TO DETERMINE THE FACTORS CONTRIBUTING TO THE SPREAD OF

PULMONARY TUBERCULOSIS AMONG SERO REACTIVE PATIENTS ATTENDING

CHEST CLINIC AT EMBU LEVEL V HOSPITAL.

BY

CHRISTINE NYAGUTHII MURIITHI

D/CM/21014/104

A DISSERTATION SUBMITTED FOR THE PARTIAL FULLFILMENT FOR THE

AWARD OF DIPLOMA COURSE IN CLINICAL MEDICINE AND SURGERY OF

KENYA MEDICAL TRAINING COLLEGE_ EMBU.

KENYA MEDICAL TRAINING COLLEGE

PO BOX 293
EMBU

DECEMBER 2023

38
DECLARATION

I declare that this research is my original work and to the best knowledge. It has not been

submitted to this or any other institution before.

CHRISTINE NYAGUTHII MURIITHI

D/CM/21014/104

SIGN--------------------DATE----------------

MR.NJENGA ANDREW

LECTURER KMTC EMBU

Table of Contents

38
DECLARATION...............................................................................................................................................i
LIST OF TABLES............................................................................................................................................v
ACKNOWLEDGEMENTS..............................................................................................................................vii
DEFINITION OF TERMS..............................................................................................................................viii
LIST OF ABBREVIATIONS.............................................................................................................................ix
ABSTRACT....................................................................................................................................................x
CHAPTER ONE..............................................................................................................................................1
1.1 INTRODUCTION.................................................................................................................................1
1.2 PROBLEM STATEMENT......................................................................................................................2
1.3STUDY JUSTIFICATION.........................................................................................................................4
1.4RESEARCH QUESTIONS.......................................................................................................................4
1.5 OBJECTIVE.........................................................................................................................................5
1.5.1 SPECIFIC OBJECTIVES.......................................................................................................................5
CHAPTER TWO.............................................................................................................................................6
2.1LITERATURE REVIEW..........................................................................................................................6
2.1.1ADHERANCE TO ART FACTORS CONTRIBUTING YO THE SPREAD OF PTB........................................6
2.1.2NUTRITION FACTORS CONTRIBUTING TO SPREAD OF PTB SERO REACTIVE PATIENTS...............8
2.1.3HOUSING FACTORS CONTRIBUTING TO SPREAD OF PTB IN SERO REACTIVE PATIENTS.................11
CHAPTER 3.................................................................................................................................................12
MATERIALS AND METHODS.......................................................................................................................12
3.1BACKGROUND INFORMATION OF THE STUDY AREA........................................................................12
3.2THE STUDY AREA..............................................................................................................................12
3.3STUDY DESIGN..................................................................................................................................13
3.4STUDY POPULATION........................................................................................................................13
3.5TARGET POPULATION......................................................................................................................13
3.6INCLUSION CRITERIA........................................................................................................................13
3.7EXCLUSIVE CRITERIA.........................................................................................................................13
3.8VARIABLES........................................................................................................................................14
3.9SAMPLING TECHNIQUE.....................................................................................................................14
3.10SAMPLE SIZE DETERMINATION.......................................................................................................14
3.11SAMPLE SIZE DETERMINATION........................................................................................................14
3.12SAMPLING PROCEDURE...................................................................................................................15

38
 3.13DATA COLLECTION TOOLS................................................................................................................15
3.14PILOTING/PRETESTING.....................................................................................................................15
3.15DATA ANALYSIS................................................................................................................................15
3.16DATA PRESENTATION.......................................................................................................................15
3.17STUDY LIMITATIONS........................................................................................................................15
3.18STUDY ASSUMPTIONS......................................................................................................................16
3.19ETHICAL CONSIDERATIONS..............................................................................................................16
CHAPTER FOUR..........................................................................................................................................17
4.1STUDY FINDINGS.............................................................................................................................17
CHAPTER FIVE............................................................................................................................................31
5.1DISCUSSION......................................................................................................................................31
5.2CONCLUSION.....................................................................................................................................32
5.3RECOMMENDATIONS........................................................................................................................33
REFERENCES..............................................................................................................................................34
APPENDIX 1...............................................................................................................................................35
WORK PLAN...........................................................................................................................................35
APPENDIX II...............................................................................................................................................36
BUDGET.................................................................................................................................................36
APPENDIX III..............................................................................................................................................37
PATIENT CONSENT FORM......................................................................................................................37
APPENDIX IV..............................................................................................................................................38
QUESTIONNAIRE....................................................................................................................................38
MAP OF EMBU LEVEL 5 HOSPITAL.............................................................................................................43

LIST OF FIGURES

38
FIGURE 4. 1 Time the respondents took their drugs................................................................17

FIGURE 4. 2 How the respondents took their drugs................................................................................18

FIGURE 4. 3 Data on alcohol drinking........................................................................................................19

FIGURE 4. 4 Data on if the respondents have been taking their drugs to date...................................20

FIGURE 4. 5 data on how many meals the respondents take each day.....................................................22

FIGURE 4. 6 Data on the respondents appetite............................................................................................23

FIGURE 4. 7 Data on whether their meals contained balanced diet.............................................................24

FIGURE 4. 8 Data on how often the respodents take fruits and vegetables.................................................26

FIGURE 4. 9 data on any supplement intake.............................................................................................27

FIGURE 4. 10 Types of houses...................................................................................................................28

FIGURE 4. 11 Data on if the houses are well ventilated..............................................................................29

38
LIST OF TABLES

Table 4. 1 If no; data on when they left their treatment and the time.........................................................21

Table 4. 2 Data on the main reasons the respondents miss their ART treatment........................................22

Table 4. 3 RESPONDENTS ON POOR APPETITE..........................................................................................26

Table 4. 4 RESPONDENTS ON UNBALANCED DIET............................................................................... 27

Table 4. 5 Data on how many windows their house has.............................................................................32

Table 4. 6Number of respodents living in the same house.........................................................................32

38
DEDICATION

I dedicate this research to my dad Anthony Muriithi and Mother Angela Muthanje, for their

financial support in all the work I have done on this research.

