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TUBERCULOSIS thesis pdf

Thesis · August 2019

DOI: 10.13140/RG.2.2.23708.64646

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 GOLIS UNIVERSITY
KNOWLEDGE AND ATTITUDE TOWARDS TUBERCULOSIS AMONG
NON MEDICAL STUDENTS OF GOLIS UNIVERSITY SPECIALLY
FACULTY OF SHAREIAH IN ERIGAVO SOMALILAND

By:

KINSI JAMA MOHAMOUD

&

NIMAO ABDI AHMED

A THESIS SUBMITTED TO THE FACULTY OF HEALTH SCIENCE

IN PARTIAL FULFILMENT OF THE REQUIREMENTS
FOR THE AWARD OF BACHELOR’S DEGREE FACULTY OF HEALTH SCIENCE
DEPARTMENTOF NURSING OF GOLIS UNIVERSITY IN ERIGAVO
SOMALILAND

SUPERVISOR BY:

Dr. HAMSE ALI ABDILLAHI

AUGUST 2019

i
 Declaration

We declare that this thesis is our original work and has never been submitted to any institution
for any award whatsoever without the writers’ consent or Golis University.

Kinsi Jama Mohamoud

Signature………………….. Date………………………

&

Nimao Abdi Ahmed

Signature………………...... Date………………………

ii
 Acknowledgement
First of all I would like to offer all glory and honor to the Lord GOD for his quick assistance in
all my life and for giving me the strength to work and to conduct my studies.

I would like to express my special thanks to my supervisor Lecture Dr. HAMZE ALI
ABDILLAHI a special thank you for his guidance, support, encouragement and timely response
from starting to the end of this without his motivational support this work would never have
reached this level. For his I will forever and ever be grateful. Study .

Secondly, we would like to give countless thanks to our honorable dean of the faculty of health
Dr. Abdullahi Abdi Dalmar and all our lectures that we can’t list all the names here, but you are
always on our minds. Finally, I wish to thank to our classmates and all staffs at the Gollis
University.

iii
 Abstract
Tuberculosis (TB) is an infectious bacterial pathogen caused by the bacillus called
Mycobacterium Tuberculosis (M.TB); an acid fast rode shaped bacillus 0.8-5μm in length and
0.2-0.6um in thickness. It typically affects the lungs (pulmonary TB) but can affect other sites as
well (extra pulmonary TB). Is transmitted through the air. This disease damages the lungs and
other organs in the human body. The study's general objective is to determine the knowledge attitude
towards tuberculosis among non medical students. The design we used in this study was cross-sectional
descriptive design, for this design we administered a simple questionnaire to the knowledge attitude
toward the tuberculosis among non medical students and Sample size was distributed among to 56 of non
medical students. The result of study is tuberculosis causes a considerable economic burden and a
significant deterioration in household income impacting negatively on welfare and utilizes scarce national
resources. Deaths due to TB results in household and by extension national loss of income and human
resources permanently. TB is still one of the most important global public health threats.. Early detection
and adequate treatment are critical control measures. Despite the fact that Africa carries one of the highest
TB burdens in the world, lack of knowledge about the disease remains an abiding problem in the country,
and thus, presents a barrier to control efforts. Most of respondents do not visit health centers after having
TB signs, were the levels of awareness is low and so on educational knowledge are low In countries with
high TB prevalence, it is significant that all opportunities to increase people awareness regarding the
disease are used to the optimal.The study concludes that there were some practices which were reported
that were likely to have a negative impact on prevention and control of TB. The communities should be
empowered through Health education to enhance the adoption of practices which will positively
contribute to prevention and control of TB such as improved ventilation in households, seeking health
care immediately one gets unwell instead of self-medication. There is need to dispel misconceptions on
TB in the community by stepping up health education strategy in the TB prevention and control
programms.

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 Glossary of terms and abbreviations

I. TB………………………………………………..Tuberculosis
II. PTB:………………………………………............Pulmonary TB
III. PZA:………………………………………………Pyrazinamide
IV. MOH………………………………………………Ministry of Health.
V. SPSS…………………………………………….Statistical Package for Social Sciences.
VI. WHO………………………………………… ….World Health Organization
VII. NTC ………………………………………...........National Tuberculosis Control Program

VIII. LTBI ………………………………………………Latent tuberculosis infection

IX. PHF………………………………………………..public health facility
X. EPTB……………………………………………....Extra-pulmonary TB
XI. KTB………………………………………………..Knowledge of TB
XII. ATB………………………………………………...Attitude of TB
XIII. SOI………………………………………………….Severity of illness
XIV. HIV…………………………………………………Human immune defense virus
XV. LTB…………………………………………………Laryngeal Tb
XVI. CTB…………………………………………………Cavitary Tb
XVII. MTB………………………………………………...Miliary Tb
XVIII. ATB………………………………………………...Adrenal Tb
XIX. LND…………………………………………………Lymph node disease
XX. OTB………………………………………................Osteal Tb
XXI. RTB…………………………………….…................renal TB
XXII. MTB…………………………………………………Meningitis TB
XXIII. TBP…………………………………………………..Tb pericarditis
XXIV. TST…………………………………………………..Tuberculin skin test
XXV. SSM………………………………………………….Sputum smear microscopy
XXVI. PCR………………………………………………….Polymerase chain reaction
XXVII. ADA…………………………………………………Adenosine Deaminase
XXVIII. ESR…………………………………………………..Erythrocyte Sedimentation rate
XXIX. SKD…………………………………………………..Severe kidney disease
XXX. LBW………………………………………………….Low body weight

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 XXXI. CD……………………………………………………Crohns disease
XXXII. PSG…………………………………………………..Persistently swollen glands
XXXIII. CATBD………………………………………………Current anti TB Drugs
XXXIV. FDA…………………………………………………..Food Drug Administration
XXXV. INH…………………………………………………..Isoniazid
XXXVI. RIF…………………………………………………...Rifampin
XXXVII. EMP………………………………………………….Ethambutol
XXXVIII. PZA………………………………………………….Ppyrazinamide
XXXIX. RBT………………………………………………….Rifabutin
XL. RPT………………………………………………….Rifapentine
XLI. SM……………………………………………………Streptomycin
XLII. DOT…………………………………………………..Directly observed therapy
XLIII. FDC…………………………………………………...Fixed dose combinations
XLIV. IUATLD………………………………………International union against Tb lung disease
XLV. MDR…………………………………………..Multi Drug Resistant
XLVI. BCG……………………………………………Bacillus calmatte guerin
XLVII. HCP…………………………………………….Health care providers
XLVIII. NTPs……………………………………………national Tb programs
XLIX. FMOH………………………………………….federal ministry of healthy
L. CSD……………………………………………Cross sectional design
LI. SCC……………………………………………Short course chemotherapy

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Table of Contents
Acknowledgement ........................................................................................................................ iii
Abstract ......................................................................................................................................... iv
Glossary of terms and abbreviations........................................................................................... v
CHAPTER ONE ........................................................................................................................... 1
1. Introduction ............................................................................................................................... 1
1.1 Global tuberculosis Burden.............................................................................................................. 1
1.2 Statement of the Problem ................................................................................................................. 2
1.3. Objectives of the study ..................................................................................................................... 3
1.3.1. Broad objective.......................................................................................................................... 3
1.3.2. Specific objectives ..................................................................................................................... 3
1.4. Research Questions .......................................................................................................................... 3
1.4.1. Main Research Question .......................................................................................................... 3
1.4.2. The specific Research Question ............................................................................................... 3
1.5 (Rationale) Justification ................................................................................................................... 3
1.6 SIGNIFICANCE OF STUDY .......................................................................................................... 3
1.7 Operational Definitions .................................................................................................................... 4
1.8 Study area:......................................................................................................................................... 4
1.9 Conceptual Frame Work .................................................................................................................. 5
CHAPTER TWO: ................................................................................................................................... 6
LITERATURE REVIEW ...................................................................................................................... 6
2.0: Introduction. .................................................................................................................................... 6
2.1: Tuberculosis ..................................................................................................................................... 6
2.2: Path physiology of Tuberculosis ..................................................................................................... 7
2.2.1: Mycobacterium tuberculosis.................................................................................................... 7
2.2.2: Transmission of Mycobacterium tuberculosis ........................................................................... 7
2.2.3: Effects of Mycobacterium tuberculosis in the body .................................................................. 8
2.3: Risk Factors of Tuberculosis .......................................................................................................... 9
2.3.1: Weakened immune system: ..................................................................................................... 9
2.3.2: Traveling or living in certain areas ........................................................................................... 10
2.4: Types of Tuberculosis .................................................................................................................... 11

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 2.4.1: Pulmonary Tuberculosis ........................................................................................................ 11
2.4.1.1: Laryngeal TB ........................................................................................................................... 11
2.4.1.2: Cavitary TB .............................................................................................................................. 11
2.4.1.4: TB Pleurisy ........................................................................................................................... 12
2.4.2: Extra pulmonary Tuberculosis .............................................................................................. 12
2.4.2.1: Adrenal Tuberculosis ............................................................................................................. 12
2.4.2.2: Lymph Node Disease ........................................................................................................... 12
2.4.2.4: TB Peritonitis ........................................................................................................................... 13
2.4.2.5: Renal TB ................................................................................................................................... 13
2.4.2.6: TB Meningitis ........................................................................................................................... 13
2.4.2.7: TB Pericarditis ......................................................................................................................... 13
2.5: Symptoms of Tuberculosis ............................................................................................................ 13
2.5.1: Pulmonary TB Symptoms: ..................................................................................................... 13
2.5.2. Physical signs ..................................................................................................................... 14
2.5.3: Symptoms of Extra pulmonary TB ................................................................................. 14
Symptoms of Extra Pulmonary Tb vary, but can include: ............................................................... 14
2.6: Diagnosis of Tuberculosis ................................................................................................... 14
2.6.1: Diagnosing Active TB ................................................................................................................. 15
2.6.1.1: Tuberculin skin test ....................................................................................................... 15
2.6.1.2: Chest-X-rays............................................................................................................................. 16
2.6.1.3: Sputum Smear Microscopy (SSM): ............................................................................. 16
1.1: Methods of obtaining sputum sample (Takahashi, 1975) ............................................................ 17
2.6.1.5: Culture ...................................................................................................................................... 17
2.6.1.6: Polymerase chain reaction (PCR) .......................................................................................... 17
2.6.1.7: Ultrasound ................................................................................................................................ 18
2.6.1.8: Adenosine Deaminase (ADA).................................................................................................. 18
2.6.1.9: Erythrocyte Sedimentation Rate (ESR)................................................................................. 18
2.6.2: Diagnosis of Latent TB Infection............................................................................................... 18
2.7: Current Anti-TB Drugs................................................................................................................. 18
2.8 Currently Used anti-TB Drugs ...................................................................................................... 19
2.2: Currently Used anti-TB Drugs ..................................................................................................... 19

viii
 Drugs classes Anti-Tb Drugs Comments ................................................................................................ 19
2.8: TB Disease Treatment Regimens: ................................................................................................ 20
2.8.1: Initial Phase ............................................................................................................................. 20
2.8.2: Continuation Phase..................................................................................................................... 21
Table 1.3: Dosage Recommendations for the Treatment of TB in Adults and Children (Principe et
al., 2015) ................................................................................................................................................. 21
2.9: Treatment for Extra pulmonary TB ............................................................................................ 22
2.10: Adjunctive treatment .................................................................................................................. 22
2.10.1: Pyridoxine (Vitamin B6) ...................................................................................................... 22
2.10.2: Steroids .................................................................................................................................. 22
2.11: Different Treatment Strategies ................................................................................................... 22
2.11.1: Fixed Dose Combinations (FDC) Of Anti-TB Drugs ............................................................. 23
2.11.2: Directly Observed Therapy (DOT) ......................................................................................... 23
2.11.1: BCG Vaccine ............................................................................................................................. 24
2.14.2: Patient Education ..................................................................................................................... 24
2.12: Statistics on Global Epidemiology of Tuberculosis .................................................................. 24
CHAPTER THEE ......................................................................................................................... 26
METHODOLOGY ....................................................................................................................... 26
3.1 INTRODUCTION ................................................................................................................................ 26
3.2 RESEARCH METHOD AND STUDY DESIGN ....................................................................................... 26
3.2.1. The Research method .............................................................................................................. 26
3.2.2. The Research design................................................................................................................. 26
3.3 THE STUDY POPULATION ................................................................................................................. 27
3.4 SAMPLE SIZE AND SAMPLING TECHNIQUE...................................................................................... 27
3.4.1 Sample size calculation ............................................................................................................. 27
3.5. The Sampling technique .................................................................................................................. 27
3.6 THE DATA COLLECTION PROCEDURE ............................................................................................... 28
3.6.1 The Data collection method...................................................................................................... 28
3.7 DATA ANALYSIS ................................................................................................................................ 28
3.8. Inclusion Criteria ............................................................................................................................. 28
3.9. Exclusion Criteria ............................................................................................................................. 28
3.10. Variables measured by the instrument ........................................................................................ 28

ix
 3.11. ETHICAL CONSIDERATIONS ........................................................................................................... 28
3.12. STUDY LIMITATIONS ..................................................................................................................... 29
CHAPTER FOUR ....................................................................................................................... 30
DATA PRESENTATION, ANALYSIS AND INTERPRETATION .......................................... 30
4.1 Introduction ............................................................................................................................... 30
4.2: Characteristics of respondents ..................................................................................................... 30
Findings sample tables of tuberculosis ......................................................................................... 58
Findings about information ........................................................................................................... 59
CHAPTER FIVE ........................................................................................................................ 62
CONCLUSIONS AND RECOMMENDATIONS.................................................................... 62
5.1 Conclusion ....................................................................................................................................... 62
Bibliography ................................................................................................................................. 65
Research questionnaire .............................................................................................................. 67
Appendix III .................................................................................................................................. 75
Time frame .................................................................................................................................... 75
Appendix IV.................................................................................................................................. 75
BUDGET FRAME........................................................................................................................ 75

