evaluation of universal access to tb diagnosis in mzimba district (malawi)

8/14/2019 Evaluation of Universal Access to Tb Diagnosis in Mzimba District (Malawi)

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UNIVERSITY OF MALAWI

THE POLYTECHNIC

FACULTY OF APPLIED SCIENCE

DEPARTMENT OF ENVIRONMENTAL HEALTH

EVALUATION OF UNIVERSAL ACCESS TO TUBERCULOSIS DIAGNOSIS IN

MZIMBA DISTRICT

PRESENTED BY:

CHRISTOPHER C. MWASE

SUPERVISED BY:

MR. C. MWENDERA

PRESENTED TO DEPARTMENT OF ENVIRONMENTAL HEALTH IN PARTIAL

FULFILLMENT OF BACHELOR OF SCIENCE DEGREE IN ENVIRONMENTAL

HEALTH


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NOVEMBER 2009

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Table of Contents

Table of Contents ........................................................................................................ i

ACRONYMS/ABBREVIATIONS ...................................................................................... iii

LIST OF TABLES .......................................................................................................... v

LIST OF FIGURES ........................................................................................................ vi

DEDICATION .............................................................................................................. vii

ACKNOWLEDGEMENTS ............................................................................................. viii

ABSTRACT .................................................................................................................. ix

CHAPTER ONE ............................................................................................................. 1

1.0 INTRODUCTION .................................................................................................. 1

1.1 Background Information ................................................................................. 1

1.2 Statement of the Problem .............................................................................. 5

CHAPTER TWO .......................................................................................................... 13

2.0 LITERATURE REVIEW ....................................................................................... 13

CHAPTER THREE ....................................................................................................... 17

3.0 OBJECTIVES ..................................................................................................... 17

3.1 Broad Objective ............................................................................................ 17

3.2 Specific Objectives ....................................................................................... 17

CHAPTER FOUR ......................................................................................................... 18

4.0 METHODOLOGY ............................................................................................... 18

4.1 Study Variables ............................................................................................ 18

4.2 Study Area .................................................................................................... 19

4.3 Study Type .................................................................................................. 19

4.4 Study Population .......................................................................................... 20

4.5 Sampling and Sample Size .......................................................................... 20

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4.6 Data Collection and Quality Control............................................................. 20

4.7 Data Management ........................................................................................ 21

4.8 Pre-testing .................................................................................................... 21

4.9 Data Analysis ............................................................................................... 21

4.10 Plan for Dissemination of Results ............................................................... 21

4.11 Ethical Consideration .................................................................................. 21

5.2 Personnel .................................................................................................... 22

6.2 Limitations .................................................................................................... 22

CHAPTER FIVE ........................................................................................................... 23

5.0 FINDINGS ......................................................................................................... 23

CHAPTER SIX ............................................................................................................ 34

6.0 DISCUSSIONS ................................................................................................... 35

CHAPTER SEVEN ....................................................................................................... 41

7.0 CONCLUSION ................................................................................................... 41

CHAPTER EIGHT ........................................................................................................ 42

8.0 RECOMMENDATIONS ....................................................................................... 42

REFERENCES ........................................................................................................... 43

APPENDICES ............................................................................................................. 46

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ACRONYMS/ABBREVIATIONS

AIDS Acquired Immunodeficiency Syndrome

ART Anti-retroviral Treatment

CBO Community Based Organisation

CHAM Christian Health Association of Malawi

DEHO District Environmental Health Officer

DHO District Health Office

DHO District Health Officer

DOTS Directly Observed Therapy Short-course

DTO District Tuberculosis Office

DTO District Tuberculosis Officer

EPTB Extra-pulmonary tuberculosis

HIV Human Immunodeficiency Virus

HSA Health Surveillance Assistant

HTC HIV Testing and Counseling Centre

IPT Isoniazid Preventive Therapy

MDG Millennium Development Goal

MDR-TB Multi-Drug Resistant Tuberculosis

MoH Ministry of Health

MPHC Malawi Population and Housing Census

NGO Non-Governmental Organisation

NTP National Tuberculosis Control Programme

OPD Out-Patient Department

PTB Pulmonary Tuberculosis

T/A Traditional Authority

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TB Tuberculosis

UATBD Universal Access to Tuberculosis Diagnosis

WHO World Health Organisation

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LIST OF TABLES

Table 1: Categories of tuberculosis...14

Table 2: Case finding..18

Table 3: Study variables.29

Table 4: Contact tracing in Mzimba.39

Table 5: TB Case detection in Mzimba45

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LIST OF FIGURES

Figure 1: Sputum collection points.35

Figure 2: TB case detection by method. 36

Figure 3: Walk-in programmes in health facilities37

Figure 4: Case detection by method. 38

Figure 5: Services that aid TB case detection..40

Figure 6: Satisfaction of HTC conuselors..41

Figure 7: Services that aid TB case detection..43

Figure 8: Satisfaction of clinical officers.44

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DEDICATION

I dedicate this report to my brothers John and Christian and to my only sister Ephrida.

You always give me joy in this world.

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ACKNOWLEDGEMENTS

A proposal of this nature could not have been completed without the assistance and

understanding of many individuals.

Firstly, I thank Mr. S. Kumwenda, the Health Systems Research Coordinator for the

great job he did in giving us lessons on how to conduct a successful research project.

Secondly, I thank Mr. C. Mwendera, my research supervisor for the wonderful advice,

encouragement and support he rendered to me during the research project.

I am also grateful to Mr B.D.K Mhango for furnishing me with tuberculosis data for

Mzimba.

Lastly but not least I thank my uncle Mr. A Mwase and my aunt Ms. A.C. Mwase for

their financial support and encouragements.

Above all I thank The Almighty God.

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ABSTRACT

Universal Access to TB Diagnosis (UATBD) is the strategy that was introduced in

Malawi in order to meet the WHO target of 70% case detection percentage per year.

Mzimba district adopted this strategy in 2007.

The aim of the study was to evaluate UATBD in order to determine whether the

programme is really meeting its objective.

The study was done in Mzimba and it was descriptive and analytical. The samples

included 53 health facilities, 2 prisons, 8 anti-retroviral treatment centres, 14 HIV testing

and counseling centres and 674 sputum collection points. Primary data was collected by

using questionnaires and secondary data was collected from records at the District TB

Office. Analysis of the data was done by using Microsoft Excel package.

The percentage of functional sputum collection points in Mzimba is 82.6%, there is also

98% coverage of walk-in programmes under the District Health Office, excellent contact

tracing, and good active case finding in high risk groups and there are no new

microscopy centres established. The annual case detection percentage is still below

70%.

It has been concluded that the implementation of UATBD in Mzimba has not helped the

case detection percentage to reach the 70% target. The DHO and the DEHO should

continue to support UATBD activities and the DTO should make the non-functional

sputum collection points and walk-in programmes functional. New microscopy centres

also need to be established in the district.