38
ACKNOWLEDGEMENTS

First I give gratitude to almighty God, protector and provider of life and strength for giving me

ability to do this research. I acknowledge my supervisor Mr.Andrew Njenga for continuous

support and in finalizing this research. I acknowledge my classmates for their social support.

Lastly to all who have played a part in developing this research including friends college

lectures, family members and respondets.

38
DEFINITION OF TERMS

Burden countries_ Twenty two countries in the world with high TB prevalence

Endemic_ Occurence of a disease in a specific area

Epidemic _ Occurence of an increase in normal disease prevalence in an area

Incidence_ Number of new cases active in a population during a certain time of period (usually a

year)

Pandemic _ Worldwide epidemic of a disease

TB prevalence_ Number of people in the population who are living with active TB

38
LIST OF ABBREVIATIONS

CDC _ Centre of disease control

DLTLD_ Division of leprosy, Tuberculosis and Lung Diseases

DOTS_ Direct observed treatments

HBC_ Home based care

MDR_ Multidrug resistance

NGO_ Non-governmental Organization

PTB_ Pulmonary Tuberculosis

TB_ Tuberculosis

TRC_ Tuberculosis Research Center

WHO_ World Health Organization

CCC_ Comprehensive Chest Clinic

HBC_ High Burden Countries

PWH_ People With HIV/AIDs

38
ABSTRACT

This study is on factors contributing to the spread of pulmonary Tuberculosis among sero
reactive patients attending comprehensive chest clinic in Embu level V Hospital.. The specific
objectives are to determine the factors that contribute to adherence of TB drugs among the
patients attending C.C.C at Embu level V Hospital leading to spread of PTB, to determine the
nutritional factors leading to the spread of PTB among patients attending C.C.C in Embu level V
and to investigate the housing factors leading to the spread of PTB among patients attending
C.C.C in Embu level V Hospital. A descriptive cross- sectional study was conducted. I used a
sample size of 44 where I selected 35 respondents using convenient non probability sampling to
fill the questionnaires. The study included all the patients attending the comprehensive chest
clinic for TB purposes and had an HIV/AIDs infection. I then analysed the data and presented it
on tables and pie charts. This study brings clearly that lack of adherence to ART is a major risk
factor contributing to the spread of pulmonary TB among the HIV patients.The study also shows
that lowered nutritional status also contributed greatly on the spread of TB with majority of
patients affording only 2 meals a day and the meals do not contain a balanced diet.They also
report on rarely taking fruits, vegetables and supplements to boost their immunity. This study
also shows that overcrowding is also a risk factor of tuberculosis with a remarkable number of
respodents living 5-10 people in the same house. Ventilation of the houses was also a
contributing factor with some of the houses having only 2 windows. Basing on my study findings
I recommend that; health providers should provide more health education to the people on
avoidance of the risk factors of TB spread and health hygiene. The public health department and
NGO should take part as a multi-sectrol approach in prevention of risk factors such as creating
job opportunities and financial support.

38
1.5 OBJECTIVES

1.5.1 BROAD OBJECTIVE

To determine the factors leading to spread of pulmonary tuberculosis among sero reactive

patients attending comprehensive chest clinic at embu level 5

1.5.2 SPECIFIC OBJECTIVES

1. To determine the adherance to ART drugs among the patients attending c.c.c in Embu level 5

leading to the spread of pulmonary tb.

2. To determine the nutrition factors leading to the spread of pulmonary tb among patients

attending c.c.c at Embu level 5 hospital

3. To investigate the housing factors leading to spread of pulmonary tb among patients attending

c.c.c at Embu level 5 hospital

38
38
CHAPTER ONE

INTRODUCTION
Tuberculosis (TB) is a major public health problem in developing countries. All countries are

affected but most cases occur in the 22 so called high burden countries(HBC's) that account for

about 80% of worlds TB cases(WHO 2009). Every year 8 million people develop TB.

Tuberculosis is a contagious infectious disease of the lung caused by mycobacterium

tuberculosis transmitter by coughing and sneezing. About 3 million people die every year from

the disease. TB can be cured by taking anti-tuberculosis drugs daily for 6 months least(WHO

global report 2009).PTB affects the lungs.

TB symptoms improves drastically during the intensive phase of treatment (1st week). However

TB treatment must continue upto 6wks to completely get rid of mycobacterium TB preventing

relapse and development of drug resistance (Norayon el al 2006). Tb is estimated to affev 1.7

million individuals worldwide with 8-10 new cases and 1.7million deaths each year(Robbins and

cotrains 2008). Kenya ranks 13th of the 22 high burden TB countries in the world and 5th burden

in Africa which contributes to 80% TB burdened cases(UDAID KENYA 2010).