x
 CHAPTER ONE
1. Introduction
1.1 Global tuberculosis Burden
Tuberculosis (TB) is an infectious disease caused by the bacillus Mycobacterium tuberculosis
(Mtb). It is the most dangerous bacterial infection responsible for severe increase in death cases.
The tubercle bacillus was discovered by Robert Koch in 1882. There are several reports
indicating that tuberculosis (TB) is an age old dreadful disease even from ancient times. The
disease was called "consumption" in the past because of the way it would consume from within
anyone who became infected. (manipal college pharmaceutical science , 2016). Tuberculosis is a
chronic granulomatous infectious disease. Infection occurs via aerosol, and inhalation of a few
droplets containing M. tuberculosis bacilli. After infection, M. tuberculosis pathogenesis occurs
in two stages. The first stage is an asymptomatic state that can persist for many years in the host,
called latent TB. When the immune system is weak, the bacteria begin replicating and cause
characteristic symptoms such as cough, chest pain, fatigue and unexplained weight loss. If left
untreated, the disease eventually culminates in death. (JEAN-PAUL ILUNGA MUSASA,
February 2011). It usually affects the lungs in 80% of cases with warning signs of cough,
hemoptysis, and chest pain, shortness of breath, fever, weight loss, and drenching night sweat.
TB is spread mainly through the air inform of droplets. When infectious people cough, sneeze,
talk, laugh or spit, droplets containing Mycobacterium tuberculosis are sprayed into the air.
People nearby may inhale the bacteria and become infected. Mycobacterium tuberculosis can
remain viable as airborne droplet suspended in the air for a long time or as part of house dust for
weeks. However, transmission usually occurs only after substantial exposure to someone with
active TB. A person can be infected by Mycobacterium tuberculosis for many years without
getting sick or spreading the organism to other people. (Anon, 2014). If a person with active
disease is left untreated, he or she will infect on the average between 10 and 15 people every
year. TB accounts for 2.5% of the global burden of disease and is the commonest cause of death
in young women, killing more women than all causes of maternal mortality combined.It
currently holds the seventh place in the global ranking of causes of death. Knowledge on TB
disease, its diagnosis and treatment therefore, is an important factor for the management and
outcomes. Even when TB-services are accessed, the response of the health staff determines
further actions. To improve case notification, there is a need to address the knowledge gaps
related to care seeking, and inappropriate actions of care providers in their interactions with
potential TB-cases. (Syed, F. and Mayosi, B. , 2007).

1
1.2 Statement of the Problem
Tuberculosis (TB) is a serious public health problem in Somalia and Somaliland. In 2013, more
than 13000 new cases were detected, one every 40 minutes. It is estimated that every 100 000
persons, 532 have contracted the disease, and the number of cases detected every year continue
to increase. (Dr. MOHAMED HUSSEIN MOHAMED, 2017). Tuberculosis (TB) is the second
leading cause of mortality from an infectious disease globally after the HIV infection.In 2013,
WHO estimated 9 million new TB cases and 1.5 million TB deaths globally, of which 80% of
the cases and 70% of deaths were reported in low-income and middle-income countries.Latent
tuberculosis infection (LTBI) is defined as a state in which individuals harbor live
Mycobacterium tuberculosis without evidence of manifestation of clinical or other symptoms of
active disease,Projections from mathematical models in 2000 estimate that over 30% of the
population globally were carriers of LTBI.one third of global population is infected
asymptomatically 5‐10% develop clinical disease. (Tariro J Basera, 1 Jabulani Ncayiyana, 1
Mark E Engel, 13 May 2016). TB is a communicable, airborne disease caused by
Mycobacterium tuberculosis. Transmission often leads to a latent TB infection that is non-
infectious and asymptomatic; an estimated one-third of the world’s total population has latent
TB. However, approximately 5–15% of all latently infected individuals will develop active TB
during their lifetime, with people living with HIV at considerably higher risk. If active TB is not
diagnosed and treated, mortality is high and the infection can remain transmissible. (Dr.Meenal,
2016). Worldwide, TB is one of the top 10 causes of death and the leading cause from a single
infectious agent (above HIV/AIDS). Millions of people continue to fall sick with TB each year.
In 2017, TB caused an estimated 1.3 million deaths (range, 1.2–1.4 million)2 among HIV-
negative people and there were an additional 300 000 deaths from TB (range, 266 000–335 000)
among HIV-positive people. Globally, the best estimate is that 10.0 million people (range, 9.0–
11.1 million) developed TB disease in 2017: 5.8 million men, 3.2 million women and 1.0 million
children. There were cases in all countries and age groups, but overall 90% were adults (aged
≥15 years), 9% were people living with HIV (72% in Africa) and two thirds were in eight
countries: India (27%), China (9%), Indonesia (8%), the Philippines (6%), Pakistan (5%),
Nigeria (4%), Bangladesh (4%) and South Africa (3%). These and 22 other countries in WHO’s
list of 30 high TB burden countries accounted for 87% of the world’s cases.4 Only 6% of global
cases were in the WHO European Region (3%) and WHO Region of the Americas (3%).The
severity of national epidemics varies widely among countries. In 2017, there were fewer than 10 new
cases per 100 000 populations in most high-income countries, 150–400 in most of the 30 high TB burden
countries, and above 500 in a few countries including Mozambique, the Philippines and South Africa.
(WHO, 2018).

2
1.3. Objectives of the study
1.3.1. Broad objective
The purpose of this study was to The Study of Knowledge and attitude towards tuberculosis
among nonmedical students golis universities faculty of Shareeco in Eriagvo city Somaliland.

1.3.2. Specific objectives

The specific objectives of the study were:

1. To measure the knowledge and attitude towards tuberculosis among the non-medical
students, in golis universities.
2. To describe the socio-demographic characteristics of the non-medical students in Golis
universities
3. To assess the minimum duration of TB treatment in somaliland

1.4. Research Questions

1.4.1. Main Research Question
The main research question of the study was what are the Knowledge and attitude towards
tuberculosis among nonmedical students Faculty of Sharia Gollis universities in Erigavo city
Somaliland.
1.4.2. The specific Research Question
1. How to assess knowledge and attitude towards tuberculosis among the non-medical
students, in Golis universities?
2. How to describe the socio-demographic characteristics of the non-medical students in
Golis universities?
3. What is the minimum duration of TB treatment in Somaliland?
1.5 (Rationale) Justification
Rising TB cases rates over the past decade in many countries in sub Saharan Africa and in parts
of South East Asia are largely attributable to the HIV epidemics. Tuberculosis still represents an
important global public health threat and it is one of the world‘s leading causes of death. The
ultimate target of the Stop TB partnership is to eliminate TB as a public health problem (less
than 1 case per million populations) by the year 2050.
1.6 SIGNIFICANCE OF STUDY
This study can also be beneficial for other researcher to help valuable evidence regarding issue
of prevention and alertness. It can also be valuable to the association working in healthcare

3
specialized especially public health staffs, this study can also provide information to those
working in the area of tropical countries.

1.7 Operational Definitions

There are a number of operational definitions that frame and help guide this research.
These include:

1. Knowledge of TB - A measure of how much the PTB patients know on the cause,
infectiousness, mode of transmission, symptoms.
2. Attitude of TB disease - It is the study subjects‟ view of TB disease.
3. Pulmonary Tuberculosis - TB occurring in the lungs.
4. Severity of illness - This was a measure of the degree of illness.
5. TB - Tuberculosis is an infectious disease caused by a bacillus called Mycobacterium
tuberculosis, an acid fast rod shaped bacillus.
6. TB symptoms - The following symptoms were considered as TB symptoms: Cough of
longer than 2 weeks, fever and night sweat, loss of weight, chest pain, shortness of
breath, coughing sputum which is blood stained (hemoptysis).
7. Extra-pulmonary TB (EPTB) - TB occurring outside the lungs.
8. Gender - The social difference between male and female.
9. Government/public health facility - Health facilities under the Ministry of Health
(MoH)
1.8 Study area:
The study was conducted Golis universities in Erigao Sanaag region.

4
1.9 Conceptual Frame Work
The following is a conceptual framework of the possible factors that influence of tuberculosis

Independent Variables

1. Being male
2. Occupations with high
environmental risk
3. Smoking/alcoholism/drug Dependent Variable
abuse
4. HIV
5. Other immunosuppressive
conditions
6. Diabetes mellitus
Tuberculosis
7. Vitamin deficiency
8. Stress
9. High population density
10. Lack of social protection
11. Geographic/ economic/
cultural barriers
12. Overcrowded housing
13. Living in urban areas
14. Poverty
15. Travel to endemic area
16. Age
17. Pregnancy
18. Level of education

5
 CHAPTER TWO:
LITERATURE REVIEW
2.0: Introduction.
Population’s knowledge on tuberculosis (TB) is crucial in early seeking of medical Care. Delay
in diagnosis for any reason contributes to advanced forms and TB transmission in the
community. Knowledge about TB in general population of is poor, including vulnerable groups
(smolovic M, 2012, April- jun). Aim: to assess knowledge about TB in a group of non-medical
students and their attitudes towards TB patients, sources of medical Information they use or
desire.

2.1: Tuberculosis
Tuberculosis (TB) is a chronic infectious disease caused by a bacterium called Mycobacterium
Tuberculosis. It usually affects the lungs in 80% of cases with warning signs of cough
Haemoptysis and chest pain, shortness of breath, fever, weight loss, and drenching night sweat.
TB is spread mainly through the air inform of droplets. When infectious people cough, sneeze,
talk, laugh or spit, droplets containing Mycobacterium tuberculosis are sprayed into the air.
People nearby may inhale the bacteria and become infected. Mycobacterium tuberculosis can
remain viable as airborne droplet suspended in the air for a long time or as part of house dust for
weeks. However, transmission usually occurs only after substantial exposure to someone with
active TB. A person can be infected by Mycobacterium tuberculosis for many years without
getting sick or spreading the organism to other people. If the immune system is weakened by
immunosuppressive disease like HIV infection, diabetes mellitus, malignancy, chronic kidney
disease, extremes of ages, and immunosuppressive agent latent TB infection can develop into
active disease. If a person with active disease is left untreated, he or she will infect on the
average between 10 and 15 people every year. TB accounts for 2.5% of the global burden of
disease and is the commonest cause of death in young women killing more women than all
causes of maternal mortality combined. Ninety-five per cent of all cases and 99% of deaths occur
in developing countries. It currently holds the seventh place in the global ranking of causes of
death. Knowledge on TB disease, its diagnosis and treatment therefore is an important factor for
the management and outcomes. Even when TB-services are accessed, the response of the health
staff determines further actions. To improve case notification, there is a need to address the

6
knowledge gaps related to care seeking, and inappropriate actions of care providers in their
interactions with potential TB-cases. (Ahmadinejad, Z, 23 May 2016).

2.2: Path physiology of Tuberculosis

2.2.1: Mycobacterium tuberculosis
Tuberculosis is an infection caused by the rod-shaped, non-spore-forming, aerobic bacterium
Mycobacterium tuberculosis. Mycobacterium commonly measure 0.5 μm by 3 μm, are classified
as Acid-fast bacilli, and have a unique cell wall structure crucial to their survival. The well
developed Cell wall contains a considerable amount of a fatty acid, my colic acid, covalently
Attached to the underlying peptidogly can-bound polysaccharide arabinogalactan (Biopolymer
Consisting of arabinose and galactose monosaccharide), providing an extraordinary lipid barrier.
This barrier is responsible for many of the medically challenging physiological characteristics of
Tuberculosis, including resistance to antibiotics and host defense mechanisms. The composition
and quantity of the cell wall components affect the bacteria’s virulence and growth rate. The
Peptidogly can polymer confers cell wall rigidity and is just external to the bacterial
cellMembrane, another contributor to the permeability barrier of mycobacterium. Another
important Component of the cell wall is lipoarabinomannan (Glycolipid and major virulence
factor in the Bacteria genus Mycobacterium), a carbohydrate structural antigen on the outside of
the organism that is immunogenic and facilitates the survival of mycobacteria within
macrophages. The cell Wall is key to the survival of mycobacterium and a more complete
understanding of the Biosynthetic pathways and gene functions and the development of
antibiotics to prevent formation of the cell wall are areas of great interest. (Knechel, (2009)

2.2.2: Transmission of Mycobacterium tuberculosis

Mycobacterium tuberculosis is spread by small airborne droplets in most cases (97%), called
Droplet nuclei, generated by the coughing, sneezing, talking, or singing of a person with
Pulmonary or laryngeal tuberculosis. These virulent bacilli once inhaled will stay in the
pulmonary alveoli, where they will be phagocytosed (to envelop and destroy bacteria and other
foreign materials). It is the primary infection may be asymptomatic. Once infectious particles are
Aerosolized, they are spread throughout a room or building by air currents and can be inhaled by
another individual. One droplet nuclei contains no more than 3 bacilli. Droplet nuclei are so
small that they can remain air-borne for extended periods of time. The most infective droplet
Nuclei tend to have a diameter of 5um. Coughing generates about 3000 droplet nuclei. Talking

7
For 5 minutes generates 3000 droplet nuclei but singing generates 3000 droplet nuclei in one
Minute. Sneezing generates the most droplet nuclei by far, which can spread to individuals up to
10 feet away. Tuberculosis begins when droplet nuclei reach the alveoli. When a person inhales
Air that contains droplets most of the larger droplets become lodged in the upper respiratory tract
like nose and throat, where infection is unlikely to develop. Generally the number of bacilli in
The droplets, the virulence of the bacilli, exposure of the bacilli to UV light, degree of
ventilation, and occasions for aerosolization all influence transmission. Introduction of M.
tuberculosis into the lungs leads to infection of the respiratory system; however, the organisms
can spread to other Organs, such as the lymphatics, pleura, bones/joints, or meninges, and cause
extra pulmonary Tuberculosis. (Knechel, (2009).

