|Year : 2014 | Volume
| Issue : 2 | Page : 81-86
Use of community volunteers to improve knowledge and uptake of tuberculosis and human immunodeficiency virus screening services among community members in Qu'an Pan Local Government Area, Plateau State
Yetunde O Tagurum1, Zuwaira I Hassan1, Daniel A Gadzama2, Danjuma A Bello1, Tolulope O Afolaranmi1, Oluwabunmi O Chirdan1, Ayuba I Zoakah1
1 Department of Community Medicine, University of Jos, Jos, Plateau State, Nigeria
2 Monitoring and Evaluation Department, FCT Primary Health Care Development Board, Abuja, Nigeria
|Date of Web Publication||18-Aug-2014|
Dr. Yetunde O Tagurum
Department of Community Medicine, University of Jos, Jos, Plateau State
Source of Support: None, Conflict of Interest: None
Background: The global impact of the converging dual epidemics of tuberculosis (TB) and human immunodeficiency virus (HIV)/AIDS is one of the major public health challenges of our time. Ignorance, fear, stigma and poverty have promoted the course of TB and HIV infections, particularly among people residing in the rural areas despite the availability of free diagnostic and treatment services. Community volunteers (CV) have been used successfully to promote and sustain knowledge and utilization of health services in various parts of the world. This study sought to determine the impact of the use of CV on knowledge and uptake of TB/HIV screening services in the study population.
Methodology: The study design was a community-based quasi-experimental study. A multistage sampling technique was used to select the study participants. The Primary Health Care (PHC centres offering TB and HIV screening services were the primary sampling units while the communities close to the PHCs were the secondary sampling units. The intervention involved a CV in each community providing education and services on TB and HIV/AIDS infections to the community members. Knowledge and uptake of TB and HIV screening services among the community members were assessed before and after the intervention.
Results: A total of 1305 people were recruited into the study and five communities each were selected per PHC. Postintervention, there was an increase in the knowledge of the cause, mode of transmission, symptoms and treatment of TB among community members from a mean score of 2.23 ± 2.31 to 5.37 ± 2.64 (P < 0.0001). There was also an increase in the knowledge of the modes of transmission, symptoms and prevention of HIV/AIDS among community members from a mean score of 6.66 ± 2.92 to 8.36 ± 3.35 (P < 0.0001). Uptake of TB screening rose from 59.4% to 75.0% (P = 0.0161) among community members with a history of chronic cough and uptake of HIV counselling and testing (HCT) also rose from 53.8% to 64.1% (P = 0.0215) among the community members.
Conclusion: Community Volunteers were found to improve the people's knowledge of TB and HIV/AIDS infections as well as uptake of HCT and TB screening services. Their use will help improve TB and HIV collaborative activities and also contribute to the reduction of morbidity and mortality associated with TB and HIV infections.
Keywords: Human immunodeficiency virus/AIDS, knowledge, screening, tuberculosis/human immunodeficiency virus uptake, tuberculosis
|How to cite this article:|
Tagurum YO, Hassan ZI, Gadzama DA, Bello DA, Afolaranmi TO, Chirdan OO, Zoakah AI. Use of community volunteers to improve knowledge and uptake of tuberculosis and human immunodeficiency virus screening services among community members in Qu'an Pan Local Government Area, Plateau State. J Med Trop 2014;16:81-6
|How to cite this URL:|
Tagurum YO, Hassan ZI, Gadzama DA, Bello DA, Afolaranmi TO, Chirdan OO, Zoakah AI. Use of community volunteers to improve knowledge and uptake of tuberculosis and human immunodeficiency virus screening services among community members in Qu'an Pan Local Government Area, Plateau State. J Med Trop [serial online] 2014 [cited 2021 May 6];16:81-6. Available from: https://www.jmedtropics.org/text.asp?2014/16/2/81/139058
| Introduction|| |
Tuberculosis (TB) and the human immunodeficiency virus (HIV) have been closely linked since the early years of the HIV/AIDS epidemic. The two infections have a synergistic interaction both epidemiologically and in their clinical manifestations. ,, TB and HIV control programs are currently advocating for the inclusion of community members in TB and HIV care as one of the approaches to improving case finding by increasing awareness in the community and increasing demand for diagnosis and treatment. For proper treatment compliance, this approach increases access to DOTS in the population and improves program performance. The community and the general public can be reached with TB and HIV messages through community health workers and village volunteers.
