Knowledge, Attitude and Practice on Tuberculosis and Coinfection of TB and HIV w

Submitted To : Department of public health Manmohan memorial Institute of health sciences Nakhkhu, lalitpur

Submitted By : Harish Singh Bista Bachelor of Public Health Third years 1st Batch Manmohan Memorial Institute of Health Sciences Nakhkhu, lalitpura 2011

Approval Sheet

The research proposal entitled Knowledge, Attitude and Practice on Tuberculosis and Co-infection of TB and HIV prepared by Harish Singh Bista has been accepted by research committee of Manmohan Memorial Institute of Health Sciences for the partial fulfillment of the requirements of Bachelor in Public Health (BPH).

Date: Lekha Bahadur Gurung Research Supervisor Head of Department Department of Public Health Manmohan Memorial Institute of Health Sciences Nepal

.. Date: Bishnu Bhattarai Campus Chief Manmohan Memorial Institute of Health Sciences Nepal

Table of Contents Approval Sheet..............................................................................................................1 Table of Contents..........................................................................................................3 1.2 Statement of the problem.......................................................................................4 1.4 Objective of the study...........................................................................................5
1.4.1 General objective.................................................................................................5 1.4.2 Specific objectives...............................................................................................6

1.5 Research questions..................................................................................................6 1.6 Conceptual Framework of the study Variable ....................................................7
3.1 Study site.............................................................................................................14 3.2 Study design.........................................................................................................14 3.3 Study method.......................................................................................................14 3.4 Study population..................................................................................................14 3.5 Sampling procedure and sample size...................................................................14 3.6 Exclusion Criteria..................................................................................................15 3.7 Unit of analysis.....................................................................................................16 3.8 Sources of data.....................................................................................................16 3.9 Data collection tools and techniques....................................................................16 3.10 Pre-testing .........................................................................................................17 3.11 Quality assurance of data...................................................................................17 3.12 Data management and analysis plan.................................................................17 3.14 Expected outcome..............................................................................................17 3.15 Ethical consideration..........................................................................................17 3.16 Risk for the study................................................................................................17 Annex:1...................................................................................................................23 Annex: 2..................................................................................................................23

References:..................................................................................................................19
Annexes Annexes I: Work Plan Annexes II: Budget Annexes IIIb: Questionnaire in Nepali 24 24 25 31

Chapter I
1 Introduction
1.1 Background
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Tuberculosis (TB) is an infectious disease. In an average 9.4 million incident cases, 14 million prevalent cases, 1.3 million deaths among HIV-negative people and 0.38 million deaths among HIV-positive people were estimated as global Burden of Disease (BoD) caused by TB in 2009. Most cases were in the South-East Asia, African and Western Pacific regions (35%, 30% and 20%, respectively). Furthermore, about 11-13% of incident cases were HIV-positive; the African Region accounted for approximately 80% of these cases. There were 5.8 million notified cases of TB in 2009, equivalent to a case detection rate (CDR, defined as the proportion of incident cases that were notified) of 63% up from 61% in 2008. Of the 2.6 million patients with sputum smear-positive pulmonary TB in the 2008 cohort, 86% were successfully treated.1 In 2010, highest rates ever of MDR-TB, with peaks of up to 28% of new TB cases in some settings of the former Soviet Union was recorded. The risk of developing TB is between 20 and 37 times greater in people living with HIV than among those who do not have HIV infection. TB is responsible for more than a quarter of deaths among people living with HIV. In response to the dual epidemics of HIV and TB, the World Health Organization (WHO) has recommended 12 collaborative TB/HIV activities as part of core HIV and TB prevention, care and treatment services. A high rate of previously undiagnosed TB is common among people living with HIV. Most importantly, active screening for TB offers the opportunity to provide preventive therapy for those who do not have symptoms and signs of TB.3, 4 In the South-East Asia Region, an estimated 1.7 million people died due to TB infection along with 4.88 million prevalent cases and an annual incidence of 3.17 million from TB in 2009, which is onethird of the global burden of TB and accounted for 35% of incident cases globally. Five of the 11 Member countries in the Region are among the 22 high-burden countries. Most cases occur in the age group of 15-54 years, with males being disproportionately affected. About 3.6 million persons are estimated to be living with HIV/AIDS in the South-East Asia region. In countries, such as in Nepal, increasing HIV prevalence among high risk groups such as intravenous drug users (IDUs), has raised concerns about the potential risk of a generalized HIV epidemic in these countries. 6 The Millennium Development Goals (MDGs) has quantified targets to make the world safer, healthier and more equitable by addressing extreme poverty in its many dimensions. The target 07 deals with HIV/AIDS and it has 06 indicators. Incidence rates of TB infection are falling globally and mortality rates at global level fell by around 35% between 1990 and 2009, and the target of a 50% reduction by 2015 could be achieved if the current rate of decline is sustained. 2

