COLLEGE OF MEDICINE AND HEALTH

SCIENCE SCHOOL OF GRADUATE STUDIES

DEPARTMENT OF PUBLIC HEALTH

Determinants of undernutrition among adult tuberculosis patients

attending public health facilities in Dire Dawa Ethiopia ,2022

By: Bethelhem amare(BSC)

advisor: Robel mekonnen (Msc)

January 2022
Presentation out line

Introduction
Statement of the problem
Objectives
Methods
Work plan and Budget
 Introduction
• Undernutrition is a state in which health and growth are limited when the nutritional
status of the person is suboptimal. (WHO, 2013)

• TB-infected individuals are more vulnerable to undernutrition compared to the

general population. Globally, one-quarter of TB infection is due to malnutrition.

Undernutrition and TB have a bidirectional relationship.(WHO 2013)

• In Ethiopia, TB is the leading cause of death from infectious diseases, and there
were 30 thousand deaths due to TB every year. (Misganaw A et al ,2015)
 Statement of the problem

• Undernutrition has a variety of negative effects on health, including increased

susceptibility to infectious diseases and worsening of existing disease. Adults who are
malnourished are less productive, less active mentally and physically, and more
susceptible to other diseases. (WHO 2012)

• Undernourished TB patients have delayed recovery and higher

mortality rates than well-nourished TB patients (Gupta et al ,2009).

• Tuberculosis (TB) causes undernutrition through raised metabolic demands and decline in
nutrition intake, and nutritional deficiencies may exacerbate the TB disease, or it takes
longer recovery by decreasing necessary immune functions. (Sinclair D et al ,2011 )
 
Continue
• Ethiopian government has implemented TB control programs like “End TB”
with the aim of reducing deaths attributed to TB few years back.

• Regardless of the efforts made to respond to nutritional status of patients

suffering from infectious disease like TB and HIV/AIDS in Ethiopia, many
patients have been died from the double burden of undernutrition.

• However, despite the high burden of TB and undernutrition in Ethiopia only

few studies have been conducted regarding the determinants of undernutrition
among TB patients in Ethiopia.
 Significance of the study
• This study can generate information on determinants of undernutrition among adult TB
patients .
• The findings of this study could be used for Dire Dawa health bureau and other
implementing partners to plan intervention strategies and co-ordinate care and support
activities for TB patients.
• Since Dire Dawa city reports the highest prevalence of TB case in Ethiopia in 2014–2015,
the findings from this study will be beneficial to Dire Dawa City Administration Health
Office and other stakeholders that offer TB diagnosis and treatment because identifying the
determinant risk factors will help to improve programmatic importance implication and it
can also be used as stepping board for those who will do further study on this area.
Conceptual framework Undernutrition
Outcome

Inadequate food intake Illness

Immediate
causes

Tuberculosis

-Insufficient Access to -Insufficient - Low access to safe

food, Awareness water and food
-absence of nutritional -Poor personal Hygiene
support Underlining
- Unsanitary
-Meal frequency causes
Environment
-life style
-

Economic factors, Monthly income

Basic causes
Socio-demographic factors (, Sex, Educational level,
Occupation,)

Conceptual framework
(Source:modified and adapted from United Nation International
Children’s Emergency Fund, UNICEF, 2003 )
 Objectives
General objectives
• To assess determinants of undernutrition among tuberculosis patients attending
public hospitals and health centres from February to April 2022.
Method and matrial
Study area Public health facilities in Dire Dawa.

Study period February 2022- April2022.

Study design Facility based case control study

Source All adult TB patients who are in follow up in public
population health facilities of Dire Dawa.
 

Study population Study population will be selected adult TB patients

who will be on follow-up in public health facilities
in Dire Dawa from February to April, 2022.
 
 Methods….
Inclusion criteria:
• Undernourished adult Tuberculosis patients with BMI < 18.5 and who are on follow
up during data collection period will be taken as Cases. Whereas, adult Tuberculosis
patients with normal BMI value and who are on follow up during data collection
period will be Controls

• All adult TB patients, who started anti-TB drugs and had a follow-up in Dire Dawa
public health facilities during the study period will be included.
 Exclusion criteria:

• All adult TB patients who are critically ill patients unable to communicate will
exclude from the study.
Methods….
Sample size determination

• Sample size is calculated by using EPI INFO version 7 by considering the following
assumption: Confidence interval (Cl) 95% ,power 80% ratio 1:2 and non response
rate 10%.

• Table:1 Sample size determination for determinant factors of undernutrition from

literature review among TB patients.
Factors considered Percentage of Percentage of Pow Sam
exposure among cases exposure among er ple
  (undernourished TB controls(normal size
patients) TB patients)  
 
   
  YES NO    
HIV/AIDS 24 7.95 80% 198
 
Eating problem 22.7 9 80% 269
 
Dietary counselling 64.1 35.9 80% 125

The largest samples size (269) is taken. Adjusting for 10% non-response rate the sample
size will be 296 (99 cases and 197 controls).
 Methods….
Sampling procedure

• All public health facilities in Dire Dawa town will considered for the study. First taking
adult TB patients who are on follow- up into consideration, all ten public health facilities
found in Dire Dawa will be included.
• The total sample size will be allocated for each public health facilities proportional to
the size of TB patients currently enrolled in each public health facility.

