Tuberculosis (TB) control amongst internally displaced persons in the Tuzla Canton of Bosnia-Herzegovina December 2002

Introduction

The TB Control Project was implemented by the Project Manager, Ms. Deirdre Vaughan, employed by HMD Response over a six-month period from June 18th to December 18th 2002.

This document, the final EC Report, will give a detailed history of the project, the activities implemented, evaluations and difficulties incurred during the project period.

It is hoped the report will benefit the local and National TB Programme currently operating in Bosnia-Herzegovina, as well as being a useful resource for future health projects in the region.

Background Information

Following the expansion of HMD Response's medical and psychosocial services to its beneficiaries in 2000, concern was raised about the increasing incidence of TB amongst its beneficiaries as well as access to TB services.

As a result, a public health specialist carried out an assessment on behalf of HMD Response. This assessment sought to identify obstacles to the successful control of TB amongst internally displaced persons in Tuzla canton. Major problems were identified at each of the key stages in this process.

In response to the assessment, the TB Project Manager was recruited to implement the TB Control project based on the assessment findings and recommendations.

Target Area and Population

The target area and population in the assessment was identified in the following municipalities: Tuzla, Zivinice, Klandanj, Gracanica and Doboj, targeting a total of 75,000 internally displaced persons (IDP's)2

Revision of Target area: In the initial phase of the project it was decided by the National and Local TB Co-ordinators and the TB Project Manager that the target area needed to be reviewed. Recent statistics of TB incidence and the high numbers of IDP's in the canton, illustrated the need for concentration and imput in the following areas: Tuzla, Zivinice, Gracanica and Lukovac municipalities. The meeting concluded that these municipalities would be the target areas of the project, with interventions directed at the main Lung and TB Dispensaries and the peripheral centres (known as ambulanta) that serve these municipalities.

Goal of the Project

The main goal of the project was to reduce morbidity resulting from TB amongst internally displaced persons in the Tuzla canton:

• By significantly improving the detection of cases; and
• The successful completion of treatment.

At the beginning of the project the general goal of the project was reviewed to include the following details.

The project aimed at extending the National TB Programme to health facilities serving the IDP communities. The TB control project sought to contribute to the achievements of the National TB Programme and objectives set out by the WHO for Bosnia -Herzegovina. These objectives are as follows:

• Improving knowledge of the DOTS strategy amongst health care workers;
• Increasing the quality of health provision; and
• Ensuring the early diagnosis and treatment of smear positive patients.

In the initial phase of the project and at the opening presentation, it was re-enforced that the central aim of the TB control project was to strengthen and work within the framework of the National TB Programme.

Original Objectives of TB Project

The original objectives as documented in the Project Proposal and Executive Summary are as follows:

1. To promote the routine use of sputum smear microscopy for diagnosis in the dispensaries of Tuzla, Zivincie and Gracanica, therefore improving and increasing case detection.
2. To train primary heath care workers in the designated health facilities in implementing the Directly Observed Therapy (DOTS) strategy.
3. To enhance the referral and transfer of those TB and TB suspects, improving follow up of patients receiving treatments.
4. To enhance community acceptance and awareness of TB amongst the internally displaced population in the project area.
5. To estimate the burden of disease amongst IDP's and assess the impact of the project.
   

Project Management Structure

The project was managed by the Project Manager with overall supervision provided by the London based Medical Coordinator of HMD Response. The National and Local TB Coordinators were also closely involved in decision making and revisions to the project objectives and activities.

Project Monitoring and Evaluation

The monitoring and evaluation of the project's progress was as follows:

• A monthly situation report was provided to the Medical Coordinator.
• A 3 monthly report was submitted to the National and Local TB Coordinators, Ministry of Health and Ministry of Social Affairs in BiH.
• Final Report to be submitted to EC, National Coordinator and relevant National/ Local Ministries.
• Activities and interventions were evaluated with questionnaires, oral and written feedback, with reports from seconded local staff.