Due to its frequency and severity TB remains an important disease of public health

significance.In 1993 WHO declared it a global emergency since the incidence of the disease had

gone upto over 7million people dying of it. This drastic increase is due to HIV/AIDs and rising

poverty levels. Infection worh HIV greatly increases the risks of developing TB and accelerates

its progress. In 2007 Africa accounted for an estimated 78% of TB among HIV/AIDs patients

worldwide(WHO 2009). In 2008 there were 1.4 million casses of TB among HIV/AIDs which

accounted for 23%. In the same year there were 400 thousand deaths globally suffering from TB

38
and 9.4 million new cases of TB occures in Asia and Africa where by Asia had 56% of global

totals. TB is the leading cause of HIV related deaths worldwide in Africa. In some countries the

higher the HIV prevalence, upto 80% of people with TB test positive for HIV . Kawi estimates

that 18-27% of HIV/AIDs people have TB (KAWI 2008). Globally, approximately 30% of HIV

infected persons are estimated to have latent TB infection (WHO Jan 2010).

TB diagnosis is best demonstrated through usage of Ziehl Nelson staining technique. If patients

fail to understand fully the treatment regimen of TB that is lack of knowledge and motivation to

also complete regimen becomes a risk (Kenya Munyadi 2008).

Treatment can be achieved through the usage of drugs like isoniazid,Rimfapicin, pyrazinamide,

Ethambutol among others. Symptoms of PTB includes chronic cough, chest pain on breathing,

tiredness, loss of appetite, night sweats, as the disease progresses the patients starts to loose

weight

PROBLEM STATEMENT
In the 21st century tuberculosis remains the world's leading cause of death from curable

infectious diseases. It's estimated that 2.3 million die from TB each year. The worlds directly

linked tuberculosis is currently exceedingly 15 billion US dollars annually. This reflects over a

million new cases every year and death rate 23% generally and upto 50% in the co-infection of

HIV(WHO 2012).

Due to its co-infection with HIV over 7 million people develop TB every year and 3 million

dying of it worldwide. Infection with HIV greatly increases risks of developing TB and

38
accelerates its progress. In the world the year 2012, 9 million people fell ill with TB and 1.3

million died from TB with a co-infection with HIV/AIDs. High rate of deaths occur in low and

middle-income countries, and it's among the top three causes of deaths for women and estimated

many children became ill and 74,000 died of TB(WHO 2012).

In Africa, the number of individuals infected with TB peaked in 2005, where nine million

individuals were infected. The death peaked at 1.8 million in 2003. Another study in Guinea

Bissau reported a total TB cases of 134 per 100000 among HIV patients (WHO 2012). A TB

survey in S. Africa had documented a total of 2,517 per 100,000.

Kenya is one of the 22 high TB burdened countries in the world with TB cases of estimate,a total

of 346 (39.7%) participants who were diagnosed with TB, 263(76%) had HIV infection and

110(41.8%) of these were sero-positive(African Health Sciences).

In Embu level 5 hospital the TB-HIV co-infection cases among participants was 41.6%. Among

20-29 years at 11.2% and 30-39 years at 14.8% increase.

38
STUDY JUSTIFICATION

The prevalence of TB in Kenya among HIV patients, out of a total of 608,312 TB cases,194,129

were HIV co-infected. The proportion of TB-HIV co-infection was higher in females (39.7%)

than in males (27.9%) (Thomas Achia). The has had many cases for upto 2012(W.Kanyi et al).

At Embu level 5 hospital chest clinic records, 170 patients are being managed yearly.

This study will help in providing findings about TB in HIV patients attending chest clinic and

also reduce the prevalence by providing knowledge about TB to people attending the chest

clinics.

It will also reduce the prevalence by providing findings on the preventive measures. The study

will provide awareness to the people on factors influencing TB and how to prevent them. The

study is also for partial fulfillment of my diploma course in Clinical Medicine. It's also useful in

determining areas of attention in support for chronic illness by the government.

Health workers will also find the study of use in determining various levels of health education

to provide and how to initiate them

RESEARCH QUESTIONS

What is the level of adherance of TB drugs among patients attending Comprehensive Chest

Clinic at Embu level 5?

38
What are the nutritional status of patients attending Comprehensive Chest Clinic at Embu

level 5?

What is the association of the housing factors of patients attending Comprehensive Chest

Clinic at Embu level 5 and TB infection?

38
CHAPTER TWO

LITERATURE REVIEW

ADHERANCE TO ART FACTORS CONTRIBUTING YO THE SPREAD OF PTB

Tb bacteria are spread from person to person through the air. About 1.7 billion people (23% of

world's population) are estimated to have ptb infection that could potentially develop into active

TB disease during their lifetime. It's estimated that between 5% and 10% of people with latent

TB fall ill with the disease at some point in their lives. TB most often affects the lungs and

people with compromised immune systems such as people living with HIV, diabetes or

malnourished have higher risk of falling ill.

