Table 1: Characteristics and analysis of health centres in the study area
A total of 49 health facilities were recruited in the TB-DM study survey; 38% had 5-10 nurses, 28% had more than 10 nurses working in the facility, while 32% of health centers did not respond.
Most health centers (28.5%) had less than 5 doctors, 7(14.2%) health centers had between 5-10 doctors, 24.5% had more than 10 doctors and 16(32.6%) health centers did not response to the questions. In administrative department, 9(18.3%) facilities employed less than 5 workers, 14.2% of health facilities harbour 5-10 administrative workers while more than 10 employees worked in 26.5% of the health facilities.
The total number of patients seen by the health facilities in a month was investigated. It was discovered that more health facilities 29(59.1%) witnessed between 100-500 patients per month, 4(8.16) facilities saw less than 100 patients in a month while more than 500 patients visited 24.5% of the health facilities included in this survey. Most of the health facilities studied during this survey 19(38%) attested to seeing more than 50 cases of DM patients in a month, 7(14.2%) of the facilities witnessed less than 10 DM patients in a month, while 16(32.6) health facilities confirmed to have seen between 10-50 patients in a month. There was no response from 7 health facilities. Finally, the total number of TB patients seen in a month was investigated, 18(36.7%) witnessed between 10-50 patients reporting with TB, while 4(8.16%) facilities saw more than 50 patients with TB in a month. However, less than 10 patients visited 15(30.6%) of the health facilities included in this survey.
Most of the health centres plotted amid this overview confirmed 19(38%) adjure seeing in excess of 50 cases of DM patients in a month, 7(14.2%) of the centres saw under 10 DM patients in a month, while 16(32.6%) asservate to have seen between 10-50 patients in a month. Seven health facilities did not respond
In closing, the total number of TB patients observed in a month was scrutinized, 18(36.7 %) witnessed between 10-50 TB patients, while 4(8.16 %) facilities saw more than 50 TB patients in a month. Less than 10 patients, however, visited 15(30.6 %) of the health facilities included in this study survey.
Table 2: Referrers, Medical diagnostics and Care of TB, HIV and DM in health facilities
Table 2 demonstrates that 30(61.2%) TB cases were treated in their facilities while 19(38.8%) allude patients to different centres. In the case of DM 38(77.6%) of health centres, offered DM management, while 11(22.4%) were allude to other centres. 41(84 %) offered treatment for HIV patients and 8(16 %) were referred to other facilities. 37(76%) dependably suggested HIV screening for TB patients, 3(6.25 %) requested that the HIV test be based on risk factors and one health center negated. 43(87.7 %) offered HIV testing and counseling, 3(6.12 %) offered HIV testing, but counseling was done elsewhere. 2(4 %) referred patients to do the test and counselling at other centres. There was however, no response from one of the centres.
Table 3: Implementation and integration of TB and DM in Health Centres in Lagos offering only TB treatment.
In Table 3, 6% of health centres recruited for this study acknowledged that there was a surveillance of diabetes care actuated among patients with tuberculosis in Lagos state. 39% of the health centres had no proposition on the existence of a surveillance, 55% of the centres were hesitant if there was a surveillance of DM among TB patients.
There was a guideline for screening all tuberculosis patients for diabetes in 4 (8%) health centers, whereas 27 (55%) health centers did not enforce the guidelines; there were instances of uncertainty in 18 (37%) health centers as the different health centers were not sure of such rules. 25 (51%) of the health employees included in this study were not familiar with routine diabetes screening in patients diagnosed with TB. However, 24 (49%) verified diabetes screening in patients with tuberculosis at different moments, sometimes screened 45%, most screened 2%, and always screened 2%. Although 29 (59%) said that in TB patients they almost never screened for diabetes, 20 (41%) of them agreed to screened at times. From this research, it was found that 14 (28.57%) screened at different moments, 4 (8.16%) screened at diagnosis and begin of therapy, 2.04% screened during therapy, while 59% did not answer the question. In all instances, 20 (40.8%) screening was performed for patients with diabetes risk variables (e.g. obesity, gestational diabetes or family diabetes), whereas 29 (59.18%) did not answer the question.
During the research, it was contrived that screening for diabetes in patients with TB was not performed in 20(40%) of instances because they think it is not a significant co-morbidity in the nation. 10% attested to have received information on diabetes from the treating physician. Some of the health care centers (12%) attributed the absence of screening to the absence of medical employees, economic and logistical means, 4% had no understanding of reasons for not screening, while 32% did not answer this question. 36% of health care employees had information about patients with or without tuberculosis who were either diagnosed with diabetes, 26.5% had information and less than 10% of patients with or without the illness had no information
Table 4: Implementation and integration of DM and TB in Health Centres in Lagos offering only DM treatment.
