CHAPTER ONE INTRODUCTION 1.1 Background of the Study Tuberculosis (TB) is a potentially serious infectious disease that mainly affects your lungs. The bacteria that cause tuberculosis are spread from one person to another through tiny droplets released into the air via coughs and sneezes. Tuberculosis with the bacteria Tubercle bacillus, in the past also called phthisis, Phthisis pulmonalis or consumption, is a wide spread and in many cases fatal infectious disease caused by various strains of Mycobacterium, usually Mycobacterium tuberculosis (Raviglione et al., 2010). Tuberculosis typically attacks the lungs, but can also affect other parts of the body. It spreads through the air when people who have an active tuberculosis infection cough, sneezes or otherwise transmits respiratory fluids through the air (Horsburgh & Rubin, 2011). Most infections do not have symptoms, known as Latent Tuberculosis. About one in ten latent infections eventually 1
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SURVEY OF THE ROLE OF COMMUNITY PHARMACISTS IN THE MANAGEMENT OF TUBERCULOSIS IN DELTA STATE
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CHAPTER ONE
INTRODUCTION
1.1 Background of the Study
Tuberculosis (TB) is a potentially serious infectious disease that mainly affects your
lungs. The bacteria that cause tuberculosis are spread from one person to another through tiny
droplets released into the air via coughs and sneezes.
Tuberculosis with the bacteria Tubercle bacillus, in the past also called phthisis, Phthisis
pulmonalis or consumption, is a wide spread and in many cases fatal infectious disease caused by
various strains of Mycobacterium, usually Mycobacterium tuberculosis (Raviglione et al., 2010).
Tuberculosis typically attacks the lungs, but can also affect other parts of the body. It spreads
through the air when people who have an active tuberculosis infection cough, sneezes or
otherwise transmits respiratory fluids through the air (Horsburgh & Rubin, 2011).
Most infections do not have symptoms, known as Latent Tuberculosis. About one in ten latent
infections eventually progresses to active disease which if left untreated, kills more than 50% of
those so infected.
1.1.1 Epidemiology of Tuberculosis
Roughly one-third of the world's population has been infected with M. tuberculosis (WHO,
2010), with new infections occurring in about 1% of the population each year (WHO, 2002).
However, most infections with M. tuberculosis do not cause tuberculosis disease (CDC, 2011),
and 90–95% of infections remain asymptomatic (Skolnik, 2011). In 2012, an estimated 8.6
million chronic cases were active (WHO, 2013). In 2010, 8.8 million new cases of tuberculosis
were diagnosed, and 1.20–1.45 million deaths occurred, most of these occurring in developing
Table 3.15c shows that the calculated chi-square on the influence of qualification on difference
of therapeutic drug revealed that qualification had no impact on the choice of therapy.
Table 3.15c: Chi-Square Tests of Significance on the Impact of Qualification on Choice of Therapy
Value df Asymp. Sig. (2-
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sided)Pearson Chi-Square 6.537a 12 .887Likelihood Ratio 8.088 12 .778Linear-by-Linear Association
.011 1 .916
N of Valid Cases 84a. 14 cells (70.0%) have expected count less than 5. The minimum expected count is .33.
Critical X2(4,5)= 21.026
Data in table 3.16 on the main risk associated with incomplete or interrupted treatment of TB, the
result revealed that 9(10.7%) indicated worsening symptoms and prolonged treatment course,
while 50(59.5%) said the development of drug resistance and 18(8.3%) attributed it to death,
7(8.3%) noted there is no serious risk.
Table 3.16: Responses on Main risk to the patient associated with incomplete or interrupted treatment course for TB
Response Frequency Percentage
Worsening of symptoms and prolonged treatment
course
9 10.7
Development of drug resistance
50 59.5
Death 18 21.4
There is no serious risk 7 8.3
Total 84 100
CHAPTER FOUR
4.1 Discussion
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Assessment of Knowledge and Awareness Level on Tuberculosis Symptoms
Findings from this study revealed that the attendance of workshops on TB by community
pharmacists was low revealing that grossly high 77.5% respondents declined attending
workshops on TB in the last one year. On their knowledge level towards the symptoms of TB, it
revealed a high level of knowledge amongst community pharmacists on the symptoms of
tuberculosis as they were able to identify cough and blood and fever as symptoms of
tuberculosis. Likewise, findings revealed that 47.6% of community pharmacists in the study
agreed one could be infected more than once. It is important to note that the knowledge and
awareness level of pharmacists on the symptoms of TB is not in agreement with their level of
attendance of training/seminars on TB. According to the Health Belief Model, knowledge,
education and socio-demographic factors are considered modifying variables of behavior,
individual characteristics that influence personal perceptions. Although, there is limited study
that has investigated the awareness of pharmacists specifically on tuberculosis, the findings of
this study is in agreement with those of Zahra, (2014) who found no correlation amongst
attendance of TB trainings/seminars and their knowledge and awareness of TB symptoms
amongst public health workers in Jamaica. Likewise, the finding disagrees with the submissions
of Bhebhe, et al., (2014) who noted that the attitudes, knowledge and practice of health workers
in a hospital setting correlated with their level of attendance of trainings and seminars on
tuberculosis management.