People living with HIV are 20 times more likely to develop PTB. In 2017, 10 million people

developed TB disease, 9% of whom were people living with HIV/AIDS .Around 70% of people

with untreated pulmonary TB die within 10years. Although the risk is reduced by being on

effective antiretroviral therapy, among people living with HIV, untreated TB is rapidly fatal in

almost all cases. PTB is the most infectious killer worldwide with 3 people dying of PTB every

minute. In 2017, there were around 1.6million TB deaths including 300,00 people living with

HIV. There has been progress in reducing TB deaths among people living with HIV in recent

years, which were reduced by 44% from 2010-2017. However Tb remains the leading cause of

death among people living with HIV, accounting for one in three AIDs-related deaths.(UNAIDs

Joint United Nations Program on HIV/AIDS 2017 report)

A review of literature on adherance to HAART regimen indicated that barriers of adherance of

ART treatment are similar to barriers to chronic treatment in general; regimen complexity, with

38
pill burden but mainly dosing shedules and patients attitude towards treatment being stronger

predictors than dosing shedules. Side effects reaulting in poor tolerability hence treatment

discontinuation. Studies showed that adherance os optimal when symptoms are controlled and

declines with occurence of side effects. Patients related factors such as forgetfulness which

happens mainly when symptoms have improved and difficulty in understanding treatment

shedules; psychological issues such as depressions, stress, hopelessness, substance abuse

adversely affecting adherance whereas support from family, friends, treatment buddies and peer

counseling were found to facilitate adherance. Patients belief system with greater adherance

found in those who believe that HAART os effective, and patient provider relationship, with a

huge role to adherance coucelling. Agood patient provider relationship assists adherance whereas

miscommunication and unmanaged side effects frustrates patients and leads to non adherance.

(chesiney M.Adherance to HAART regimens. AIDs patients careSTDs 2013 April 17)

A study conducted which used qualitative methods to identify context specific constrins to

adherance showed that despite a high motivation on the side of the patients to take drugs, some

factors were challenging adherance. The included transport costs and user fees and at times

absence of adequate transportation: Waiting times overanging as high as 5 hours in some set ups

with patients having to miss their daily work for their srugs refills. Hunger mainly when the body

regains strength and weight, was a common problem for patients withs some discontinuing

treatment because of lack of food. HIV related stigma was a major factor, with loss of job,

isolation by families and community members reports that many patients do not tell about their

HIV status to their families, hence having to hide their medication intake which reaulted at timea

in irregular intake. Also patients resulted in patients not being able to get social support. Side

effects had lead to treatment discontinuation in patients. Some patients are not informed about

38
side effects and that these could subside over time. Quality coucelling which is key requirement

for successful ARV adherance was also found to be valiable in different countries. Heavy

workloads at thw clinics were also challenges noted in the study since ART scale up was also

followed by an increase in health personel.(Hardon AP, Akurut D, Comoro C, Gemita T et al,

Hunger waiting time and transport costs; time to control challenges to ART adherance in Africa.

AIDs care 2014 May).

Two other studies were also conducted to asses the effects of DOTs on treatment outcomes.

Among 431 HIV patients, showed a SERO report adherance of 57.3% ( Davey G ARVs

treatment adherance July 2012). A case control showed that 13.6% of patients who had not come

to the clinic had defaulted; less than 40% of patients defaulters were traced but had incorrect

address but those who were traced had lost hope in medication, lack of food, money, transport,

were given reasons for defaulting.( Tropical Med International Health 2015 March)

NUTRITION FACTORS CONTRIBUTING TO SPREAD OF PTB SERO

REACTIVE PATIENTS

Joint United Nations Program on HIV/AIDs (UNAIDs) data estimated that 25.5 million people

are living with HIV/AIDS (PWH) in Africa accounting for 68% of global population living with

HIV)AIDs.(HIV/AIDs UNPO, UNAIDS Data 2020: UNAIDs, Geneva 2020). The 90-90-90

global target on increasing HIV awareness states that by 2020 90% of PWH should be

diagnosed, 90% of those diagnosed treated and 90% of those treated virally suppressed.( WHO-

HIV/AIDs Regional Officer Africa 2021)

38
One significant contextual barrier is food insecurity. Successful HIV/AIDs management relies on

optimal nutritional status as a core component in a successful treatment regimen, as good

nutrition supports the positive immune response to ART.(WHO 2016) HIV related weight loss

and wasting, due to low energy intake and increased energy demands from HIV infection, may

be complicated with a context of food insecurity and low income and become a risk factor for

HIV progression and mortality and TB co-infection.(HIV Med 2006) Food insecurity is the lack

of regular access to safe and nutritious food for normal growth and development and an active

and healthy life, due to unavailability of food and or lack of resources to obtain food.( FAO.

Regional Overview of food insecurity. Africa, Italy 2015)

Synergistically, there is an abundance of evidence that cuptures the harmful interactions between

HIV/AIDs and TB in Africa, where the overlap and clusters of both diseases interact to

negatively impact the health populations; driven by various social, cultural and economic factors.

( Mendenhall, New path yo health research. Lanet 2017) The prevalence of all HIV/AIDs and

TB co-infection was 31.25% in African countries as of 2017, 72% of global HIV associated TB

cases were in Africa. In 2020, 214000 TB deaths (14.1%) come from HIV positive individuals.

Nevertheless Sub Saharan Africa accounts for 25% of new global TB cases. The vulnerability to

TB among PWH has positioned TB as leading cause of mortality among PWH.(WHO 2021)

The double burden of HIV and TB is linked to malnutrition, unemployment, substance use

disorder, poverty and homelessness. When coupled with highly prevalent food insecurity, HIV

and TB co-infection interacts worsening negative health outcomes among PWH. This

interactions further establishes because active TB has a strong nutritional impact, presenting as

weight loss or wasting in infected individuals. Nutritional symptoms such as wasting and

malnutrition are highly prevalent. In HIV patients there is bidirectional relationship between

38
nutritional symptoms and HIV infections, where the immunopathology of HIV reduces the

appetite of infected individuals hence limiting their ability to consume healthy quality and

quantity food opening up the body to more infections.( D.C malnutrition in TB Diagn Microbial

2007) (S.significance of Nutrition On pulmonary TB 2015).

