Résumé exécutif.<p>Introduction.<p>La tuberculose est une maladie infectieuse qui constitue un fardeau pour la société et en ce sens qu’elle est responsable d’un important taux de mortalité spécifique, surtout dans les pays en développement. Malgré les grands progrès en termes de méthodes de diagnostic, de prévention et de traitement, près de 9 millions de nouveaux cas apparaissent chaque année au niveau mondial et les 30% se trouvent en Afrique. On estime que la tuberculose est responsable de près de 2 millions de morts par an, principalement parmi les populations les plus pauvres. Pourtant, la maladie peut être guérie à l’aide des médicaments dont le coût est inférieur à 18 USD par patient. <p>Pour faire face à ce problème lié à la tuberculose, l’OMS a recommandé vers 1994 l’application de la stratégie « Directly Observed Treatment Short-course, (DOTS) ». Cette stratégie, constituée de 5 points clés, n’a donné que des résultats partiels. Par conséquent, les experts de l’OMS ont conçu et ont publié une autre stratégie appelée « Halte à la Tuberculose » en 2006. Cette nouvelle stratégie, allant au delà des 5 principaux points de la stratégie DOTS, fait appel à toutes les structures sanitaires publiques et privées et à tous les acteurs de santé, y compris la communauté, pour participer au dépistage et à la prise en charge des tuberculeux.<p>A Madagascar, la lutte contre cette maladie est coordonnée par l’équipe du Programme national de lutte contre la tuberculose (PNT). Ce programme est fonctionnel depuis 1991 et applique les stratégies recommandées par l’OMS. Par ailleurs, il a conçu un manuel destiné aux prestataires de soins et aux différents responsables du niveau opérationnel. Le PNT s’est fixé comme principaux objectifs d’améliorer le système de dépistage et d’atteindre un taux de guérison de 85%. En 2006, 15 ans après la mise en œuvre du programme, le taux de notification des nouveaux cas de tuberculose à frottis positif (TPM+) était de 81 pour 100.000 habitants par an et la proportion de réussite au traitement pour ce dernier groupe de tuberculeux était encore de 78%. La létalité et le taux d’échec au traitement à Madagascar est relativement bas. La relativement faible proportion de réussite, inférieure à l’objectif, est avant tout liée au taux d’abandon élevé. Depuis 2006, le PNT a adopté le système décentralisé dans la prise en charge des malades. <p>Généralement, un tuberculeux a un parcours long et ardu à effectuer à partir de l’apparition des premiers signes d’imprégnation tuberculeuse jusqu’à la guérison. Ce parcours est à la fois d’ordre géographique et thérapeutique. Bien que les malades présentent des signes cliniques quasiment identiques, demandant un schéma thérapeutique standard, ils vivent dans des contextes différents. Et chaque contexte a un effet spécifique sur l’adhésion au traitement. Pourtant, ces contextes sont rarement considérés dans les stratégies conçues au niveau national et international. Soulignons que Madagascar est un vaste pays de 590.000 km² ayant des contextes (contexte géographique, contexte culturel, nombre de formations sanitaires, etc.) très variables d’une région à l’autre et d’un district à l’autre. L’application des directives sans tenir compte ces différents contextes locaux pourrait être à l’origine de la non réussite su système de suivi des malades et donc du contrôle de la tuberculose. Inversement, les districts et les centres de diagnostic et de traitement (CDT) qui adaptent les directives selon leurs contextes et/ou qui prennent des initiatives répondant aux contextes des malades, ont plus de chance de réussir le contrôle de la tuberculose.<p>Objectifs.<p>D’une manière spécifique, la présente thèse vise à :<p>-\ / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