Awareness on Curability and WHO Standards
This study further revealed that community pharmacists had a low level of knowledge on
the standard duration of treating a newly diagnosed TB case showing less than 50% of them
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knew it surrounds at about 5-6 months or more. A surprising trend also revealed that most
community pharmacists had a very low level of knowledge on specific anti TB regimen; it also
revealed that only few pharmacists’ 26.2% and 35.7% respondents are aware of the WHO
standard definition for relapse and defaulters. There is no doubt that this observation justifies the
earlier observation made on non attendance of TB training sessions/seminars while agreeing with
the submissions of Bhebhe, et al., (2014) that the attitudes, knowledge and practice of health
workers is correlated with their level of attendance of trainings and seminars on tuberculosis
management. On the same note, it further gives credence to the Health Belief Model of Janz, et
al., (1984) that behavior and practice of health workers is a product of the level of awareness,
knowledge and education gained.
Level of TB Referral Cases and TB Prevalence
Findings from this study revealed a very low level of referral cases of TB to pharmacist as 63.1%
of respondents claimed not to have had any case of referral while 1.2%, 13.1%, 4.8%, 17.9%
daily, weekly, monthly and yearly respectively. Relative to whether TB was a major public
health problem in Delta State, respondents submitted that most pharmacists declined to this
claim. On those who stood the highest risk of contracting the disease, it was submitted that those
having HIV/AIDs stood a higher risk. The implication of this observation is that most
community pharmacists are scarcely patronised relative to TB cases and that there may be a high
level of implementation of TB management and control guidelines in Delta stateas well as the
utilization of the state owned tuberculosis centre.
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Level of Publicity Given to TB by Pharmacists
Results from this study revealed community Pharmacists believes that health education
on TB should be given more on world TB day while a few of them said it should be left to
general clinical setting, some others said it should be limted to only confirmed cases and their
families. The implication of this observation is that most community pharmacists are not
involved in the promotion of public health education on TB. It also gives credence to the earlier
claims of non involvement in training as they cannot offer what they do not have. These
submissions are not in consonance with the submissions of WHO (2011) who noted that the
current role of pharmacists in the fighting of the scourge of TB includes the proper provision of
education on TB management as well as acting as major sources of clinic referrals in suspected
TB cases. It further noted that the services of pharmacists in the control of TB have not been
sufficiently engaged.
Impact of Qualification on TB Diagnostic and Therapeutic Practices
Although community pharmacists had a high level of knowledge on the utilization of TB
diagnostics and therapeutics, the results revealed that the qualification of pharmacists only had
impact on their choice of diagnostic test while qualification had no impact on the therapeutic
drug used by the pharmacists. a p-value of 0.008 and 0.887 was observed for choice of
diagnostic test and therapeutic drug respectively. A careful observation of the choice of
diagnostic practice revealed that the use of chest-x-ray was more prevalent amongst all the
qualifications while the use of Rifampin was more prevalent amongst all the qualification of
community pharmacists. These submissions give credence to the submission that the minimum
skill level required to conduct DOTS with confirmed patients corresponds to that of self-efficacy,
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the confidence in one’s ability to perform a specific function (Glanz, et al., 2002; Hayden, 2009).
The study of Zahra, (2014) also submits that the minimum level of expertise necessary to
conduct DOTS was a with clinical training, such as a registered nurse; followed by highly
qualified/ trained HCWs being the second most commonly noted skill level required.
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CHAPTER FIVE
5.1 Conclusion
This study surveyed the role of community pharmacists in the management of
tuberculosis in Delta state. Findings from the study revealed quite a high level of awareness on
tuberculosis symptoms and a very low level of attendance in tuberculosis seminars, trainings and
workshops. Although they were aware of the symptoms, the study revealed a low level of
awareness on the curability and WHO standards relative to relapse and defaulters, while showing
a sharp contrast relative to their knowledge of diagnostic tests and therapeutic drugs, it was
revealed that most community pharmacists had little or no referral cases on TB, the study further
revealed that community pharmacists had a low level of participation in the promotion of
education on TB cases, qualification of the pharmacists had no impact on their choice of
diagnostic test and therapeutic drug for TB management.
Conclusively, the study wishes to make the following submissions as the major highlights
of the study;
Very little proportion of tuberculosis patients are treated by community pharmacists.