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CHAPTER ONE

1.0 INTRODUCTION

1.1 Background Information

Tuberculosis (TB) is a communicable infectious disease caused by a bacterium called

Mycobacterium tuberculosis. Most infections are caused by inhalation of droplet

particles (nuclei) containing virulent human strains of the bacillus. Sometimes infection

occurs with Mycobacterium bovis through drinking of unpasteurized cow milk. About 75-

80% of tuberculosis involves the lungs (pulmonary TB), and 20-25% occurs in other

organs outside the lungs .i.e. extra-pulmonary TB (MoH, 2007a).

Pulmonary TB (PTB) can further be classified as smear-positive and smear negative

pulmonary TB. A smearpositive PTB patient has at least two sputum specimens

positive for acid-fast bacilli on microscopy or at least one sputum specimen positive for

acid-fast bacilli on microscopy and radiographic abnormalities consistent with

pulmonary TB or at least one sputum specimen positive for acid-fast bacilli on

microscopy which is culture positive forMycobacterium tuberculosis. A smear-negative

PTB patient is a patient who has been coughing for more than three weeks with: at least

two sputum specimens negative for acid fast bacilli on microscopy, lack of clinical

response to one week of broad-spectrum antibiotics, and radiographic abnormalities

consistent with pulmonary TB or a patient who is severely ill with at least two sputum

specimens negative for acid fast bacilli on microscopy and radiographic abnormalities

consistent with extensive pulmonary TB (interstitial or military). Military TB is classified

as pulmonary tuberculosis.

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Extra-pulmonary tuberculosis (EPTB) refers to disease outside the lungs. This includes:

pleural effusion, pericardial disease, lymphadenopathy, peritonitis and/or

gastrointestinal disease, meningitis, spinal or bone disease, genito-urinary disease and

skin disease. The most common types of EPTB in Malawi are pleural effusion,

lymphadenopathy, ascites and pericardial disease (MoH, 2007a).

Adult patients with smear positive PTB are the main source of infection. They spread

the bacilli by coughing (droplet infection). Close and prolonged contact with a patient

who is smear-positive is associated with a high risk of becoming infected.Categories of

TB are shown in the table below:

Table 1: Tuberculosis categories.

Category Description

New A patient who has never taken anti-TB drugs for more than one month.

Relapse A patient who has previously been treated and completed treatment and

has now developed active tuberculosis with smear-positive sputum.

Failure A newly diagnosed TB patient who is sputum-smear positive five months

or more after the start of chemotherapy.

Treatment

interrupted

(treatment after

default)

A patient who interrupted treatment for more than two months after at least

one month of chemotherapy and is subsequently found to have smear-

positive tuberculosis.

Transfer in A patient who has been recorded on treatment in another TB register and

has been transferred to another district to continue treatment.

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Other A patient who does not fulfill any of the above categories. Examples are:

a) Chronic case- a patient who remains smear-positive after

completing a re-treatment regimen under supervision

b) Recurrent TB case- a patient who has previously been treated and

completed treatment and has now developed active TB with smear-

negative TB or extra-pulmonary TB.

Source: National TB Control Programme 2006.

During the 1990s the international community reached consensus on a strategy for

controlling TB, based on finding and treating infectious cases. The strategy is known as

Directly Observed Therapy Short-course Strategy (DOTS) and has five core

components. The components are: government commitment to TB control, diagnosis by

smear microscopy, mostly on self-reporting symptomatic patients, standardized short-

course chemotherapy under proper case management conditions; including direct

observation of treatment, at least during the initial phase, secure system of regular high-

quality drug supply and outcome evaluation of each patient through a standardized

recording and reporting system. Progress in the control of TB is monitored by the World

Health Organisation (WHO) (Nunn et al, 2005).

The targets for the DOTS strategy are to detect at least 70% of sputum smear-positive

cases and to successfully treat at least 85% of the cases. Achieving these targets

reduces the transmission of TB and, in the absence of HIV, incidence falls. A well

executed programme can reduce notifications by 6-8% per year (Nunn et al, 2005).

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WHO (2007) states another strategy that is of great importance in TB control; the Stop

TB Strategy launched by WHO in 2006. The core of this strategy is DOTS, the TB

control approach launched by WHO in 1995. The six components of the Stop TB

Strategy are: pursuing high-quality DOTS expansion and enhancement, addressing

TB/HIV, multi-drug resistant TB (MDR-TB) and other challenges, contributing to health

system strengthening, engaging all care providers, empowering communities and

people with TB, and finally enabling and promoting research.

Stop TB Strategy intends to achieve the following targets:

Millennium Development Goal (MDG) 6, Target 8: to halt and begin to reverse

the incidence of TB by 2015.

Targets linked to the MDGs and endorsed by the Stop TB Partnership:

by 2005: detect at least 70% of new sputum smear-positive TB

cases and cure at least 85% of these cases.

by 2015: reduce TB prevalence and death rates by 50% relative to

1990.

by 2050: eliminate TB as a public health problem (1 case per

million population).

Malawi adopted both the DOTS and the Stop TB Strategies and is committed to

meeting the targets of these strategies. The Ministry of Health is responsible for the

implementation of the strategies.

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1.2 Statement of the Problem

On 26th August 2005, African Health Ministers from 46 member states declared TB an

emergency in Africa during their 55th session of the WHO Regional Committee Meeting

for Africa, held in Maputo, Mozambique. Following the declaration of TB as an

emergency in the African region, many African countries followed suit by declaring TB

as an emergency in their respective countries (MoH, 2007c).

The Government of Malawi, through MoH declared TB as a National Public Health

Emergency in the country on 27th March 2007. At the same time the National TB Control

Programme (NTP) 5-year Development Plan was launched. By declaring TB as a

national emergency, it means that extraordinary resources in terms of human and

finance are required for the control of TB in Malawi. Furthermore some routine activities

within the NTP need to be done differently (MoH, 2007a).

According to MoH (2008) the advent of HIV infection has led to a rapid increase in TB

notification rates particularly in urban areas, resulting in the numbers of TB cases rising

over five-fold in the past 20 years.

MoH (2007c) states that tuberculosis is the biggest single cause of adult illness and

death from a communicable disease in Malawi and one whose greatest impact is on the

poor, with overcrowding and poor nutrition favouring transmission and development of

active disease from latent infection.

