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BARRIERS TO TUBERCULOSIS TREATMENT ADHERENCE IN URBAN SLUMS: A CASE STUDY OF INFECTIOUS DISEASES HOSPITAL KANO
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Tuberculosis (TB) is one of the most lethal infectious diseases in the world and it is one of the top ten causes of death in the world. The World Health Organization Global TB Report estimates that TB resulted in around 1.3 million deaths in 2022, slightly less than 1.6 million in 2021 a situation partly interrupted by the effects of the COVID-19 pandemic on the TB diagnosis and treatment services (WHO, 2023). Sub-Saharan Africa disproportionately bears the world TB burden, and Nigeria is the country with the highest burden of this disease in Africa and the sixth-highest in the world (FMOH Nigeria, 2024).
The high burden of TB in Nigeria is worsened by the high rate of TB/HIV co-infection, increasing drug-resistant TB (DR-TB) and high disparity in case identification and treatment outcomes. It is approximated that only a percentage of the projected TB cases are reported every year and lack of adherence to treatment among diagnosed patients is a bottleneck situation when it comes to control of TB. The failure to comply with the anti-TB treatment not only decreases the personal rate of cure but also gives rise to the emergence of TB strains that are resistant to drugs, forming a cycle of prolonged illness, high costs of healthcare, and transmission of the disease in the community (Adisa et al., 2021).
In Nigeria, urban slums pose a distinctly tricky location to control TB. Slum settlement features such as overcrowding, poor ventilation, lack of proper sanitation, malnutrition and abject poverty provide the perfect environment of TB spread. A cross-sectional investigation of Nigerian urban slums determined that the community knowledge level was poor, crowded living, and socioeconomic obstacles are important factors that predict TB vulnerability (Dogar et al., 2019). The second-largest in Nigeria and the home to over 4 million residents, Kano Metropolis is a centre of TB infection and treatment issues, as some of the most densely populated urban settlements in the country.
Directly Observed Treatment Short-course (DOTS) approach is still the main pillar of the national TB program in Nigeria, as a supervised administration of drugs is a requirement to maintain compliance. Nevertheless, the cross-sectional study of TB patients taking DOTS in Kano and Kaduna States revealed that the mean medication adherence scores were below optimal, and a range of sociodemographic and clinical variables, such as co-infection with TB and HIV, extended treatment duration, and side effects, had a significant predictive value of non-adherence (Gimba et al., 2021). Furthermore, research of TB care quality in cities such as Kano has found TB management guidelines in the private sector that were not adhered to (Rosapep et al., 2022). These facts require a sensitive exploration into the concrete obstacles at work in the urban slum communities of Kano.
1..2 Statement of the Problem
Although the people in the urban slums of Kano have free access to anti-TB drugs as a part of the DOTS program, the treatment compliance of TB patients in Kano is at a sub-optimal level. Patients often skip treatments, take medications irregularly or defaul to finish the six-month course of treatment. This non-adherence is facilitated by a multi-level of factors at the patient, provider and structural level (knowledge gaps, side effects, stigma), at the provider level (poor provider counselling, unfriendly services), and structural factors (costs of transportation, distance to DOTS centres, poverty, and informal work schedule). The results are disastrous: failure of treatment, relapse of the disease, the development of the additional risk of the DR-TB, and the further spread of the disease in the community.
Although national qualitative meta-syntheses have recently determined general obstacles to TB treatment in Nigeria (Uchenna et al., 2021), no urban slum-specific quantitative and qualitative data is found in Kano Metropolis. In a setting where prevalent obstacles are without a precise understanding, interventions will not be properly tuned. This study thus aims at identifying and evaluating carefully the challenges of TB treatment adherence in urban slum communities of Kano Metropolis patients.
1.3 Aim of the Study
To assess the barriers to tuberculosis treatment adherence among patients residing in urban slum communities of Kano Metropolis, Nigeria.
Specific Objectives
- To determine the prevalence of TB treatment non-adherence among patients attending DOTS centres in Kano urban slums.
- To assess patient-level barriers (knowledge, stigma, side effects) to TB treatment adherence in the study area.
- To evaluate health system-related barriers (service quality, provider attitudes, facility access) to TB treatment adherence.
- To identify socioeconomic barriers (income, transport costs, loss of workdays) influencing adherence in urban slum settings.
- To determine the association between TB/HIV co-infection and treatment adherence among the study population.
1.4 Research Questions
- What is the prevalence of TB treatment non-adherence among patients in Kano urban slums?
- What patient-level factors act as barriers to TB treatment adherence in the study communities?
- What health system factors impede TB treatment adherence among patients in Kano?
- What socioeconomic factors influence TB treatment adherence in the urban slum setting?
- Is there a significant association between TB/HIV co-infection and non-adherence?
1.5 Research Hypotheses
- H₀: There is no significant association between stigma and TB treatment non-adherence in Kano urban slums.