1.2 Statement of the problem

In the year 2009, World Health Organization (WHO) estimates the prevalence of all forms of tuberculosis (TB) cases for Nepal at approximately 71,000 (241/100000). Every year 21, 827 new infectious TB cases are expected to arise. In Nepal, about 45 percent of the total population is infected with TB, of which 60 percent are adult. Every year, 40,000 people develop active TB, of whom 20,000 have infectious pulmonary disease. These 20,000 are able to spread the disease to others and 5,000-7,000 people still die per year from TB.8, 9 During 2008/09, National Tuberculosis Programme (NTP)/Nepal registered 35,407 TB cases; among these 48% were sputum smear positive (all forms: new smear positive, relapse, failure and return
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after default). Case finding rate for mid July 2008 to mid July 2009 period was 75% for national level. Multi drug Resistance (MDR) among new cases is 2.9% and 11.7 % among retreatment cases which is a very high percentage. Similarly the prevalence of extensively drug resistant (XDR) TB among MDR is at 5%. Importantly TB HIV co infection is rapidly increasing which is at 2.4 % among TB patients.1 ,7 National Strategic Plan (July 2010 to July 2015)/Nepal is focused to increase case finding in Nepal, and hence to reach the goal: to reduce the mortality, morbidity and transmission of tuberculosis until it is no longer a public health problem. The impact targets are: to halt and begin to reverse the incidence of TB by 2015 and to reduce by 50% prevalence and mortality rates by 2015 relative to 1990 levels. Since the ultimate goal is to eliminate TB (less than 1 new sputum positive TB case per million population per year) from Nepal by 2050.10 DOTs Centers are established up to VDC level and Anti-Retro Viral therapy has been provided free of cost by 21 hospitals to 3,424 persons living with AIDS. The number of voluntary counseling and testing centers number 179 in 65 districts and 22 Anti retroviral therapy center out of 75 districts. The prevention of mother to child transmission scheme has been implemented in 17 hospitals and an increasing number of HIV-positive women have enrolled in the scheme.9 In this context, this KAP study aims to assess knowledge, attitudes and practices (behaviors) about prevention and control measures on TB control and co-infection of TB and HIV among general population and sub- group population.

1.3 Rational of Study

National Health Policy (1991)/Nepal has committed to strengthen the primary health care system and making effective health care services readily available at the local level and Second Long Term Health Plan (SLTHP 1997-2017) provided the broad framework from which the 20 components of the Essential Health Care Services (EHCS) package were identified and control of infectious diseases including tuberculosis and HIV as priority elements.11, 12 Furthermore, Three Years of 10th Five Year Plans Health Programmes( January 2002) aims to extend Integrated and coordinated programs for HIV/AIDS and tuberculosis control with the joint initiatives of the government, the private sector and NGOs. NHSP-IP II (2010-2015) has stated to increase access to and utilization of quality essential health care services including TB control services by reducing cultural and economic barriers to accessing health care services. It also identified Tuberculosis control as one of the Priority 1 programme based on the parameters of: burden of disease, implementation capacity, equity consideration, programmes directed to the poor, marginalized, vulnerable and disadvantaged groups. 9, 13 National level of KAP study has not been conducted regarding to TB and TB HIV co-infection, and national KAP is also essential for baseline benchmark and for evaluation purpose. Addition to that findings will be comparable with some of the NDHS (2006) information. In this context, finding and recommendations of this study will be helpful for policy makers, planners and managers involved in TB control activities and also supports to Government strategy to achieve MDGs.

