasoa Polyclinic’s Disease Control unit’s TB patient register. The unit’s register for the latter six month period of 2013 was reviewed and the communities of Ofakoor, New Town, Zongo and Crispool City were found to have the highest number of patients diagnosed with TB. These communities were selected as the locations for implementation of this project's activities which lasted for a two week period.

Sensitization process: TB Training was organized for the group of five individuals who implemented the outreach program. The disease control Head of Kasoa Polyclinic delivered a three hour TB education training to the outreach group. After the training, the group led by Cheerful Hearts Foundation public health volunteer Elana Desrivieres went out to the four preselected communities and delivered TB education. Upon canvasing communities, the following locations gave permission for TB sensitization to be conducted at their facilities: Covenant Child Preparatory School, Ebenezer School, Royal Seed School and Orphanage, He Reigns School Complex, Gaipanic School, Liberty Evangelistic Bible Ministries, Dominion Ministries Church, Kasoa Zongo Palace. Additionally, house to house community sensitization was also conducted. Three schools received a skit about the TB disease and then a question and answer session followed.

At the end of the TB education piece, the team of TB educators were on hand to provide referrals to individuals reporting symptoms of the disease. Individuals with any of the five symptoms (loss of appetite, weight loss of 10 kilos or more in month, blood in sputum, cough that lasted anywhere from 3 days to two weeks or more, days sweats and night fevers) were given referrals to Kasoa Polyclinic Disease Control unit for free diagnostic testing. A questionnaire called the Tuberculosis Symptom Screener was created using the WHO’s TB symptom guidelines and used as tool for data collection.

Individuals who did not report to the clinic for testing within a week of receiving the referrals were given a reminder call to visit the clinic. Any individual who had a positive sputum test for TB would be given free treatment for the disease.

Methods

Results

Results

Discussion

The Tuberculosis education and prevention program’s objective is to provide sensitization and linkage to TB testing and treatment to selected communities in Awutu Senya East Municipal. Free TB sputum testing and treatment is available at the Kasoa Polyclinic Disease Control unit.

A total of 35 individuals encountered at the outreach locations completed the Tuberculosis Symptom Screener form and received referrals for sputum testing at Kasoa Polyclinic. Individuals who reported symptoms ranged in ages of

2 years to 78 years, with the majority of individuals aged in their 20's followed by 30's. The symptoms reported were as follows:

Figure 1. Tuberculosis Symptom Screener Form Summary of Responses

Public health education is a low cost and simple tool that can significantly reduce the spread of diseases like Tuberculosis. In developing countries and areas with limited resources it is especially necessary to maximize education efforts to reach communities and who may not have regular contact with health systems. In a country like Ghana where TB testing and treatment is free there should be additional efforts that educates about the disease and links individuals exhibiting signs of the disease into care. The structure of the medical system makes it that individuals who lack funds often delay seeking treatment until their condition is serious because they may not have the funds to pay. Thus the reason it is important to raise awareness about a disease like TB which is contagious and deadly.

During a short time period this program was able to achieve its goal of providing TB sensitization and linkage to care for anyone reporting the symptoms of the disease. It is recommended that NGO's and Departments of Health continue to devote resources to such efforts.

Conclusions

 

Question (N=) %(N)

1. Have you had a cough that has lasted for the past 2 weeks or more?

Yes

No

29

6

83%

18%

2. Have you had night sweats or afternoon fever?

Yes

No

22

13

66%

37%

3. Have you had loss of appetite

YesNo

1916

57%46%

4. Have you had unexplained weight loss of 10 kilos or more during a short period of time (one month)

Yes

No

(N=)

16

19

(N=%)

46% 54%

5. Have you had blood stained phlegm or sputum?

Yes

No

5

30

14%

86%

6. When did your symptoms start?

Month Year

51% one month ago or less

49% more than a month ago

7. Have you been given treatment?

Yes

No

15

19

43%

54%

8. How have you treated the symptoms?

7 (clinic/hospital)

8 (pharmacy/drug store)

47% of those who received treatment went to clinic/hospital

53% of those who received treatment went to drug store

Discussion

Discussion

Symptom Screener symptom analysisOf the 35 individuals who were given referrals for sputum testing at Kasoa Polyclinic, the predominant symptom reported was a cough that lasted anywhere from three days to two or more weeks with 83% of individuals experiencing this symptom. The next highest reported symptom was night sweats with 66% of individuals experiencing this symptom. Loss of appetite was the next most reported symptom with 57% of individuals experiencing this.

