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Tuberculosis; Advocating A New Approach For The Nigerian Government. By Franklin E. Ehiwobu (RN, BSc [Hons], MSc Nursing).
Date Posted: 29/Jan/2020

Tuberculosis (TB) is an infectious disease that is caused by a micro-organism and it can be transmitted from one person to another through a droplet transmission. Although it is currently one of the public health challenges affecting 1/3 of the general public, only a small portion of this population falls sick making it difficult to eradicate. Furthermore, about 1.5 million people loses their lives to tuberculosis annually with a cost of 2.3 billion dollars annual cost needed to implement an active intervention. The World Health Organization in 2017, stated that 417,000 peoples died from the disease in Sub Sahara Africa and over 25 % of the TB death occur in Africa region.

Nigeria was ranked 4th in the countries currently having tuberculosis globally with about 80% of undetected cases. According to a recent study, Nigeria has an estimated incidence rate of 322 per 100,000 persons with 100,000 new cases and 78,000 deaths. These compared to a country like the UK which has witnessed a 10% decrease with an incidence rate of 10.2 per 100, 000 population implies that Nigeria, remain an endemic region for tuberculosis and the rate is predicted to continually increase.

This could be due to factors such as lack of or poor health facilities, poor tuberculosis monitoring, and poor procurement and supply management system. Additionally, other factors could include poor lifestyle, Multi Drug Resistant (MDRT) strains and comorbidity that influences the disease making it more difficult to eradicate. In line with this, it was reported by the World Health Organization that about 490,000 cases of MDRT occurred recently with about 3.6 million cases being among those having a comorbidity and/ or unreported cases.

Nevertheless, the Nigerian government in partnership with the World Health Organization chose an intervention called Directly Observed Treatment Short-Course (DOT) for the management of tuberculosis. This is an internationally recognized strategy to address the issue of tuberculosis in countries with the disease. It is aimed at reducing the transmission rate of tuberculosis, decreasing the morbidity associated with the disease and preventing tuberculosis-related death by way of early detection and treatment, and it was introduced in Nigeria in the year 2003.

Just like every public health intervention, either chosen by an individual (health practitioner), government or an organization is underlined by a theory, concept or values. This set of values enable the intervention planners to prioritize and decide on the right intervention to adequately address the public health challenge. However, it could be argued that the possibility of one intervention to properly address a public health issue is not feasible. This is because most of these public health challenges either have a multifactorial causes, predisposing factors or factors which favors their transmission thus making it difficult for an approach to completely eliminate the disease within a population. There are few public health practitioners such as Naidoo and Wills and Daniel et al that favors DOTs as an approach that is based on the medical model of public health.

The medical model of health is a model that is underpin by the belief that a disease is caused by a biological factor which requires a biomedical and/ or pharmaceutical intervention to be cured. Furthermore, the medical model helps to provide the necessary guidelines aim at treating a health problem and also help to predict the outcome of the guidelines employed. Also, the medical model as an approach is cheaper and uses the top-down approach of intervention; this type of approach requires expert knowledge to achieve the needed result.

Nevertheless, it can argued that the medical model as a scientific approach to treatment is only useful for phenomenon that is quantifiable and factors such as the social and psychological causes of illness are merely recognized by this model. These factors play an important role in the causes of illness just as the biological factor. Similarly, the biomedical model believes all diseases to produce certain signs and symptoms and that health is the absent of diseases. Tuberculosis is said to be asymptomatic at the first period of infection therefore if signs and symptoms are used to determine when an individual is sick and needed treatment, the eradication would not be possible as the individual must have infected more people with the disease. Moreover, the biomedical model is too reductionistic and cannot fully explain other forms of ill health.

Tuberculosis as a disease, although caused by a micro-organism (biological), has factors such as overcrowding, poor hygiene, poverty and other life-style issues as contributing factors. Therefore, adopting an intervention which has a multifactorial implication (socio-medical or biopsyco-social model) is necessary in order to understand the totality of the disease condition and these could aid in the planning of adequate preventive measures. The biopsychosocial model is a model that incorporates other factors such as biological, behavioral, emotional, economic as well social factors in determining the circumstances of a disease.

These factors are necessary and should be considered in deciding about a public health issue as they can interact and influence the outcome of the disease and the intervention. Similarly, the biopsychosocial model provides a conceptual framework for dealing with information that are disparate and helps to remind the users that there are more important issues beyond the biological. Hence, understanding and adopting the right model to the development of any intervention is very essential as this will determine when an individual is perceived to be sick thus facilitating the need for urgent and the right approach to treatment.

This model has been successfully used in tackling a few public health issues such as deviant behaviors as well as understanding the various factors that were impacting on the adherence of TB treatment in the Eastern part of Africa.

Therefore, I strongly recommend that the Nigerian government adopts the biopsyco-social model as it will be more effective in curbing the disease due to its ability to recognize the biological, social and psychological factors that influences health, actions, and perception of illness.

References:

Dim C.C and Dim N.R (2013) Trends of tuberculosis prevalence and treatment outcome in an under-resourced setting: The case of Enugu State, South-east Nigeria: Nigerian Medical Journal vol 54(6)390-397

Gabriella M, Gomes G. Medley F and Squires B (2016) End TB strategy; the need to reduce risk inequalities; Journal of Infectious Diseases 16 (32) 1-5.

Kainne E.D, Odume B, Muianga C and Olutola A (2015) Building and strengthening infection control strategies to prevent tuberculosis: Nigerian Morbidity and Mortality Weekly Report vol 65(10)263-268.

Naidoo J and Wills J (2005) public health and health promotion; developing practice London Elsevier

Okanlawon F.A and Oladeji M.O (2012) Influence of directly observed therapy on client’s compliance with combined anti-tuberculosis drugs in Ibadan Nigeria; West African Journal of Nursing 25-33.

Public Health England (2017) Tuberculosis in England 2017 report (presenting data to end of 2016) [Online] Available from  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/686185/TB_Annual_Report_2017_v1.1.pdf

World Health Organization (2017) Tuberculosis [online] Available from http://www.who.int/tb/en/

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