1.4 Objective of the study

1.4.1 General objective To assess Knowledge Attitude Practice (KAP) on prevention and control measures of TB and TB HIV co-infection among general people, people with TB, family members of TB patients and health care providers.
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1.4.2 Specific objectives 1. To assess the KAP on prevention and control measures of TB among general people, people with TB, family members of TB patients and health care providers. 2. To assess the KAP about TB HIV co-infection among general people, people with TB, family members of TB patients and health care providers. 3. To establish baseline information for programme intervention on TB and co-infection of TB and HIV.

1.5 Research questions

In order to achieve above objectives following research questions has been developed; 1. What is the level of knowledge attitude and practices about TB among general people, people with TB, family members of TB patients and health care providers in Achham? 2. What is the level of knowledge attitude and practices about TB HIV co-infection among general people, people with TB, family members of TB patients and health care providers in Achham?

1.6 Conceptual Framework of the study Variable

Independent Variables Variables Sociodemographic Age, Sex, Marital Status, Occupation, Previous history Use of TB Drug, Types of Treatment, Etiological Factors Cause of TB, Mode of transmission, Sign & Symptoms, Course of dots Accessibility Distance of dots centre Traveling Time KAP on TB/HIV coinfection Dependent

Health worker behavior Friendly, Assertive Time given

1.7 operational definitions

MDR TB: TB cases in which the M. Baccili is resistant to at least Rifampicine and Isoniazid drugs. Compliance: Patient's adherence to a recommended course of treatment. MDRTB patients: Those Tuberculosis patients who were receiving treatment of second line drug therapy under DOTS plus program. Socio-demography: It refers to age, sex, marital status, education and occupation. Previous History: It refers to use of TB Drugs, types of treatment duration of treatment, regularity of treatment prior to DOTS plus. Knowledge: Refers to cause of TB, mode of transmission, Sign & Symptoms, course of DOTS plus, follow up sputum examination, and side effect of drug of TB and MDR TB. Accessibility: It refers to distance of DOTS plus, traveling Time, mode of traveling and waiting time for the MDR TB patients. Health Worker Behavior: It refers to friendliness and time given by health worker to MDR TB patients. Expenditure: Refers to traveling cost, fooding cost, accommodation cost and extra cost of the MDR TB patients require for treatment period.

Educational level: It refers to individual attainment of education. In this study, Upon asking the respondent, it has categorise following: Illiterate (not able to read and write), Literate (able to read and write), Primary (can read and write and who have schooling up to class five), Secondary (Formal education from 6 to 10 class), SLC and above (have SLC passed above the SLC i.e. Higher secondary/ University degree). Economic Status: It refers the ranking of family on the basis of family income. Upon asking the respondents the response will be lower status (her family income is not sufficient to fulfil the daily expenses), Middle status (say her family income is hardly sufficient to fulfil daily expenses) and Higher status (her family income is sufficient to fulfil the daily expenses and Surplus). Type of family: It refers to composition of family. Upon asking the respondents the response will be Nuclear family (This includes father, mother and their unmarried offspring), Joint family (This includes grandparents, uncles, aunts, father, mother and their offspring). Occupation: It refers the work in which the respondent spends maximum of her time. Upon asking the respondents the response will be categorized as below: Agriculture (Work in farm or field), Labour (Work done as wages basis in factory, industries, loader etc), Business (Buying or selling own commerce/ trade), Service (Works/ job on basis of salary e g. Teacher, officer etc), Others (all the work not mentioned above are included in this category with are none employed including house wife).
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1.8 Limitation of study

Sample will be purposively selected. So may not be generalized the whole district and whole nation. Time and resource constraint for the research
Study only focus on TB and TB/HIV co-infection