In African context, its plausible that food insecurity is a nutritional risk factor for active TB

infection among immunocompromised patients due to the strong nutritional influence of TB

infection among infected patients due to the strong nutritional influence of TB infection among

infected patients. Low body mass index (BMI) due to nutritional causes, is associated with

increased TB. Research also suggests that macronutrients supplementation among food insecured

individuals with HIV may improve health outcomes.(int.J.Union Against TB.lung disease 2006)

Insufficient or lack of macronutrients ( ie carbohydrates, fats, proteins) are more telling signs of

food insecurity as the human body relies on these nutritional sources for required energy and

immunity (J.int.Union Against TB lung disease 2016)

The review aims to synthesize published evidence on the characteristics of the synergistic

relationship between HIV/AIDs and TB co-infection and food insecurity with the high

prevalence of HIV and food insecurity that leads to spread of infections like TB, there is a

broadened holistic understanding of the influence of highly prevalent contextual factors ie Food

security _ Nutritional factors) on clinical and other health related outcomes among the HI/AIDs

and TB co-infection among the infected population.

38
HOUSING FACTORS CONTRIBUTING TO SPREAD OF PTB IN SERO REACTIVE

PATIENTS

A study by Chantal L Edge, Emma J King, and Martin Mckee on prisoners co-infected with

tuberculosis and HIV brought out the housing factors contributing to spread of TB. A study in

Maryland documented an increased risk of infection with TB among prisoners who were HIV

positive. First, immunosuppression from HIV infection predisposes individuals to TB

reactivation.(Biadglegne F, Rodioff AC, Sack U Epidermiol Infect 2015)

Condition in prisons, such as poor ventilation and overcrowding, increases the risks of

transmission of TB too. Those who also engaged in high risk behaviours eg injecting drugs

highly stimulated spread of TB .(Molaeipoor L, Mohranz M, Epidemiol Health 2014).

In 1991 a New York State correctional facility experienced a TB outbreak from January to

November 1991. Eight persons were identified as having the TB, seven of whom were HIV

positive inmates and one a correctional facility experienced a TB outbreak from January to

November 1991. Eight persons were identified as having the TB (MDR-TB New York Prison

system, 1990- 1991, J Tuber Lung Dis 1994) In South Carolina contact tracing of 323 prisoners

housed in the same dormitory as a TB index case, found 31 HIV- positive inmates infected with

TB(HOV infected prisons inmates S.Carolina united states. Int J Tuber Lung Dis 2012)

Another study on TB outbreaks occuring among HIV housing units in two separate California

Correctional facilities; In prison A, a 500- person HIV housing unit, 14 inmates were diagnosed

38
with drug- susceptible TB. In prison B , a 180 person HIV housing unit, 15 further cases of TB

among inmates was brought up.(clin infect Dis 2012)

CHAPTER 3

MATERIALS AND METHODS.

This chapter will explain the methodology of this research

BACKGROUND INFORMATION OF THE STUDY AREA

Embu level 5 hospital, previously known as Embu Provincial General Hospital, is a county

referral facility that was started in 1924 as a dispensary and by 1960 had grown to a district

hospital. In 1984 a major expansion program was started by the government that would see the

facility upgraded to a provincial generay hospital. It's located at the outskirts of Embu business

center approximately 2.5km from Embu town.Embu town is the Head Quarter of Embu County

and its approximately 170km from Nairobi.

Embu town serves as the gateway to Masing, Mwingi, Machakos, and Kitui on the Eastern from,

while on the Western fronts it serves as a gateway to Kangaru, Meru and Isiolo, Southern front

it's entry to Murang'a, Thika and Nairobi while North it's entry to Mbeere.

The hospital has a catchment area of 645km2. It's surrounded by the Manyatta constituency,

Mbeere North and Mbeere South constituencies Embu county has a population of 608,599

persons as at 2019 cencus with 304,208 males, 304,367 females and 24 intersex persons.

38
THE STUDY AREA

The study area is Embu level 5 hospital located in Embu County.

STUDY DESIGN

A descriptive cross section study design was used in this study and hospital based research that

involves determining spread of PTB among SERO reactive patients attending c.c.c at Embu level

5 hospital.

STUDY POPULATION

The targeted clients were HIV/AIDs patients attending CCC at Embu level 5 hospital

TARGET POPULATION

The targeted population was the number of people who attended the CCC with positive results of

PTB.

INCLUSION CRITERIA

All patients living with HIV/AIDs attending CCC at Embu level 5 hospital and willing to be

questioned.

All patients presenting with TB ath the chest clinic.

Those who provide informed consent.

38
EXCLUSIVE CRITERIA

Patients unwilling to take part in the study.

Patients attending the CCC for other reasons other than TB.

Anyone who is HIV/AIDs negative.

VARIABLES

Dependant variables : Spread (prevarence) of PTB among HIV patients

Independent Variables : Age

Level of Education

Economic status

HIV/AIDs status

SAMPLING TECHNIQUE

I used on probability sampling technique to obtain targeted number of respondents. Patient

attending CCC and were coughing were questioned on different days of the study period.