The DOTS Strategy clearly explains that the most effective way of combating TB is

early detection of TB cases, and prompt administration of anti-TB drugs to the patients

to cure the disease. WHO and the NTP require District Tuberculosis Offices in Malawi to

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have at least 70% case detection percentages of smear-positive TB cases in a year. In

the years 2005-2006 Mzimba district was unable to meet this target as shown by the

baseline data below:

Table 2: Case detection for Mzimba 2005-2006

YEAR NEW SMEAR

POSITIVE TB

CASES

TARGET ON

SMEAR

POSITIVE TB

CASES

CASE

DETECTION

PERCENTAGE

PROJECTED

POPULATION

2005 352 558 63% 743,374

2006 364 568 64% 757,000

Source: Mzimba District TB Office 2009.

Simwaka et al (2007) found that the poor, in Malawi, were faced with innumerable

barriers when accessing TB care, due to geographical distances and high opportunity

costs. She adds that long waiting time (queuing) at the health facilities in Malawi

contributes to this problem.

As one way of responding to the declaration of TB emergency in Malawi, the NTP has

adopted the strategy of Universal Access to TB Diagnosis (UATBD) as the main driving

force to increase TB case detection rate in Malawi; and to achieve the Millennium

Development Goals (MDGs) in line with the Stop-TB Strategy and the DOTS strategy.

UATBD strives to comprehensively address the barriers outlined by findings of Simwaka

et al (2007).

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UATBD uses seven strategies in order to increase the case detection rate and they are:

(a) Expansion of community-based TB initiatives (Mtsiliza model)

There is undoubted confidence that with various segments involved in the communities,

the health service can be augmented in its efforts of addressing challenges including

infectious diseases (Sambo, 2006 cited in Kachipande, 2008). The idea of community-

based TB initiatives was inspired by this observation.

In this strategy, community members are sensitized and mobilized to organize

themselves to establish sputum collection points/centres right at the community level.

All TB suspects within the catchment area submit sputum specimens at this centre. The

specimens are brought to the nearest health facility by the community members

themselves with logistical arrangements made by the District Health Office (DHO). A

community member manages the sputum collection point and is also responsible for

transporting the sputum to the health facility. All necessary logistics are given to the

community. The logistics include chronic cough registers (or community TB registers),

sputum containers, laboratory forms and sputum carrier boxes. It is required that the

results from the health facility should be communicated to the community within 7 days.

Community members also encourage people with chronic cough in the community to

submit their sputum for testing. In communities where it is not possible to establish

sputum collection points, suspects are referred to the nearest health facility using the

simple referral slips or community referral form. In Mzimba community-based TB

initiatives were not there before the introduction of UATBD. There are now 674 sputum

collection points in the district.

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These initiatives are a form of active case finding in which TB suspects are detected in

their communities rather than passive case finding where suspects refer themselves to

the hospital.

(b) Establishment of walk-in programmes (rapid diagnostic pathway) in all health

facilities

People who are TB suspects are encouraged to demand for TB diagnostic services. TB

suspects who need only sputum submission do not queue in the general outpatient

department, but rather go straight to a TB corneror TB office at the health facility and

submit sputum as per the NTP guidelines. Where possible, hospitals have a designated

TB cornerwhere TB suspects easily access sputum containers. Health workers do not

turn away such TB suspects when they demand for the TB diagnostic services. Walk-in

programmes had never been used before in the district until the introduction of universal

access. When sputum is collected the suspect is given a date when he can collect

results.

(c) Intensification of contact tracing

Claessens et al (2001b) found that there is a high frequency of tuberculosis in

households of index tuberculosis patients. They carried out a case control study in 44

non-private hospitals in Malawi which register and treat patients with tuberculosis. The

findings of this study are an inspiration to the birth of contact tracing.

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In this strategy all children under the age of 6 years who are contacts of smear positive

index cases are screened for TB. If TB has been diagnosed TB treatment is given. If

there is no TB, isoniazid preventive therapy is given for at least 6 months. All adult

symptomatic household contacts of smear positive index cases are also screened for

active TB. Contact tracing was not done in the district before the advent of UATBD. This

is also active case finding.

(d) Active case finding in high risk groups

In a study in Malawian prisons conducted by Nyangulu et al (1997) cited in MoH

(2007d), they state that a much higher rate of TB was found in a prison population at a

rate of 5,142/100,000 population compared with 209/100,000 in the general population.

The impact of human immuno-deficiency virus (HIV) on TB has been devastating with

approximately 10% of all global TB cases now attributable to HIV-were it not for HIV, TB

would already be declining worldwide(Nunn et al, 2005).

It is clear that high risk groups are prisoners, clients attending HIV testing and

counseling (HTC) and clients at ART centres. On regular basis, these high risk groups

are screened for active TB. Mzimba district had no form of active case finding before the

introduction of UATBD. In Mzimba there are 2 prisons, 26 HTC centres and 17ART

centres.

(e) Expansion of TB microscopy network

Harries et al (1998) found that overall 84% of patients with smear-negative pulmonary

tuberculosis in Malawi between January 1997 and June 1998 had sputum smears

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examined and that in each of the 6-months periods there was a significant increase in

the proportion of patients whose smears were evaluated. With this confidence in the

quality of service delivery of its microscopy centres the NTP decided to expand its

microscopy network so that more people can have their sputum examined and results

communicated to them quickly.

The plan was to train more microscopists and to open more microscopy centres. Before

UATBD there were only 7 microscopy centres in Mzimba. These microscopy centres

and microscopists were only found in admission hospitals.

(f) Involvement of other stakeholders

During 1998 briefing sessions were conducted with traditional healers in five districts in

Malawi as part of the NTPs initiative in collaborating with traditional healers and

informing them about tuberculosis and its management (Harries et al 1998). Mzimba

was one of the districts involved.

Later Claessens et al (2001a) conducted a country-wide study on traditional healers

and pulmonary tuberculosis in Malawi. In the study there were 770 patients of whom

248(32%) had visited a traditional healer before diagnosis of pulmonary tuberculosis.

Those with new tuberculosis and those who had a farming occupation were significantly

more likely to visit a traditional healer. Of 248 patients who visited a traditional healer,

15 (6%) had been referred to health facilities for sputum smear examination.

The study by Claessens et al (2001a) suggested that health personnel alone cannot

successfully fight TB. There is a need to involve other people like the traditional healers

in case finding. According to MoH (2007c) UATBD is not implemented by the district

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health office alone. Other stakeholders from within and outside the health system are

also involved. Some examples of stakeholders outside the health system are traditional

leaders,chiefs, volunteers, community based organizations (CBOs), non-governmental

organizations (NGOs), grocery owners and others.

(g) Strengthen monitoring and evaluation to include other parameters

De Cock and Boerma (2006) in their presentation, on monitoring progress towards

Universal Access 2010 in the health sector, call for establishment of rigorous systems of

monitoring and evaluation to enable information to be collected nationally on case

finding and treatment.

All necessary arrangements are made to monitor and evaluate activities for UATBD. All

recording and reporting tools are made available at all levels. Regular supervision is

done, and data collected at all levels, including the community level.