Chapter II

Literature Review 2.1 Literature

Tuberculosis (TB) is considered as the leading infectious killer for people living with HIV/AIDS (PLHIV) worldwide with at least one in three people with HIV developing an active TB disease. HIV promotes the progression of latent or recent TB infection to active TB disease. TB-HIV coinfection has affected the African countries the most where 80% of global co-infected people reside. The rapidly growing epidemics of HIV seem to be a crucial barrier for TB control in South East Asia Region (SEAR) including Nepal. SEAR bears about 17% of Global TB and HIV co-infection cases. Thus, collaboration between TB and HIV/AIDS program is essential to improve access to comprehensive TB and HIV prevention, care and support services for affected populations and saving lives. According to the WHO (2009c), one third of the 33.2 million people living with HIV/AIDS worldwide in 2007 were co-infected with Mycobacterium tuberculosis (WHO 2009). Globally, out of the 9.27 million new cases of TB detected in 2007, approximately 1.37 million (15%) occurred in HIV positive individuals. The African Region accounted for 79% of these HIV positive TB cases and the South-East Asia Region for 11%. In 2007, HIV/TB co-infection accounted for 456,000 deaths globally (WHO 2009a). In the South East Asia Region (SEAR), India, Myanmar, Nepal and Thailand have been identified by the WHO as high TB/HIV burden countries. According to SEARO (2008), The prevalence of TB among people living with HIV/AIDS has been estimated at 5.2% in India, 7.1% in Myanmar, 3.1% in Nepal and 7.6% in Thailand. The HIV epidemic has reached a generalized stage in Thailand, Myanmar and in six states in India. Concentrated HIV epidemics are being reported from Indonesia, Nepal, Bangladesh (among IDUs) and in some states in India. The increasing prevalence of HIV/AIDS and HIV/TB co-infection is of public health concern to several countries in this region. After successfully pilot testing the HIVTB cross-referral mechanism in Maharashtra, HIVTB joint activities were first rolled out in six high burden states in 2004. Under the revised 2009 intensified package of HIVTB collaborative activities is currently being implemented in 17 states and it is planned to cover the entire country by 2012. During the years, cross-referrals have progressively improved and a consistently increasing number of HIV infected TB patients have been diagnosed. In 2005, 54 000 patients were cross-referred and 10 000 HIVTB co infected patients were identified. In 2009, there were 7 80 000 cross-referrals between the two programmes resulting in the diagnosis of 27 900 HIVTB co infected patients. Technical oversight for the programme is provided by a
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national technical working group, comprising key officials from NACO and the Central TB Division. Similarly, working groups at the state level and coordination committees at the state and district levels also conduct regular meetings to address issues in the implementation of HIVTB collaborative activities. Tuberculosis is one of Nepal's major public health problems. About 45% of the population is infected with TB, out of which 60% are in the productive age group. Every year, 44,000 people develop active TB, of whom 20,000 have infectious pulmonary disease. These 20,000 can spread the disease to others. Introduction of treatment by Directly Observed Treatment Short course (DOTS) has already reduced the numbers of deaths; however, 8,000-11,000 people continue to die every year from this disease. Expansion of the cost-effective and highly-successful DOTS treatment strategy has proven its efficacy in Nepal and has had a profound impact on mortality and morbidity. By achieving the global target of diagnosing 70% of new infectious cases and curing 85% of these patients, 60,000 deaths will be prevented over the next five years. High cure rates will reduce the transmission of TB, lead to a decline in the incidence of this disease, and ultimately aid in achieving our objectives of TB control. DOTS was introduced in 1996 after a joint Government/WHO review of the National Tuberculosis Programme (NTP) revealed that only 30% of TB cases were registered, and of these only 40% were treated successfully. The cure rate in the first cohort of DOTS patients was over 89%. By July 2000 the program had been expanded to 178 treatment centers in 66 districts and covered 75% of the population. The treatment success rate in DOTS centers is now approximately 89%; and, the national treatment success rate has reached nearly 85%. In the period 2007/08, a total of 33,419 TB patients were registered and treated under the NTP. One of the reasons for the persistent burden of TB is a failure to address the principal risk factors. The risk associated with TB can be put in three groups: the process of infection, progression to disease and outcome of a disease episode. Environmental factors that govern exposure to infecting bacilli include crowding, hospitalization, migration, imprisonment, ventilation and the ambient prevalence of infectious disease (mostly sputum smear positive). Among factors that influence the progression to diseases following infection, HIV coinfection is outstandingly important; others are age, sex, diabetes, tobacco, alcohol, TB strain virulence and malnutrition. Factors that affect the outcome of a disease episode include where treatment is given (eg. public or private sector), whether treatment is interrupted and drug resistance. The adverse outcomes most commonly measured are treatment failure and death. Some other risk factors for TB are commonly invoked but ill defined, ethnicity and poverty among them.