SAMPLE SIZE DETERMINATION

It's used to display the number of respondents to interview from the total target population. It is

the representation of the whole population of study.

38
SAMPLE SIZE DETERMINATION

Sample size was arrived at by using the Yamane Formula;

Where:

n = N/(1 + N (e)2)

N is the total population (estimated at 50)

e is the level of precision (0.05)

Therefore:

n = 50/( 1 + 50 (0.05) 2)

= 44

SAMPLING PROCEDURE

I used convenient non probability sampling where I administer 44 questionnaire to the

respondents

Confidentiality was wholly adhered to.

38
DATA COLLECTION TOOLS

Structured questionnaire, pencils, pens, note books, rubber, calculators.

PILOTING/PRETESTING

Pretesting of data collection tools was done prior to the material day with help of few

individuals.

This helped to find the effectiveness of the data collection tools.

DATA ANALYSIS

Data from questionnaire was entered into a computer access data and imported to Ms Excell

where data cleaning, coding and validation was done.

DATA PRESENTATION

Presentations was done on tables, pie charts and graphs.

STUDY LIMITATIONS

Language barrier limited the scope of the study.

STUDY ASSUMPTIONS

I anticipated that the respondents would give true information.

38
ETHICAL CONSIDERATIONS

Permission on the process of performing the study was obtained from Kenya Medical Training

College Embu, Clinical Medicine department. Participants were informed of the purpose of the

interview, their right to refuse to participate and the way to answer specific questions.

Confidentiality was assured to encourage patients/ participants to answer embarrassing questions

frankly. Permission to conduct the study at the Embu level 5 Hospital was also obtained from the

hospital management. Informed consent was obtained from the respondent.

38
CHAPTER FOUR

STUDY FINDINGS

This chapter presents data collected from thirty four respondets in the study area. Data

was presented in tables and pie charts.

The time the respondents took their drugs.

DRUGS ADHERANCE

25
5

EVERY DAY
ALTERNATE DAYS
NEVER

75

FIGURE 4. 1 Time the respondents took their drugs.

The study showed that majority of respodents are not consistent in taking their ARVs

38
How the respondents took their drugs.

RESPODENTS DRUGS CONCISTENCY

30 30

50

DOCTOR PRESCRIPTION DAYS MOODS LOWER DOSE

FIGURE 4. 2 How the respondents took their drugs.

The study shows that a substantial amount of 50% of the participants took their drugs

according to their days moods with only 30% taking their drugs according to the doctors

prescription.

38
Data on alcohol drinking

ALCOHOL DRINKING

40

60

Alcoholics Non alcoholic

FIGURE 4. 3 Data on alcohol drinking

60% of the total respodents reports on being alcoholics with only 40% being non-

alcoholics.

38
Data on if the respondents have been taking their drugs to date

ADHERANCE OF DRUGS TO DATE

30

70

YES NO

FIGURE 4. 4 Data on if the respondents have been taking their drugs to date

A remarkable number of participants amounting to 70% are still taking their drugs to date

with 30% of them not being compliant.

Table 4. 1 If no; data on when they left their treatment and the time

TIME FREQUENCY n=10 PERCENTAGE %

Two months ago 5 50%

4 months ago 2 20%

38
 6 months ago 3 30%

Totals 10 100%

Generally 50% of the 10 respondents ie 30% of the total respodents who are not compliant to

treatment reports on leaving their medication 2 months ago, 20% left the treatment 4 months ago

and 30% 6 months ago

Table 4. 2 Data on the main reasons the respondents miss their ART treatment.

REASON FREQUENCY PERCENTAGE

n=10

Couldn't afford 3 30%

travel cost

Side effects of 4 40%

the drugs

Health workers 3 30%

not friendly

Feeling cured 0 0%

Totals 10 100%

38
The respondents reports on some reasons which might have made them stop the ART treatment.

30% of the total non-compliance respodents reports on not affording the travel cost to reachthe

facility where they correct their ART drugs, with 40% complaining on some severe side effects

and 30% complains on having an exposure to non friendly health workers.

38
Data on how many meals the respondents take each day.

MEALS TAKEN EACH DAY

30

70

THREE OR MORE MEALS TWO OR LESS MEALS

FIGURE 4. 5 data on how many meals the respondents take each day

In general, a substantial amount of respodents ie70% of the total respodents could only afford 2

or less meals in a day with only 30% affording 3 or more meals.

38
Data on the respondents appetite.

RESPONDENTS APPETITE
30

70

GOOD POOR

FIGURE 4. 6 Data on the respondents appetite.

Majority of the respondents ie 75% of the total respodents reports on having a greatly reduced

appetite hence end up skipping most of their meals reasons being:

38
Table 4. 3 RESPONDENTS ON POOR APPETITE

REASONS FREQUENCY n=29 PERCENTAGE %

Medications side effects 6 20%

Stress 9 31%

Poor nutrition or diet 7 24%

Foorld intorelance 2 7%

Fatigue or lack of energy 5 17%

Totals 29 100%

Data on whether their meals contained balanced diet.

BALANCED DIET
20

80

YES NO

38
FIGURE 4. 7 Data on whether their meals contained balanced diet

In addition, majority of the these respodents did not have access to a balanced diet ie 80% with

only 20% of the totals managing to have a balanced diet reasons being:

Table 4. 4 RESPONDENTS ON UNBALANCED DIET

REASONS FREQUENCY PERCENTAGE

Lack of access to healthy 15 56%

foods

Poor knowledge on glood 3 11%

nutrition

Poor eating habits.(skipping 4 15%

meals)

Time constrains.(work or 5 19%

school)

Totals 27 100%

Data on how often the respodents take fruits and vegetables.