2.2.3: Effects of Mycobacterium tuberculosis in the body

Once inhaled, the infectious droplets settle throughout the airways. The majority of the bacilli are
trapped in the upper parts of the airways where the mucus-secreting goblet cells exist. The mucus
produced catches foreign substances, and the cilia on the surface of the cells constantly beat the
mucus and its entrapped particles upward for removal. This system provides the body with an
initial physical defense that prevents infection in most persons exposed to tuberculosis Bacteria
in droplets that bypass the mucociliary system and reach the alveoli are quickly surrounded and
engulfed by alveolar macrophages, the most abundant immune effectors cells present in alveolar
spaces. These macrophages, the next line of host defense, are part of the innate immune system
and provide an opportunity for the body to destroy the invading mycobacteria and prevent
infection. Macrophages are readily available phagocytic cells that combat many pathogens
without requiring previous exposure to the pathogens. Several mechanisms and macrophage
receptors are involved in uptake of the mycobacteria. Macrophages are readily available
phagocytes cells that combat many pathogens without requiring previous exposure to the
pathogens. Several mechanisms and macrophage receptors are involved in uptake of the
mycobacteria. The mycobacterial lipoarabinomannan is a key ligand for a macrophage receptor.
The complement system also plays a role in the phagocytosis of the bacteria. The complement
protein C3 binds to the cell wall and enhances recognition of the mycobacteria by macrophages.
Opsonization (an immune process where particles such as bacteria are targeted for destruction by
an immune cell known as a phagocyte) by C3 is rapid, even in the air spaces of a host with no
previous exposure to M tuberculosis. The subsequent phagocytosis by macrophages initiates a

8
cascade of events that results in either successful control of the infection, followed by latent
tuberculosis, or progression to active disease, called primary progressive tuberculosis. After
being ingested by macrophages, the mycobacteria continue to multiply slowly,8 with bacterial
cell division occurring every 25 to 32 hours. Regardless of whether the infection becomes
controlled or progresses, initial development involves production of proteolytic enzymes and
cytokines by macrophages in an attempt to degrade the bacteria. Released cytokines attract T
lymphocytes to the site, the cells that constitute cell-mediated immunity. Macrophages then
present mycobacterial antigens on their surface to the T cells. This initial immune process
continues for 2 to 12 weeks; the microorganisms continue to grow until they reach sufficient
numbers to fully elicit the cell-mediated immune response, which can be detected by a skin test.
(Janssen, T., 1940).

2.3: Risk Factors of Tuberculosis

Tb disease can develop soon after becoming infected (within weeks) before immune system can
fight the TB bacteria. Some people may get sick years later, when their immune system becomes
weak for another reason. Overall, about 5 to 10% of infected persons who do not receive
treatment for latent TB infection will develop TB disease at some time in their lives. For persons
whose immune systems are weak, especially those with HIV infection, the risk of developing TB
disease is much higher than for persons with normal immune systems. Certain factors can
increase the risk of tuberculosis. These factors include:

2.3.1: Weakened immune system:

A healthy immune system often successfully fights TB bacteria, but body can't mount an
effective defense if resistance is low. A number of diseases and medications can weaken immune
system, including:

 HIV infection (the virus that causes AIDS)

 Diabetes
 Severe kidney disease
 Cancer treatment, such as chemotherapy
 Drugs to prevent rejection of transplanted organs
 Some drugs used to treat rheumatoid arthritis,
 Crohn's disease and psoriasis
 Malnutrition
 Very young or advanced age

9
  Low body weight (10% below ideal)
 Certain cancers (Head and neck cancer). (MOHAMED., Dr. MOHAMED HUSSEIN,
2017).

2.3.2: Traveling or living in certain areas

The risk of contracting tuberculosis is higher for people who live in or travel to countries that
have high rates of tuberculosis and drug-resistant tuberculosis, include:

 Africa
 Eastern Europe
 Asia
 Russia
 Latin America
 Caribbean Island

2.3.3: Poverty and substance abuse

 Lack of medical care: If we receive a low or fixed income, live in a remote area, have
recently immigrated to the United States, or are homeless, may lack access to the medical
Care needed to diagnose and treat TB.
 Substance abuse: IV drug use or alcohol abuse weakens immune system and makes more
vulnerable to tuberculosis.
 Tobacco use: Using tobacco greatly increases the risk of getting TB and dying of it.

2.3.4. Place of work or living

 Health care work: Regular contact with people who are ill increases the chances of
exposure to TB bacteria. Wearing a mask and frequent hand-washing greatly reduce the
risk.
 Living or working in a residential care facility: People who live or work in prisons,
immigration centers or nursing homes are all at a higher risk of tuberculosis. That's
because the risk of the disease is higher anywhere there is overcrowding and poor
ventilation.
 Living in a refugee camp or shelter: Weakened by poor nutrition and ill health and living
in crowded, unsanitary conditions, refugees are at especially high risk of tuberculosis
infection. (Desalu, O., Adeoti, A, 2013)

10
2.4: Types of Tuberculosis
Tuberculosis is a dangerous and highly contagious disease caused by the bacterium
Mycobacterium tuberculosis. While TB usually affects the lungs, it can also infect other parts of
the body including the spine, brain and kidney. If proper medical attention is not received, TB
can be fatal. The medical community divides this disease into two categories--pulmonary and
extra pulmonary, which together cause 11 distinct types of tuberculosis. Pulmonary tuberculosis
is responsible for four of these and extra pulmonary the remaining seven. Extra pulmonary
tuberculosis occurs primarily in those with a compromised immune system.

2.4.1: Pulmonary Tuberculosis

TB disease most commonly affects the lungs; this is referred to as pulmonary TB. In 2011, 67%
of TB cases in the United States were exclusively pulmonary. Patients with pulmonary TB
usually have a cough and an abnormal chest radiograph, and may be infectious. Although the
majority of TB cases are pulmonary, TB can occur in almost any anatomical site or as
disseminated disease. Different types of pulmonary tuberculosis are given below:

2.4.1.1: Laryngeal TB
Laryngeal TB occurs when the bacterium attacks the throat's vocal chords. This highly
uncommon pulmonary TB is frequently confused with other throat diseases like chronic
laryngitis and laryngeal carcinoma. (Iseman, 2016)

2.4.1.2: Cavitary TB
Cavitary TB involves the upper lobes of the lung. The bacteria cause progressive lung
destruction by forming cavities, or enlarged air spaces. This type of TB occurs in reactivation
disease. The upper lobes of the lung are affected because they are highly oxygenated (an
environment in which (M.tuberculosis thrives).Symptoms include productive cough, night
sweats, fever, weight loss, and weakness. There may be hemoptysis (coughing up blood).
Occasionally, disease spreads into the pleural space and causes TB empyema (pus in the pleural
fluid). (Desalu, O., Adeoti, A, 2013)

11
2.4.1.3: Miliary TB
"Miliary" describes the appearance on chest X-ray of very small nodules throughout the
lungsthat look like millet seeds. Miliary TB can occur shortly after primary infection. The
patientbecomes acutely ill with high fever and is in danger of dying. The disease also may lead
tochronic illness and slow decline. Symptoms may include fever, night sweats, and weight loss.
Itcan be difficult to diagnose because the initial chest x-ray may be normal. Patients who
areimmune suppressed and children who have been exposed to the bacteria are at high risk
fordeveloping miliary TB.

2.4.1.4: TB Pleurisy
This usually develops soon after initial infection. A granuloma located at the edge of the lung
ruptures into the pleural space, the space between the lungs and the chest wall. Once the
bacterium invade the space, the amount of fluid increases dramatically and compresses the lung,
causing shortness of breath (dyspnea) and sharp chest pain that worsens with a deep breath
(Pleurisy). Tuberculosis pleurisy generally resolves without treatment; however, two-thirds of
patients with tuberculosis pleurisy develop active pulmonary TB within 5 years.

2.4.2: Extra pulmonary Tuberculosis

Extra pulmonary TB disease occurs in places other than the lungs, including the larynx, the
Lymph nodes, the pleura, the brain, the kidneys, or the bones and joints. Different types of Extra
pulmonary tuberculosis are following:

2.4.2.1: Adrenal Tuberculosis

Adrenal TB is an extrapulmonary form of TB that affects the adrenal gland and the production of
adrenal hormone. Patients with this form of TB often feel weak or faint due to insufficient
adrenal gland production. (Manso, 2016)

2.4.2.2: Lymph Node Disease

When the TB bacterium impacts the lymph nodes and causes them to become enlarged, lymph
node disease is diagnosed. This extra pulmonary TB can even cause the lymph nodes to become
so large they rupture through the skin if not diagnosed in time. (Janssen, T., 1940)

2.4.2.3: Osteal Tuberculosis

Osteal TB is an infection of the bones caused by the TB bacteria. This extra pulmonary form can
lead to bone tissue weakening and even bone fractures depending on where the disease has

12
spread in the body. While infection can occur in any bone, the spine is most usually attacked,
which can lead to compression fractures and back deformity. (Janssen, T., 1940)

2.4.2.4: TB Peritonitis
Mycobacterium tuberculosis can involve the outer linings of the intestines and the linings inside
the abdominal wall, producing increased fluid, as in tuberculosis pleuritis. Increased fluid leads
to abdominal distention and pain. Patients are moderately ill and have fever. (Janssen, T., 1940)

2.4.2.5: Renal TB
When a patient has pyuria, or white blood cells in the urine, this can be an indication of renal TB.
If renal TB spreads undetected, it can affect reproductive organs. In men, renal TB can lead to
swelling of the tube that connects the testicles with the vas deferens, a condition known as
epididymitis. (Hawes, 2016)

2.4.2.6: TB Meningitis
Patients that show signs of a stroke or a brain tumor should be checked for the presence of the
TB bacterium. If present, TB meningitis is diagnosed. This potentially fatal form of extra
pulmonary tuberculosis infects the brain. (Thwaites, 2000)

2.4.2.7: TB Pericarditis
Tuberculosis pericarditis occurs when excess fluid builds around the heart. When TB affects this
area the ability of the heart to fill with blood and beat properly can be hampered. (Syed, F. and
Mayosi, B., 2007)

2.5: Symptoms of Tuberculosis

2.5.1: Pulmonary TB Symptoms:
The main symptoms of pulmonary tuberculosis are:

 Persistent cough of 2 weeks or more or any duration if HIV positive

 Fever for more than 2 weeks
 Drenching night sweats
 Unexplained weight loss (more than 1.5 kg in a month)

A productive cough, often accompanied by systemic symptoms such as fever, night sweats or
loss of weight, is the commonest presentation of pulmonary tuberculosis. Every patient with a
positive symptom screen must be investigated appropriately. Not all those with TB will have a
cough; therefore, a high index of suspicion is required, particularly in people who are HIV

13
positive who may only have one of the above symptoms. Some patients may present with chest
pains (due to pleurisy, muscle strain), breathlessness (due to extensive lung disease or
concomitant pleural effusion), localized wheeze due to local tuberculosis bronchitis, or because
of external pressure on the bronchus by an enlarged lymph node. (Boahen, E., 2014).

2.5.2. Physical signs

Physical signs may not be helpful in confirming the diagnosis, but it is important to examine the
Patient carefully. Some of the common signs are:

Fever – the body temperature may be high or irregular (greater than 38.5 degrees Celsius)

Pulse – the pulse rate may be raised because of fever

Chest – there may be no abnormal signs, crackles in the lung apices more pronounced on deep
Breathing; localized wheeze in local obstruction or pressure; dullness where there is effusion and
in chronic disease there may be extensive fibrosis with the trachea pulled to one side. All
Individuals suspected of having pulmonary tuberculosis should have at least one sputum
Specimen examined for bacteriological confirmation of TB disease using the rapid diagnostic
Tests. (Hawes, 2016)

2.5.3: Symptoms of Extra pulmonary TB

Symptoms of Extra Pulmonary Tb vary, but can include:
 Persistently swollen glands
 Abdominal (tummy) pain
 Pain and loss of movement in an affected bone or joint
 Confusion
 Persistent headache
 Seizures (fits) (Manso, 2016).

2.6: Diagnosis of Tuberculosis

The diagnosis of TB depends on numerous factors namely; self-presentation of persons with TB
symptoms to health care facility, high index of TB suspicion among health care professionals,
TB screening practices in health facilities, sensitivity and specificity of diagnostic test used,
turnaround time for delivery of laboratory results, and the capacity to trace people with positive
results and start them on treatment.

14
2.6.1: Diagnosing Active TB
Active TB disease can be difficult to diagnose, especially in children and those who have
weakened immune systems, additional tests beyond medical examinations are required. The
following tests may be used to determine if a patient has active TB disease:

1. Tuberculin Skin Test (TST)

2. Chest Radiograph (X-ray)
3. Sputum Smear Microscopy (SSM)
4. Culture
5. Polymerase Chain Reaction (PCR)
6. Ultrasound
7. Adenosine Deaminase (ADA)
8. Erythrocyte Sedimentation Rate (ESR)
9. TB LAM (lateral flow version)

2.6.1.1: Tuberculin skin test

The TST has been in existence for over 100 years. The tuberculin test has limited value in
clinical work, especially where TB is common. The test shows hypersensitivity to proteins of the
TB bacillus, as a result either of infection with M. tuberculosis or induced by Bacille Calmette-
Guérin (BCG) vaccination. A positive TST does not indicate TB disease, only infection.
Infection is one of the criteria used in the diagnosis of TB in children. A negative result does not
rule out the diagnosis of TB disease as various conditions, including HIV, may suppress the
reaction.TST test is done by injecting small amount of liquid containing TB proteins into the
lower part of the arm. The injection site is examined by a trained healthcare professional 2 – 3
days later. If the person has LTBI, the body recognizes the proteins that were injected and
responds by forming a lump where the TB proteins were injected.

The skin test result depends on the size of the raised, hard area or swelling. It also depends on the
person’s risk of being infected with TB bacteria and the progression to TB disease if infected.