Presentation of TB Project to Relevant Local Officials/Personnel

A presentation of the TB project was presented to local officials from the Ministry of Health, Directors of the Local Health Dispensaries and the local TB Co-ordinator. The aim of the presentation was to inform all participants involved in the project of the goal, objectives and planned activities of the TB project. An extensive questions and answers session was held after the presentation to clarify any outstanding issues.

Before any project activities were implemented, official approval was sought from the Ministry of Health, the Ministry for Social Affairs, Sarajevo and the National TB Co-ordinator. The approval included a summary of the Project proposal/activities and budget plan. Despite delay in receiving official approval, no project activities were implemented until permission was granted. In addition, several meetings were held with the local TB Co-ordinator of the Tuzla canton and the National TB Co-ordinator based in Sarajevo to discuss each objective in detail and any revisions that were required.

Project Implementation

This section will examine each objective, the rationale behind revisions to the original objective, activities carried out and difficulties incurred with evaluation of activities.

Objective 1. To promote the routine use of sputum smear microscopy for diagnosis in the dispensaries of Tuzla, Zivincie and Gracanica

Proposed Activities:

• Supply a microscope to Zivinice dispensary
• Assess the present quality of sputum smear microscopy in the 3 dispensaries and train a nurse to take this role on in Zivince.
• Conduct a workshop for relevant health professional and agree a protocol of the use of sputum smear microscopy.
  

Actual Activities:

1. After several meetings with the senior microbiologist from the Tuzla Clinical Centre, microscopes and equipment were ordered from London based Medical Company Approval is sought and necessary documentation for the importation of the medical equipment into Bosnia-Herzegovina. Official approval is received and medical equipment is imported into Bosnia-Herzegovina.
   
2. Microscopes, supporting equipment and long term supply of all consumables required for sputum smear microscopy is received and distributed to Tuzla and Zivinice TB and Lung Dispensaries.
   
3. Visits and consultation are made to the three dispensaries in the target area to discuss the present quality of sputum smear microscopy. A local microbiologist from Tuzla Clincial Centre is recruited by HMD Response for the period of one month to train a nurse in sputum smear microscopy. "Sputum smear microscopy" training and supervision is arranged for a nurse from Zivinice Dispensary by the local microbiologist. Nurse undergoes 5 days training with follow up and supervision at Zivinice Dispensary.
   
4. A workshop for relevant health professional is conducted by senior microbiologist with agreement on protocol for the use for sputum smear microscopy
   

Revisions:

The National Co-ordinator suggests that 2 microscopes be donated in order to commence and implement the project. Consultation is sought with HMD Medical Co-ordinator and it is agreed that 2 microscopes will be donated to the Tuzla canton on behalf on the TB Project.

Difficulties experienced:

Official approval and necessary documentation for importation of medical equipment requires some time with the process taking several months and hence the equipment is not received until November 2002. The delay in receiving the medical equipment results in delays in the training and sputum smear microscopy to be implemented in Zivinice Dispensary.

Evaluation:

• Receipt of purchase of microscopes and lab. Equipment is received.
• Report and quality assurance assessment is submitted by microbiologist on nurse training in sputum smear microscopy.
• Attendance record of participants at workshops is recorded along with questioners.18 local Specialist Doctors, laboratory technicians and nurses from surrounding dispensaries attend this workshop. Questioners indicate that all participants welcome workshops and prove very useful to clinical practice and knowledge.

Objective 2 To train primary heath care workers in the designated health facilities in implementing the Directly Observed Therapy (DOTS) strategy.

Proposed Activities:

1. Conduct a series of training workshops for primary health care workers
2. Conduct field based teaching and assessments of primary health care workers
3. Provide ongoing supervision and monitoring health care practice
   

Actual Activities:

A series of 5 TB training workshops are conducted for primary health care workers (PHC) . This workshop covers the following areas:

• Refresh knowledge on TB
• Introduction to DOTS Strategy, as recommended by the WHO
• National TB Programme of BiH
• TB prevention and Health education for PHC workers.