In Mzimba the implementation of UATBD was started in 2007. This study intends to

evaluate UATBD from 2007-2009. This evaluation will focus on determining the impact

of UATBD on the annual case detection percentage. The first six strategies of achieving

UATBD will be assessed and their impacts will be assayed either qualitatively or

quantitatively. Information obtained from this study will help various stakeholders

involved in UATBD to know if they are making progress in scaling up the case detection

rate or not. The study will identify areas of UATBD that need more effort in order to

scale up the case detection rate (if such areas exist) or will recommend the programme

to go on as it is (if it is meeting the objectives of UATBD).

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CHAPTER TWO

2.0 LITERATURE REVIEW

In 2002, there were an estimated 8.8 million new TB cases in the world, including 0.71

million people infected with HIV. TB led to the death of 1.8 million people, including a

0.25 million people with HIV infection. Poor people are most at risk of TB, and most TB

deaths occur during the economically productive years of 15-54 years of age. Detecting

and curing TB is therefore, a key intervention for addressing poverty and inequality

(WHO, 2007).

TB and HIV have become a co-epidemic that poses a great burden on health systems

worldwide. The WHO (2003) cited in Nunn et al (2005) estimates that about 8% of the

8.8 million new cases of TB were HIV infected. Of the 1.7 million people who are

thought to have died with TB in 2003, 229,000 were probably infected with HIV. Africa is

the only continent where TB incidence is rising; however this trend is sufficient to cause

a global increase of about 1.0 % per year.

People with HIV easily contract TB because of their weakened immune system and go

to develop active TB. People with healthy immune systems easily recover from primary

TB infection and have only 10% chance of re-developing TB in their lifetime. In addition

sputum microscopy in TB/HIV co-infected people is not as effective in picking up TB as

in people without TB (WHO, 2006).

On poor access to DOTS strategy in the world, Elzinga et al (2004) gives the following

reasons: on the part of health systems they mention lack of human resources, limited

laboratory capacity, inconvenient opening hours, location of health facilities being far

from some communities, and limited awareness of tuberculosis among some health

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workers. On the part of patients factors include limited tuberculosis awareness and

inability to afford costs related to health care access.

Elzinga (2004) also emphasize on promotion of community action. They state that

communities have played a significant part in tuberculosis control in developed

countries and they are also essential to demand and deliver care under the DOTS

strategy in developing countries.

The incidence of TB in the African region has increased in tandem with the HIV/AIDS

epidemic. On average about one third of TB patients notified in countries in the African

region are co-infected with HIV, and in most countries in southern Africa-e.g. Lesotho,

Malawi, South Africa, Swaziland, Zambia and Zimbabwe- over two thirds of adults and

children are co-infected with HIV (WHO, 2006).

Eight out of the 22 high TB burden countries are in sub-Saharan Africa. In high HIV-1-

prevalence populations e.g. many countries in eastern and southern Africa- tuberculosis

incidence is increasing at 10% per year without full implementation of the DOTS

strategy. During the phase of rapidly increasing TB incidence driven by HIV-1, achieving

the targets of 70% case detection and 85% cure rate will only slow down the rate of

tuberculosis increase to 7% per year. A strategy of expanded scope is needed to

counter the HIV-1 driven TB epidemic, consisting of measures aimed directly at TB (full

implementation of the DOTS strategy with intensified case finding and preventive

treatment) and measures against HIV-1 including prevention of HIV-1 and provision of

antiretrovirals (Elzinga et al, 2004)

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Establishing a reliable monitoring and evaluation system with regular communication

between the central and peripheral levels of the health system is vital. This requires

standardized recording of individual patient data, including information on treatment

outcomes, which are then used to compile quarterly treatment outcomes in cohorts of

patients. These data, when compiled and analysed, can be used at the facility level to

monitor treatment outcomes, at the district level to identify local problems as they arise,

at provincial or national level to ensure consistently high-quality TB control across

geographical areas, and nationally and internationally to evaluate the performance of

each country. Regular programme supervision should be carried out to verify the quality

of information and to address performance problems (WHO, 2009).This shows how

important monitoring and evaluation is for the successful implementation of TB

programmes.

Malawi is not spared from the global TB burden. According to MoH (2007b) tuberculosis

is the biggest single cause of adult illness and death in the country. DOTS coverage

remains at 100% in all the districts. Both TB case detection and cure rates targets set at

70% and 85% respectively are yet to be achieved. WHO scores Malawi as achieving a

low case detection rate of just under 50%, in spite of having 100% DOTS coverage.

From 1999 to 2002 the NTP piloted the WHO coordinated Pro-Test Project. The project

was aimed at increasing the uptake of HIV testing and counseling by the general public

with focus on TB patients. In 2005, 47% of TB patients registered in public health

facilities underwent HIV testing and of those 69% tested positive (MoH, 2007b). These

findings indicate a high rate of TB/HIV co-infection in Malawi.

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The complexity of TB diagnosis requires repeated visits, long queues, and delays in

sending results. This reduces poor women and men's ability to access and adhere to

services. The costs of seeking TB care are high for poor women and men up to 240%

of monthly income as compared to 126% of monthly income for the non-poor (Simwaka

et al, 2007). This was the situation before the introduction of UATBD. The effectiveness

of UATBD in addressing these problems is yet to be known.

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CHAPTER THREE

3.0 OBJECTIVES

3.1 Broad Objective

To evaluate UATBD in Mzimba district.

3.2 Specific Objectives

1. To assess the functioning of sputum collection points.

2. To determine the proportion of health facilities that have established walk-in

programmes and to assess how these programmes are working.

3. To assess the extent of contact tracing in the district.

4. To assess active case finding in high risk groups in the district.

5. To establish the number of new TB microscopy centres.

6. To determine the level of involvement of other stakeholders in universal access

to tuberculosis diagnosis.

3.3 Hypothesis

Universal access to tuberculosis diagnosis has helped Mzimba to reach the 70% case

detection percentage target.

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CHAPTER FOUR

4.0 METHODOLOGY

4.1 Study Variables

Table 3: Study variables.

VARIABLE INDICATOR

DEPENDENT VARIABLE Increase in the case detectionrate

Reaching the 70% target

INDEPENDENT VARIABLES Functioning of sputumcollection points.

Presence of functional sputumcollection points incommunities.

Sputum collection pointscontributing to overall casedetection.

Proportion of health facilitieswith walk-in programmes

Presence of a walk-inprogramme in a health facility.

Extent of contact tracing Number of smear-positiveindex cases whose contactshave been screened for TB.

Number of household contactsaged 5years or less put onisoniazid preventive therapy.

Active case finding in high riskgroups

Number of people in prisons,HTC and ART centresscreened for TB

Number of new TBmicroscopy centres

Presence of new microscopycentres in the district.