Submitted in fulfilment of the requirements for the Master of Health Sciences in Nursing, Durban University of Technology, 2017. / Tuberculosis (TB) is South Africa’s greatest community health problem. Nurses have a critical role in supporting patients in the TB treatment process. An estimated 480 000 new cases of Multidrug-Resistant Tuberculosis (MDR-TB) and 190 000 people died in 2014. An estimated 43 million lives were saved between 2000 and 2014 with effective diagnosis and treatment of TB. Despite these measures TB remains one of the world’s biggest threats. In an attempt to improve the practice of nurses in the prevention of MDR-TB, the knowledge of nurses with regards to the prevention of MDR-TB is essential. Aim of the Study The aim of the study was to describe the practice of the nurses in the prevention of MDR-TB and to determine whether the practice was effective in the prevention of MDR-TB. Methodology Quantitative, descriptive survey was used to conduct the study. Purposive sampling method was employed to select six primary health care clinics at uThungulu District. The target population consisted of professional nurses and enrolled nurses working in these clinics. The sample size was 122. The questionnaire was used to collect data. Descriptive statistics was used to describe the data graphically. In order to test for significant trends in the data, inferential statistics were applied. Results The findings of the study revealed that nurses were implementing measures of preventing MDR-TB like tracing of patients who interrupted TB treatment although there were inconsistencies with implementation of other measures. There were gaps related to attendance of TB courses by TB staff. Nurses were working in an overcrowded environment where it was difficult to implement measures for preventing MDR-TB. There was an increase in the workload due to the high number of patients having TB. Conclusion In this study, the majority of nurses working in primary health care clinics scored well in infection control measures with regard to practicing cough hygiene, placing patients in a well-ventilated area, collection of sputum from patients suspected of having TB and giving of health education to patients with TB and relatives but there areas that need improvement. The findings indicate knowledge gap with regard to TB. There is a need for attendance of short courses in TB, increase of staff attending to TB patients so as to cope with the workload and efficient allocation of resources. / M

This thesis is an investigation into the socio-economic constraints that influence the decisions of tuberculosis sufferers in the health seeking process and therapeutic management of tuberculosis in Grahamstown, the Eastern Cape. It is shown that structural violence influences experiences and perceptions of tuberculosis at all levels. Management of tuberculosis in the formal health sector is explored at local levels and related to national and global strategies of health care. The role of health workers, and particularly voluntary health workers, is explored and it is shown that they work within a context of growing burden of sickness and co-infections and a lack of government commitment to deal with increasing TB and HIV incidences. Kleinman’s notion of explanatory models is explored and it is evident that although knowledge of the aetiology of tuberculosis is well-known to patients and general members of the communities, they are nevertheless victims of increased stigmatisation and marginalisation as a result of illness. The importance of social support in curing tuberculosis is explored using Janzen’s concept of therapy managing groups. Social capital is a fundamental component in adhering to biomedical therapy, but is commonly weak among the structurally poor. The availability of temporary social grants for people living with TB influences health seeking behaviour. In a context of structural poverty the sick are faced with what Nattrass terms “perverse incentives”, having to choose between the right to health and the right to social security, both guaranteed in the South African Constitution, for him/herself and dependants. Although adherence to biomedical therapy is essential in curing tuberculosis, it is shown throughout this thesis that ignoring wider structural causes of disease limits the patient’s ability to get well. The ethnography shows that the right to health is a social and economic right which is not the reality for most South Africans.

A quantitative, descriptive, explorative survey was conducted to explore and describe factors contributing to underutilisation of HIV testing services among tuberculosis patients and clients in Malawi. Sampled were 282 participants attending an outpatient clinic. A self administered questionnaire was used. The findings revealed that 80.5% of the respondents perceived themselves susceptible to HIV infection, 55% believed there were negative consequences of HIV Testing and Counselling (HTC), 87.6% perceived HTC had benefits, most of the respondents (76.8%) mentioned the benefit of knowing the HIV status helping one to plan life, 65% believed in themselves, that they could accept and undergo HIV testing with ease. The study recommends that all HTC providers be thoroughly trained in knowledge and skills to offer services with confidentiality and avoid stigma and discrimination of those found HIV positive. The importance and benefits of HTC should be emphasised in all behaviour communication messages / Health Studies / M.A. (Public Health)

MCur / Department of Advanced Nursing Science

Thesis (Ph.D. (Nursing Science)) -- University of Limpopo, 2017 / The aim of this study was to develop a model to ensure the integration of Tuberculosis (TB) and Human Immune Deficiency Virus (HIV) services in the Primary Health Care (PHC) facilities of Limpopo Province. An explanatory sequential mixed method was used in this study to develop a model for ensuring the integration of TB and HIV services in the PHC facilities of the Limpopo Province. The researcher collected quantitative data followed by qualitative data. Quantitative data was collected through administration of questionnaires to 450 PHC nurses in the five districts of Limpopo Province. The qualitative data was collected by conducting focus group discussions to five groups of Community Home Based Carers (CHBCs) and five groups of TB/HIV co-infected patients in the five districts of Limpopo Province. Audiotape and field notes were used to capture verbal and non-verbal cues. The Statistical Package for Social Sciences (SPSS) computer programme version 22.0 was used for capturing and analysis of the quantitative data. Content analysis was used to analyse the qualitative data from the CHBCs and the TB and HIV co-infected patients’ focus group discussions. The study revealed lack of knowledge and skills on TB and HIV management due to insufficient training of PHC nurses about TB and HIV management. Staff shortage of PHC nurses in the facilities was also indicated by PHC nurses. Furthermore, TB and HIV coinfected patients are faced with challenges in the PHC facilities and in the community. Challenges that are faced by CHBCs and the TB and HIV co-infected patients include negative attitudes of some clinic staff members towards them. The patients’ families also have some negative attitudes towards the CHBCs as they leave the patients to them without assisting them in the caring duties. The community members also has negative attitudes as they do not accept the CHBCs in their homes to support the patients. Based on the results, a model was developed to ensure the integration of TB and HIV services. The model was validated by PHC nurses and the experts in research and model development. The validation results showed that the model was clear and simple to be used in the PHC facilities for integration of TB and HIV services. The study recommends that the model should be used by PHC facilities for integration of TB and HIV services. The PHC nurses should attend TB and HIV capacity-building courses.