Community Volunteers (CV) are an integral part of community TB care, one of the WHO strategies to control the disease but in Plateau State little has been documented regarding the activities of CV in TB and HIV/AIDS control. There is limited awareness of TB and HIV screening services particularly in remote rural areas. Poor knowledge about what types of TB and HIV services are available and effective as well as stigma also contributes to underutilization of services and to the social costs of these infections.
The use of CV as part of a community directed approach to disease prevention and control has been successfully implemented in the management and control of a number of diseases within and outside Nigeria. ,, In Mozambique, community health workers working within their communities were used to improve accountability, relevance, and geographical access to basic health services.  Improvements in TB and HIV outcomes such as higher TB cure rates, decrease in death rates, improved recording and reporting, increased HIV counselling and testing (HCT) among TB patients and stigma reduction with improved knowledge of HIV and links between TB and HIV were also recorded in Malawi following the use of volunteers in a TB and HIV collaboration programme.  Volunteers have also been used successfully as community-based distributors of ivermectin within and outside Nigeria in the community-directed treatment of onchocerciasis with ivermectin programme. 
This study sought to determine the impact of the use of CV on knowledge and uptake of TB and HIV screening services by community members in the study setting.
| Methodology|| |
The study was conducted in two predominantly rural Local Government Areas (LGAs) located in the southern part of Plateau State. Qua'an Pan LGA which was selected as the intervention LGA has an estimated population of about 196,929  while the control LGA was Shendam LGA with a population of about 287,063. , The predominant ethnic groups in the two LGAs are Doemak, Merniang, Goemai, Hausa and Kwalla. ,, The main religions practiced in both LGAs are Christianity, Islam and Traditional worship. The inhabitants are mostly farmers and traders. Comprehensive TB and HIV services are available in the secondary health facilities located in these LGAs while only a small fraction of the Primary Health Care (PHC) facilities provide free TB and HIV screening services.
This was a community-based quasi-experimental study conducted among adult men and women living in communities which are within a 5 km radius of the two selected PHCs in Namu and Shendam towns of Qua'an Pan and Shendam LGAs respectively.
Sample Size Determination
The sample size was determined using the formula for an experimental study,  and a minimum sample size of 280 adults per group was calculated.
Multistage sampling technique was used to select the PHCs and respondents in each community.
Data Collection and Intervention
Baseline data was collected to assess knowledge, level of awareness and uptake of TB and HIV screening services among community members in Namu and Shendam towns. Thereafter, five CV were nominated from Namu (intervention community) in conjunction with its Health Development Committee. Those nominated were informed about the study and consent was obtained from them. These CV were then trained on basic HIV and AIDS and TB facts, transmission, prevention and availability of testing, counselling and treatment services at the PHC facility. After the training, they sensitized their community members by going from house to house and providing health education on TB and HIV and AIDS infections and their services; and the need for the community members to access these services at the PHC. Postintervention surveys were conducted 3 months later using the same instrument employed in the baseline assessment.
Scoring and Grading of Responses
In order to assess knowledge of TB, seven questions were used: Knowledge of aetiology, mode of transmission, cure, correct treatment, free cost of diagnosis and awareness of a health facility for TB screening were scored one mark each while knowledge of correct symptoms carried a maximum of four marks (half a mark was given for each correct symptom mentioned). A mark was awarded for each correct answer given while an incorrect or missing response was scored as zero mark. A total TB knowledge score was created by summing the scores for all the questions. The higher the score, the greater the respondent's knowledge of TB. The maximum score for knowledge of TB was 10.
In order to assess knowledge of HIV and AIDS, five questions were asked: Mode of transmission was awarded a maximum of four marks, correct symptoms of AIDS a maximum of three marks (half a mark was given for each correct symptom mentioned), methods of prevention of HIV and AIDS a maximum of three marks (half a mark was given for each correct method of prevention mentioned), cost of treatment one mark and awareness of health facility for HCT services one mark. A mark was awarded for each correct answer given and no mark was awarded for a wrong or missing answer. A total HIV and AIDS knowledge score was also calculated by summing the scores for all the questions. The higher the score, the greater the respondent's HIV and AIDS knowledge. The maximum score for knowledge of HIV and AIDS was 12.