Level of involvement of otherstakeholders in UATBD.

Grocery owners referring TBsuspects to the hospital forsputum examination.

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4.2 Study Area

The study area was Mzimba district. It is in the Northern region of Malawi. It borders

with Zambia to the west, Kasungu to the south, Nkhata-Bay to the east, Nkhotakota to

the southeast and Rumphi to the North. The current population for Mzimba is 724,873

(MPHC PreliminaryReport, 2008).The total land area is 10,430 square kilometers. It is

linked with other districts mainly through the M9 road, which connects to Mzuzu -

Lilongwe M1 road. The dominant tribe is Tumbuka followed by Ngoni and the patrilineal

system is dominant in the district. Christianity is the major religion and the major

economic activity in the district is agriculture.

Mzimba DHO has 53 health facilities. There are four hospitals (Embangweni,

Ekwendeni and St Johns which are CHAM hospitals and Mzimba District Hospital); 4

rural hospitals, two of which belong to CHAM, 39 health centres and the rest are

dispensaries. Malaria is the main cause of health problems (34% of OPD attendance)

followed by pneumonia and diarrhoea including HIV/AIDS related infections.

Tuberculosis is also a major health problem. In Mzimba about 70% of tuberculosis

patients are HIV positive. Eighteen percent (18%) of tuberculosis cases die.

Tuberculosis services have been scaled up in the district.

4.3 Study Type

The study was descriptive. It was carried out in the third quarter (July-September) of the

year 2009. It involved the collection of both qualitative and quantitative data from the

study units. It focused on assessing how the strategies of UATBD are being

implemented and it also assessed the contribution of these strategies towards

increasing the case detection rate.

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4.4 Study Population

The study population comprised of 674 sputum collection points, 53 health facilities, 26

HTC centres, 17 ART centres and 2 prisons.

There were no new TB microscopy centres in the district and there were no records for

grocery owners hence the two were not studied.

4.5 Sampling and Sample Size

All of the following study units were not sampled (entire populations were studied):

health facilities, prisons and sputum collection points.

Quota sampling was used when selecting ART and HTC centres where to administer

questionnaires.

The sample sizes were as follows: 53 health facilities, 2 prisons, 8 ART centres, 14

HTC centres and 674 sputum collection points.

4.6 Data Collection and Quality Control

Data on sputum collection points, walk-in programmes and contact tracing was

collected from the District TB Office (DTO).

Questionnaires were used to collect data on active case finding in high risk groups.

They were administered to HTC counselors, clinical officers in ART centres and health

workers in prisons.

Questionnaires were also intended to be used to collect data on the level of involvement

of other stakeholders in UATBD. These were to be administered to grocery owners who

were oriented on TB issues.

For data collection tools see appendices 1 and 2.

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4.7 Data Management

The data was stored on a Microsoft Word master sheet for easy management of the

data.

4.8 Pre-testing

Pre-testing of the questionnaires was done at Mzimba boma. The exercise enabled

evaluation of the effectiveness, sensitivity and objectivity of the data collection tools.

4.9 Data Analysis

The data was analysed by using Microsoft Excel package. The data has been

presented in the form of graphs and pie charts. Some of the data is in table form.

4.10 Plan for Dissemination of Results

This study has obtained valuable data on the impact of UATBD on TB case detection

rate in Mzimba. The findings of the study will be presented to the Department of

Environmental Health at the Malawi Polytechnic in partial fulfillment of Bachelor of

Science Degree in Environmental Health. The findings will also be disseminated to key

players in UATBD in Mzimba so that they should see their progress or shortfalls in the

fight against tuberculosis. This will allow them to identify areas that need more effort in

order to scale up the case detection rate and at the same time they will also identify

areas where they are doing well.

4.11 Ethical Consideration

Verbal consent was sought from the District Environmental Health Officer (DEHO) of

Mzimba South. Permission to carry out the study was also asked from the District

Environmental Health Officer of Mzimba North who also took the time to write an

introductory letter for me (see appendix 3). For the questionnaires that were

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administered in health facilities, ART centres and HTC centres consent was sought from

either the in-charges of the institutions or from the persons found on duty.

5.2 Personnel

The person carrying out the study was the only person responsible for data collection as

well as management of the entire research project.

6.2 Limitations

The main limitation of the study is the fact that it was not able to cover the last quarter of

the year 2009. However, all the quarters from January 2007 to September 2009 have

been evaluated. The other limitation of the study is that the case detection percentage

and the contact tracing data for 2009 are both from January to June since data for the

whole year were not available at the time of the study. Lastly poor record keeping by the

DTO on the number of grocery owners who were oriented on TB issues resulted in only

3 grocery owners being interviewed.

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CHAPTER FIVE

5.0 FINDINGS

5.1 Assessment of the functioning of sputum collection points.

From the total population (674) of sputum collection points 82.6% (557) are

functional and the remaining 17.4% (117) are non-functional. This is presented in

a pie chart below:

Figure 1: Sputum collection points.

In the first quarter of 2009, sputum collection points contributed 40% (37 cases)

to the total TB case detection (92 cases) in that quarter. The scenario is depicted

in the pie chart below:

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Figure 2: TB case detection by method

5.2 Proportion of health facilities that have established walk-in programmes

and assessment of how they are functioning.

Ninety eight percent (52) of the health facilities under Mzimba DHO have walk-in

programmes. The remaining 2% is a dispensary which is in a hard to reach area. In

addition to this, there are 20 private health facilities that have functional walk-in

programmes.

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Figure 3: Walk-in programmes in health facilities.

In the third quarter of the year 2009 walk-in programmes contributed 14% (13 cases) to

the overall TB case detection (93 cases). The remaining 86% (80 cases) was for the

other methods that are used in case detection i.e. self-referral and sputum collection

points. This is shown in the pie chart below:

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Figure 4: Case detection by method.

5.3Assessment of the extent of contact tracing in the district.

In Mzimba contact tracing was done for all smear positive index cases that were

detected from January 2007 to June 2009. In addition to this all the contacts that were

found to be 5 years or less were put on isoniazid preventive therapy. Contact tracing

was also able to contribute some TB cases. The table below offers a good summary of

what has been explained.

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Table 4: Contact tracing in Mzimba.

Note: It is important to note that the data for 2009 is from January to June because it

was impossible to have data for the whole year at the time of the study.

5.0Assessment of active case finding in high risk groups.

5.4.1 Prisons

All the 2 prisons in Mzimba have members of staff oriented on TB issues. In addition

both prisons educate their in-mates on TB.

One prison (Mzuzu prison) collects sputum and sends it to the hospital for microscopy

examination while the other prison (Mzimba prison) examines sputum on-site.