The knowledge level of community Pharmacists on Symptoms and signs of TB is high;
however, they have low level of management of the disease.
There is no significant relationship between qualification of Pharmacists and their
management skills of tuberculosis.
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5.2 Recommendations
Based on the conclusion made above, the following are recommended
1. Community pharmacists as essential collaborators in the health care sector should always
make themselves available for trainings and seminars so as to keep up to date their
knowledge base and development in certain disease management.
2. The pharmaceutical council of Nigeria should at intervals promote development
workshops and seminars for practicing pharmacists on advances, new trends and
development in certain high risk factor diseases.
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A SURVEY OF THE ROLE OF COMMUNITY PHARMACISTS’ IN THE MANAGEMENT OF TUBERCULOSIS
Dear Respondent,
I am a final year student of Faculty of Pharmacy, Delta state University Abraka, undertaking a research work on the above topic. Please indicate appropriately your view regarding the statement or questions below. Information provided would be used strictly for research purposes and will be treated with utmost confidentiality. Thanks for your anticipated assistance and cooperation.
1. Sex: Male ( ) Female ( )2. Age: 20-30years ( ) 31-40 Years ( ) 41-50 years ( ) Above 50 Years ( )3. Qualification: B.Pharm ( ) PharmD ( ) M. Pharm ( ) Others ( )4. Years of Practice Intern ( ) 1-5 Years ( ) 5-10 Years ( ) Above 10 Years ( )5. Other Practice Experiences: Hospital ( ) Academia ( ) Industry ( )
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6. Location of practice;
Section B: Knowledge and Awareness
7. In the past 12 months have you attended a lecture, seminar or workshop on Tuberculosis? Yes ( ) No ( )
8. What is/are the main symptoms that are used as an indicator for infectious, active TB disease? Cough≥3 weeks ( ) cough with blood ( ) fever ( ) Weight loss ( ) Night Sweats ( ) Diarrheal ( ) Do not know for certain ( )
9. Can someone be infected with TB for more than once in their life time? Yes ( ) No ( ) Do not know for certain ( )
10. What is the standard length of treatment for a newly diagnosed case of TB? <1Month ( ) 1-2 Months ( ) 3-4 months ( ) 5-6 Months ( ) > 6 months ( ) Do not know for certain ( )
11. How can someone with TB be cured? TB cannot be cured, only managed ( ) Herbal remedies ( ) Bed rest without medicine ( ) General antibiotics ( ) Specific anti-TB regimen ( ) Do not know for certain ( )
12. What is WHO classification of a defaulter case?Patients who remained or became smear positive again near the end of the treatment ( )Patients whose treatment was interrupted for two months or more and returns to the treatment with bacteriologically confirmed TB ( )Patients who was previously treated and cured, but once again bacteriogically confirmed TB ( )Do not know for certain ( )
13. What is the WHO classification criterion for a relapse case?a. Patients who remained or became smear positive again near the end of the treatment
course ( )b. Patient whose treatment was interrupted for two (2) month or more and returns to the
treatment with bacteriological confirmed active TB ( )c. Patient who was previously treated and cured, but once again bacteriologically
confirmed TB ( )d. Do not know for certain ( )
Section C: Practices
14. How often do you get tuberculosis referred cases Daily ( ) Weekly ( ) Monthly ( ) Year ( ) Never ( )
15. In your opinion is TB a major public health threat in Delta State? Yes ( ) No ( ) Do not know for certain ( )
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16. Who are the persons most likely to become infected in Delta state? Homeless person ( ) Children under 5 years ( ) People living with HIV/AIDS ( ) Health care worker treating a confirmed case ( ) Family members of a confirmed case ( ) Prison inmates ( )
17. Under what circumstances are health education messages on TB given to patients? World TB day ( ) BCG immunization ( ) General health promotion/education messages delivered in clinical settings ( ). With suspected/Confirmed cases only (i.e. no family members) ( ) Health Education on TB is generally not done with patients ( )
18. What is the primary diagnostic test that is usually requested in order to confirm or rule out a case active pulmonary TB? Nasopharyngeal swab ( ) Chest X-ray ( ) Mantoux test ( ) Sputum Smear microscopy ( ) Blood Culture ( )
19. What qualification is needed by community pharmacists to effectively conduct directly Observed treatment (DOT) with a patient with TB? B.Pharm ( ) Pharm.D ( M.Pharm ( ) FPC Pharm ( ) Others ( )
20. What is the most effective therapy for patients with TB? Isoniazid ( ) Rifampin ( ) Ethambutol ( ) Pyrazinamide ( ) Combination therapy ( )
21. What do you consider to be the main risk to patient associated with incomplete or interrupted treatment course for TB? Worsening symptoms and prolonged treatment course ( ) Development of drug resistance ( ) Death ( ) There is no serious risk ( )