Ethical approval was obtained from the Jos University Teaching Hospital Ethical Committee. Permission was sought and obtained from the LGA Chairmen and the Village Heads of both the intervention and control communities after the aim and objectives of the study were explained to them. Informed consent was also obtained from each respondent before enrolment into the study.
All the data generated from the community members at baseline and at postintervention was entered and analyzed using EPI Info version 3.5.2 statistical package (Centers for Disease Control and Prevention, Atlanta USA). Chi-square was used to test for associations between categorical variables and proportions. At 95% confidence interval, a P ≤ 0.05 was considered statistically significant. The differences observed in the intervention and control populations and as well as the differences observed at preintervention and postintervention stages were compared for statistical significance.
| Results|| |
Three hundred and fifty-one respondents were interviewed in the intervention group at the preintervention stage and 309 postintervention while in the control group, 345 and 300 respondents were interviewed at the pre and postintervention stages resulting in an attrition rate of 9.1% and 11.8% for the intervention and control groups respectively. The age range of the respondents in the intervention and control groups was 18-68 and 18-69 years respectively; (P = 0.1198). In both groups, males constituted more than half of the respondents; 176 (50.1%) and 194 (56.2%) in the intervention and control groups respectively (P = 0.1075). The major ethnic groups in the intervention group were Doemak 133 (37.9%) and Merniang 102 (29.1%) while those of the control group were Goemai 112 (32.5%) and Hausa 72 (20.9%). This was statistically significant, (P < 0.001). The two populations were comparable in terms of education as majority of respondents in the two groups had at least a primary education, only 66 (18.8%) respondents in the intervention group had no formal education, while in the control group 115 (33.3%) had no formal education (P = 0.0901). In both groups, a large number of the respondents interviewed were students; 101 (28.9%) in the intervention group and 82 (23.8%) in the control group. There was no statistically significant difference between the two populations in terms of occupation (P = 0.3030). Majority of the respondents in the two populations were married; 169 (48.1%) and 198 (57.4%) for the intervention and control groups respectively (P = 0.129). Most of the respondents in the two groups lived within 5 km of a clinic or hospital; 315 (89.7%) respondents in the intervention and 285 (82.6%) in the control groups (P = 0.4258) [Table 1].
|Table 1: Characteristics of respondents in Namu (intervention) and Shendam (control) communities|
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The preintervention mean TB knowledge score was 2.41 ± 2.05 out of ten (10) for the intervention group and 2.24 ± 2.31 out of ten (10) for the control group (P = 0.3122). After the intervention, there was a statistically significant difference (P < 0.0001) between the mean TB knowledge score for the study and control groups as the mean TB knowledge score increased to 5.37 ± 2.64 for the study group and 3.05 ± 2.29 for the control group. The preintervention mean HIV/AIDS knowledge score was 6.66 ± 2.92 for the intervention group and 6.98 ± 3.24 for the control group (P = 0.1868). After the intervention, the mean HIV/AIDS knowledge score increased to 8.36 ± 3.35 and 7.21 ± 2.96 for the study and control groups respectively. This difference was statistically significant (P < 0.0001) [Table 2].
|Table 2: Effect of community volunteers on mean knowledge score of TB and HIV/AIDS among respondents|
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At baseline, 19 (59.4%) and 28 (59.6%) respondents with a history of cough lasting >3 weeks in the study and control groups respectively had ever had sputum TB test (P = 0.8855). After the intervention, the number of respondents who had ever had sputum test for TB screening increased in both groups as 42 (75.0%) and 41 (71.9%) of the respondents in the study and control groups respectively said they had ever had screening for TB (P = 0.6308). One hundred and eighty-nine (53.8%) and 168 (48.7%) respondents in the study and control groups respectively said they had ever had HCT at baseline (P = 0.1741). After the intervention, the number of respondents who had had HCT increased in the study group to 198 (64.1%), while in the control group, there was a decrease to 146 (48.7%). The difference was statistically significant (P = 0.0001) [Table 3].