• The study participants fulfilling definition of cases and controls will be included
consecutively till the required sample size reached for each public health facility.
 Dire Dawa town
Eight health centre and two public Hospitals

Dilcho Sabian Legaha Melkaje Dechat Gender Goro Gend Addis Dire
ra primar re bedu u kore health gerada ketem Dawa
y health health health health centre health a health
referr centre
hospita centre centre centre centre health centre
al
l centre
hospit
al
55 44 44 32
80
19 48 32 30 40

13 56 34 22 21 28 38 31 31 22

296

Figure 1: Schematic Presentation of Sampling technique

 Methods….
Data collection techniques

• Primary data will be collected using an interviewer‑administered questionnaire

by trained nurses.
Data quality control

• The questionnaire will be prepared in English then translated to local languages

Amharic, Afan Oromo and Somali and back to English.

• Questionnaire will be pretested on 5% of the calculated sample size

 Methods….

• Data will be collected by qualified nurses and supervision of the data collection
process will be managed by supervisors working in the health facilities and the PI.

• Training be give to data collectors and supervisors

• Each questionnaire will be reviewed daily by the supervisors and the principal
investigator to check for its completeness.
 Methods….
Variables of the study
Dependent variables
• Undernutrition among TB patients.

Independent variables
• Sociodemographic and economic factors
• Nutritional status(nutritional support, food
frequency and dietary counselling)
• Health status
• Behavior and Co- morbidities
Methods….
Data processing and analysis

• Data will be Cleaned and entered into Epi Data 7.2.5.0 version and analysis of the data
will be conducted by using the statistical package for social sciences version 23.
• Frequencies and proportions will used to describe the study subjects in relation to the
studied variables.

• Logistic regression models will be applied to assess the relationship between

determinants and undernutrition among TB patients. Multivariable analysis will be used.
• Adjusted odd ratio along with 95% CI was calculated to see strength of association
and P<0.05 was taken as level of statistical significance.
 Operational definition
• Undernutrition: A person with BMI <18.5 kg/m2 were considered as Undernutrition.
• Body mass index (BMI): BMI is defined as weight of the individual Divided by the
square of the same individual height in meter.

• Dietary Diversity Score: the number of food groups in a daily diet of individuals or
households are often measured by 24-hour recall. Each participant is required to list all
foods and drinks consumed on the previous day without quantifying them. An item
consumed from a specific food group is counted only once and dietary diversity score
of < 4 represents poor diversity.
 
Operational def.…
• Eating Difficulty: experience one of the following conditions: loss of appetite,
nausea, vomiting, or swallowing difficulty in the past 6 months.

• Dietary counselling :Is a process by which a health professional with special training in
nutrition helps people make healthy food choices and form healthy eating habits.

• Nutritional Support :Nutritional support is having numerous components like nutrition

education and counselling in health facilities, water, and hygiene or food safety
interventions to avert diarrhoea as well as provision of sufficient quantity/quality of
food and food aid by any organization.
 
Operational def.…

• Alcohol Consumption :an individual was considered as a “current drinker” if they

consumed more than 21 standard drinks/week for men and more than 14 standard
drinks/week for women in the past 30 days.

• Cigarette Smoking: an individual was considered as a “current cigarette smoker” if

she/he had smoked a minimum of one cigarette per week within the last 30 days
preceding the study.

• Khat Chewer: an individual was considered as “current khat chewer” if he/she had
chewed at least one bundle of khat per week within the last 30 days.
 
Ethical consideration
• Ethical clearance will be obtained from Research Affairs Directorate of Dire Dawa
University.
• consent will be obtained from the selected health facilities.

• The aim of the study will be informed for each participant

• confidentiality will be assured by data collectors.

• Informed consent will be obtained from each participants.

• The participants have a right to refuse/ discontinue without restriction

Work and Budget plan
• This project will take a total of nine months (from Oct 2021-Jun 2021).

• The total budget required for this study is 16,455 ETB

 References
• World Health Organization. Guideline: Nutritional Care and Support for Patients with Tuberculosis.
Geneva: World Health Organization; 2013.
• Guideline, W., nutritional care and support for patients with tuberculosis. 2013. 2016.

• Misganaw A, Haregu TN, Deribe K, Tessema GA, Deribew A, Melaku YA, Amare AT, Abera SF, Gedefaw M,
Dessalegn M, Lakew Y, Bekele T, Mohammed M, Yirsaw BD, Damtew SA, Krohn KJ, Achoki T, Blore J, Assefa Y,
Naghavi M. National mortality burden due to communicable, non-communicable, and other diseases in Ethiopia, 1990–
2015: findings from the Global Burden of Disease Study 2015. Popul Health Metrics 2017;15(1).
https://doi.org/10.1186/s12963-017-0145-1.
• K.B. Gupta,R.Gupta. A Atreja, M Verma , S Vishvkarma , Lung India • Vol 26 • Issue 1 • Jan - Mar 2009

• Sinclair D, Abba K, Grobler L, Sudarsanam TD (2011) Nutritional supplements for people being treated for active
Tuberculosis: areviwe, Cochrane Collaboration 2: 11.
• .T Brhane, H Merga , L Ayele, Gemeda D, Undernutrition among Tuberculosis Patients on Directly Observed Short-Course
Therapy: An Epidemiological Study from Northern Ethiopia. https://www.dovepress.com/ by 196.190.154.202 on 27-Dec-2021
• . Dargie B, Tesfaye G, Worku A. Prevalence and associated factors of undernutrition among adult tuberculosis patients in some
selected public health facilities of Addis Ababa, Ethiopia: a cross-sectional study. BMC Nutr. 2016;2(1):7. doi:10.1186/s40795-
016-0046-x