The workshops are conducted in the following venues: Zivinice, Lukovac, Tuzla and Gracanica Dispensaries with primary health care workers attending from surrounding ambulanta and dispensaries. A workshop is also conducted for HMD Response nurses, doctors and psychosocial workers at the Tuzla office.

Local TB Co-ordinator also contributes to these workshops by giving a lecture on the National TB Programme in BiH.

Field based teaching is undertaken at local ambulanta and the collective centres with HMD nurses.

Revisions: nil required

Difficulties experienced:

1. As a result of other objectives being implemented, there is delay in implementing these workshops with approval from the Directors of each dispensaries required and from local TB Co-ordinator.
   
2. Due to the length of the TB project and working time of Project Manager, the Project Manager is unable to follow up health care practice after workshops and this activity is handed over to National Programme to be followed up on a later time.

Evaluation:

Record of Attendance at workshops for primary health care workers:

• Zivinice: 15 attendants
• Gracanica: 11 attendants
• Tuzla: 26 attendants
• Lukovac: 11 attendants
• HMD Response, Tuzla office: 16 attendants

Questionnaires collected on workshops indicated good results from attendants understanding the need and relevance on DOTS strategy in TB control. Suggestions are made that more health education and awareness raising activities on TB is needed

Objective 3. To enhance the referral and transfer of those TB and TB suspects, thus improving follow up of patients receiving treatments.

Proposed Activities:

1. Develop referral/transfer documentation
2. Liase with health services in the Republica Srpska (RS)

Actual Activities:

1. Several discussions with the local TB Co-ordinator about the referral and transfer documentation found that the WHO referral and transfer documentation is already in place and being used in all of the Dispensaries in the project area.
   
2. Meetings with the Directors of Srebrenica and Bratunac Dispensaries in the RS about supply of TB drugs to TB patients returning and registration in the RS, resulted in assurance from the Directors that returning IDP's have full access to TB treatments in the RS.

Revisions:

After consultation with HMD Response Medical Co-ordinator and relevant personnel about the problems in documenting successful transfers due to current social and political problems existing between the RS and the Tuzla canton, the Project Manager is unable to document successful transfers of patients to RS.

Difficulties Experienced:

Difficulties were found in the successful transfer of patients from the Tuzla canton to the RS. This is mainly due to the majority of IDP's preferring to receive their treatments and follow- up care from the Dispensaries in the Tuzla canton. In addition, there are difficulties in registering of TB patients and follow up care due to perceived discrimination in the RS and the complex returnee process.

It was found there is little communication and co-ordination between health facilities in the Tuzla canton and RS, due to reduced contact and limited resources. The Project Manager found it was not in her capacity to address this problem and more time and effort is needed in this area.

Evaluation:

Project Manager and local TB Co-ordinator compared the WHO transfer and referral system with the existing documentation and it was found that the current documentation is working in adherence with the WHO referral and transfer system.

Objective 4. To enhance community acceptance and awareness of TB amongst the IDP population in the project area.

Proposed Activities:

1. Conduct counselling and educational sessions with new TB patients.
2. Interview a random selection of patients to assess the coverage and quality of these sessions.
3. Develop and distribute posters and information leaflets
4. Conduct activities to raise awareness of TB in the community.

Actual Activities:

1. Documented counselling and educational sessions with newly diagnosed TB patients and relapse cases were conducted by the TB Project Manager. Advice and education was given on need for treatment adherence and contact tracing of family members.
   
2. Follow up sessions, informal interviews and random conversations with TB patients were conducted during visits to the collective centres and refugee settlements.
   
3. Educational/ information leaflet and poster designed and developed by Project Manager. The local and National TB Co-ordinators also made invaluable contributions to the information leaflet, reviewing the final edition. The poster was designed specifically for illiterate IPD's with diagrammatic and pictorial sequences explaining TB, modes of transmission and prevention measures.
   
