CHAPTER-I

Introduction
“The biggest disease today is not Leprosy or Tuberculosis, but rather the feeling of being
unwanted.” Mother Teresa

Tuberculosis (TB) is an airborne Infectious disease caused by the

bacterium Mycobacterium tuberculosis. It effects respiratory system and infects lungs in
mammalian system. Tuberculosis can easily spread through air when TB active person cough,
spit or sneeze. Active infection occurs more in people effected with HIV or who smoke.
Symptoms of tuberculosis are cough with blood sputum, weight loss, fever.1

Tuberculosis (TB) remains a public health concern worldwide. 2 According to

World Health Organization (WHO), tuberculosis caused 1.7 million deaths per year and more
than 9 million deaths globally till 2019. In developing countries including Asia, Africa and Latin
America, the prevalence of TB averages from 10-30%. In African countries, the HV and TB
prevalence is very high; from 30-40%. In Middle East and North Africa region, the TB
prevalence ranges from 10-15%. It is estimated that annual TB a prevalence of 3.2 per 100,000
populations in Saudi Arabia in 2018. Total mortality of TB in KSA around 2-5% of cases, and
most of the TB death due to drug resistance in KSA. Most of the TB cases in the southern
region.2 Saudi Arabia has a rapidly growing economy with a presence of high numbers of
expatriates. Most of these workers belongs to countries, high prevalence of TB such as India,
Pakistan, Bangladesh, Indonesia, and Yemen. Presence of high-risk cases has adversely affected
TB control in the kingdom, which has started National TB Control Program (NTP) for over 30
years. In 2000, the National TB Control Programme was started to directly observe treatment,
short course (DOTS) in all regions of the Saudi Arabia.
 Background of the study:

Tuberculosis (TB) is an old disease – studies of human skeletons show that it has affected
humans for thousands of years. Its cause remained unknown until 24 March 1882, when Dr
Robert Koch announced his discovery of the bacillus responsible, subsequently named
Mycobacterium tuberculosis. The disease is spread when people who are sick with TB expel
bacteria into the air (e.g. by coughing). TB typically affects the lungs (pulmonary TB) but can
also affect other sites (extrapulmonary TB).3

Tuberculosis (TB) is an infectious air borne disease and it is a major global public health burden.
Individuals with the active disease can spread the infection to at least ten people every year. TB
is endemic in most of the under developed countries and is a leading cause of death.4

WHO has published a global TB report every year since 1997. The main aim of the
report is to provide a comprehensive and up-to-date assessment of the TB epidemic, and of
progress in prevention, diagnosis and treatment of the disease, at global, regional and country
levels. This is done in the context of recommended global TB strategies and targets endorsed by
WHO’s Member States, broader development goals set by the United Nations (UN) and targets
set in the political declaration at the first UN high-level meeting on TB (held in September
2018).5

More than nine million people are developing active TB every year and it causes approximately
two million deaths. Infection with TB is present in nearly about two billion people which
constitutes one third of the world’s populations. The increasing trend of TB is due to the disease
association with poverty, inequity and most of the new cases are from South East Asian region. It
constitutes around 35% of new cases globally.6

TB can affect anyone anywhere, but most people who develop the disease are adults, there are
more cases among men than women, and 30 high TB burden countries account for almost 90%
of those who fall sick with TB each year. TB is a disease of poverty, and economic distress,
vulnerability, marginalization, stigma and discrimination are often faced by people affected by
TB.7

TB control activities are targeted to achieve Sustainable Development Goals (SDG) in 2030
and the ultimate aim is to eliminate TB by 2050. The 30 high TB burden country. 1.Globally, an
estimated 10.0 million (range, 8.9–11.0 million) people fell ill with TB in 2019, a number that
has been declining very slowly in recent years. There were an estimated 1.2 million TB deaths
among HIV-negative people and an additional 208, 000 deaths among people living with HIV.
Adults accounted for 88% and children, aged <15 years, for 12% of all people with TB. Most
people who developed TB in 2019 were in the WHO regions of South-East Asia (44%), Africa
(25%), and the Western Pacific (18%), with smaller percentages in the Eastern Mediterranean
(8.2%), the Americas (2.9%) and Europe (2.5%). Eight countries accounted for two thirds of the
global total: India (26%), Indonesia (8.5%), China (8.4%), the Philippines (6.0%), Pakistan
(5.7%), Nigeria (4.4%), Bangladesh (3.6%) and South Africa (3.6%).8