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In the context of Nepal, a situation analysis of TB-HIV co-infection was conducted in 2006. The study revealed the fact that there is an absence of policy framework for collaborative work as well as lack of resource allocation from government for collaborative activities. The study also highlighted lack of formal referral mechanism between two programs though some informal referral system exists in certain cases. However, both the program has major individual strategies like DOTS for NTP and VCT for HIV/AIDS. In recent times, Nepal has made some progress in TB-HIV collaborative program. The National Tuberculosis Program (NTP) in its revised Long Term Plan (2010-2015) has envisaged collaboration with National AIDS Program (NAP) to decrease the burden of TB-HIV in population affected by both diseases. A cross-sectional analytical study was conducted Between January 2004 and August 2005, with a general objective to determine the Tuberculosis co-infection status in HIV/AIDS cases of Nepal. Altogether 100 HIV infected persons visiting different Voluntary counseling and testing centers (VCT) and HIV/AIDS care centers located in Kathmandu valley were enrolled in the study. Investigation of tuberculosis was done by standard method prescribed by WHO using sputum specimen. Among 100 HIV infected cases, 66 (66.0%) were males and 34 (34.0%) were females. Majority of the HIV cases were in the age group 21-30 (60.0%) followed by 31-40 (31.0%). Tuberculosis was detected in 23 cases with highest prevalence in the age group 21-30 years (65.2%). No significant relationship could be established between gender and TB (c2 =0.83, p>0.01).Significant relationship was established between smoking/alcoholic habit and the subsequent development of tuberculosis(c2 = 7.24, p<0.05 for smoking habit; c2=4.39, p<0.05 for alcoholic habit at 1 degree of freedom). Among 22culture positive isolates the predominant was mycobacterium avium complex (40.9%) followed by M. tuberculosis (27.3%), M. kansasii (18.2%), M. fortuitum (9.1%) and M. chelonae (4.5%). Among the 23 cases of tuberculosis, 22 cases were diagnosed by cultural technique of which 4 cases were smear positive while the remaining one case was diagnosed by direct microscopy although it was culture negative. Smear negative Tuberculosis is found to be alarmingly higher in HIV positive individuals of productive age group. The disease significantly higher in smokers and alcoholic. Three Hundred newly diagnosed TB cases attended to BPKIHS DOTS clinic were tested for HIV. Among 300 newly TB patients, 14 (4.7%) patients were HIV positive. All were males. The study has shown very high (4.7%) TB/HIV co-infection. This is an alarming situation. Similar operational research can be conducted in different parts of Nepal to know the exact scenario of TB/HIV coinfection, which is necessary for formulating national policy & guidelines for TB/HIV control in the country. Among 300 newly TB patients, 14 (4.7%) patients were HIV positive. There were 196 (65.3%) males and 104 (34.7%) females. The maximum number (57, 29.1%) of malesand (37, 36.5%) females were in 21-30 years of age group (Table1). All 14 TB & HIV co infected patients were
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males. Among these,8 (57.2%) were in 31-40 years and rest 6(42.8%) in 21-39 years age group. These SAARC Journal of Tuberculosis Lung Diseases & HIV/AIDS 3age groups are sexually very active. Maximum number 236 (78.7%) patients were from Sunsari, followed by Jhapa (16, 5.4%)and Morang districts (Table 2). Among 14 TBand HIV co-infected patients, 12 were from Sunsari and one each from Morang and Jhapa districts. Out of 196 males patients, 145 (74%) were diagnosed pulmonary and rest 51 (26.0%) extra pulmonary TB (Fig. 1). Similarly among104 female patients, 73 (70.2%) were diagnosed as pulmonary TB and rest 31(29.8%) were extra pulmonary TB. Among 300 TB cases, 100 (33.3%) males and 63 (21.0%) females were sputum positive and rest negatives. There was previous history of TB present in 34 (11.3%) patients. Out of these 34 patients with previous history of TB, 22 were males and 12females (Fig 2.).There were 6 (42.8%) sputum positive pulmonary TB cases, 4 (28.6%) sputum negative pulmonary TB cases and rest 4(28.6%) extra pulmonary TB cases among14 TB/HIV co-infected patients.