4. "Community Health " Workshops conducted in several refugee settlements and collective centres. Project manager and HMD staff devised these workshops, according to needs of the communities. The Workshops included practical advice on the following topics: Hygiene and nutritional advice, (HMD nurses), Family planning and Women's health (HMD nurse), Tuberculosis education and prevention, addressing the issue of stigma (TB Project Manager), Psychological Health -Trauma & Anxiety (HMD psychosocial workers), Physical education (HMD physiotherapist). The educational and information leaflet was distributed at these workshops with all teaching and education all conducted through the use of pictures and diagrams.
   

Revisions:

It was felt that addressing TB in these traditional communities could be problematic given the nature and stigma of the disease. Therefore, it was decided that addressing TB in a holistic way, addressing other important health issues would prove to be more successful in reaching communities.

Difficulties Experienced:

It was found that despite building up good relationships with the TB suspects/patients, several clients did not want to talk about their disease and the risk to family members. This serious problem is perceived to be widespread in the canton with clients refusing to accept their disease and hence refusing diagnosis and treatments.

There were difficulties experienced in reaching some collective centres and settlements due to no facilities/space present to conduct workshops.

Evaluation:

1. Results of pre and post intervention interviews were recorded with an increased understanding and awareness of TB, particularly retaining positive messages about he disease i.e. TB is curable with correct treatments, TB treatments and examinations are free in Bosnia Herzegovina. Feedback from the workshops showed fear about the disease appeared to be considerably reduced.
   
2. 500 posters and 250 leaflets were printed and distributed throughout collective centres, refugee settlements, TB and Lung dispensaries in Tuzla canton and the RS and surrounding ambulanta.

Objective 5. To estimate the burden of disease amongst IDP's and assess the impact of the project.

Revisions:

After consultation with HMD Medical Co-ordinator and the National TB Co-ordinator it was concluded that the implementation of this objective would be problematic due to the limited time of the Project. It proved difficult to access recorded incidences and statistics of the burden of TB amongst this specific group in the Tuzla canton.

In addition as regards assessing the impact of TB treatments this is problematic given that the TB treatments are 6 months and the working time of the Project Manager was 6 months.

It was concluded that this objective be handed over to the National Programme to assess the impact of the project at a later time, when cases are recorded at the TB and Lung Dispensaries.

Conclusion:

The final conclusion and impact of the project activities will now be reviewed. The review of the project will be divided into two sections; the technical and training/ educational aspects of the Project. Objectives will be addressed collectively were appropriate.

Technical Aspect:

This section will address the positive impact of the introduction and implementation of the diagnostic technique of sputum smear microscopy into Zivinice Lung and TB dispensary.

The end of the project saw the trained nurse conducting sputum smear microscopy in Zivinice independently. However, it was agreed with the senior microbiologist from Tuzla clinical centre that he would continue to follow up her progress and provide assistance where necessary.

One of the greatest challenges to successful control of TB in the Tuzla canton, is reduced access for the IDP population to TB services. The health care system is centralised in Bosnia Herzegovina, whereby communities living in remote areas have reduced access to these services, particularly the IDP communities who are placed predominately in remote and isolated areas.

The introduction of this technique at Zivinice Dispensary, where there is a disportionately high incidence of TB will achieve an average of 1 microscope per 85,781. This will allow the domicile and IDP communities to have increased access to TB examinations in Zivinice municipality and commence treatments immediately. With sputum smear microscopy, diagnosis is achieved with in 24-48 hours, reducing delays in diagnosis and allowing smear positive cases to commence treatments as soon as possible.

In addition, the support and co-operation of the Director and medical/ nursing personnel of Zivinice Dispensary was viewed as fundamental to the successful implementation of the technique. All staff involved in the project in Zivinice Dispensary welcomed and co-operated fully with the introduction and engagement of this technique into their clinical practice. This co-operation will facilitate the continuous promotion and practice of this technique into their daily clinical practice at the Dispensary.