The least reported symptom was blood stained sputum with 86% not having this symptom, followed by unexplained weight loss with 54% of individuals never experiencing this symptom. Most individuals had their symptoms for one month or less, and 53% of those individuals self- treated symptoms with drugs from a pharmacy.

Preliminary results from sputum testing

Of the 35 individuals given referrals for sputum testing, only 14 individuals reported to the clinic for testing at the end of the two week education period. All tests were negative for the Tuberculin bacteria.

The Tuberculosis education and prevention program among social networks delivered education to a significant number of both adults and children over a two week period. Health education is an important part of disease control that can help reduce the spread of diseases like Tuberculosis. Although only 35 individuals received referrals for TB testing, the education received by those encountered during this program's activities will positively impact their lives. Adults as well as children were equipped with the knowledge that would prompt them to seek medical intervention if ever they or their loved ones exhibit the symptoms of TB.

The analysis of the TB Symptom Screener forms showed that the most reported symptom was a cough that last for three or more days. 83% of individuals reported this symptom. The symptoms of TB can easily be disregarded or mistaken for other diseases. The Awutu Senya Municipal is a place with many environmental hazards that can trigger conditions like coughs. Sanitation issues, unpaved roads which contribute to constant dust, all may influence respiratory problems in individuals. As a result a symptom like a cough may be disregarded as something not life threatening. Further,66% of individuals reported night sweats and day fevers. This symptom may also be linked to a disease like Malaria. The referral component to this program created a much needed avenue to help individuals rule out a deadly disease like TB as the source of their symptoms.

In the existing literature, some experts see screening of individuals who are not at high risk for TB as a strain on health resources. Although this is a valid concern, TB continues to be a deadly disease which continues to claim the lives of individuals especially those in low resource settings. A high risk area in the US is different from a high risk area in Ghana. At Kasoa Polyclinic where in 2013 94 individuals were diagnosed with TB, the goal should be to contribute to efforts that would identify those who are infected with the disease and link them to care. Also important is to note that because of the inability to pay for medical services, many individuals fail to seek medical care which makes the likelihood of a TB diagnosis slim, and the likelihood for infection from the infected to their social network great.

Special Thanks to Cheerful Hearts Foundation in particular Executive Director Eric Opoku Agyemang and Kasoa Polyclinic Disease Unit Head David Sarkordie for the collaboration on this project . To health education team on this project from the Cheerful Hearts Foundation Ekimini Ikddee (public health volunteer), Douglas Agyemang, Godwin Godack Acquah, Emmanual Ato Yamoah and from Kasoa Polyclinic’s disease control unit Ishmael Amponsah and Maxwell Adobo, your commitment and enthusiasm on this project were unmatched. You all showed that in small numbers we can do great things. We can stop TB.

Discussion Discussion Discussion Discussion Discussion Discussion Figure 1 continued

Yearly more than 1.6 million people die from the airborne disease called Tuberculosis (TB). Every time a person with TB coughs they release 40,000 droplets of TB bacteria into the air making it easily contagious to anyone who shares the same breathing space. The World Health Organization estimates that yearly more than 8 million people develop active TB, and if left untreated each person with TB can infect 10-15 people yearly. With about 1/3 of the world’s population affected with TB, it is imperative that communities are sensitized about the disease and connected to care. With the right intervention that includes education, and linkage to TB diagnostic testing and treatment, the infection rate of the disease can be reduced. In Ghana, many are unaware that TB diagnostic testing and treatment is free. Community sensitization about the disease and linkage to care is necessary. Contact testing which is testing individuals with close contact with a TB infected person is vital in containing the disease. Although during contact screening the greatest concern is for the immediate household members, the TB index person may also have a larger social network who may have been exposed to the disease. According to a US Center for Disease Control report, the likelihood of TB disease in someone after exposure is influenced by medical conditions, duration of contact, proximity and air circulation. This statement supports that the immediate family may not be the only ones susceptible to TB infection from the index person. Thus the reason this program took the approach by by identifying communities with high numbers of TB patients, and then target these communities for outreach activities.