India is the highest TB burden country in the world having an estimated incidence of 26.9
lakh cases in 2019 (WHO). To address this, the ability to achieve complete surveillance coverage
is the prerequisite. Complete surveillance coverage would enable all levels of program
management to ensure that complete and adequate diagnostic, treatment and preventive services
are provisioned to all affected cases. 2019 marks another milestone year for TB surveillance
effort in India, with a record high notification of 24 Lakh cases; an increase of over 12% as
compared to 2018. Of the 24 lakh TB cases 90% (N=21.6 lakhs) were incident TB cases (New
and Relapse/ Recurrent).This translates to an incident notification rate of approximately 159
cases/lakh against the estimated incidence rate of 199 cases lakh population; thus, closing the
gap between the estimated and notified incident cases to just 40 Cases per lakh population, or an
approximate of 5.4 lakh missing cases across India.9

Efforts to end TB in India through implementation of the National Strategic Plan (2017-
2025) has completed the first three years of implementation. During this period, the programme
has seen tremendous success and is better poised today, to meet the ambitious goal pronounced
by our Honourable Prime Minister at the Delhi End TB Summit in March 2018 of ending the TB
epidemic by 2025 from the country, five years ahead of SDG goals for 2030, responding to
which, some States/ UTs have committed to end TB even before 2025 - Kerala (2020), Himachal
Pradesh (2021), Sikkim, Lakshadweep (2022) Chhattisgarh, Jammu & Kashmir, Madhya
Pradesh, Tamil Nadu and Bihar, Jharkhand, Puducherry and Dadra Nagar Havelli & Daman Diu
(2025).9
 The global report has predicted that the disruptions in both the demand and the supply side
of TB treatment may have catapulted the bacterial infection to the second most fatal infectious
disease in the world. “The latest year for which WHO has published estimates of global deaths
by cause is 2019… TB was the 13th leading cause of death worldwide and the top cause from a
single infectious agent. In 2020, it is anticipated that TB will rank as the second leading cause of
death from a single infectious agent, after COVID-19,” the report said. Globally the goal is to
end TB by 2030 but India aims to do so by 2025. The ‘End TB Strategy’ milestones for
reductions in TB disease burden by 2020 were a 35 per cent reduction in the number of TB
deaths, and a 20 per cent reduction in the TB incidence rate, compared with levels in 2015.In
actual terms, the reduction in the number of TB deaths between 2015 and 2020 was only 9.2 per
cent.10

Need of the study

A case-control study conducted by Faisal Alsharani1 et al ( 2021) at the military hospital of

Asir region of KSA. A total of 135 sample which is divided into 67 cases and 67 controls. The
study result found that mean age of study participants (cases and control) are 38.04 ± 9.66 and
40.16 ± 7.72 respectively. Most important factors associated with tuberculosis patients are
overweight and obese [OR = 4.40, 95% CI 1.27-15.25 and 2.38 (1.61-9.22)], Smoker [OR =
1.34, 95% CI 0.52-3.43], abnormal sleep at night (<8 hours) [OR = 5.03, 95% CI 1.57-16.10],
blue color job worker [OR = 2.69, 95% CI 1.02-7.28], physical exercise <3 days/week [OR =
1.41, 95% CI 1.21-3.47].12

Another descriptive cross-sectional study was conducted in 2011 comprising diagnosed

tuberculosis patients above the age of 15 years. Data were collected on social status (example,
level of education, employment, and income), associated risk factors (example, smoking and
alcohol consumption, contact history, narcotic drug use) and lifestyle changes during treatment
(example, employment status, social interactions). Number of patients included was 425.
Tuberculosis was found to be strongly prevalent among participants from the lower socio-
economic status. It was also common in participants with a low level of education, unemployed,
if employed, those who are engaged in unskilled employment and have low levels of income.
Risk factors associated with the patients were smoking, alcohol consumptions, narcotic drug use,
imprisonment, close contact history with active TB patients and chronic medical conditions.13
 A retrospective case-control study conducted by K. Tocque et al Multiple logistic
regression showed that, before diagnosis, cases were 7.4 times more likely to have had visitors
from abroad; 4.0 times more likely to have been born abroad; and 3.8 times more likely to have
lived with someone with tuberculosis. Subtle socioeconomic factors were also evident with cases
4.0 times less likely to have additional bathrooms. Lifestyle factors emerged with cases 2.3 times
more likely to have smoked for at least 30 yrs., 3.8 times less likely to eat dairy products every
week and 2.6 times less likely to have had high blood pressure. At interview, these factors were
still evident, but cases, unlike controls, had reduced their smoking and alcohol consumption and
were less likely to go out of the home or exercise than before their illness.14

Tuberculosis diagnosis and treatment currently revolves around clinical features and
microbiology. The disease however adversely affects patients’ psychological, economic, and
social well-being as well, and therefore our focus also additionally needs to shift towards quality
of life (QOL). Both generic and specific QOL scales show a wide variety of derangements in
scores, and results vary across countries and patient groups. In particular, diminished capacity to
work, social stigmatization, and psychological issues worsen QOL in patients with tuberculosis.
Although QOL has been consistently shown to improve during standard anti-tubercular therapy,
many patients continue to show residual impairment. It is also not clear if specific situations like
presence of comorbid illnesses, drug resistance, or co-infection with human immunodeficiency
virus additionally worsen QOL in these patients.15 