 Positive skin test: This means the person’s body was infected with TB bacteria.
Additional tests are needed to determine if the person has latent TB infection or TB
disease. A health care worker will then provide treatment as needed.
 Negative skin test: This means the person’s body did not react to the test, and that latent
TB infection or TB disease is not likely. (Salmanzadeh, 2015)

15
2.6.1.2: Chest-X-rays
Chest X-rays are used to check for lung abnormalities in people who have signs and symptoms
of TB disease in the lungs. Although chest x-rays may suggest that TB disease is present, a chest
X-ray alone cannot definitely diagnose a tuberculosis infection in the lungs or anywhere else in
the body. Chest x-rays are necessary in patients who cannot produce sputum or who have
negative expert results and are HIV positive, and where extra pulmonary TB (such as pleural
effusions and pericardial TB) is suspected. While CXR is non-specific for TB, the presence of
infiltrates, lymph nodes or cavities is highly suggestive of TB. The x-ray findings must be
interpreted in the light of the patient’s history and clinical findings. Other indications for the use
of chest x-rays include:

 To assist in the diagnosis of suspected complications of TB disease such as

pneumothorax, pleural effusion or patients with frequent or severe haemoptysis.
 To help in diagnosing other concomitant lung diseases such as lung cancer,
bronchiectasis (abnormal widening of the bronchi or their branches, causing a risk of
infection), lung abscess (bacterial infection that occurs in the lung tissue) and
pneumoconiosis (a disease of the lungs due to inhalation of dust, characterized b
inflammation, coughing, and fibrosis). (Knechel, (2009)

2.6.1.3: Sputum Smear Microscopy (SSM):

This is a simple laboratory test that examines sputum for bacteria using a microscope. Since
some other non-TB bacteria appear similar to Mycobacterium tuberculosis, it cannot always
distinguish between TB and other infections. It is commonly used to diagnose active TB disease
because it can quickly determine if a person is infected. However, it sometimes gives a negative
result even in people with TB disease so a negative result cannot be relied upon. (Gandhi, M.,
Kumar, A., Toshniwal, M., Reddy, R., Oeltmann, J., Nair, S., Satyanarayana, S., 2012)

16
1.1: Methods of obtaining sputum sample (Takahashi, 1975)
Method Description Advantage Disadvantage
Sputum sample Patient coughs up sputum Easy to perform Patient may not be able to
into sterile container cough up sputum
Education and supervision
of the patient is required
Nebulisation/ A tube is inserted into the Used to obtain sputum Must be done early
Sputum induction stomach through the in children who do not morning before eating
patients mouth or nose to cough up sputum Patient may need to be
obtain swallowed sputum hospitalized
Bronchoscopy A scope is passed through Used to obtain sputum Requires special
the mouth or nose to the when the patient equipment
diseased part of the lung to cannot cough and Must be done in a hospital
obtain sputum or lung gastric aspirate cannot by a specialist
tissue be done.

2.6.1.5: Culture
Culture techniques are used to grow live TB bacteria in a laboratory. This is a reliable method
fordetecting active TB disease as long as a suitable sample containing the TB bacteria can
beobtained. TB can be cultured from a variety of specimens. This test can also provide
informationon which antibiotics would be effective in treating the infection. A major drawback
of this test isthe length of time it takes to obtain the results (2-6 weeks).

2.6.1.6: Polymerase chain reaction (PCR)

These tests detect the presence of genetic material in bacteria. PCR can detect small amounts of
genetic material. However, to be effective, the samples still have to contain a certain number of
TB bacteria. It is sometimes difficult to obtain a good sample so people with TB disease may
give a negative PCR result. The test is also quite complicated and can be expensive.

17
2.6.1.7: Ultrasound
The ultrasound can be used as a supplementary investigation in the diagnosis of extra pulmonary
TB particularly abdominal and pericardial TB.

2.6.1.8: Adenosine Deaminase (ADA)

ADA is an enzyme found in most cells, it is elevated in TB effusions (>30μl). This test may
therefore be useful in confirming the cause of an effusion when it doubt (Salmanzadeh, 2015)

2.6.1.9: Erythrocyte Sedimentation Rate (ESR)

This test is not a confirmatory test for TB. A number of infections and diseases result in elevated
ESR, therefore low specificity for TB.

2.6.2: Diagnosis of Latent TB Infection

Latent TB Infection (LTBI) can convert to active disease, especially in people with a weakened
immune system that may be unable to control the latent infection. It is therefore important to
identify those people with LTBI and treat them before they convert to active TB disease and pass
it onto others. Risk groups are with higher rates of conversion to active disease include children,
the elderly, transplant patients, people who are HIV positive, and those being treated for
rheumatoid arthritis. (Ahmadinejad, Z, 23 May 2016)

2.7: Current Anti-TB Drugs

Currently, there are 10 drugs approved by the U.S. Food and Drug Administration (FDA) for the
treatment of TB disease. In addition, the fluoroquinolones (levofloxacin, moxifloxacin, and
gatifloxacin), although not approved by the FDA for TB disease, are commonly used to treat TB
disease caused by drug-resistant organisms or for patients who are intolerant of some first-
linedrugs. Rifabutin, approved for use in preventing Mycobacterium avium complex disease in
patients with HIV infection but not approved for TB disease, is useful for treating TB disease
inpatients concurrently taking drugs that interact with rifampin (e.g., certain antiretroviral
drugs).Amikacin and kanamycin, nearly identical aminoglycoside drugs used in treating patients
withTB disease caused by drug-resistant organisms, are not approved by the FDA for treatment
ofTB. Of the approved drugs, isoniazid (INH), rifampin (RIF), ethambutol (EMB),
andpyrazinamide (PZA) are considered first-line anti-TB drugs and form the core of
standardtreatment regimens. Rifabutin (RBT) and rifapentine (RPT) may also be considered
firstlinedrugs under certain circumstances. RBT is used as a substitute for RIF in the treatment of

18
all forms of TB caused by organisms that are known or presumed to be susceptible to this
agent.RBT is generally reserved for patients for whom drug-drug interactions preclude the use of
rifampin. Streptomycin (SM) was formerly considered to be a first-line drug and, in some
instances, is still used in the initial treatment regimen. However, an increasing prevalence of
resistance to SM in many parts of the world has decreased its overall usefulness. The remaining
drugs are reserved for special situations such as drug intolerance or resistance. (Boahen, E.,
2014)

2.8 Currently Used anti-TB Drugs (Boahen, E., 2014)

Drugs classes Anti-Tb Drugs Comments

First-line drugs Ionized (INH) INH, RIF, PZA, and EMB form the core of
Rifampin (RIF) initial treatment regimen
Pyrazinamide (PZA)
Ethambutol (EMB)
Rifabutin (RBT) May be used as a substitute for RIF in the
treatment of all forms of TB caused by
organisms that are known or presumed to be
susceptible to this agent.

2.2: Currently Used anti-TB Drugs.(Boahen, E., 2014)

Drugs classes Anti-Tb Drugs Comments

Drugs classes Anti-Tb Drugs Comments
Rifapentine (RPT) May be used once weekly with INH in the
continuation phase of treatment for HIV-
negative patients with noncavitary,
drugsusceptible pulmonary TB who have
negative sputum smears at completion of
the initial phase of treatment
Second line drugs Streptomycin (SM) SM was formerly considered to be a first-
line drug and in some instances, is still used

19
 in initial treatment. Increasing prevalence of
resistance to SM in many parts of the world
has decreased its overall usefulness
Cycloserine, Terizodine, These drugs are reserved for special
Ofloxacin, situations such as drug intolerance or
Levofloxacin, Ethionamide, resistance
Moxifloxacin,Gatifloxacin,A
mikacin,
Kanamycin

2.8: TB Disease Treatment Regimens:

There are four basic treatment regimens recommended for treating adults with TB disease caused
by organisms that are known or presumed to be susceptible to INH, RIF, PZA, and EMB. Each
treatment regimen consists of an initial 2-month treatment phase followed by a continuation
phase of either 4 or 7 months. The 4-month continuation phase is used for the majority of
patients. Although these regimens are broadly applicable, there are modifications that should be
made under specified circumstances.

2.8.1: Initial Phase

The initial phase of treatment is crucial for preventing the emergence of drug resistance and
determining the ultimate outcome of the regimen. Four drugs—INH, RIF, PZA, and EMB—
should be included in the initial treatment regimen until the results of drug-susceptibility tests are
available. Each of the drugs in the initial regimen plays an important role. INH and RIF allow for
short-course regimens with high cure rates. PZA has potent sterilizing activity, which allows
further shortening of the regimen from 9 to 6 months. EMB helps to prevent the emergence of
RIF’s resistance when primary INH resistance is present. If drug-susceptibility test results are
known and the organisms are fully susceptible, EMB need not be included. For children whose
clarity or sharpness of vision cannot be monitored, EMB is usually not recommended except
when the risk of drug resistance is high or for children who have “adult-type” (upper lobe
infiltration, cavity formation) TB disease.

20
 2.8.2: Continuation Phase
If the Mycobacterium tuberculosis isolate is sensitive to isoniazid, rifampicin, and pyrazinamide,
then isoniazid and rifampicin are given for 4 months in the continuation phase (i.e., 6 months of
total treatment). Total therapy for 9 months is considered for patients with extensive skeletal TB,
especially when large joints are involved with slow clinical response. Patients with CNS TB
receive 7 to 10 months of continuation phase therapy (9 to 12 months total). Patients with MDR
TB should have their final regimen based on the results of drug-susceptibility testing, in
consultation with an expert. (Ray, A. and Gulati, K., 2007)

Table 1.3: Dosage Recommendations for the Treatment of TB in Adults and Children
(Principe et al., 2015)

Drug Adults/ Daily 1 time/week 2times/week 3 times/week

Children
EMB Adults weight 40–55 kg 14.5–20 36.4–50 21.8–30
mg/kg(800 mg/kg(2000 mg/kg(1200
mg) mg) mg)
56- 75 kg 16–21.4 mg/kg 37.3–50 26.7–35.7
(1200 mg mg/kg(2800 mg/kg(2000
mg mg)
76–90 kg 17.8–21.1 44.4–52.6 26.7–31.6
mg/kg(1600 mg/kg(4000 mg/kg(2400
mg) mg) mg)
Children 15–20 mg/kg(1000 50mg/kg(2500
mg) mg)
*

21
2.9: Treatment for Extra pulmonary TB
Six months treatment is as effective in extra-pulmonary as in pulmonary disease. In some
instances of severe or complicated disease (meningitis, TB bones/joints, miliary TB) treatment
may need to be extended to nine months. The intensive phase remains two months and the
continuation phase is prolonged to seven months-2(RHZE)/7(HR) that means the duration of the
initial phase is 2 months and drug treatment is daily, with rifampicin (R), isoniazid (H),
pyrazinamide (Z) and ethambutol (E). The continuation phase is 7 (RH). The duration is 7
months, with rifampicin (R) and isoniazid (H) three times per week,

2.10: Adjunctive treatment

2.10.1: Pyridoxine (Vitamin B6)
The use of Pyridoxine is recommended for all adults patients started on TB treatment to prevent
peripheral neuropathy most commonly caused by Isoniazid. Dose of Pyridoxine: 25mg daily if
patient develops peripheral neuropathy at any stage during TB treatment, the dose can be
increased to 50 – 75mg (up to maximum of 200mg) until the symptoms subside, then reduce to
25mg daily.(Boahen, E., 2014)

2.10.2: Steroids
The use of corticosteroids is recommended in extra-pulmonary tuberculosis, particularly for TB
meningitis and pericarditis. High dose steroid treatment for 2-4 weeks and the taper off gradually
over several weeks depending on clinical progress is recommended. The response to treatment is
assessed clinically. (Boahen, E., 2014)

2.11: Different Treatment Strategies

Various treatment strategies are employed for treatment of TB. Initially the treatment consisted
of single drugs. But on administration of single drugs to patient having infection with sensitive
and resistant organisms, the sensitive organisms got killed, while the resistant ones proliferated
and developed greater resistance to the drugs. Hence double or triple drug therapy was initiated
in the treatment of TB to obtain complete eradication of all bacteria. Between (1948-1952),

Short course chemotherapy (SSC) was introduced with combinations of streptomycin and Para
amino salicylic acid. But still problem of patient compliance and missed doses remained, for
which the World Health Organization (WHO) introduced Fixed Dose Combinations (FDCs).

22
Further Directly Observed Treatment (DOTS) was also implemented with the purpose of direct
monitoring of the administration of Anti-TB drugs. (Ray, A. and Gulati, K., 2007)

2.11.1: Fixed Dose Combinations (FDC) Of Anti-TB Drugs

Currently the use of standardized regimen for the treatment of Tb is the fundamental strategy of
World Health Organization (WHO) and International Union against Tuberculosis and Lung
Diseases (IUATLD). Deviations from such regimen result in increased risk of side effects, or
decreased chance of cure or both. One of the best ways of ensuring compliance with such
regimens is to physically combine the requisite drugs into simple FDC products. FDC
formulation is a combination of two or more first line anti-TB drugs (rifampicin ,pyrazinamide,
isoniazid, etambutol) into a fixed proportion. WHO and IUATLD also advocate use of FDCs of
two, three or four anti-TB drugs even in DOTS programme. Use of FDCs as a routine therapeutic
regimen, simplifies TB treatment thereby increasing patients adherence to the therapy. (Ray, A.
and Gulati, K., 2007)

2.11.2: Directly Observed Therapy (DOT)

DOT is a component of case management that helps ensure patients adhere to therapy. It is the
method whereby a trained health-care worker or another trained designated person watches a
patient swallow each dose of anti-TB drugs and documents it. DOT is the preferred core
management strategy recommended for treatment of TB disease and, if resources allow, for
latent tuberculosis infection (LTBI) treatment. DOT can reduce the development of drug
resistance, treatment failure, or relapse after the end of treatment. Good case management, which
includes establishing a relationship with the patient and addressing barriers to adherence,
facilitates successful DOT. Nearly all the treatment regimens for drug-susceptible TB disease
can be given intermittently if they are directly observed. Using intermittent regimens reduces the
total number of doses a patient must take, as well as the total number of encounters with the
health-care provider or outreach worker, making these regimens more cost-effective. Drug
resistant TB disease should always be treated with a daily regimen and under direct observation.
There are no intermittent regimens for treatment of multidrug-resistant (MDR) TB. If anti-TB
drugs for the treatment of MDR TB need to be given twice daily, then DOT should be provided
twice daily as well. (Thwaites, 2000).