In the past, it has been documented there has been reluctance for medical personnel to engage in sputum smear microscopy due to training resources and attitude of the specialist doctors with a reliance on conventional diagnostic methods. At Zivinice, staff were enthusiastic and well informed about the technique, particularly after the training and educational workshops, positive imput of the local TB Co-ordinator and senior microbiologist in the canton.

Training and Educational Aspect:

TB is found to be highly stigmatised in Bosnia and Herzegovina. Throughout the Project Manager assessments and visits it was also found that there was a lack of knowledge about the DOTS strategy amongst hospital based and community health care workers.

In line with the project objectives, there was considerable time invested in the training and educational workshops. After several assessments and interviews, it was felt that there was average to good knowledge of TB, signs and symptoms and its treatments. However, there was a lack of knowledge and understanding in the following areas:

• The relationship between TB control and the Primary health care services.
• Stigma and fear attached to TB
• The process of awareness raising and the role of the PHC workers
• Clarification on the DOTS strategy in TB control

The workshops were developed and tailored according to these areas and needs of the health care workers, as well as refreshing knowledge of TB. The workshops were conducted in a participatory manner allowing attendants to contribute.

The feedback on the workshops for the PHC workers was exclusively positive, through questionnaires, informal interviews and feedback from each dispensary. The sessions were found to be very useful to clinical practice in promoting contact tracing and passive detection in the primary health care setting, namely the ambulanta.

The educational workshops for the refugees were also very successful. These workshops were specifically developed to reach illiterate communities. They were designed with basic and simple practical advice on relevant health issues to the IDP community. They were structured informally; allowing the attendants to feel relaxed in asking questions and interrupt, promoting and generating discussion amongst IDP's.

In general, HMD staff and the Project Manager concluded that the workshops were very productive particularly on the TB education and women's health section. In addition, it was concluded that HMD staff would continue these community health workshops in the future reaching more settlements and collective centres in remote areas

Recommendations /Learning Points:

1. Primary health care workers involvement in TB control
   Assessments and feedback found that there was a lack of knowledge on the role of primary health care workers in TB control. The Project Manager found that many PHC workers did not recognise they have an important role in identifying new cases and creating awareness about TB.
   
   This was particularly poignant in the ambulanta where primary health care workers have an important role in TB control through passive case finding and contract tracing. Identifying this role in the workshops proved very productive in allowing PHC workers to recognise this in their practice. PHC workers received explanations in the workshops that the most common presenting symptom in the ambulanta is cough, and therefore they have an important function in identifying new cases and considering TB in their assessments.
   
   The relationship between TB control and primary health care is an area that could be developed in the future either through the National TB Programme and Government commitment to WHO TB control strategy. Further opportunities in these areas could be explored at low cost, maximising PHC worker invaluable contribution to TB control through awareness raising and patient education.
   
2. Attitudes of specialist doctors.
   Although there was considerable co-operation from medical staff the TB Project recommends that more imput is needed identifying the advantages of the DOTS strategy and encouraging the use of sputum smear microscopy. The DOTS strategy must be integrated into every day clinical practice through the work of the National TB Programme and Medical Institutions facilitating attitude change towards this technique.
   
3. Follow- Up by National TB Programme.
   It is hoped that the National TB Programme will continue to implement educational workshops for PHC workers. The feedback on the workshops conducted by the TB project showed that there was a willingness and interest in further theoretical and practical training, particularly in the area of TB education.
   
   The TB project recommends that further education on the DOTS strategy is needed throughout he Dispensaries and peripheral centres.
   
4. Co-ordination between RS and Tuzla canton.
   The TB project recommends that further effort and resources are needed to explore opportunities in building and maintaining links between the health facilities in the RS and Tuzla canton. At present, the TB project found that there is very little communication and co-ordination between these two entities, which poses difficulties in the follow up of TB patients returning to RS and vice versa.

Acknowledgements
Thanks to Prof. Nurkic, senior microbiologist at Tuzla Clinical Centre, for his continuous assistance throughout the project, particularly his support for the introduction of sputum smear microscopy to Zivinice Dispensary.
Also, special thanks to the staff at HMD Response, Tuzla.