|Table 3: Effect of community volunteers on uptake of TB screening services and HCT among respondents|
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| Discussion|| |
Majority of the respondents in the two groups at the preintervention stage had a poor knowledge of TB. This is consistent with previous studies carried out among rural dwellers in China, Vietnam, Pakistan and Tanzania where knowledge of TB was shown to be generally poor particularly in the rural areas. ,,, In the intervention study carried out in rural Vietnam, the average knowledge score preintervention was 4.3 ± 2.1 out of a maximum of eight.  In this study after intervention, the mean TB knowledge score increased from 2.41 ± 2.05 to 5.37 ± 2.64 (P < 0.0001) for the intervention group. In the control group, the mean TB knowledge score increased marginally from 2.24 ± 2.31 to 3.05 ± 2.29. The preintervention mean HIV/AIDS knowledge score for the study and control groups respectively was also comparable (P < 0.0001). This level of knowledge even though lower than findings from studies carried out in different parts of Nigeria such as Ibadan, Lagos and Kano where it was revealed that respondents had a moderate to high knowledge of HIV/AIDS, ,, can be attributed to the effect of awareness campaigns being carried out all over Nigeria. These findings are similar to that of a cross sectional study carried out in Dar-es-Salaam among the Moran population which showed that over 60% of respondents had moderate knowledge about HIV/AIDS and its mode of transmission, prevention and HCT.  After the intervention, the mean HIV/AIDS knowledge score increased to 8.36 ± 3.35 and 7.21 ± 2.96 for the intervention and control groups respectively. This difference was statistically significant (P < 0.0001).
At baseline, 59.4% and 59.6% of respondents with a history of cough lasting >3 weeks in the study and control groups respectively had ever had sputum TB test and these responses were comparable. This level of uptake of TB screening is high when compared with Nigeria's case detection rate which was only 19% as at 2009 , but still falls short of the national target of 70%. This level of uptake of TB screening is probably due to the low level of knowledge about TB infection and may also be because TB is not seen as a major problem in these communities. Stigma associated with the disease may also be contributory. There was a statistically significant increase (P = 0.0161) in the uptake of TB screening by the respondents with a history of chronic cough in the intervention group from 59.4% to 75.0% after the intervention. This is consistent with findings from a study carried out on the use of peer educators in reaching out to migrant populations in which TB screening uptake increased from 44% to 75% after the intervention.  It is also similar to that of the study conducted in Malawi where enhanced awareness of TB by community members led to an increase in the number of people accessing diagnostic services. 
Referral for HIV testing is important whether the test is positive or negative. A negative test offers opportunities for prevention among HIV negative persons and early diagnosis of HIV in positive persons can help to target prevention in couples particularly where partners do not have the same HIV status. This study revealed that 53.8% and 49.0% respondents in the study and control groups respectively said they had ever had HCT at baseline. These results were comparable and this finding is quite encouraging as it shows that more people are now interested in knowing their HIV status and in taking measures to prevent infection. This is higher than the findings from the 2008 Nigeria Demographic and Health Survey which showed that only 16% of the respondents had ever been tested for HIV.  In the study carried out in Ethiopia, only 28% of the respondents interviewed had had HCT in the 3 months prior to the commencement of the study.  However, after the intervention, the percentage of respondents who had had HCT increased in the study group to 64.1%, while in the control group, there was a decrease to 48.7%. The difference was statistically significant (P = 0.0001). This change is consistent with the study carried out in Haiti where over half of the patients with a new diagnosis of HIV were referred directly by, or could name, a CV.  In Ethiopia, people receiving HIV testing and counselling rose from 500 000 to 1 600 000 from 2006 to 2007 after CV were trained to deliver these services, among other interventions. 
The study demonstrated the benefit of using trained CV in raising awareness on health issues. It showed the effect CV have on the knowledge and uptake of TB and HIV/AIDS screening services among community members. CV trained to provide TB and HIV prevention messages were effective in increasing the knowledge of the cause, mode of transmission, symptoms and treatment of TB among the members of their communities when compared with the control group. They were also effective in increasing the knowledge of the modes of transmission, symptoms and prevention of HIV/AIDS among their community members when compared with the control group. CV also contributed to increasing the uptake of TB screening and HCT among the community members.
The role of CV in the PHC system in Nigeria as human resources that can be used in disseminating TB and HIV/AIDS prevention messages as well as in case detection should be strengthened by the Federal and State Ministries of Health as well as by LG Health Departments in order to improve people's knowledge of TB and HIV infections and uptake of TB and HIV screening services.
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[Table 1], [Table 2], [Table 3]