23
2.11.1: BCG Vaccine
BCG vaccines are live vaccines derived from a strain of Mycobacterium bovis. BCG is used in
many countries with a high prevalence of TB to prevent childhood tuberculous meningitis and
malaria disease. However, BCG is not generally recommended for use because of the low risk of
infection with Mycobacterium tuberculosis, the variable effectiveness of the vaccine against
adult pulmonary TB, and the vaccine’s potential interference with tuberculin skin test reactivity.
TSTs and TB blood tests to detect TB infection are not contraindicated for persons who have
been vaccinated with BCG. Evaluation of TST reactions in persons vaccinated with BCG should
be interpreted using the same criteria for those not BCG-vaccinated. Unlike the TST, TB blood
tests do not detect the presence of BCG and are less likely to give a false-positive result

2.14.2: Patient Education

Educating patients about TB disease helps ensure their successful completion of therapy. Health
care providers must take the time to explain clearly to patients what medication should be taken,
how much, how often, and when. Patients should be clearly informed about possible adverse
reactions to the medications they are taking and when to seek necessary medical attention.
Providing patients with the knowledge they need regarding the consequences of not taking their
Medicine correctly is very important. In addition, patients should be educated about infection
Control measures and potential need for isolation. HIV testing and counseling is recommended
for all patients with TB disease in all health-care settings. The patient must first be notified that
Testing will be performed. The patient has the right to decline HIV testing and counseling (opt-
out screening (smolovic M, 2012, April- jun)

2.12: Statistics on Global Epidemiology of Tuberculosis

WHO In 2017 10 million people fell ill with Tb and 1.6 million dead from disease including 0.3
million among people with HIV in 2017 one million children became ill with the TB and
230,000 children dead Tb. WHO estimates that there were 558,000 new cases with resistance
rifampicin and estimated 54 million live were saved though TB DX and RX

Roughly one-third of the world's population has been infected with M. tuberculosis, and new
Infections occur at a rate of one per second. However, not all infections with M. Tuberculosis
cause tuberculosis disease and many infections are asymptomatic. In 2007, there were an
estimated 13.7 million chronic active cases, and in 2010 there were 8.8 million new Cases, S

24
and 1.45 million deaths, mostly in developing countries. 0.35 Million of these deaths occurring
those co-infected with HIV.In 2009, it was estimated that there were over 9 million new cases of
TB across the world Resulting in an estimated prevalence of over 14 million cases. There were
also an estimated 1.3 Million deaths among HIV-negative cases and an additional 0.4 million
deaths among confected Patients with TB and HIV in 2009. In 2014, 1.2 million people died of
HIV and this Includes the 0.4 million TB deaths among HIV positive people. People, who have
both TB and HIV when they die, are internationally classified as having died from HIV. There
were an Estimated 9.6 million new cases of TB in 2014.There were an estimated 3.2 million
cases and 480,000 TB deaths among women. There were also an estimated 1.0 million cases of
TB in Children and 140,000 deaths. In 2014, an estimated 480,000 new cases of MDR-TB and
an Estimated 190,000 people died of MDR-TB. Due to its vast public health implications, it is
one of the three communicable diseases specifically mentioned under the Millennium
Development Goals (MDGs). This has contributed to structured efforts on a global scale with
notable Improvements in National TB Programmes (NTPs) worldwide. In spite of this though,
TB Remains a public health challenge globally.(Rom and Gray, 1996). In Somalia, the effort of
controlling tuberculosis began in the early 1960s with the establishment of TB centers and
sanatorium in three major urban areas of the country (FMOH Somalia 2008).

A nationwide survey conducted in Somalia between 1987&1990 showed that the annual risk of
infection of 1.4% which is lower than the 3.0% reported in 1953-1955 (Azbite M. 1992). In
1992, a standardized TB prevention and control program, incorporating directly observed
treatment, short course (DOTs) was started as a pilot in western (Somaliland) and central regions
(FMOH Somalia 2008).

Some researchers have surveyed the knowledge about TB among non-medical university
students in other countries (Akin S, Gorak G 2010). However the latest estimated for all forms of
the TB in Somalia were 290 per 100,000. The incidence of sputum smear positive cases was 160
per 100,000 populations. As states of (MOHAMED., Dr. MOHAMED HUSSEIN, 2017)

25
 CHAPTER THEE

METHODOLOGY
3.1 INTRODUCTION
This chapter describes the study design, study population, selection of participants and the
methods used for data collection and data analysis. In addition, the validity and reliability of the
study and ethical considerations of the study are discussed.

3.2 RESEARCH METHOD AND STUDY DESIGN

3.2.1. The Research method
The quantitative research method was used in order to answer the research questions of this
study. According to (Polit, F.D. & Beck, C.T., "2004"), the quantitative methodology uses
deductive reasoning to generate hunches that are tested in the real world. Therefore, to quantify
and measure the knowledge attitude towards TB among non medical students a quantitative
research method is required. Although a qualitative approach could have given a good
exploration or in-depth analysis of participant’s knowledge,.
Both quantitative and qualitative methods were used to make sure that all the important and
relevant information for the study was utilized. Another rationale is to neutralize the biases
inherited in either method through strength of the other or minimize their weaknesses. According
to Lisle (2011), mixed research methods strengthen the validity of the research findings. It also
improves instrumentation for the data collection approaches. Many explanatory variables were
incorporated to identify their effect on the dependent variable
3.2.2. The Research design
A research design refers to the structured approach followed by a researcher to answer a
particular research question (Joubert, G., Ehrlich, R., Katzenellenbogen, J. & Abdool Karim, S.,
"2007"). A cross-sectional design was used to conduct this study. According to (Polit, F.D. &
Beck, C.T., "2004") a cross-sectional design involves the collection of data at one point in time:
hence the phenomena under study are captured during one period of data collection. This study
design was chosen in that it provides a proficient and rapid means of revealing the knowledge
attitude towards TB among non medical students, and it analyses data with numerical
comparisons. In addition, it has the advantage of being less costly and more economical in time

26
than other designs. However, its core limitations are the probability of recall bias, bias in the
design and using a questionnaire to collect sensitive information.

3.3 THE STUDY POPULATION

The estimated study population was based on the average students registered in the Erigavo
district universities. In 2019 there were 65 registered. Therefore, the estimated study population
was 65 students.

3.4 SAMPLE SIZE AND SAMPLING TECHNIQUE

3.4.1 Sample size calculation
Based on the population size of 65 and a confidence level of 95%, the sample size of 56 was
calculated using the method described by Saunders et al. (2009:581-582):
 The confidence level was estimated at 95% (z value of 1.96).
 The confidence interval or margin of error was estimated at 5%
Assuming that 5=0.05 percent
The minimum required sample size was determined using the formula
𝑛 65 65 65
1. 𝑛 = n= n=65×0.0025 n= = = 56
1+𝑛(𝑒)2 1+65(0.05)2 1+0.1625 1.1625

Where
 N is the minimum sample size required
 N is the population
 The confidence level was estimated at 95% (z value of 1.96)
 e% is the margin of error was estimated at 5%

The minimum adjusted sample size used in this study is therefore 56 students.

3.5. The Sampling technique

This research will be employed by probability sampling technique in a probability sampling,
especially random sampling. The random sampling means that every case of the population has
an equal probability of inclusion in sample.

27
3.6 THE DATA COLLECTION PROCEDURE
3.6.1 The Data collection method
Data was collected through using a structured questionnaire. The research instrument used was a
structured questionnaire which collected data on knowledge attitude towards TB among non
medical students. The questionnaire itself had three sections: Section 1 covered demographic
characteristics; Section 2 with items measured the information TB; section 3 with items
measured the knowledge attitude of students on TB (Appendix number A).

3.7 DATA ANALYSIS

Prior to data analysis, data editing was performed to identify errors and strange values and to
compare them to the questionnaire for correction. Then the data was captured and analyzed using
Statistical Package for Social Sciences (SPSS) software version 16 and Excel.
Data Analysis is the process of evaluating data using analytical and logical reasoning to examine
each component of the data provided. This form of analysis is just one of the many steps that
must be completed when conducting a research experiment. Data from various sources is
gathered, reviewed, and then analyzed to form some sort of finding or conclusion.

3.8. Inclusion Criteria

Respondents include all students which are non medical students and recently registered in the
Erigavo district universities; both male and female candidates were included in the study.

3.9. Exclusion Criteria

All medical students and other Respondents who are not recently registered in the erigavo
districts universities were excluded from the study.

3.10. Variables measured by the instrument

The dependent variables measured are knowledge attitude related to TB.
The independent variables include the knowledge attitude status of the respondent and
demographic characteristics such as age, sex, and education.

3.11. ETHICAL CONSIDERATIONS

The following ethical issues were observed during the process of conducting this study:
(i) Ethical clearance was obtained from the academic dean and the dean of health science college
GOLLIS University – Erigavo Campus, while authorization to conduct research was sought from
the Ministry of Health and Ministry of Education department of Higher Education and research.

28
(ii) A written informed consent was obtained from the respondents after providing them with
information on the purpose of the study and their rights of participation in the research.
(iii) Anonymity and confidentiality was ensured by using questionnaire that did not require
respondents to divulge their identity.

3.12. STUDY LIMITATIONS

Although it was expected that participants would answer honestly and with integrity, it is also
possible that some of them might hide the truth when giving answers. This might affect the study
results and should be considered as a possible study limitation. Another possible study limitation
may be related to the fact that the study is context-specific to the culture and environment and
this may limit the generalization of findings to other areas that are not similar to the above
district. Also Language barrier: some respondents don’t understand the English language which
causes to translate to Somali language this problem becomes obstacle to get response easily.
Time and financial: The other limitation of the study is time and financial constraint. Lastly
Lack of research unit: it’s hard to get convenient or suitable data for our study in our country
because there is no research centre. Also there is no enough secondary data in the libraries of
universities of the district.

29
 CHAPTER FOUR
DATA PRESENTATION, ANALYSIS AND INTERPRETATION
4.1 Introduction
During this chapter in deeply present the analysis of data, and their interpretations. The data
analysis and interpretation was based on the research questions as well as research objectives,
this presentation is divided in to two parts. The first part presents the respondents‟ demographic
information such as, age, gender, education and marital status while the second part of the
presentation deals with, interpretation and analysis of the research questions and objectives by
using SPSS and sometimes in excel software. The following pages are the data presentations and
analysis of research findings

4.2: Characteristics of respondents

Table: 4.2.1Gender of the Respondents

Respondents were also asked to identify their gender and below are the responses:

Gender

Frequency Percent Valid Percent Cumulative Percent

Valid male 24 42.9 42.9 42.9

female 32 57.1 57.1 100.0

Total 56 100.0 100.0

Primary data source 2019

male, 24
female, 32

According to the above table 4.2.1 majority of the respondents were female at 57.14% while
42.86% were male. Therefore this analysis suggested that most of the Respondents were female.

30
Table: 4.2.2Marital status of Respondents

Marital status

Frequency Percent Valid Percent Cumulative Percent

Valid single 33 58.9 58.9 58.9

married 20 35.7 35.7 94.6

divorced 3 5.4 5.4 100.0

Total 56 100.0 100.0

Source: primary data source 2019

divorced
5%

married
36%
single
59%

Table 4.2.2 shows that the majorities’ respondents of the study were single which 58.9% is,
This represents to 33 respondents while married are 35.7% which represents to 20 respondents
and the others (divorced and widowers) are 5.4% which represents to 3 respondents, and that
indicates the most of students responded the questions are single.
Table 4.2.3 level of education attained

level of education attained

Frequency Percent Valid Percent Cumulative Percent

Valid Certificate 23 41.1 41.1 41.1

Diploma 16 28.6 28.6 69.6

Degree 17 30.4 30.4 100.0

Total 56 100.0 100.0

Source: primary data source 2019

31
 80
41.1
60 28.6 30.4
40 23 16 17
20 0
0
level of education attained Certificate Diploma Degree

Series1 Series2 Series3

The above table 4.2.3 shows us most of the respondents 41.07% are attended or hold at
certificate; this represents to 23 respondents, another 30.36% of the respondents are attended
bachelor degree , this represents to 17 respondents, while 28.57% of respondents were hold
diploma level and represents to 16 respondents most interesting issue the respondents there is no
one hold on masters degree level . That clarifies most people who takes part to the survey was
students.
Table 4.2.4 Current occupations status

Current occupations status

Frequency Percent Valid Percent Cumulative Percent

Valid Student 52 92.9 92.9 92.9

Self-employed 3 5.4 5.4 98.2

Employed 1 1.8 1.8 100.0

Total 56 100.0 100.0

Source: primary data source 2019

32
 Self-employed Employed
5% 2%

Student
93%

The above figure 4.2.4 shows us most of the respondents 92.9 % are students ; while 4.4% % of
respondents are self-employed respondents and 1.8% of the respondents are employed . That
clarifies most people who takes part to the survey was students.

Table 4.2.5 Age of the Respondent (years)

Age of respondent ( years)

Frequency Percent Valid Percent Cumulative Percent

Valid 18-21 11 19.6 19.6 19.6

22-25 19 33.9 33.9 53.6

26-29 19 33.9 33.9 87.5

32-35 7 12.5 12.5 100.0

Total 56 100.0 100.0

Source: primary data source 2019

18-21
22-25
26-29
32-35

33
The above table 4.2.5 shows that the most of the repeated Age for the respondents were the
groups Between 22-25 and 26-29 and its percentage is 33.9% each while the Age between 18-21
is 19.6% and age between 32-35 where 12.5%, therefore majority of respondents whose
participate this questionnaire were the middle age which is the age between 22- 29 years.