Tuberculosis (TB) is well known to be associated with poverty and multiple social factors.
However, relatively little attention has been paid to the behavioural factors, apart from those
associated with drug abuse, alcoholism and HIV infection In particular, smoking has been
associated with excess risks of TB infection, disease and mortality. Only limited evidence is
available for the association between TB disease and passive smoking or the use of biomass
fuels. Nutrition status also plays an important role. Malnutrition or underweight is associated
with increased risk of TB disease, and obesity appears to be protective. On the other hand,
diabetes mellitus increases the risk of TB disease, but mainly among those with poor diabetic
control. Although the increase in TB risk is only modest for most lifestyle factors, their
prevalences are increasing rapidly in some Asian communities.16 
 A descriptive cross-sectional study consisted of all diagnosed tuberculosis patients, who were
above the age of 15 attending to Central Chest Clinic Colombo. The total sample size comprised
of 266 Tuberculosis patients, who have completed the first two months of treatment course.
Tuberculosis is associated with the lower socio-economic status and linked with poverty. It is
common in people with lower level of education and unemployment. More negative lifestyle
changes were commonly seen in the socially disadvantaged group of patients which could further
worsen their social status. More lifestyle changes had significant associations with male sex, low
education level, employment, low income level, retreatment and infective patients, residing
within the CMC area and substance abuse (alcohol, smoking, narcotic drug use). 17 why I am doing this

study?

Problem Statement:

Assessment of lifestyle of tuberculosis patient in a selected DOTS Center of Purba Bardhaman,

West Bengal.

Purpose of the study:

The purpose of the study is to identify the lifestyle of tuberculosis patient.

Objectives of the study:

1. To assess the life style of Tuberculosis patient.

2. To identify association between the lifestyle of TB patient with demographic variables.

Variables:

Research variable

Life style of tuberculosis patient.

Demographic variable

The demographic variable was age, sex, religion, education, occupation, marital status, family
income, habit of smoking, consumption of alcohol, dietary pattern, exercise.

Operational Definition:
 Tuberculosis patient- In this study it refers to adult people who are diagnosed with
Tuberculosis(TB) and treated under new case category.

Life style: In this study life style refers to the abilities of the persons affected by TB to perform
the activities of daily living, to maintain relationship with others, to continue his/her occupation,
to seek healthy behavior and to have usual sleep pattern as measured through structured
interview schedule.

Dots Center—In this study DOTS stands for Directly Observed Treatment Short Course. In
DOTS center health care workers observe patient directly when they take their medicine.

Assumptions:

The researcher assumes that:

The tuberculosis disease brings about some changes in lifestyle of the patient who are suffering
from tuberculosis.

Conceptual Framework

The conceptual framework model is a schematic representation of a theory. It gives direction to the
search for relevant questions about phenomenon and they point out solution to practical problem. In this
study the conceptual framework based on Rosenstock’s (1974) Health belief Model.
This model addresses four major components for recommended seriousness of the tuberculosis patient,
perceived benefits of taking preventive and curative of action of tuberculosis and its complication, and
perceived barriers is the self-efficacy due to weight loss, loss of appetite, sleepless, exhausted, financial
problem, social stigma.
According to this model individual perception means one’s chances of getting a health condition and how
serious it is and its consequences. In this study individual perception means perceived susceptibility about
health problem due to tuberculosis.
Delimitations of the study:

The study will be delimited to

Persons affected by TB who will be willing to participate in the study at the time of data collection.

Summary:

This chapter deals with introduction, background of the study, need of the study, problem
statement, objectives of the study, operational definition, assumption, delimitation, and
conceptual framework.

Organization of the report

Chapter- I

This chapter deals with the introduction of the study which includes background of the study
denoting the magnitude of the problem about assessment of lifestyle of tuberculosis patient in a
selected DOTS Center of Purba Bardhaman, West Bengal, need for the study, which lay down
the justification for conducting the study. It also includes problem statement, objectives,
operational definition, assumption, conceptual framework, and delimitation of the study.

Chapter-II- would present a review of related literature with research studies and non-research
articles related to the present study.

Chapter- III- would explain the methodology of the study, including a research approach,
research design, and variables under study, the setting, sample and sampling technique,
development and description of tools and a plan for data analysis.

Chapter-IV- would present the details of data analysis and interpretation.

Chapter- V- would present brief summary, major findings, conclusion, implications, limitations,
and recommendations based on the findings of the study. The end of the chapters would also
give a selected list of the references and appendices.