Health workers who handle TB cases were questioned on whether they are satisfied or

not on the role they play in UATBD. The one from Mzimba prison said that he is not

satisfied because he only knows about microscopy and would prefer to get advanced

27

Year Totalnumber of

smearpositiveindexcases

Totalnumber

ofsmearpositiveindexcaseswhosecontactsweretraced

Totalnumber of

householdcontactsinvestigatedfor TB

Totalnumber of

householdcontactsaged 5years orabovediagnosedwith TB

Totalnumber of

householdcontactsaged5years orless

Totalnumber of

householdcontacts puton isoniazidpreventivetherapy(5years orless)

2007 337 337 578 14 138 138

2008 282 282 209 9 172 172

2009 62 62 62 3 59 59


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training in TB so that he can offer better services to the in-mates. The other one from

Mzuzu said that he is satisfied with the role he plays in UATBD.

5.4.2 HTC centres

All of the HTC centres in Mzimba have members of staff oriented on TB. In addition all

of the HTC centres educate their clients on TB.

Seventy one percent (10) of the HTC centres refer their clients to the hospital for TB

screening (sputum microscopy) when they suspect TB and the remaining 29% (4)

collect sputum from the clients suspected of having TB and send the sputum to nearby

hospitals for examination. There is no HTC centre that offers sputum examination. This

is illustrated graphically below:

Figure 5: Services that aid TB case detection.

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When the HTC counselors (one from each HTC centre that was visited) were asked

about their satisfaction on the role they play in helping to find TB cases 36% (5) of them

said they are satisfied with their role and 64% (9) said they are not satisfied. This is

shown in the pie chart below:

Figure 6: Satisfaction of HTC counselors.

The reasons that were given for being the cause of satisfaction are:

People who are referred by the counselors for TB screening are usually found

with TB.

Due to the health education they offer clients go to seek advice at the HTC

centres when they have a prolonged cough (cough more than 3 weeks). In

addition the referred clients get to know their TB status and this diffuses fear.

The fact that they are tackling both TB and HIV/AIDS collectively.

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They easily refer people to walk-in centres where people easily access TB

diagnosis.

The reasons that were given for being the cause of dissatisfaction are:

The need for more training on TB.

The desire to have a microscopy centre on-site.

The desire to collect sputum from clients suspected of having TB in the HTC

centres where they do not collect sputum.

5.4.3 ART centres

All of the ART centres have members of staff who are oriented on TB. In addition all of

the ART centres educate their clients on TB.

On the help they render in detecting TB cases; 88% (6) of the ART centres refer their

clients suspected of having TB to hospitals for sputum microscopy. The remaining 12%

(2) collect sputum from their clients and send it to the hospital for examination. There

are no ART centres that offer sputum smear microscopy. This is shown in the figure

below:

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Figure 7: Services that aid TB case detection.

When the clinical officers from the ART centres (one from each centre that was visited)

were asked about their satisfaction on the role they play in helping to find TB cases

37.5% (3) of them said they are satisfied with their role and the remaining 62.5% (5)

said they are not satisfied. This is shown in the graph below:

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Figure 8: Satisfaction of clinical officers.

Those satisfied gave the following reasons:

Because they detect some cases and refer them for treatment.

Because they help patients get TB treatment and therefore help prevent spread

of TB.

Those dissatisfied gave these reasons:

There is the need to offer sputum examination on-site.

There is the need to collect sputum and refer it for examination if they cannot

examine the sputum themselves.

There is the need for more centres that offer TB treatment to open.

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5.4.4 Establishment of the number of new sputum microscopy centres

There are no new sputum microscopy centres opened in the district since the

commencement of UATBD in 2007.

5.4.5 Determination of the level of involvement of other stakeholders in UATBD.

The HSA who was responsible for the training of grocery owners was not able to

remember the exact number of grocery owners who were trained due to poor record

keeping. The trainer was only able to recall 5 grocery owners and of these one died and

another moved away from the boma as a result only 3 people were available for

interview. It was obvious that data obtained from the 3 people would be insignificant so

the study did not proceed on this group of people.

5.4.6 Case detection in the district.

Table 5: TB Case detection in Mzimba.

YEAR NEW SMEAR

POSITIVES

DETECTED

TARGET OF NEW

SMEAR POSITIVES

CASE DETECTION

PERCENTAGE

2007 337 528 64%

2008 282 573 49%

2009 185 296 63%

The TB case detection percentages for the years 2007, 2008 and 2009 in Mzimba were

below the 70% target set by WHO.

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CHAPTER SIX

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6.0 DISCUSSIONS

On the assessment of the functioning of sputum collection points it is encouraging to

learn that 82.6% of the sputum collection points that were established in the

communities are functional. This is an indication that communities have the capacity to

sustain initiatives that actively involve them. Despite the fact that there is a large

percentage of sputum collection points that are functional the remaining 17.4% also

need to be made functional.

The 40% contribution of sputum collection points to the total case detection of the first

quarter of 2009 proves the point that sputum collection points are key in scaling up case

detection in the district.

The findings on the assessment of the performance of sputum collection points agree

with Elzinga et al (2004). The author states that communities have played a significant

part in tuberculosis control in developed countries and believes that communities are

also essential to demand and deliver care under the DOTS strategy in developing

countries.

The District TB Office (DTO) has done a great job in achieving 98% coverage of walk-in

programmes in the health facilities of Mzimba DHO. However, they should work hard to

ensure that the remaining health facility is also covered because the current situation

does not meet the 100% time frame coverage stipulated in MoH (2007c). It is also

impressive to learn that they have also embarked on establishing walk-in programmes

in private health facilities.

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Walk-in programmes also have an important role to play in scaling up the case

detection as shown by their 14% contribution to the total number of cases detected in

the third quarter of 2009.

During the implementation of UATBD contact tracing has been excellent in Mzimba.

Household contacts of every smear positive index case were visited. In addition all

contacts aged 5 years or below were put on isoniazid preventive therapy (IPT).

Furthermore, some TB cases have been identified via this strategy as shown in table 4.

All in all the performance of the DTO on contact tracing shows all the necessary

indicators stated in MoH (2007c) namely: screening of contacts of smear positive cases

and putting on IPT contacts aged 5 years or below.

The overall performance of the DTO on active case finding in high risk groups has been

good. The DTO has taken the initiative to involve actively staff from prisons, HTC

centres and ART centres in TB activities.

It is impressive to note that all of the prisons in Mzimba have at least one member of

staff oriented on TB. It is further encouraging learning that all of the prisons educate

their in-mates on TB. These two issues are very critical in finding TB cases in prisons

because members of staff who are knowledgeable on TB can find TB suspects without

problems. In addition in-mates who are knowledgeable about TB are very likely to be

cooperative during TB screening and can even refer themselves to prison health

workers for medical attention when they suspect themselves of having TB.