Table 4.2.6 Total monthly income

Total monthly income

Frequency Percent Valid Percent Cumulative Percent

Valid less than $100 32 57.1 57.1 57.1

$100-$300 20 35.7 35.7 92.9

$300 - $600 2 3.6 3.6 96.4

$600 - $900 1 1.8 1.8 98.2

More than $1000 1 1.8 1.8 100.0

Total 56 100.0 100.0

Source: primary data source 2019
The above table 4.2.6 indicates that the most of the respondents income is less than $100, there
percentage is half and above of the respondents he is 57.1% which is 32 of respondents, while
the respondents get monthly income $100-$300 are 35.7% where the 3.6 % get $300-$600
monthly income is 19.6%, therefore majority of respondents whose participate this questionnaire
were the law income which there monthly income is less than $100
Axis Title

60
50
40
30
20
100 Series3

Series1

Total monthly less than More than

$100-$300 $300 - $600 $600 - $900
income $100 $1000
Series1 0 32 20 2 1 1
Series2 0 57.1 35.7 3.6 1.8 1.8
Series3

34
Table 4.2.7. What is the number of your family members (including you self)

Frequency Percent Valid Percent Cumulative Percent

Valid 1-3 10 17.9 17.9 17.9

4-7 25 44.6 44.6 62.5

More than 7 20 35.7 35.7 98.2

7 1 1.8 1.8 100.0

Total 56 100.0 100.0

Source: primary data source 2019

Family Members
Series1 Series2 Series3

17.9
10 44.6
25
1.8
1
35.7
3-Jan 7-Apr
7
20
0
1 2 3 4

The above table 4.2.7 shows that the most of the respondents family member are between 4-7
members which is 44.6%, where 35.7% there members are more than 7 members, and 17.9% are
between 1-3 family members, while only 1.8% are contain 7 members, so the majority of
respondents whose participate this questionnaire were their families contain 4-7 members.
Table 4.2.8, What is the number of rooms in your house

What’s is the number of rooms in your house

Frequency Percent Valid Percent Cumulative Percent

Valid 1-2 10 17.9 17.9 17.9

4-7 43 76.8 76.8 94.6

More than 7 3 5.4 5.4 100.0

Total 56 100.0 100.0

Source: primary data source 2019
35
 120

100

80 Series2
60 Series1
40
76.8
20
17.9 5.4
0
2-Jan 7-Apr More than 7

The above table 4.2.8 shows that76.8% of the respondents houses rooms contain 4-7
rooms,17.9% their houses room contain 1-2 rooms, while 5.4% only their rooms are more than 7
rooms, therefore the research shows that the majority of respondents whose participate this
questionnaire were their live middle houses which contain 4-7 rooms.
Table 4.2.9. How far do you live from the nearest health clinic or hospital?

How far do you live from the nearest health clinic or hospital

Frequency Percent Valid Percent Cumulative Percent

Valid Less than 2 kilo meters 20 35.7 35.7 35.7

3-5 kilometers 4 7.1 7.1 42.9

6-10kilometres 17 30.4 30.4 73.2

More than 10 kilometers 15 26.8 26.8 100.0

Total 56 100.0 100.0

Source: primary data source 2019

How far do you live

from the nearest Health Centers
health clinic or hospital 0% Less than 2 kilo meters
0% 36%
More than 10
kilometers
27%

6-10kilometres 3-5 kilometers

30% 7%

36
The above table 4.2.9 shows the that the most of respondents are far from the nearest clinic or
hospitals, more than half of respondents which are 57.2% (30.4%+26.8% ) are far from 6km – 10
km and more than, where 35.7% respondents are in less than 2km, and the rest of respondents
7.1% are between 3km-5km.

4.2.10. Where do you usually go if you are sick, or to treat a general health problem

Where do you usually go if you are sick, or to treat a general health problem

Frequency Percent Valid Percent Cumulative Percent

Valid private clinic 30 53.6 53.6 53.6

government clinic or hospital 18 32.1 32.1 85.7

traditional 8 14.3 14.3 100.0

Total 56 100.0 100.0

Source: primary data source 2019

60

40 32.1
53.6
20
14.3 Series2
0

private clinic Series2

government clinic or
hospital traditional

The above table 4.2.10 shows that 53.6% of the respondents go to the private clinics if they sick,
were 32.1% of the respondents if they sick go to the government clinics or hospitals and 14.3%
go to the traditional clinics, therefore the research shows that the majority of respondents whose
participate this questionnaire go to the private clinics it they sick.
4.2.11. Have you ever heard about Tuberculosis?

Have you ever heard about Tuberculosis

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 53 94.6 94.6 94.6

No 3 5.4 5.4 100.0

Total 56 100.0 100.0

Source: primary data source 2019

37
 Percent
5.4

1
2

94.6

The above table 4.2.11 Indicates that the most of respondents which are 94.6% are responded
they are heard the Tuberculosis, where only 5.4% of the respondents answered No they have not
heard anything about tuberculosis.
4.2.12. What is your attitude towards tuberculosis?

What is your attitude towards tuberculosis

Frequency Percent Valid Percent Cumulative Percent

Valid Very serious 19 33.9 33.9 33.9

Somewhat serious 22 39.3 39.3 73.2

Not very serious 8 14.3 14.3 87.5

I have no idea 7 12.5 12.5 100.0

Total 56 100.0 100.0

Source: primary data source 2019

70
60
50
39.3 Percent
40 33.9
Frequency
30
20 14.3
10
0
Very serious Somewhat serious Not very serious

38
The above table 4.2.12 shows that 39.3% of respondents are answered their attitude towards
Tuberculosis is somewhat serious were other 33.9% of respondents said their attitude is serious
for Tuberculosis, while 14.35 are answered in not very serious, and 12.5% have no any idea
about Tuberculosis, therefore that result shows the most of respondents have serious attitude
towards tuberculosis.
4.2.13. Do you think a traditional medicine can cure TB?

Do you think a traditional medicine can cure TB

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 16 28.6 28.6 28.6

No 29 51.8 51.8 80.4

I don,t know 8 14.3 14.3 94.6

Strong agreed 3 5.4 5.4 100.0

Total 56 100.0 100.0

Source: primary data source 2019

Percent

60

50
1
40
2
30 51.8 3
20 28.6 4
10 14.3
5.4
0
1 2 3 4

The above table 4.2.13 shows that51.8% of respondents are answered NO, were 28.6% of
respondents said YES and others which are 14.3% have no any idea about curing Tuberculosis,
while 5.4% strongly agree, therefore the most respondents believe or think that traditional
medicine cannot be cured in Tuberculosis.

39
4.2.14. Have you ever taken the tuberculosis treatment?

Have you ever taken the tuberculosis treatment

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 0 0 0 0

No 56 100.0 100 100.0

Total 56 100.0 100.0

Source: primary data source 2019

Yes
No

The above table 4.2.14 shows that the most of respondents are answered NO, who are 100% of
the total respondents, were there is no any respondents said YES, we have taken tuberculosis
treatment.
4.2.15. How often do you generally seek health care at a clinic or hospitals?

How often do you generally seek health care at a clinic or hospital

Frequency Percent Valid Percent Cumulative Percent
Valid Monthly or more 4 7.1 7.1 7.1
Four times a year or more 5 8.9 8.9 16.1
Twice a year or more 7 12.5 12.5 28.6
Once per year 17 30.4 30.4 58.9
Less than once a year but at least
9 16.1 16.1 75.0
twice in past 5 yaers
Once in past 5 years 5 8.9 8.9 83.9
Never in past 5 years 9 16.1 16.1 100.0
Total 56 100.0 100.0
Source: primary data source 2019

40
 How often do you
generally seek health Chart Title Monthl
care at a clinic or y or
hospital 0% more Four times a year or
Never in past 5 years
0% 16% 7% more
9%

Once in past 5 years

9% Twice a year or more
13%

Less than once a year

but at least twice in Once per year
past 5 yaers 30%
16%

The above table 4.2.15 shows that the most of respondents which are 30.4% have seek health
care once per year, were 16.1% seek less than one year but, and other 16.1 never seek in past five
years, while 12.5% of respondents seek twice a year, and so on, this figure conclude how
respondents seek health care in clinic or hospitals and that shows they seek once or twice a years
and other never seek health care.
4.2.16. Do you have radio or television at home?

Do you have radio or television at home

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 56 100.0 100.0 100.0

Source: primary data source 2019

Do you have radio or television at home

100

41
The above table 4.2.16 shows that all of respondents are answered Yes we have television or
radio at the house, and this result show us how television and radio’s spread at the house in this
information age.
4.2.17. Do you have radio or television at home?

Where did you first learn about tuberculosis or TB

Frequency Percent Valid Percent Cumulative Percent

Valid Newspapers and Magazines 1 1.8 1.8 1.8

Radio 1 1.8 1.8 3.6
TV 4 7.1 7.1 10.7
Brochures , posters and other
1 1.8 1.8 12.5
printed materials
health workers 14 25.0 25.0 37.5
family, friends, neighbours
6 10.7 10.7 48.2
and coleagues
Teachers 28 50.0 50.0 98.2
Others 1 1.8 1.8 100.0
Total 56 100.0 100.0
Source: primary data source 2019

60
50
40
30
20
10 Series2
0
Series1

42
The above table 4.2.17, shows that 50% of respondents which are the majority of respondents are
learned Tuberculosis at teachers, were 25% of respondents learned on health workers, while the
rest of respondents which learned other source such family, friends, night burs, radio, TV,
magazines and newspapers
4.2.18. The information you got about TB was understandable

the information you got about TB was understandable

Frequency Percent Valid Percent Cumulative Percent
Valid Yes, fully 16 28.6 28.6 28.6
Yes, partly 32 57.1 57.1 85.7
No 8 14.3 14.3 100.0
Total 56 100.0 100.0
Source: primary data source 2019

14.3
28.6

Yes, fully
Yes, partly
No
57.

The above table 4.2.18 indicates that 57.1% of respondents understand information about TB
partially while 28.6% understand fully and other 14.3% were answered NO they did not
understand the information about TB. And that shows the half and above understands partially to
the TB information

43
4.2.19. Is TB a common disease in your community?

Is TB a common disease in your community

Frequency Percent Valid Percent Cumulative Percent
Valid Yes 36 64.3 64.3 64.3
No 5 8.9 8.9 73.2
I don’t know 15 26.8 26.8 100.0
Total 56 100.0 100.0

Source: primary data source 2019

Chart Title
Is TB a common disease in your community Yes No I don’t know

0%

27%

64%
9%

The above table 4.2.19 shows that the most of respondents answered Yes, TB is a common in our
community, which are 64.3% and other 26.6% said they have not know , while 8.9% answered
No , it is not common. But the research shows that TB is common in community,
4.2.20. In your opinion, how serious a disease is TB.

In your opinion, hoe serious a disease is TB

Frequency Percent Valid Percent Cumulative Percent

Valid Very serious 17 30.4 30.4 30.4
Somewhat serious 19 33.9 33.9 64.3
Not very serious 14 25.0 25.0 89.3
I have no idea 6 10.7 10.7 100.0
Total 56 100.0 100.0

44
Source: primary data source 2019
20
18 30
16 34 25
14
12
10
Series1
8
11
6 Series2
4
2
0
0
In your opinion, Very serious Somewhat Not very serious I have no idea
hoe serious a serious
disease is TB

The above table 4.2.20. shows that 33.9% of respondents are answered their opinion of
Tuberculosis disease is somewhat serious were other 30.4% of respondents said their opinion is
very serious for Tuberculosis, while 25% are answered in not very serious, and 10.7% have no
any idea about Tuberculosis, therefore that result shows the most of respondents opinion in how
serious a tuberculosis is very serious.
4.2.21. How many types of TB have heard?

How many types of TB have you heard

Frequency Percent Valid Percent Cumulative Percent

Valid One Type 23 41.1 41.1 41.1
Two types 17 30.4 30.4 71.4
More than two 15 26.8 26.8 98.2
4 1 1.8 1.8 100.0
Total 56 100.0 100.0
Source: primary data source 2019

45
 45

40 41.1

35

30 30.4
26.8
25 Series1

20 Series2

15 Series3

10

5
1.8
0
1 2 3 4

The above table 4.2.21 indicates 41.1% of respondents have heard one type of TB and 30.4% of
them heard a two types of TB were 26.8% of respondents answered they have heard more than
two types , and only 1% have answered they heard a 4 types of TB. We have taken these result
the most respondents awareness of TB is o1-2 types.
4.2.22. How can a person get TB?

How can a person get TB

Frequency Percent Valid Percent Cumulative Percent

Valid Through handshakes 5 8.9 8.9 8.9

Through the air when a person

41 73.2 73.2 82.1
with TB coughs or sneezes

Through sharing dishes 3 5.4 5.4 87.5

Through eating from the same

2 3.6 3.6 91.1
plate

I do not know 5 8.9 8.9 100.0

Total 56 100.0 100.0

Source: primary data source 2019

46
 4
9 9 Through handshakes

5 Through the air when a person with

TB coughs or sneezes
Through sharing dishes

Through eating from the same plate

I do not know
73

The above table 4.2.22 shows that the most respondents of these research believe a person can
get TB though the air when person cough or sneezes, these respondents are 73.2% of total
respondents, while the rest percent believe a person can get TB through handshakes, sharing
dishes and eating from same plate, were 9% have not any idea about how person can get TB.
Therefore the research shows us the TB can spread or person can get mostly through the cough
or sneezes of infected person.
4.2.23. How can a person prevent getting TB?

How can a person prevent getting TB

Frequency Percent Valid Percent Cumulative Percent

Valid Avoid shaking hands 5 8.9 8.9 8.9

Covering mouth and nose when
28 50.0 50.0 58.9
coughing or sneezing
Avoid sharing dishes 1 1.8 1.8 60.7
Washing hands after touching
1 1.8 1.8 62.5
items in public places
Through good nutrition 14 25.0 25.0 87.5
I do not know 7 12.5 12.5 100.0
Total 56 100.0 100.0
Source: primary data source 2019

47
 30
25
20
15
10
Series2
5
Series1
0
How can a Avoid Covering Avoid Washing Through I do not
person shaking mouth and sharing hands after good know
prevent hands nose when dishes touching nutrition
getting TB coughing or items in
sneezing public
places

The above table 4.2.23 shows 50% of respondents answered the person can prevent getting TB
though covering mouth and noise, were 25% believe a person can prevent TB though good
nutrition, and 12.5% have no idea on this issue. Were others answered the person can prevent or
avoid shaking hand ( 8.9%), avoid sharing dishes(1.8%) and washing hands after touching item
in public places (1.8%). Therefore the research indicates us the spread of getting other person for
TB can prevent mostly covering mouth and noise and taking good nutrition.
4.2.24. Can Tuberculosis be cured?