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Chapter III 3. Methodology

3.1 Study site In order to provide District level representation, Achham district have been selected following simple random sampling techniques with adopting the concept of Probability Proportionate to Size (PPS) method for each region taking care of heterogeneous distribution of major TB indicators (treatment success rate, case finding rate and default rate) and literacy rate. 3.2 Study design Cross-sectional descriptive study design will be adopted. 3.3 Study method Quantitative and qualitative data collection methods will be applied. Quantitative indicators are essential for measuring results and gauging impact while qualitative indicators can provide a more nuance understanding of results. 3.4 Study population Four groups of study population will be identified for this KAP study, which includes: 1) General population at households, 2) People with TB, 3) Family of TB patients, and 4) Health service providers. The study will be conducted in the selected VDCs and DOTS centers of each selected district. 3.5 Sampling procedure and sample size One hospital will be selected from Achham district, while one PHCC having high TB case load among total PHCCs will be selected. Similarly, two HPs (one having high TB case load among HPs located near to the municipality/district headquarter (HQ) area and another among HPs located little far away from the area) will be selected from each selected district. For the selection of two SHPs in each case, the same procedure will be followed. High case load situation will be identified after discussing with D(P)HO/DTLA of respective district. Therefore, 1 hospital, 1 PHCC, 2 HPs and 2 SHPs will be selected from each district (Table 1). Table 1. Sample size of health facility by districts
Districts Achham Total SHPs 2 2 HPs 2 2 PHCCs 1 1 Hospitals 1 1

Sampling procedure and sample size of General Population for KAP survey Sample size for General people (for infinite population)

n =

2 1 - /2

P (1 P ) d
2

Where, At 95 percent Confidence Interval, Z0.05, = 1.96 P = Prior information; for safest point, overall knowledge of TB among community people was 50 percent, so p = 0.5 1-P = 1-0.5=0.5
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d = Effect size (precision), lets assume over knowledge of community people must have been fluctuates in between 5 percent points, i.e. (45% to 55%), if so, d will be expressed as decimal (0.05). n = (1.96)2 x 0.5 x 0.5 = 384.16 = 384 (0.05)2 The sample is further increased by 5 percent to account for contingencies such as non-response or recording error. n + 5% of n = 384 + 19.2 (5% of 384) = 403.2 = 403 Therefore, there will be total 403 households (HHs) for KAP survey for general population (Table 2). Table 2. HHs sample size by districts for general population
Districts Achham Total Total HHs 49733 49733 Sample size 17 17

Sampled health facility (whichever will be selected) located Ward of the concerning VDC will be the study area for HH survey for general population. From each selected Ward, HHs will be selected by using systematic random sampling technique. Head of the HH will be identified for interview. If he/she will not agree to give his/her consent for interview, the study team will try to ask him/her to identify another person for interview. If no one agrees to give interview, the team will move to next nearest HH. Sampling procedure and sample size of people with TB for KAP survey In each selected health facility, the list of TB patients registered in 2nd and 3rd quarters of FY 2067/68 will
be prepared. From the list, 30% patients will be selected using random sampling techniques. After the selection of the patients, the team will either go to visit these patients in the VDC or wait for them in the health facility from where the list will be obtained. Required number of patients (either in health facility or home) will be traced maximum for seven days in each district. If the team will unable to find the required number of TB patients, the team will compensate those short falls while conducting survey in another district.

Sampling procedure and sample size of family of TB patients for KAP survey When the TB patients will be selected using the strategy of sampling frame, his/her one accompanying person will also be interviewed (but in separate place) during their health facility visit, or interviewers home visit. The sample size of the family members of TB patients will be same as the sample size of the TB patients. Sampling procedure and sample size of health care providers for KIIs For selecting health providers, one person from each health facility will be selected. This way there will be 6 health care providers to be interviewed for each selected district. Sampling procedure and sample size of people with TB for FGDs People with TB infection and attending for treatment in DOTS centers will be involved in FGDs. About 7-9 persons will participate in FGD in each group. There will be one FGD among such group in each selected district. 3.6 Exclusion Criteria TB patients/their family members/health care providers/general people who will be reluctant to participate (or not be able to give their consent) in the proposed study will not be included in this study.
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3.7 Unit of analysis Respondents of the households, people with TB, their family members and health workers will be the unit of analysis in this study. 3.8 Sources of data Primary and secondary sources of information will be collected by using both qualitative and quantitative methods. 3.9 Data collection tools and techniques In order to fulfill the objectives of this study, primary sources of data will be collected from qualitative and quantitative techniques and tools. Briefs of Method and Material
Objectives To assess the KAP on prevention and control measures of TB among general people, people with TB, family members of TB patients and health care providers in Nepal. To assess the KAP about TB HIV coinfection among general people, people with TB, family members of TB patients and health care providers in Nepal To establish baseline information for programme intervention on TB and co-infection of TB and HIV in Nepal Techniques KAP survey Tools Questionnaire Study population -Head of HHs, -People with TB, -Family of TB patient Health care providers People with TB Total sample size #HHs Survey with General people=403 # HHs survey with TB patients= 30% of regd. cases # HHs survey with TB patients Family=30% of regd. Cases # KII with Service providers=60( one in each district) # FGDs with TB patients =10 (one in each health facility)

