An Assessment of the Impact of COVID-19 on Tuberculosis Notifications in Mission Health Facilities in Zambia: An Interrupted Time Series Analysis
Table of Contents
1.1 Background of the Study. 5
1.2 Statement of the problem.. 6
1.5 Significance of the study. 7
1.8 Definition of key terms and concepts. 7
3.8 Ethical Considerations. 10
3.10 Project Administration and Monitoring. Error! Bookmark not defined.
LIST OF TABLES
LIST OF ABBREVIATIONS
1.0 Introduction
This chapter gives the background of the study. It also states the statement of the problem, aims of the study, objectives, and research questions, importance of the study, delimitation as well as limitations of the study and finally, operational definitions of key terms used in the study.
1.1 Background of the Study
The coronavirus breakout has seen a great effect on the performance and care programs as almost all the attention has been diverted to adopting the policies in response to the Covid-19 pandemic (Wang et al., 2021). Many policies, including lockdowns and controlled gatherings, have been put in place to try and thwart the spread of the virus, not giving the required attention to the TB cases, which has led to a critical increase of deaths from tuberculosis in various countries (World Health Organization, 2021).
China had implemented a series of public health laws to prevent the ravaging effects of the virus. These policies had significantly impacted the TB notification rate in China compared to the past when the pandemic had not attacked. Research shows that the TB notification rate dropped by approximately sixty percent in the worst waves of the virus compared to the average level of 2017-2019 (Abayneh et al., 2020). The result also shows that the patients' delay in the worst times was significantly longer than before the pandemic; therefore, TB notification in China was significantly impacted by the virus.
In Malawi, the virus has affected tuberculosis diagnosis and care. Even though Malawi had no official lockdown, schools and borders were closed at the breakout of the covid-19 pandemic. In the aftermath, there was an instant reduction in TB notification by 35.9%. The fear of covid-19 even led to the temporary closure of some health facilities dealing with TB due to inadequate protective equipment against covid-19 (Soko et al., 2021). Covid-19 adversely impacted the TB disease diagnosis, treatment, and prevention as the medical attention is reversed to the covid-19 pandemic, leading to a rise in TB deaths (Aznar et al., 2021). The analysis also shows that the effects of the covid-19 pandemic, both the direct and indirect effects in Malawi, led to reduced TB notifications as the health sector was overwhelmed by these effects. It also created fear in them due to some of the health workers were being infected.
On the other hand, Zambia is one of the nations with the highest TB and TB burden; Zambia was missing at least 38-40% of the predicted TB burden by 2020. Zambia, however, scaled-up innovations to discover missing individuals with TB through a collaborative approach in 2020, making it achieve a more significant performance (Kapata et al., 2016). However, on the arrival of the covid-19 pandemic, the fight against tuberculosis was negatively affected. During the first eight weeks of the covid-19 breakout in Zambia, there was a reduction of 18% in weekly TB notifications all over the country. With the restrictions in personal contact, fewer people could visit the health facilities, hence reducing TB diagnosis.
1.2 Statement of the problem
Following the trends on COVID-19 and its effects on other health-related issues, research is needed to examine this relationship. The concern is to explore the impacts of Tuberculosis notifications and problems on Zambia's mission health facilities. According to the world health organization (2020), the current trends in the COVID 19 infection can affect TB patients if their treatment is interrupted. COVID 19 is more prevalent in TB patients as the two diseases affect the lungs with the same symptoms, such as fever and difficulty breathing (Mwamba, et al., 2020). This makes the diagnosis of the condition hard and mistaken for the viral attack, making the cases of TB notification limited, thus resulting in an 18 percent reduction in Weekly TB notification throughout the country. The effects were accelerated by the imposed measures in the attempt to control the COVID 19 spread worldwide, reducing the ability of the TB patients to access health facilities due to restrictions and coronavirus stigma, which affected service delivery, TB control, diagnosis, and programming (Kargarpour Kamakoli, et al., 2021). In addition, people examined for TB dropped immediately after reporting the first COVID-19 case; the drop was from 55% in 2019 to 51% in 2020. TB notification during the same period dropped from 714 to 589.
The various issues associated with this coronavirus, which significantly affect the effectiveness of service delivery in hospitals, have been a significant area of interest—facing challenges due to the measures that have been put in place to curb the spread of the virus. Since the coronavirus discovery, many shifts and changes in the daily activities and behaviors were implemented, whose effects have been felt globally across all sectors. The results are more prevalent to the health care servant where the high cases of infection have increased the burden overwhelming them. In contrast, they have increased risks, such as infection, limiting their response to other patients (Adams, & Walls, 2020). Thus, our project proposes to examine the impacts of COVID-19 on Tuberculosis notifications in mission health facilities. Using both an interrupted time series analysis for the quantitative review and qualitative methods, we will be in a position to assess the research objectives.