Table 4 showed that 18 (36.7%) of the health centers visited thought that there was no TB monitoring program among patients with diabetes, and 30 (61.7%) were uncertain as to whether this program existed. 1 (2%) of the recruited health centres reported recognized tuberculosis screening monitoring in patients with diabetes. On the other side, the guidelines for screening tuberculosis patient for diabetes had not been enacted by 28 (57.1%) health centres while the screening was suggested by 2 (4%). 19 (38.7%) health centres were not sure if there were guidelines for screening TB patients for DM., 26 (53%) of the health workers profiled in this study acknowledged never to have screened for in diagnosed diabetes patients. However, 23 (46.8%) of the centers verified tuberculosis screening in DM patients at distinct times; 4% always, 6.1% most times, and 36.7% do so sometimes. 28 (57%) facility centres never screened for tuberculosis in patients with diabetes, 20 (40.8%) sometimes agreed to have screened, no reply was given by 2%, 14 (28.5%) tested at different moments, 5 (8.16%) screened at diagnosis and begin of therapy, while 61.2% did not table this question. Screening was conducted at various instances in patients with risk variables of the disease (e.g. exposure, HIV, alcohol, smoking) 14(28.5%) of health care staff screened for diabetes while 5(8.16%) screened for patients with suggestive symptoms of TB.
Most health centers used the chest x-ray technique for TB screening 18 (35.3%), while others used gene xpert 13 (25.5%), sputum Microscopy / Culture/ Sensitivity 12 (23.5%) and clinical symptom score 8 (15.7%). It was observed that health workers did not screen for TB in patients with diabetes in 46.9 percent of instances because they thought it was not a significant co-morbidity, 6% obtained tuberculosis information from the treating Physician, while 6% attributed the absence of screening to the absence of personnel, economic and logistical resources, 2% had no screening discernment for the objective, while 34.7% did not respond. Lastly, 30% of health workers had information about diabetes patients who are either diagnosed with tuberculosis or not. 26.5% of these health care staff had information on patient with or without the disease. For about 10-50% of patients, 4% of these health care centres had data on these non-communicable diseases.
Results of Interviews conducted at five health centres that have integrated TB/DM Screening Measures
Five (5) of the 49 participating health centres interviewed, one (1) attested to have integrated screening measures for TB/DM in the facility and identified possible challenges faced during treatment of both diseases. The summary of the interviews excerpts are reported below:
Participants (Head of Centres) in this study stated that the success of TB/DM integration was impeded and encumbered by the inconsistency in the organisation of health care chain. Subjects (Heads of centres) in this study believed that sparse funds were being pervaded in the integration of TB/DM. Findings in this research disclosed that in curbing the threat of this co-morbidity there were problems, according to two the health centres;
“The problem we face usually is about logistics and finance and the education of the populace at large because the orientation is absent and not well conducted in instances in this part of the world” Interviewee 1 Question 2
According to other participating centres, there is a level of acceptability for integrative TB/DM screening as this will go a long way in improving the health care policy of the government. “The people in my opinion think it’s the way forward, and it gives them a better way of living and accessing good healthcare. I think the response has been very positive” Interviewee 1 Question 3
Results of interviews for centres that have not integrated TB/DM Screening Measures
Some of the recruited health centres that have not integrated the screening measures of TB/DM identified reasons why integration of TB/DM does not take place in their facility; they alluded however, the importance of screening for both diseases. Below is a detailed explanation of the retrieved information from the participants (Centres).
“Tuberculosis and diabetes are not diseases that we are aware that could be co-infected with each other that is the reason we have not integrated it in our facility” Interviewee 5 Question 1
Lack of awareness and government poor policies on health matters are major setback why integration of TB/DM is hindered in a lot of health care facilities in Nigeria. Many hospitals/health care facilities have no idea that there is an on-going collaborative framework on the screening for TB/DM. Hence, they are unaware of guidelines requesting them to screen for these diseases.
“We have not particularly been on the lookout for such association because we haven’t really seen any indicators that may make us be on the lookout for that” Interviewee 4 Question 1
Most health care workers in different centres had no prior understanding of TB / DM inclusion, resulting in no needed screening measures being introduced.
Head of health centres believed that integrative testing and therapy for TB / DM would enhance the quality of life of patients as well as rural and urban communities.
“In my opinion I think it would be really important because if something like that is happening and we do not screen people for it that means that we are overlooking something that is so important” Interviewee 5 Question 2
The respondents believed that screening for TB / DM is viable (conveniently performed) since most health care centres have the manpower and equipment available. “Feasibility is not an issue with us. I mean we have the staff, we have the technical abilities, we have the equipment to use, we do all of the TB tests that are necessary. We have the chest x-ray, we do our acid fast bacilli, we do that 2-3 times as necessary, we do the gene expert as necessary. So screening for TB at diagnosing of diabetes mellitus should not be a problem for us” Interviewee 4 Question 3
The national tuberculosis control program of the Nigerian government, stop TB and other Non-governmental Organisations should create an enabling platform /environment for the successful implementation of TB/DM integrative screening and treatment in various primary health care centres in Lagos and across the country.
“I think the government should be responsible for implementing the program because when the government becomes responsible, they are able to put in resources to ensure that adequate awareness is done amongst the people” Interviewee 5 Question 4