Can TB be cured
Frequency Percent Valid Percent Cumulative Percent
Valid Yes 47 83.9 83.9 83.9
Don't know 9 16.1 16.1 100.0
Total 56 100.0 100.0
Source: primary data source 2019

Can TB be cured

16.1

83.9 2

48
The above table 4.2.24 shows 83.9% which are the majority of respondents answered
Tuberculosis can be cured while 16.1% have not any idea about the issue of curing tuberculosis.
4.2.25. How can someone with TB be cured
How can someone with TB be cured

Frequency Percent Valid Percent Cumulative Percent

Valid Herbal remedies 3 5.4 5.4 5.4
Home rest without medicine 1 1.8 1.8 7.1
Specific drugs given by health
46 82.1 82.1 89.3
care
I do't know 6 10.7 10.7 100.0
Total 56 100.0 100.0
Source: primary data source 2019

2
10.7 5.4

How can someone with TB be cured

Herbal remedies
Home rest without medicine
Specific drugs given by health care
82.1
I do't know

The above table 4.2.25 shows 82.1% which are the majority of respondents answered
Tuberculosis can be cured specific drugs given by health care, and 10.7% of respondents don’t
know, were 5.4% believe can be cured home rest without medicine. Therefore the researches we
can take the most respondents believe the TB can be cured by specific drugs b health care
centers.

49
4.2.26. How long is the TB treatment?
How long is the TB treatment
Frequency Percent Valid Percent Cumulative Percent
Valid Less tham 3 monts 3 5.4 5.4 5.4
3 months 3 5.4 5.4 10.7
6 months 34 60.7 60.7 71.4
9 months 4 7.1 7.1 78.6
1 year 6 10.7 10.7 89.3
I have no idea 6 10.7 10.7 100.0
Total 56 100.0 100.0
Source: primary data source 2019

0 0

10 7
5
How long is the TB treatment

10
Less tham 3 monts
3 months
7
6 months
9 months
1 year

60 I have no idea

The above table 4.2.26 shows 60.7% of respondents answered the treatment long of Tuberculosis
is 6 months, while 10.8% (5.4% + 5.4%) can answered it 3 months and less than. Were 7.1% and
10.7% of respondents believe the treatment long of TB is 9 months and one year respectively.
And other 10.7% of respondents have no any idea about treatment long of Tuberculosis.

50
4.2.27. Where the Tuberculosis can get the treatment?
Where the TB can get the treatment
Frequency Percent Valid Percent Cumulative Percent
Valid governmental hospitals 30 53.6 53.6 53.6
health centers 20 35.7 35.7 89.3
private hospitals 1 1.8 1.8 91.1
private clinics 2 3.6 3.6 94.6
I have no idea 3 5.4 5.4 100.0
Total 56 100.0 100.0
Source: primary data source 2019

0 0

Where the TB can get the treatment

36
governmental hospitals
health centers
53
private hospitals
private clinics

6 I have no idea
Total

4 2 1

The above table 4.2.27 shows 53.6% of respondents answered they get the treatment of
Tuberculosis to the governmental hospitals. While 35.7% of respondents get on health centers,
and 5.4% get in private hospitals and clinics, were 5.4% of respondents have no idea on where
the TB infectors get the treatment.
4.2.28. Do you think there is vaccination against TB
Do you think there is vaccination against TB
Frequency Percent Valid Percent Cumulative Percent
Valid Yes 44 78.6 78.6 78.6
No 1 1.8 1.8 80.4
I have no idea 11 19.6 19.6 100.0
Total 56 100.0 100.0
Source: primary data source 2019

51
 0 0 Do you think there is vaccination
against TB

20
78
Yes

No

2
I have no idea

Total

The above table 4.2.28 shows that the most of respondents which are 78.6% of respondents
answered Yes there is a vaccination against TB while 20% of respondents say We don’t know
and we haven’t any idea, were 1% only said No there is no vaccination against TB.
4.2.29. What was your reaction when you found out that you have TB?
What was your reaction when you found out that you have TB
Frequency Percent Valid Percent Cumulative Percent
Valid Fear 29 51.8 51.8 51.8
Surprise 2 3.6 3.6 55.4
Shame 6 10.7 10.7 66.1
Embarrassment 14 25.0 25.0 91.1
Sadness or Hopelessness 5 8.9 8.9 100.0
Total 56 100.0 100.0
Source: primary data source 2019
0 0
What was your reaction when you
found out that you have TB
25

Fear
52

9 Surprise
11
Shame

52
The above table 4.2.29 shows that 52.8% of the of respondents feel fear when they found out
they have TB, while 25% feel embarrassment, and 10.7% their reaction is shame were 8.9% feel
sadness and hopeless and 3.6% feel surprise. Therefore the reaction of respondents mostly is fear
and embarrassment when they found they have Tuberculosis,
4.2.30. What do you think about TB centre service offered?
What do you think about TB centre services offered

Frequency Percent Valid Percent Cumulative Percent

Valid Excellent 11 19.6 19.6 19.6
Very Good 15 26.8 26.8 46.4
Good 29 51.8 51.8 98.2
Bad 1 1.8 1.8 100.0
Total 56 100.0 100.0
Source: primary data source 2019
180
160
140
120
100
80
60 Series3
40 Series2
20
0 Series1
What do Excellent Very Good Good Bad Total
you think
about TB
centre
services
offered

The above table 4.2.30 shows that 51.8% of the of respondents think the service offered by TB
centers is good, and other 26.8% believe or thinks these service is very good, while 19.6% are
answered the service is excellent and only 1.8% showed that service of TB centers offered is bad.
Therefore the research shows us the attitude of respondents towards TB service centers is good.

53
4.2.31. Do you know how TB is transmitted?
Do you know how TB is transmitted

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 51 91.1 91.1 91.1
No 5 8.9 8.9 100.0
Total 56 100.0 100.0
Source: primary data source 2019

Do you know how TB is transmitted

8.9

1
2

91.1

The above table 4.2.31 shows that 91.07% of the respondents answered YES, we know how TB
is transmitted while few respondents which are 8.93% are responded No we don’t know how is
transmitted to TB. Therefore we can understand that the respondents are aware of more about TB
transmission.

4.2.32. What do you think is cause of the TB?

What do you think is cause of the TB

Frequency Percent Valid Percent Cumulative Percent

Valid Virus 4 7.1 7.1 7.1
Bacteria 45 80.4 80.4 87.5
I don't know 7 12.5 12.5 100.0
Total 56 100.0 100.0
Source: primary data source 2019

54
 Frequency

60

50

40

30 56 Frequency
45
20

10
4 7
0
Virus Bacteria I don't know Total

The above table 4.2.32 shows that the most of the respondents which are 80.4% of total
respondents think the cause of Tuberculosis is bacteria, while 7.1% have answered the cause is
virus and 12.5% have not know the cause of Tuberculosis.
4.2.33. TB can be transmitted between people living in same house or working together?
TB can be transmitted between people living in the same house or working together

Frequency Percent Valid Percent Cumulative Percent

Valid Agree 20 35.7 35.7 35.7

Strongly Agree 25 44.6 44.6 80.4

Disagree 9 16.1 16.1 96.4

Strongly Disagree 2 3.6 3.6 100.0

Total 56 100.0 100.0

Source: primary data source 2019
60

50

40

30 Series2
56
20 Series1
25
10 20
9
0 0
TB can be transmitted between people living in the
AgreeStrongly
same house Agree
Disagree
Strongly DisagreeTotal
or working together

55
The above table 4.2.33 shows that 44.64% of the respondents strongly agreed TB can be
transmitted people living in the same house or working together were 35.71% agree this issue
and 16.07% disagree while 3.57% strongly disagree that TB can transmitted to people who live
in same place or work together.
4.2.34. Correctly taking TB medication, covering your mouth when coughing, disposing
sputum appropriately can prevents others from getting TB

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 45 80.4 80.4 80.4

No 1 1.8 1.8 82.1

Don't know 10 17.9 17.9 100.0

Total 56 100.0 100.0

Source: primary data source 2019

Frequency
50
45
40

30

20 Frequency

10 10

0 1
Yes No Don't know

The above table 4.2.34 shows that most of the respondents answered which are 80.4% Yes ,
while 17.9% did not know anything about thing, and 1.8% are answered No, therefore we can
take this research that respondents believe the TB correctly can prevent in TB mediation,
covering mouth and disposing sputum4.2.35. The minimum duration of TB treatment is 6
months
The minimum duration of TB treatment in Somaliland is 6 months

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 36 64.3 64.3 64.3

No 2 3.6 3.6 67.9

Don't know 18 32.1 32.1 100.0

Total 56 100.0 100.0

Source: primary data source 2019

56
 The minimum duration of TB treatment in
Somaliland is 6 months

Don't
know
32%

Yes
64%
No
4%

The above table 4.2.35 shows that 64.29% of the respondents answered Yes the minimum
duration of TB treatment in Somaliland is 6 months, were 32.14% are answered they don’t know
, and 3.57% said No the minimum is not 6 month, therefore the research shows us the minimum
duration of treatment in Somaliland is 6 month.

4.2.36. The minimum duration of TB treatment is 6 months

Do you believe a person with TB should be rejected by the community

Frequency Percent Valid Percent Cumulative Percent

Valid Yes 35 62.5 63.6 63.6
No 7 12.5 12.7 76.4
Don't know 13 23.2 23.6 100.0
Total 55 98.2 100.0
Missing System 1 1.8
Total 56 100.0
z
Source: primary data source 2019

57
 100
90
80
70 62.5
60 Series2
50 Series1
40
30 23.2
20 12.5
10
0
Yes No Don't know

The above table 4.2.36 shows that 63.5% of the respondents answered Yes we believe a person
with TB should be reject by the Community, were 23.6% are answered they don’t know , and
12.7% said No, should not be reject. Therefore the research shows us the most of respondents
believe a person with TB should be reject by the Community

Findings sample tables of tuberculosis

Findings about personal
The genders of respondents are both 24 male where respondents 42.9%and female32 where the
respondents are 57.1% this shows the gender of the respondents is mostly female. Age of the
respondents 19.9% are 18-21 years, while the33.9% year is 22-25 , and 33.9% years is 26-29,
and 12.5% years are 32-35 age of the respondent it show the age of respondent were mostly the
age. Marital status his shows 5.4% divorced, while married 35.7% ,and also single 58.9%
.the respondents of the Total Monthly income is the number of respondents are 57.1% are the
less than $100, where 35.7% are $100-300, while 3.6% are 300-600 ,and 1.8% $600-900,
and1.8% more than $1000. are 05% The answered by the respondents are monthly income less
than $100. the level occupations in respondents the student are 92.9%, where are self employed
5-4%,where are employed 1.8% .level education the respondent 0f the certification level 41%.

58
while 28.6% are the respondent of diploma ,where respondent degree 30.4%. the respondent
number of family is 44.6% is 4-7 peoples ,and while 35.5% more than 7 peoples, and
also17.9% is 1-3 peoples ,while 1.8% is 7 peoples . number room the respondent of house
rooms contain76.8% is 4-7 room ,while 17.9% is1-2 room, and 5.4% is more than 7 rooms.
Nearest health clinic or hospital the respondent of from the nearest clinic or hospital 35.7%
less than 2 kilo meters ,while 30.4% is 6-10 kilo meters, and 26.8% is more than 10 kilo meters
.and while 7.1% is 3-5 kilo meters.

Findings about information

As indicating the above and table of the respondents, by yes 94.6% are responded they are head
of the tuberculosis , Where the 5.4% the respondent are no anything about tuberculosis. shows
that very serious 39.3% of respondents are answered their attitude towards Tuberculosis
somewhat serious were other 33.9% of respondents said their attitude is serious for
Tuberculosis, while 14.3% are answered in not very serious, and 12.5% have no any idea about
Tuberculosis, therefore that result shows the most of respondents have serious attitude towards
tuberculosis. Attitude towards tuberculosisthat51.8% of respondents are answered NO, were
28.6% of respondents said YES and others which are 14.3% have no any idea about curing
Tuberculosis, while 5.4% strongly agree, therefore the most respondents believe or think that
traditional medicine cannot be cured in Tuberculosis. have taken tuberculosis treatment that the
most of respondents are answered NO, who are 100% of the total respondents.