1.3 Research Objectives
The following are the objectives of the study. They have been categorized as general and specific objectives: -
- General Objective
- The main objective of the study is to assess the impact of COVID-19 on TB notifications in mission health facilities of Zambia
- Specific Objectives
- To determine the impact of COVID-19 on TB notifications in mission health facilities in Zambia using an interrupted time series approach
- To examine the impact of COVID-19 on TB notification by sex in the mission health facilities
- To investigate the factors affecting TB notifications
1.4 Research Questions
This study seeks to answer the following research questions;
- What is the impact of COVID-19 on TB notifications in mission health facilities in Zambia?
- How is the impact of COVID-19 on TB notifications by sex in the mission health facilities in Zambia?
- What are the factors affecting the TB notifications in mission health facilities in Zambia?
1.5 Significance of the study
The study on the impacts of COVID-19 on Tuberculosis notifications in mission health facilities is one of the most significant researches in the present day, enhancing our understanding of this newly discovered and deadly virus. Despite the increased cases of infection, worldwide consideration needs to be made on the effects of the pandemic on the services delivery to the patient suffering from various conditions. This is necessary as the pandemic has increased the pressure on the health care workers who are the health care. Furthermore, the effects are considered to the TB patients as the pandemic infection has similar symptoms as TB and the areas of infection, respiratory surfaces, thus direct effects to TB notification program. This research aims to provide strategies implemented to curb the spread of the virus and how they would affect the response to other infections such as tuberculosis.
1.8 Definition of key terms and concepts
CHAPTER 2
2.0. Literature Review
2.1. COVID-19 and Tuberculosis Management
In examining the effects of COVID 19 on the health care services delivery to the patient, most concerns are gunned around tuberculosis. The impact of the pandemic of tuberculosis is fatal in most countries where the extent has not been discovered (Aznar et al., 2021). The effects involve the management of the disease due to the development of the various measures by the world health organization to counter COVID 19 infections. In return, this resulted in the drop in the notification of cases of people with TB by proximately 21% worldwide. The effects were increased transmission cases due to late diagnosis and death among the patients (World Health Organization, 2020). Research in Spain reported that about 70% of TB units said changes in their normal TB operations. This can be used as evidence that COVID-19 has caused significant changes in TB care. Increased latent TB and active TB in children are also justified for an advanced transmission of TB among households due to the anti-COVID-19 measures.
2.2. Unsuccessful Tuberculosis Treatment Outcomes among Tuberculosis/HIV Co-Infected Patients
Various factors are associated with the unsuccessful treatment of tuberculosis. These factors have significant consequences on people with preexisting complications such as HIV infections. According to Azeez et al. (2018), the HIV endemic substantially contributes to the increased TB incidences. They also added that the joint between HIV and TB has extremely affected healthcare, especially in countries with limited resources. They researched to examine the pathological attributes, TB outcomes, and factors contributing to the unsuccessful results among the TB patients in various hospitals (Azeez et al., 2018). The research revealed that there were unsuccessful treatment outcomes with co-infected patients. This can be applied with COVID-19 and TB, where the two exist; the result would be unsuccessful treatment outcomes for both diseases.
2.3. Relationship between COVID-19 and tuberculosis notifications in Blantyre Malawi
According to Soko and Colleagues (2021), despite the lockdown measures in Malawi being limited to schools and border closure, the effects on the TB notification program were recorded to have increased. An immediate 35.9 percent drop in TB notification was experienced in April, with women being impacted more than men (Soko et al., 2021). This decline is associated with fear of COVID-19 infection, inadequate protective equipment, temporary facility closure, and COVID-19 stigma, which elevated the symptoms of TB (World Health Organization, 2020). There is a need for public health to deploy measures that can help to address the challenges associated with TB and coronavirus. This effort should convince the patients that diagnostic services are available and safe to attend even amid the pandemic.