KIIs FGDs

KII schedule FGD guideline

KAP survey

Questionnaire

-Head of HHs, -People with TB, -Family of TB patient Health care providers People with TB -Head of HHs, -People with TB, -Family of TB patient Health care providers People with TB

KIIs FGDs KAP survey KIIs FGDs

KII schedule FGD guideline Questionnaire KII schedule FGD guideline

Quantitative A KAP survey technique will be applied in this study. KAP survey tool will include both close ended and open ended questionnaire. KAP survey tool will be implemented in general population, TB patients and their family members to assess knowledge attitude and practices. Three separate KAP survey tool will be developed and implemented for each separate groups for data collection. Qualitative Key Informant Interview (KII) method will be implemented among health care providers in each of the selected district. This interview schedule will include issues related to prevention and control of TB and co-infection of TB and HIV/AIDS. Tape recording and note taking will be done to capture the information during KIIs. Focus Group Discussion (FGDs) will be done with TB patients to know about the reasoning. A FGD guideline will be developed, which includes the issues related to TB and HIV prevention and control issues. Tape recording and note taking will ne done to capture the information during FGDs. Secondary data will be also collected from report, annual progress report and midterm reports.
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3.10 Pre-testing Before implementing KAP survey tools, the pre-testing will be done. The changes from pre-testing will be incorporated in the tools. 3.11 Quality assurance of data Quality assurance of the data will be maintained by the supervision of supervisors. A part from that, principal investigator and consultant will also supervise the work of enumerators and facilitators. 3.12 Data management and analysis plan Processing: Collected data will be verified and coded daily after completing the field activities. Prior to the data entry, data will be cleaned in a meeting with the district supervisor in the respective districts. A cleaned data will be entered into MS Excel and transferred to SPSS 13 in Kathmandu. The findings will be processed/analyzed using computer software, standard statistical tools, manually and will be entered in computer programming for relevancy, consistency, accuracy and scientific proceedings. A. Quantitative Findings: Data entry file will be prepared using SPSS 13 or MS excel. Appropriate check codes will be prepared to check data entry. The collected data will be entered and the file will be transferred to SPSS 13. The data will be summarized using appropriate tools and techniques. B. Qualitative Findings: For the qualitative data and content analysis will be done. Each of the topic guide will be provided with the description, positive, things needs to be improves and some for the flavor from quotations Analysis: The quantitative data will be analyzed using the basic statistical tools. The results of quantitative and qualitative will be presented separately in the analysis section with appropriate tables, bars and diagrams. Quantitative findings will be analyzed in accordance with the distribution of data. The collected data will be entered and the file will be transferred to SPSS 13. The filled questionnaires will be kept in research institute for 5 years. Qualitative findings will be done with a content analysis method and the notes takers note will be matched and verified with transcription of recorders. The findings will be presented in narrative forms, verbatim, comparative charts and quotations. 3.14 Expected outcome 1. Assessed KAP on prevention and control of TB and co-infection of TB and HIV/AIDS among general population 2. Assessed KAP on prevention and control of TB and co-infection of TB and HIV/AIDS among TB positive patients 3. Assessed KAP on prevention and control of TB and co-infection of TB and HIV/AIDS among health workers 3.15 Ethical consideration Ethical consideration will be maintained by obtaining the approval from the study respondents and participants. A formal letters from NHRC will be useful to ensure timely implementation. However, an informed consent will be taken from the respondent/participants. 1. KAP Questionnaire- Written consent from the respondent 2. KII/FGD - Verbal consent Yes- and the signature of participants and facilitator.