38
 FREQUENCY OF TAKING FRUITS AND VEGETABLES
10

30

60

TWO DAYS A WEEK FOUR DAYS A WEEK EVERY DAY

FIGURE 4. 8 Data on how often the respodents take fruits and vegetables.

Only 10% of the total respodents would afford fruits and vegetables to accompany their meals

everyday, Although the remaining percentage could still manage the fruits and vegetables they

only did this only when they could afford or on alternate days. In addition, of the total

participants only 30% affordable extra supplements like calcium to boost their immunity with

70% not taking any supplements.

38
Data on any supplements (calcium) intake.

SUPPLIMENTS INTAKE
30

70

YES NO

FIGURE 4. 9 data on any supplement intake

38
Types of houses

TYPES OF HOUSES
10

30

60

PERMANET SEMI -PERMANET TEMPORARY

FIGURE 4. 10 Types of houses

The study reveals that 60 % of the total participants live in temporary houses, with 30% living in

semi-permanent houses and only 10% affording to live in permanent houses.

38
Data on if the houses are well ventilated.

GOOD VENTILLATION

40

60

YES NO

FIGURE 4. 11 Data on if the houses are well ventilated.

The above figure shows that only 40% live in well ventilated houses with 60% of the

respondents living in poorly ventillated houses

38
Table 4. 5 Data on how many windows their house has.

NUMBER FREQUENCY PERCENTAGE

2 windows 17 50%

3 windows 12 35%

More than 3 windows 5 15%

Totals 34 100%

Table 4. 6Number of respodents living in the same house

NUMBER OF PEOPLE FREQUENCY PERCENTAGE

Less than 5 23 68%

6 _ 10 9 26%

More than 10 2 6%

Totals 34 100%

38
CHAPTER FIVE

DISCUSSION

This study reveals that most of the people who are HIV positive are at a risk of increased spread

of pulmonary TB infection. According to the study it showed that only 25% of the total

respodents are adherent to their medication as majority of them take took their ART drugs only

on alternate days with 5% having stopped taking their drug regimen completely hence they are

not adherent. This has led to a remarkable spread of TB among PWH. The main reasons as to

why the majority of the respondents are not adherent were; someof them could not afford the

travel cost, some complained of the drugs side effects and other complained of non friendly

health workers. The study also shows that alcohol consumption was one of the factors that

largely interfered with the respondents atherence to the ARTs with 60% respodents consuming

alcohol. This has contributed to some of them failing to take their medication as prescriped to

them.

Based on the study nutritional status of the respondents have also contributed to the spread of

PTB. Majority of the respondents barely affordable 3 meals a day which actually didn't meet the

constitution of a balanced diet. The ART regimen greatly reduced the appetite among majority

respondets hence contributing to poor food intake of meals. A remarkable number of the

respondents also reports on not including fruits and vegetables in their meals or only did so less

often. They also report on not taking any supplements loke calcium that would aid in boosting

their immunity considering they are immunocompromised hence futher lowered immunity that

led to greater risk of PTB infection spread.The study also reveled that majority of the

38
respondents lived in overcrowded houses with majority of them living 5-10 people on one

house. In addition these houses had have only 2 windows necessiting poor ventilation.

CONCLUSION

This study on the factors leading to the spread of pulmonary tuberculosis among sero reactive

patients shows that a number of positive risk factors have highly contributed to this spread:

1. Lack of adherence to the ART drugs among patients attending CCC at Embu level V was one

of the main risk factor leading to the spread of PTB. Majority of patients are not adherent to their

medication, with some having completely left their medication and nolonger follow the doctors

prescription with some still taking alcohol in line with their treatment interfering with the drugs

metabolism hence greatly lowered immunity that lead to PTB coinfection.

2. Nutritional factors are also a major cause of PTB coinfection in PWH. From the study most of

the patients reports on only affording two meals a day which are actually not well balanced with

fruits and vegetables and extra supplements to boost their immunity. They also report on reduced

appetite.This has lead to an increase in the spread of PTB among the HIV patients, making

nutritional factors one of the major risk factor.

3. The study also reveals that different housing factors have a positive contribution to PTB

coinfection with HIV. A substantial amount of the patients live in poorly ventillated houses with

only 2 windows and also around 5 people in one house. These respodents reported of this

coinfection hence showing that this is alsoma majir factor that lesd to the spread of PTB among

these sero reactive patients.

38
RECOMMENDATIONS

Basing on my study findings I recommend that:

1. Health workers should provide more health education to the people on avoiding risk factors of

Tb and health hygiene among PWH

2.The public health center, the government and NGO should take part as a multi sectorial

approach in prevention of risk factors such as creating job opportunities and financial support.

3.Data and burden of Tb diseases are important for programme planners to determine resource

requirements and moniyor impact of tb control measures.

4.DOTs should be implemented to reduce spread of HIV Infection in high risk imdividuals

5.Health sector should come up with awareness to on the ART patients that drug side effect will

end on time and encourage on adhearance.

6.Mobile clinic should be introduced to take medicines near patients home hence it will not

burden the patient to come collect the drugs.