2.4. Quality of Tuberculosis Services in Health Care Centers
A critical area of concern is the quality of services in health care centers, especially in rural areas. According to, Bulage, et al. (2014), quality of care plays a significant role in TB control, influencing timely diagnosis, treatment adherence, and completion. To facilitate the provision of comprehensive quality services to the patients' supervision of the health care workers, enforcement of the patient follow-up procedures and installation of safety control measures are key aspects (World Health Organization. (2020). Staffing in the health care sector is the main factor affecting quality services to the patients (Katende, & Omona, 2021). The key factors affecting the services provided to the TB patients involve the poor altitude developed by the health care workers due to the fear created by the chances of getting infected by the diseases. This factor was constituted by the reported cases of limited safety resources for nurses and physicians, thus affecting the quality of services offered.
2.5. Prevalence of Tuberculosis in Zambia
Tuberculosis has been a significant disease affecting the Zambians. The reported prevalence cases are at 455cases per a hundred thousand people in the country, but the issue is made more fatal by the high chances of multi-drug resistance among the TB patients (Mutembo et al., 2019). Tb treatment is associated with a long treatment period where the drugs are toxic, resulting in high cases of mortality among TB patients. The greatest challenge in the treatment is the lack of reliable data on TB prevalence and measurements. According to Kapata et al. (2016), the risks of having TB were five times higher for HIV-positive individuals and HIV-negative individuals. At the end of the study, which announced that TB prevalence in Zambia was higher than previously estimated.
CHAPTER 3 3.0 Methodology
3.1 Introduction
This section entails the techniques deployed in data collection and analysis—integrating both quantitative and qualitative techniques to obtain a meaningful data analysis. These techniques would offer an interrupted time series analysis of data on the impacts of COVID-19 on tuberculosis notifications in facilities in mission health care facilities in Zambia.
3.2 Research Design
This study will use a quasi-ex-experimental design using retrospective data. The design will be useful to establish the cause-and-effect relationship between COVID-19 and tuberculosis notifications. This will be done using already existing data collected for other reasons in this context; we will use the CHAZ data.
3.3 Study Population
This study will use TB infected patients belonging to the Churches Health Association of Zambia (CHAZ). The size would include patients registered for TB treatment during the period December 2019 and March 2020. The sample size will be calculated based on the estimated proportion of prevalence of successful TB treatment among patients.
Eligibility Criteria
The study entails natives from Zambia. Also, it will include TB infected patients belonging to the Churches Health Association of Zambia (CHAZ). The sample would include patients registered for TB treatment during the period December 2019 and March 2020. The study will also include participants whose age is above 18 years.
Any individual who does not meet any of the above requirements will be left out of the study.
3.4 Sample Size
This study will use TB infected patients belonging to the Churches Health Association of Zambia (CHAZ). The size would include patients registered for TB treatment during the period December 2019 and March 2020. The sample size will be calculated based on the estimated prevalence of successful TB treatment prevalence among patients.
3.5 Sampling Techniques
This will employ a purposive sampling method and include all the mission health facilities that offer TB services and support the CHAZ (Churches Health Association of Zambia. Chaz.org.zm, 2021).
3.6 Data Collection
Data on TB case notification will be collected from the Churches Health Association of Zambia (CHAZ) DHIS 2 database from January 2018 to June 2021. The data collected will be monthly notifications.
3.7 Data Analysis
Data entry and analysis will be carried out using Microsoft Excel and STATA version 16, respectively. After entry, the data will be explored, checked, and cleaned, with preliminary data descriptions done to detect missing values and errors. Also, a comparison will be made for both defaulters and non-defaulters to examine the relationship between COVID-19 and tuberculosis treatment. All the data will be tabulated for descriptive statistics, and categorical variables summarized in terms of frequency and percentage. Numerical variables will be described in mean and standard deviation and interquartile ranges. Also, depending on data distribution, other statistical tests such as regression will be conducted.
The analysis will take one month, involving systematic procedures. From data entry to analysis in the software. The data collected will be at random without discrimination in terms of the genders or content provided. The process will involve calibrating the data to determine the cases of the patients who were giving notification and who did not. To discover this, it will include the generation of a table where the average population will be determined and mean and standard deviation and interquartile ranges. This will help determine the variables necessary to facilitate the process of data collection and the outside factors rather than COVID 19 affecting the program's progress.
3.9 Ethical Considerations
The clearance for research will be obtained from the University of Lusaka Ethics Committee prior to the study. The authority to undertake the study will be sought from the University of Zambia Biomedical Ethics Research Committee (UNZA-BREC) and the National Health Research Authority (NHRA).
Furthermore, permission to conduct the studies in these mission health facilities will be requested by the investigator from the Executive Director of the Churches Health Association of Zambia.
Furthermore, all the respondents to the questionnaire will have to consent to the study upon information, such as study benefits and confidentiality.
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