- H₁: There is a significant association between stigma and TB treatment non-adherence in Kano urban slums.
- H₀: Socioeconomic barriers do not significantly predict TB treatment non-adherence in the study area.
- H₁: Socioeconomic barriers significantly predict TB treatment non-adherence in the study area.
1.6 Scope of the Study
The target population of this research will be TB patients aged 18 years and older with pulmonary TB taking part in DOTS treatment in the selected primary and secondary health facilities serving the urban slum communities in Kano Metropolis, namely, Fagge, Gwale, and Dala Local Government Areas which are some of the most densely populated and TB-afflicted urban LGAs in Kano State The research will evaluate adherence to TB treatment, patient knowledge, stigmatization, side effects, factors in the health system, and socioeconomic variables. The data will be collected during the 2024-2025 academic year.
1.7 Significance of the Study.
This research will play a significant role in helping Nigeria work towards the End TB Strategy goal of cutting down on TB deaths and infections by 90 and 80 percent respectively by 2030. In the case of the Kano State TB and Leprosy Control Programme, the results will be used to make evidence-based interventions that address low DOTS adherence rates among high-burden urban areas. To the healthcare providers and DOTS facility workers, the study outlines the areas where improvement of service can be made to ensure that TB care is more patient-centred and accessible. To urban planners and social welfare agencies, the results highlight the nexus of TB and urban poverty, which substantiates the argument to include TB care in larger poverty alleviation initiatives. In the academics, the study has a gap in the slum-specific TB adherence studies in northern Nigeria and offers basis to comparative studies throughout the West African region. The findings of the study will also assist the community leaders, NGOs, TB advocacy groups in designing support systems that can be used by the community to provide support to TB patients on a community level.
1.8 Operational Definition of Terms
- Tuberculosis treatment adherence: The degree to which a TB patient takes anti-TB medications as prescribed, in the correct doses, at the correct times, and for the full duration of the prescribed regimen.
- Non-adherence: Missing two or more consecutive doses of anti-TB medication in a given month or interrupting treatment for more than two consecutive months.
- Urban slum: A densely populated urban settlement characterized by substandard housing, limited access to clean water and sanitation, poverty, and social marginalization, as defined by UN-Habitat criteria.
- DOTS (Directly Observed Treatment Short-course): The WHO-endorsed TB treatment strategy requiring a healthcare worker or community volunteer to directly observe the patient swallowing anti-TB medications.
- TB stigma: Negative social attitudes, discrimination, and internalized shame associated with a tuberculosis diagnosis that may deter patients from seeking care or adhering to treatment.
References
Adisa, R., Ayandokun, T. T., & Ige, O. M. (2021). Knowledge about tuberculosis, treatment adherence and outcome among ambulatory patients with drug-sensitive tuberculosis in two directly-observed treatment centres in Southwest Nigeria. BMC Public Health, 21(1), 668. https://doi.org/10.1186/s12889-021-10698-9
Dogar, O., Pillai, N., Dogar, D., Zahid, R., Lane, T., Majara, G., Boyles, T., Desmond, N., & Siddiqi, K. (2019). Predictors of tuberculosis knowledge, attitudes and practices in urban slums in Nigeria: A cross-sectional study. Pan African Medical Journal, 32(60). https://doi.org/10.11604/pamj.2019.32.60.14804
Federal Ministry of Health (FMoH). (2024). National Tuberculosis, Leprosy and Buruli Ulcer Management and Control Guidelines (7th ed.). FMoH.
Gimba, Z. M., Nwankwo, B. B., Musa, B. M., Alkali, Y., Hamza, U., Imam, M., Isa, I. G., Sufiyan, M. B., Mijinyawa, M. S., & Habib, A. G. (2021). Nonadherence to tuberculosis treatment and associated factors among patients using directly observed treatment short-course in north-west Nigeria: A cross-sectional study. SAGE Open Medicine, 9. https://doi.org/10.1177/2050312120986338
Rosapep, L. A., Baruwa, E. M., Sorum, M. K., Adamu, A. A., & Pai, M. (2022). Tuberculosis care quality in urban Nigeria: A cross-sectional study of adherence to screening and treatment initiation guidelines in multi-cadre networks of private health service providers. PLOS Global Public Health, 2(1), e0000150. https://doi.org/10.1371/journal.pgph.0000150
Uchenna, D. C., Ugwu, L. I., Lemoha, C., Nwofor, A., Umezurike, C. C., & Arua, C. C. (2021). A qualitative meta-synthesis of facilitators and barriers to tuberculosis diagnosis and treatment in Nigeria. BMC Public Health, 21, 244. https://doi.org/10.1186/s12889-021-10305-z
World Health Organization. (2023). Global tuberculosis report 2023. WHO Press. https://www.who.int/publications/i/item/9789240083851