3.16 Risk for the study When field implementation activities could be carried out according to schedule than study report could be produced within deadline. If political situation, banda/strike and other unavoidable condition hamper to the field implementation and in such condition HERD will inform to NTC and will try to complete task and produce study report as far as possible.
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References:
WHO Report. Global Tuberculosis Control, 2010 (http://www.who.int/tb/publications/global_report/2010/gtbr10.pdf (Accessed on 2011/02/15) 2. Tuberculosis Global Facts.2010/2011. WHO, The stop TB Partnership. 3. WHO. Guidelines for Intensive Tuberculosis Case Finding and Isoniazid Preventive Therapy for People Living with HIV in Resource Constrained Setting, Geneva, 2010 4. SAARC Tuberculosis and HIV Center (STAC)/Nepal. HIV and AIDS SAARC Region Up- date, 2009 5. WHO. Fact Sheet No.104, Nov 2010( accessed on 2011.02.15)2010 6. WHO Status Report. TB/HIV in the South-East Asia Region, 2009, Delhi 7. National Tuberculosis Control Center (NTC)/ Nepal. Annual Report,2008/2009 8. DoHS/MoHP/Nepal. Annual Report, 2008/09 9. Ministry of Health and Population/GoN. Nepal Health Sector Programme Implementation Plan II(NHSP-IP 2)2010-2015.2010 10. NTP/MoHP/Nepal. Tuberculosis Control Programme Nepal National Strategic Plan Implementation of Stop TB Strategy (16 July 2010 15 July 2015),2010 11. Ministry of Health and Population/GoN. National Health Policy(1991).1991 12. Ministry of Health and Population/GoN. Second Long Term Health Plan(19972017).1997 13. National Planning Commission/Nepal. Three Year Interim Plan.2002 14. WHO/HTM/STB .Advocacy, communication and social mobilization for TB control: A guide to developing knowledge, attitude and practice surveys, WHO/HTM/STB/2008.46 15. Andrew A Fisher, John Etaing, John E Stoe el, John W Townsend. Handbook for Family Planning Operations Research Design. Population Council. One Dag Hammarskjold Plaza. New York, New York 10017.1991 16. S. P. Yadav, M. L. Mathur and A. K. Dixit. Knowledge and Attitude toward Tuberculosis among sandstone quarry workers in desert parts of Rajasthan. Indian Journal of Tuberculosis. 2006 17. Maria Christina N. Bacay-Domingo, Anna Lisa Ong-Lim. A descriptive study of the knowledge attitude and practices on TB among treatment partners of pediatric patient in Tarlac city. PIDSP Journal 2009 Vol. 10(1). 18. National Tuberculosis Center and Britain Nepal Medical Trust. Knowledge, Attitude and Practices Study on Tuberculosis among Community People of Sindhupalchowk district. 2009
1.

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Annexes I: Work Plan

The total estimated duration of the study will be about one month including preparation time till final report is submitted. Research team will provide the technical and research supervision during the entire study process. Then, process and analyze the date and prepare the final report. Octobe S.N Activities April May June July August September
r

1 2

Topic Selection Literature review

3 4 5 6 7

Development of proposal Proposal presentation Data collection Data entry and analysis Findings presentation and report of writing Submission final report

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Annexes II: Budget

S.N 1 Activities Literature review 2 Information collection Net searching 1,200 1,000 Total amount (NRs)

Proposal writing Typing printing 200 800 1,200 3,500

3 4 5

Stationary Travel & Transportation Data collection Data Collectors Logistics Fooding

1,500 1000 3000

6 7

Tabulation & analysis Typing, Printing & binding Report Questionnaire

1,000

1,500 1000 1000 1000 18,900

8 10

Dissemination Miscellaneous Total

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Annexes III: Questionnaire

22

Annex:1
Sampling Districts Districts Developme nt Region Far-western Ecologica l Region Hill Treatment Success rate % 89 Default Rate % 0 Case Finding Rate (per 100,000) 33 Literac y Rate (%) 45

Accham

Annex: 2

Sampling frame of Health facilities Districts Achham Total SHPs 60 398 HPs 12 82 PHCCs 2 27 Hospital s 1 14

23