38
REFERENCES

Arnadottir T., Rieder H.L., Trebueq A., Waaler H.T. Guidelines for surveys in high

prevalence countries. Tubercle and lung Disease, 2012; 77 (Suppl.): 1_20.

Borgdorff M.W. New measurable indicator for TB case detection. Emerging Infections

Diseases, 2011; 10(9): 1523_1528.

Carter et al 2013_Rate of D.OT adherence.

CDC 2016 Testing for diagnosis Mycobacterium Tuberculosis Infection

DLTD MOH 2013 July Guidelines for management of TB and leprosy in Kenya_

National Leprosy and Tuberculosis Programme, MOH

Hamid Salim M.A., Declercq E., Van Deun., Saki K.A. Gender differences in tuberculosis

Hong Y.P., Kim S.J., Kim S.J., Lew W.J., Lee E.K., Han Y.C. The seventh nationawide

tuberculosis prevalence

International journal of Tuberculosis and Lung Disease, 2013; 46(3): 171- 178

Munro el al 2017- Adherence to treatment is an obstacle if finding an effective solution to

TB

National Leprosy and T.B programme, 2015 TB/HIV curriculum participants Manual,

Ministry of Health.

38
N.A.BOON N.R College and B.R Walker, 20th Edition, 2006 Davidson's Principles and

practices, "TB in HIV"

WHO global report 2013; Robbins and contrains 2011; USAID Kenya 2014. Kawi 2014.

WHO introduction of D.O.T_ General WHO.

WHO 2013 Global TB Control: WHO Report 2013, WHO, Geneva

38
APPENDIX 1

WORK PLAN

TIME MAY JUNE JULY AUGUST SEPTEMBER OCTOBER November

2023 2023 2023 2023 2023 2023 2023

PROPOSAL

PRESENTATION

PRETEST

DATA

COLLECTION

DATA

ANALYSIS AND

PRESENTATION

REPORT

PRESENTATION

38
APPENDIX II

BUDGET

ITEM COST

TYPING 1000

PRINTING QUESTIONNAIRE AND 2500

DOCUMENTS

FLASH DISK 1000

SERVICE 500

INTERNET 1000

TOTALS KSH.6000

38
APPENDIX III

PATIENT CONSENT FORM

Factors influencing prevalence of TB among patients attending chest clinic in Embu Level V

Hospital.

"I have read the information sheet concerning this study (or have been given a clear oral

account)"

"My questions concerning this study have been answered to my satisfaction by the

respondents.

"On these terms I agree to take part in the study" or "I'm assured of my confidentiality

in the study"

Signed................................................................................................Date.........................................

......................

Patient

number...............................................................................................................................................

...........

Witnessed

by...........................................................Sign.........................................Date.....................................

...

Initials......................................................................................................................,.........................

...........................

38
APPENDIX IV
QUESTIONNAIRE

A study on the factors contributing to spread of pulmonary TB among sero reactive patients

attending Comprehensive Chest Clinic at Embu level 5

INSTRUCTIONS

1. Do not write your name or signature on the questionnaire.

2.Tick or write against a questionnaire.

3. Information given on this questionnaire is for study purposes only and confidentiality of your

response is guaranteed.

KNOWLEDGE ON ADHERANCE TO ART DRUGS

1. When do you take your drugs?

a) Everyday ( )

b) Alternate days( )

c) Never ( )

2. How do you take your drugs?

a) According to the doctors prescription ( )

b) According to your days mood ( )

c) A lower dose than the prescribed one ( )

38
3.Do you take alcohol?

a) Yes ( )

b) No ( )

4. Have you been taking your drugs to date?

a) Yes ( )

b) No ( )

5. If No:

When did you leave your treatment? (Give the date also)

6. What is the main reason for missing your ART treatment?

38
 a) Couldn't afford travel cost ( )

b) Side effects of the drugs ( )

c) Health workers are not friendly ( )

d) Feeling cured ( )

NUTRITIONAL STATUS

7. How many meals do you take each day?

a) 3 or more meals ( )

b) 2 or less meals ( )

8. How good is your appetite?

a) Poor ( )

b) Good ( )

If poor; what are the reasons?

a) Medication side effects ( )

b) Stress ( )

c) Poor nutrition or diet ( )

d) Food intolerances ( )

38
 e) Fatigue or lack of energy ( )

9. Does your meal contain a balanced diet? ( Proteins, vitamins, carbohydrates)

a) Yes ( )

b) No ( )

If no, what are the reasons?

a) Lack of acces to healthy foods ( )

b) Poor knowledge on good nutrition ( )

c) Poor eating habits ( skipping meals) ( )

d) Time constrins ( work or school) ( )

10. How often do you include fruits and vegetables in your meal ( )

a) 2 daya a week ( )

b) 4 days a week ( )

c) Everyday ( )

11. Do you take any supplements (calcium) to boost your immunity?

a) Yes ( )

b) No ( )

38
If yes how often.

HOUSING FACTORS

12. What kind of a house do you live in?

a) Permanent ( )

b) Semi-permanent ( )

c) Temporary ( )

13. Is your house well ventilated?

a) Yes ( )

b) No ( )

14. How many windows does it have?

a) 2 windows ( )

b) 3 windows ( )

c) More than 3 windows ( )

38
15. How many people do you live with in your house?

a) Less than 5 ( )

b) 6_10 ( )

c) More than 10 ( )

38
MAP OF EMBU LEVEL 5 HOSPITAL

38