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It is an improvement that Mzimba prison offers sputum smear microscopy on-site. The

other prison would also do well if it had a microscopy centre on-site as per required by

MoH (2007c).

It is not surprising to discover that the health worker at Mzimba prison is not satisfied

with the TB services he offers because he is merely a microscopist. This is supported

by the reason that he needs advanced training. It is also a consolation to note that the

health worker at Mzuzu prison said that he is satisfied with the role he plays in UATBD

despite the fact that no reasons were given for the answer.

It is also good to learn that all of the HTC centres have members of staff oriented on TB.

It is even better to note that all of the HTC centres educate their clients on TB. This is

good news as far as the implementation of UATBD is concerned. It is obvious that

members of staff who are educated on TB will offer good health education and advice

on TB to their clients. Clients who have been counseled on TB are also very likely to be

cooperative when asked to go for TB screening.

It is a good development by the HTC centres to directly offer help in the detection of

new TB cases. This is evidenced by 71% of the HTC centres that refer their clients to

the hospital for TB screening and the remaining 29% that collect sputum from the clients

suspected of having TB. It would be very expensive and some how inappropriate to

have microscopy centres in the HTC centres but sputum collection helps increase case

detection at a cheap cost. The most obvious hindrance in referring TB suspects to the

hospital is the fact that some suspects can choose not to go to the hospital. This issue

is a serious problem that needs immediate attention. However, this can be taken care of

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by also introducing sputum collection in the HTC centres that only refer the TB

suspects. This is better because when sputum is collected the persons physical home

address is also recorded in the TB suspects register such that when the sputum

examination confirms that the suspect has TB he can be easily followed up.

The fact that 36% of the HTC counselors are satisfied with the role they play in UATBD

is encouraging. However, it raises a big concern to know that 64% of the HTC

counselors are not satisfied with the role they play on TB. It is very important to address

the concerns that these people have raised i.e. the reasons that were given. This can

be done by strengthening monitoring and evaluation as suggested by MoH (2007b).

It is also good for UATBD in Mzimba to note that all ART centres in the district have at

least a member of staff who is oriented on TB. The fact that all ART centres in the

district educate their clients on TB is also a good a development. As is the case with

HTC centres staff educated on TB can deliver effectively in offering TB related services

to their clients. At the same time full cooperation is also expected when dealing with

clients who are informed via health education.

Since active case finding in high risk groups is one of the key strategies towards

achieving the objectives of UATBD it is therefore good to have 88% of the ART centres

referring clients suspected of having TB to hospitals. Despite this success there is need

to address the problem of some suspects not going to the hospital when referred. As

already suggested this can be addressed by collecting sputum from the clients. It is

possible to collect sputum in the ART centres as shown by the 2 ART centres that are

already doing this.

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Having a small percentage (37.5%) of clinical officers who are satisfied with their

contribution to UATBD is an indication that there are some issues that need to be

addressed in order to allow ART centres to contribute to their full potential in the fight

against TB. The issues that require attention are the reasons that 62.5% of the clinical

officers who were dissatisfied gave. This can also be addressed by monitoring and

evaluation in the form of supervisory visits by the district TB officer. Monitoring and

evaluation is a good problem solving tool as suggested by MoH (2007b).

The absence of any new sputum microscopy centres in the district since the

commencement of UATBD in 2007 is a major setback to scaling up the case detection.

According to WHO (2006) the recommended method of TB diagnosis is sputum smear

microscopy. Failure to increase the number of microscopy centres means that some

people in the district are being denied easy access to TB diagnosis. This thinking is

based on the findings of Simwaka et al (2007) who discovered that people who are far

away from microscopy centres find it hard to access TB diagnostic services. It has to be

understood that increasing the number of microscopy centres means increasing

peoples access to TB diagnosis.

Knowing the performance of other stakeholders in UATBD is important because it acts

as a guide to how best the stakeholders can be involved in TB activities. Failure to

assess the performance of grocery owners due to the absence of their records at the

DTO was disappointing. Absence of such records is also an indication that the district

TB office is unable to monitor and actively involve the stakeholders. This is also a

problem that needs to be taken seriously.

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It is no good news to see that the yearly case detection percentages are still below the

70% WHO target despite the implementation of UATBD. It is bad because UATBD was

introduced to scale up the case detection percentage. This seems to correspond with

WHO (2009b) which states that case detection is still low in developing countries.

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CHAPTER SEVEN

7.0 CONCLUSION

This study has come to the following conclusions:

Implementation of UATBD in Mzimba has failed to reach the 70% case detection

percentage set by WHO.

Many sputum collection points in Mzimba are functional and they are contributing

significantly towards case detection.

Community involvement is very important in the implementation of UATBD.

Ninety eight percent of health facilities under Mzimba DHO have walk-in

programmes and these programmes are making a contribution towards case

detection.

Contact tracing in the district is at an excellent level.

Active case finding in high risk groups in the district is good but it needs some

improvements.

There are no new sputum microscopy centres that have been established in

Mzimba.

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CHAPTER EIGHT

8.0 RECOMMENDATIONS

8.1 To the DHO and the DEHO

Monitor closely the implementation of UATBD activities in order to quickly

address problems that occur during the implementation.

8.2 To the DTO

Work towards making the non-functional sputum collection points functional.

Establish a walk-in programme in the remaining health facility.

Introduce sputum collection in the HTC and ART centres that do not offer the

service currently.

Immediately introduce new microscopy centres in the district.

Train new grocery owners in UATBD and actively involve them in case finding.

Always keep records of the people trained by the DTO for future use.

Strengthen monitoring and evaluation of UATBD activities.

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REFERENCES

Claessens, N.J.M., Gausi, F.F., Meinjeni, S., Weismuller, M.M.,

Salaniponi, F.M., & Harries, A.D., 2001a. Traditional healers and

pulmonary tuberculosis in Malawi. Research and Review Studies from

Malawi National Tuberculosis Control Programme, 2002 Publications.

Claessens. N.J.M., Gausi, F.F., Meinjeni, S., Weismuller, M.M.,

Salaniponi, F.M., & Harries, D., 2001b. High frequency of tuberculosis in

households of index tuberculosis patients. Research and Review Studies

from the Malawi National Tuberculosis Control Programme, 2002

Publications.

De Cock, K.M. &Boerma, T., 2006. Monitoring progress towards universal

access 2010 in the health sector. WHO.

Elzinga, G., Raviglione, M.C., & Maher, D., 2004.Scale up: meeting

targets in tuberculosis control. The Lancet, 363, p 814-819.

Government of Malawi, Ministry of Health (2007a). Manual of the national

tuberculosis control programme. 6th ed. Ministry of Health. Lilongwe.

Government of Malawi, Ministry of Health (2007b). National tuberculosis

control programme five year development plan II 2007-2011.Ministry of

Health. Lilongwe.