Decentralisation of the multidrug resistant tuberculosis (MDR TB) programme to primary health care (PHC) facilities in the Nelson Mandela Metropolitan was implemented in order to improve the effectiveness of MDR TB services. This study explored the knowledge gaps of nurses at PHC facilities as regards MDR TB. A quantitative, cross-sectional descriptive study was conducted; data was collected using a structured questionnaire. Non-probability sampling was applied in this study. A convenient sampling technique was used and 25 of the 42 facilities were selected. Thirty-two respondents completed the questionnaire with a response rate of 64%. Descriptive statistics were used to describe the data. Only 38% of the nurses had been trained on MDR TB. Overall scores were high with a mean knowledge score of 61%. However there were knowledge gaps regarding side effects of MDR TB medication. This study revealed gaps in knowledge of certain areas of MDR TB management / Health Studies / M.A. (Public Health)

This quantitative, descriptive study investigated risk factors for MDR-TB in Addis Ababa, Ethiopia. A total of 439 medical records belonging to MDR-TB and non MDR-TB patients managed in public health centres from January 2008 to December 2011 were analysed. Data were transcribed from each TB patient‟s medical records using a specifically designed checklist. The findings revealed that male gender, previous history of TB treatment, poor treatment adherence, an outcome of failure after TB re-treatment, previous category of failure, pulmonary involvement of TB infection and HIV infection were associated with MDR-TB. The findings illustrate that efforts should be made to prioritise the development and implementation of effective MDR TB screening and treatment protocols for these high risk groups to improve treatment outcome and minimize the emergence of XDR TB. / Health Studies / M. Public Health

The purpose of this study was to investigate the Isoniazid preventive therapy (IPT) initiation amongst eligible HIV positive patients at health facilities in the Polokwane subdistrict to identify key features in the knowledge and practice of health professionals as well as available resources at the health facilities. A quantitative non-experimental, descriptive, cross-sectional design was used to describe the practice of IPT initiation in health facilities. Data were collected using a structured questionnaire with medical doctors, operational managers and registered nurses from the district’s 34 health care facilities. The census sample was 124. Data were captured and analysed using Statistical Package for the Social Sciences (SPSS) Version 24. The results showed that the health care professionals knew the policy and procedures for the implementation of IPT but lacked knowledge on patient screening. The findings further suggest that record keeping and data capturing was not implemented sufficiently. Resources at the facilities were found to be sufficient. / Health Studies / M. P. H.

BACKGROUND: The prevalence of tuberculosis (TB) has been rapidly on the ascendency in the recent years globally due to its co-infection with HIV/AIDS. TB case finding is one of the technical pillars of the Directly Observed Treatment Short course (DOTS) TB strategy and there has been advocacy for early TB case detection to be the new focus of TB control efforts. PURPOSE: The purpose of this non-experimental study was to assess the determinants of TB case finding among pulmonary TB patients registered for treatment in Makana Municipality METHOD: A quantitative, non-experimental, cross sectional descriptive study among PTB patients registered for treatment at the primary health care clinics in Makana Municipality was done. Data collection was by self-administered questionnaires while sampling was by systematic sampling of PTB patients at five systematically selected clinics. RESULTS: Patient–related delay contributed more to total delay, in this study sample, than health system-related delay. Health system delay was found to be significantly associated with poorer finances, passive smoking history, seeking care from multiple health providers, initially visiting a non- NTCP health provider, TB stigma , overcrowding in the household and having difficulty with breathing as an initial symptom (p<0.05). CONCLUSION: There was a significant delay in TB case finding among PTB patients in this local municipality and patient related determinants contributed more than health system related determinants to this delay. There is need for the municipal TB programme to embark on an aggressive health education programme to furnish the populace with accurate information about TB, improve their health seeking behaviour and help address the issue of stigma associated with TB. / Health Studies