The most of respondents which are 30.4% have seek health care once per year, were 16.1%
seek less than one year but, and other 16.1% never seek in past five years, while 12.5% of
respondents seek twice a year, and so on, this figure conclude how respondents seek health care
in clinic or hospitals and that shows they seek once or twice a years and other never seek health
care and once in past 5 years8.9% and four times years8.9% and also monthly or more is 7.15%.
And all of respondents are answered Yes we have television or radio at the house, and this result
show us how television and radio’s spread at the house in this information age .and also that 50%
of respondents which are the majority of respondents are learned Tuberculosis at teachers, were
25% of respondents learned on health workers, while the respondents other sources such family,
friends, night burs10.7%, radio 1.8%, TV 7.1%, magazines and newspapers1.8% ,while other
1.8%,and brochures posters and other printed materials1.8%.that 57.1% of respondents
understand information about TB partially while28.6% understand fully and other 14.3% were
answered NO they did not understand the information about TB. And that shows the half and
above understands partially to the TB information. that the most of respondents answered Yes,
TB is a common in our community, which are 64.3% and other 26.6% said they have not know ,
while 8.9% answered No , it is not common. But the research shows that TB is common in
community. that 33.9% of respondents are answered their opinion of Tuberculosis disease is
somewhat serious were other 30.4% of respondents said their opinion is very serious for
Tuberculosis, while25% are answered in not very serious, and 10.7% have no any idea about
Tuberculosis, therefore that result shows the most of respondents opinion in how serious a
59
tuberculosis is very serious. the41.1% of respondents have heard one type of TB and 30.4% of
them heard a two types of TB were 26.8% of respondents answered they have heard more than
two types , and only 1% have answered they heard a 4 types of TB. We have taken these result
the most respondents awareness of TB is o1-2types. that the most respondents of these research
believe a person can get TB though the air when person cough or sneezes, these respondents are
73.2% of total respondents, while the rest percent believe a person can get TB through
handshakes8.9%, sharing dishes5.4% and eating from same plate3.6%, I don’t know 8.9%any
idea about how person can get TB. Therefore the research shows us the TB can spread or person
can get. the 50% of respondents answered the person can prevent getting TB though covering
mouth and noise, were 25% believe a person can prevent TB though good nutrition, and 12.5%
have no idea on this issue. Were others answered the person can prevent or avoid shaking hand (
8.9%), avoid sharing dishes(1.8%) and washing hands after touching item in public places
(1.8%). Therefore the research indicates us the spread of getting other person for TB can prevent
mostly covering mouth and noise and taking good nutrition. The 83.9% which are the majority of
respondents answered Tuberculosis can be cured while 16.1% have not any idea about the issue
of curing tuberculosis. And 82.1% which are the majority of respondents answered Tuberculosis
can be cured specificsssss drugs given by health care, and 10.7% of respondents don’t know,
were 5.4%believe herbal remedies and home rest without medicin1.8%. Therefore the research
we can take the most respondents believe the TB can be cured by specific drugs b health care
centers The 60.7% of respondents answered the treatment long of Tuberculosis is 6 months
,while 10.8% (5.4% + 5.4%) can answered it 3 months and less than. Were 7.1% and 10.7% of
respondents
believe the treatment long of TB is 9 months and one year respectively. And other 10.7% of
respondents have no any idea about treatment long of Tuberculosis.53.6% of respondents
answered they get the treatment of Tuberculosis to the governmental hospitals. While 35.7% of
respondents get on health centers, and 5.4% get in private hospitals 1.8%andclinics, were 5.4%
of respondents have no idea on where the TB infectors get the treatment .that the most of
respondents which are 78.6% of respondents answered Yes there is a vaccination against TB
while 1.8% of respondents say We don’t know and we haven’t any idea, were 19.6% only said
No there is no vaccination against TB. that 52.8% of the of respondents feel fear when they
found out they have TB, while 25% feel embarrassment, and 10.7% their reaction is shame, were
8.9% feel sadness and hopeless and3.6% feel surprise. Therefore the reaction of respondents
mostly is fear and embarrassment when they found they have Tuberculosis. that 51.8% of the of
respondents think the service offered by TB centers is good, and other 26.8% believe or thinks
these service is very good, while 19.6% are answered the service is excellent and only 1.8%
showed that service of TB centers offered is bad. Therefore the research shows us the attitude of
respondents towards TB service centers is good. that 91.07% of the respondents answered YES,
we know how TB is transmitted while few respondents which are 8.93% are responded No we
don’t know how is transmitted to TB Therefore we can understand that the respondents aware of
more about TB transmission .that the most of the respondents which are 80.4% of total
respondents think the cause of Tuberculosis is bacteria, while 7.1% have answered the cause is
virus and 12.5% have not know the cause of Tuberculosis. that 44.64% of the respondents
strongly agreed TB can be transmitted people living in the same house or working together were
35.71% agree this issue and 16.07% disagree while 3.57% strongly disagree that TB can
transmitted to people who live in same place or work together. that most of the respondents
answered which are 80.4% Yes , while 17.9% did not know anything about thing, and 1.8% are

60
answered No, therefore we can take this research that respondent believe the TB correctly can
prevent in TB mediation, covering mouth and disposing sputum. that 64.3% of the respondents
answered Yes the minimum duration of TB treatment in Somaliland is 6 months, were 32.1% are
answered they don’t know , and 3.6% said No the minimum is not 6 month, therefore the
research shows us the minimum duration of treatment in Somaliland is 6month.that 62.5% of the
respondents answered Yes we believe a person with TB should be reject by the Community,
were 23.2% are answered they don’t know , and 12.5% said No, should not be reject. Therefore
the research shows us the most of respondents believe a person with TB should be reject by the
Community.

61
 CHAPTER FIVE

CONCLUSIONS AND RECOMMENDATIONS

5.1 Conclusion
Tuberculosis has long been recognized as a major public health problem in worldwide since the
1950s. By considering the impact, WHO initiated implementation of DOTS strategy in the 1990s
to minimize the problem, still remains a major health problem in Somaliland and other
developing countries. Humans have struggled with tuberculosis (TB) for thousands of years. This
thesis addresses some important areas in tuberculosis control in resource-limited settings. In
conclusion, tuberculosis causes a considerable economic burden and a significant deterioration in
household income impacting negatively on welfare and utilizes scarce national resources in
terms of its management. Deaths due to TB results in household and by extension national loss
of income and human resources permanently. The cost burdens of TB are extremely high for
poor households. TB is still one of the most important global public health threats. If global
control of the disease does not improve, the annual global incidence is expected to increase from
the current 21% to 61% by 2020.Early detection and adequate treatment are critical control
measures. Despite the fact that Africa carries one of the highest TB burdens in the world, lack of
knowledge about the disease remains an abiding problem in the country, and thus, presents a
barrier to control efforts. In countries with high TB prevalence, it is significant that all
opportunities to increase people awareness regarding the disease are used to the optimal. In line
with the WHO settings approach to health promotion. schools must be seen as significant way
for TB health teaching given the multiplier outcome such intervention is likely to have on the
students, their families, communities and others in their community networks. Coordination of
TB health promotion in schools, and educational centers with local TB control departments and
district-level Centers for Disease Control and Prevention must be strengthened on a constant
basis. The level of awareness on tuberculosis was middle. Knowledge on TB was average with
some gaps in knowledge existing in some key areas like the causative agent, modes of
transmission and prevention of TB. Based on the findings the study therefore concluded that
there is need for TB education at the facility and community level to address the knowledge gaps
for the purpose of perpetuating the available information on prevention and control of TB and
disseminating correct information. Communities need to be empowered to support TB patients
and accepting the disease and learning to disclose in order to acquire support from family and

62
community. The study concludes that there were some practices which were reported that were
likely to have a negative impact on prevention and control of TB. The communities should be
empowered through Health education to enhance the adoption of practices which will positively
contribute to prevention and control of TB such as improved ventilation in households, seeking
health care immediately one gets unwell instead of self-medication. There is need to dispel
misconceptions on TB in the community by stepping up health education strategy in the TB
prevention and control programme.

5.2 RECOMMENDATIONS

The researcher forwards the following recommendations based on the above findings:

1. It would be much helpful if awareness creation activities like disseminating important

information on TB infection and its vaccination are done, especially in areas where had
knowledge deficiencies and unfavorable attitudes.
2. Governmental and non-governmental organizations need to consider expanding the
currently available prevention facilities and put in place sustainable infection control and
prevention strategies.
3. Counseling and education tailored according to different target group needs.
4. Empowering both TB patients and communities by increasing their knowledge through
proper education programmes will effectively contribute to the effort of controlling TB.
5. Strengthen TB information, education and counselling.
6. Increase the level of education for the community
7. Co-ordination between ministry of health and ministry of education to discuss the
findings of this study.
8. To improve seeking of care for those with tuberculosis symptoms,should continue to
engage in social marketing,and should also explore the possibility of using previous
tuberculosis patients as peer educators to sensitize the community to seek care and
treatment.
9. Incidence of TB should be reported very early and patients should comply with treatment
as required by the medical assistants.

63
10. The district administration should engage local leaders in their attempt to operationalize
the district health plan.Local community involvement is critical to any TB prevention
plans whether national or local in scope.
11. Government should have to Strengthen monitoring and evaluation system, and provide integrated
regular supportive supervision at all level for prevention and control matters.
12. The Ministry of Health and Social Services should build the capacity of health workers
by providing them with skills for better client education.
13. Health education for prevention with focus on care and treatment for TB/HIV/malaria
infections should be strengthened.
14. improvement in understanding of epidemiology, transmission and methods of prevention
by strengthening all channels of communication for community matters.
15. Should improve the utilization of free diagnostic and treatment services available at
various governmental institutions.
16. Lastly, government and other institutions such as non-governmental agencies should
make it their ultimate aim of publicizing the awareness of TB, thus, it causes, effects,
treatment and prevention.

64
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Developing Knowledge, Attitude and Practice Surveys. Stop TB partnership. [Online], Available:
http://www.whqlibdoc.who.int/publications/2008/9789241596176_eng.pdf [Accessed:
31/05/09 12:45PM].

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 Gollis University
Erigavo Campus
Faculty of nursing

Dear of respondent

We are the students from Gollis University doing Bachelor degree in nursing, we are conducting
a study whose objective is to create, Information of the knowledge and attitude of tuberculosis,
We friendly requested you to fill in this questionnaire with a lot of frankly and to the best of your
knowledge, The data you offer will be only used for academic purpose and the information you
offer will be treated with most confidently, your role of answering these questions will be
exceedingly appreciated.

Thanks a lot.

Research questionnaire
Please tick (√)

1. Section one: Demographic characteristics of the respondents

1. Gender
A) Male B) Female

2. Marital status
A) Single B) Married C) divorced

3 Level of education attained

A) Certificate B) diploma C) degree D) master’s degree E

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 4 Type of University

A) Public university b) private university

5 Current occupations status

A. Student
B. Self- employed
C. Employed
D. Un employed
E. Home- maker
F. Unable to work

6.Age of the respondent (years)

A. 18- 21
B. 22- 25
C. 26- 29
D. 32-35

7. Total monthly income

A) Less than $100 B) $100 – $300 C) $300 – $600 D) $600 – $900

E) more than $1000

8. What is the number of your family members (including yourself)?

1. 1 – 3
2. 4-7
3. More than 7

9. What is the number of rooms in your house?

1. 1 – 2 rooms
2. 4-7
3. More than 7

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 10.How far do you live from the nearest health clinic or hospital?

1. Less than 2 kilometres

2. 3–5 kilometres
3. 6–10 kilometres
4. More than 10 kilometres

11. Where do you usually go if you are sick, or to treat a general health problem?

1. Private clinic
2. Government clinic or hospital
3. Traditional
4. Clinic run by a nongovernmental organization

2. Section two: information about TB

1. Have you ever heard about Tuberculosis?

A) Yes B) No

3. What is your attitude towards tuberculosis?

A. Very serious
B. Somewhat serious
C. Not very serious
D. I have no idea

4. Do you think a Traditional medicine can cure TB?

A) YES
B) No
C) I don’t know
D) Strong agreed

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5. have you ever taken the tuberculosis treatment?
1. Yes
2. No

6. How often do you generally seek health care at a clinic or hospital?

1. Monthly or more
2. Four times a year or more
3. Twice a year or more
4. Once per year
5. Less than once a year but at least twice in past 5 years
6. Once in past 5 years
7. Never in past 5 years
8. Other: (defined)_______

Section three: knowledge and attitude of Tuberculosis

1. Do you have radio or television at home?

1. Yes
2. No
2.Where did you first learn about tuberculosis or TB?

1. Newspapers and magazines

2. Radio
3. TV
4. Brochures, posters and other printed materials
5. Health workers
6. Family, friends, neighbours and colleagues
7. Religious leaders
8. Teachers
9. Other (please explain)

3. The information you got about TB was understandable?

1. Yes, fully
2. Yes, partly
3. No

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 4.IS TB a common disease in your community?

1. yes
2. no
3. don’t know

5.In your opinion, how serious a disease is TB?

E. Very serious
F. Somewhat serious
G. Not very serious
H. I have no idea

6. How many types of TB have you heard?

A. One type (define )

B. Two types (define )
C. More than two (define

7. How can a person get TB?

A. Through handshakes
B. Through the air when a person with TB coughs or sneezes
C. Through sharing dishes
D. Through eating from the same plate
E. Through touching items in public places (doorknobs, handles in transportation)
F. I Do not know

8. How can a person prevent getting TB?

1. Avoid shaking hands

2. Covering mouth and nose when coughing or sneezing 3
3. Avoid sharing dishes
4. Washing hands after touching items in public places
5. Closing windows at home

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 6. Through good nutrition
7. Do not know
8. Other (please explain): __...........................................

9.Can TB be cured?

1. Yes
2. No
3. Don’t know

10.How can someone with TB be cured?

1. Herbal remedies
2. Home rest without medicine
3. Specific drugs given by health centre
4. I Do not know

11.How long is the TB treatment?

1. Less than 3 months

2. 3 months
3. 6 months
4. 9 months
5. 1 year
6. I have no idea

12.Where the TB patient can get the treatment

1. Governmental hospital
2. Health centres
3. Private hospitals
4. Private clinic
5. Non-governmental organization clinic,
6. Elsewhere
7. I have no idea

13.Do you think there is vaccination against TB?

1. Yes
2. No
3. I have no idea

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14.What was your reaction when you found out that you have TB?

1. Fear
2. Surprise
3. Shame
4. Embarrassment
5. Sadness or hopelessness

15.What do you think about TB centre services offered?

1. Excellent
2. Very good
3. Good
4. Bad

16.Do you know how Tuberculosis is transmitted?

A) Yes B) No

17.What do you think is the cause of the Tuberculosis?

A) Virus B) Bacteria C) Fungi D) I don’t know

18.TB can be transmitted between people living in the same house or working together
A) Agree B) Strongly agree C) Disagree D) Strongly disagree

19.Correctly taking TB medication, covering your mouth when coughing, disposing sputum
appropriately can prevent others from getting TB
1. Yes
2. No
3. Don’t know

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20.The minimum duration of TB treatment in Somaliland is 6 months
1. Yes
2. No
3. Don’t know

21. Do you believe a person with TB should be rejected by the community?

1. Yes
2. No
3. Don’t know

Participant’s name………………………..

Participant’s signature……………………

Date………………

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 Appendix III

Time frame
No Duration Activity

1 25April 2019 Title approval

2 4 May2019 Chapter one
3 23 May 2019 Chapter two
4 7 June 2019 Questionnaire
5 20 June 2019 Chapter three
6 24 July2019 Chapter four
7 26 July2019 Chapter five
8 26July 2019 Primarily pages
9 28 July2019 Copy and printing

Appendix IV

BUDGET FRAME
NO Description Amount
1 Transportation cost $ 19
2 Internet excess $ 32
3 Printing and copy cost $ 20
5 Total $ 71

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