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Government of Malawi, Ministry of Health (2007c). Plan to implement

universal access to tuberculosis diagnosis in Malawi 2007-2009.Ministry of

Health. Lilongwe.

Government of Malawi, Ministry of Health (2007d). Malawi policy on

tuberculosiscontrol in prisons. Ministry of Health. Lilongwe.

Government of Malawi, Ministry of Health (2008). TB/HIV Operational

Framework. Ministry of Health. Lilongwe.

Harries, A.D., Banerjee, A., Gausi, F., Nyirenda, T.E., Boeree, M.J.,

Kwanjana, J., & Salaniponi, F.M., 1998. Traditional healers and their

practices in Malawi. Research and Review Studies from Malawi National

Tuberculosis Control Programme, 2002Publications.

Harries, A.D., 2004.Expanding antiretroviral therapy in Malawi: drawing on

the countrys experience with tuberculosis. Education and Debate

(Online), Available at: http://pepfarhaiti.com/New

Pepfar/Document/documents/14.pdf

Kachipande, A., 2008. Evaluation of IDSR programme. BSc. The

Polytechnic: University of Malawi.

Mzimba DTO, 2009. Case finding. ( Call) (Personal communication, 26

June, 2009).

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National Statistical Office, 2008. Malawi population and housing census

preliminary report. National Statistical Office. Zomba.

Nunn, P., Williams, B., Floyd K., Dye C., Elzinga, G., & Raviglione, M.,

2005. Tuberculosis control in the era of HIV. Science and Society .volume

5, p 819-826.

Simwaka, B.N., Bello, G., Banda, H., Chimzizi, R., Squire, B.S.B., &

Theobald, S.J., 2007.The Malawi National Tuberculosis Programme: an

equity analysis. International Journal of Equity and Health, (Online).6(24),

Available at: http://www.equityhealthj.com/content/6/1/24

World Health Organization, 2006. The health of the people: the African

regional health report. World Health Organisation. Geneva.

World Health Organisation, 2007. Tuberculosis monitoring and evaluation-

surveillance workshop. World Health Organisation. Geneva.

World Health Organisation, 2009a. Pursue high-quality DOTS expansion

and enhancement. (Online).

Available at:

http://www.who.int/tb/dots/monitoring_evaluation/en/index.html (accessed

29 June 2009).

World Health Organisation, 2009b. WHO Report 2008 (Summary).

(Online).

Available at:

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http://www.equityhealthj.com/content/6/1/24http://www.who.int/tb/dots/monitoring_evaluation/en/index.htmlhttp://www.equityhealthj.com/content/6/1/24http://www.who.int/tb/dots/monitoring_evaluation/en/index.html


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http://www.who.int/tb/publications/global_report/2008/summary/en/index.ht

ml

APPENDICES

APPENDIX 1

QUESTIONNAIRE ON ACTIVE CASE FINDING IN HIGH RISK GROUPS

Informed consent

Hello, my name is Christopher Mwase

I would like to ask you to participate in this research by answering questions inthis questionnaire. It is a research on Universal Access to TB Diagnosis and itsresults will be used for academic purposes. Remember that you have the right toaccept or not to accept this request. All information collected will be treated withconfidentiality.

Part A

46
http://www.who.int/tb/publications/global_report/2008/summary/en/index.htmlhttp://www.who.int/tb/publications/global_report/2008/summary/en/index.htmlhttp://www.who.int/tb/publications/global_report/2008/summary/en/index.htmlhttp://www.who.int/tb/publications/global_report/2008/summary/en/index.html


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1. What is the category of this institution?

1. HTC centre Tick in the appropriate box

2. ART centre

3. Prison

2. Do you have any member of staff who is oriented on TB issues?

1. Yes 2. No Tick in the appropriate box

3. Do you educate your clients/ in-mates on TB?

1. Yes 2.No

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4. If yes, how often? .

Part B

5. How do you assist in detecting new TB cases?

1. Refer people for TB screening.

2. Offer TB screening.

6. If you offer TB screening services who carries out the screening?

.

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7. If you offer screening do you have the necessary materials for screening?

Explain:..

.

8. Are you satisfied with the role you play on TB?

Explain: .

.

...

..

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THE END

THANK YOU FOR YOUR PARTICIPATION

APPENDIX 2

QUESTIONNAIRE TO GROCERY OWNERS ON THEIR INVOLVEMENT IN

UNIVERSAL ACCES TO TB DIAGNOSIS.

Hello, my name is Christopher Mwase.

I would like to ask you to participate in this research by answering questions in

this questionnaire. It is a research on Universal Access to TB Diagnosis and its

results will be used for academic purposes. Remember that you have the right to

accept or not to accept this request. All information collected will be treated with

confidentiality.

Part A

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1. What do you understand by the term Universal Access to TB Diagnosis?

2. What role do you play in Universal Access to TB Diagnosis?

Part B

3. If you help refer TB suspects to the hospital how many have you referred from

July this year up to now? .

4. Are you satisfied with the role you play in Universal Access to TB Diagnosis?

1 Yes 2. No

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5. Explain why you are satisfied or not satisfied with your role?

.

.

.

.

6. What other roles do you think you can play to enhance UATBD?

THE END

THANK YOU FOR YOUR PARTICIPATION

APPENDIX 4

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Budgetary Estimates

DESCRIPTION AND QUANTITY AMOUNT MALAWIAN KWACHA

Stationery

2 rims of plain paper @ K950.00 K 1900.00

15 ball pens @ K30.00 each K 450.00

15pencils @ K20.00 each K 300.00

5 rubbers @ K60.00 each K 300.00

1 sharpener @ K100 K 100.00

1flash disc (4 GB) @ K4500.00 K5,000.00

Cost of photocopying questionnaires K 1500.00

Subtotal K 9,550.00

Training of research assistants

4 research assistants @ K2000.00 for one day K4,000.00

10 bottles of refreshments @ K50.00 each K 500.00

6 packets of biscuits @ K150.00 each K 900.00

Subtotal K5,400.00

Data collection

4 research assistants @ K2,000.00 each for

10 days

K20,000.00

Fuel costs for 4 motorbikes K 20,000.00

Transport costs Blantyre to Mzimba and back K 8,000.00

Subtotal K 48,000.00

Report writing

Printing and binding costs K 3500.00

Total K66,450.00

Contingency 10% of the total cost K 6,645.00

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Grand total K 73,095.00

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APPENDIX 5

PROJECT MANAGEMENT

5.1 Work Plan

Month(2009) April May June July August September October November

Activity

Literature

Review

Project proposal

preparation

Proposal

submission

Data collection

Data analysis

Report writing

Report

submission

Presentation

evaluation of universal access to tb diagnosis in mzimba district (malawi)

Documents