IMPLEMENTING A COMMUNITY-BASED TUBERCULOSIS PROGRAMME IN THE OMAHEKE REGION OF NAMIBIA : NURSES ’ PERCEIVED CHALLENGES

Tuberculosis (TB) is a resurgent disease in many regions of the world, including Namibia, fuelled by poor TB control programmes, human immunodeficiency virus (HIV) and poverty. The purpose of this survey was to identify nurses’ perceived challenges in implementing a community-based TB programme in the Omaheke region of Namibia. Structured interviews were conducted with 40 nurses involved in providing TB treatment and care in the Omaheke region. Patient-related challenges which hampered TB treatment included alcohol and drug abuse, poverty and stigma. Lack of transport for nurses to do community-based TB work, centralised TB services and patients’ lack of transport were access-related challenges. Knowledge-related challenges involved a lack of TB knowledge by both nurses and community members. The HIV pandemic has increased the number of TB patients and increased nurses’ workloads, aggravating the burden of TB as a resurgent disease in this region. Decentralisation of TB care to community and family levels would be necessary to reduce the number of people with active TB in the community, and to enhance the TB cure rates, in the Omaheke region of Namibia. In order to implement a successful communitybased TB programme, the patient-related, access-related and knowledge-related challenges, perceived by the nurses, need to be addressed effectively.

Globally, 9.2 million new cases and 1.7 million deaths from TB occurred in 2006, of which 0.7 million cases and 0.2 million deaths occurred among HIV-positive people (WHO, 2008:1).The most important risk factors in becoming infected with TB are the length of contact with an infected source and the number of bacilli in the air (Rieder, 2002:29, 118;WHO, 2001b:1), emphasising the dire necessity to reduce the number of active PTB patients in any community, by providing effective TB treatment.

Overview of TB in Namibia
Namibia is the driest country south of the Sahara with an average rainfall ranging from 25 mm to 600 mm.An estimated 66% of the population reportedly lives in rural areas.With an average population density of 2.5 people per square kilometre, Namibia is one of the most sparsely populated countries in the world.Its population was estimated to be approximately two million in 2006 (Government of the Republic of Namibia Census, 2007:6).
In Namibia, TB continues to be a major public health problem, being the second most prevalent reason for hospitalisation and a significant cause of outpatients' visits.TB accounted for 15% of all institutional deaths, second only to AIDS, which was responsible for 22% in 1998 (UNDP, 1999:97).However, a third of all AIDS deaths were due primarily to TB, thus making TB the most prevalent cause of institutional deaths in Namibia.
Namibia's national TB control programme review for revealed many challenges, including: • geographic inaccessibility of TB care, as many patients live far away from clinics with an absence of public transport in many areas; • low levels of education; • decreasing donor support for TB programmes;  (Maletsky, 2006:1); and • nurses rotate frequently between health care services, making it hard to build up a competent TB nursing workforce at primary care levels (Maletsky, 2006:1).
Figure 1 shows the estimated TB prevalence per 100 000 of the population for the 14 SADC countries in 2000, with Namibia having the second-highest prevalence (preceded by Swaziland) of 758/100 000 (WHO, 2001a:12-14).

Overview of TB in the Omaheke region of Namibia
The Omaheke region is one of the 13 administrative regions in Namibia.It covers 84 732 km 2 and has a total of 68 039 people with an average population density of 0.8 people per square kilometre (Government of the Republic of Namibia Census, 2003:3) (Oxfam, 2002:37).In the late 1990s Omaheke was the worst region in Namibia concerning the management and control of TB and HIV/ AIDS (Oxfam, 2008:1).
During 2002 when the study was conducted, TB patients were admitted for their initial two months of TB treatment to the medical ward of the Gobabis Hospital, the major government hospital in the Omaheke region.This compulsory admission of TB patients led to overcrowding of the medical ward, with an average of 85 patients in a ward with an official bed capacity of 52 (implying a bed occupancy rate of 163%).After the completion of the two months of hospital-based TB treatment, the patients were expected to obtain their daily TB treatment from Gobabis Hospital's outpatient department or from clinics, amounting to health facility based DOTS.Incomplete and inaccurate records were kept and there were no formal links between the clinics and the communities concerning TB programmes.
Community-based DOTS did not exist (Zvavamwe, 2006:17).Nurses at the outpatient department and clinics did not follow up defaulters, as they had no vehicles.In the Omaheke region even four-wheeled drive vehicles would negotiate the heavy Kalahari sands with difficulty.The majority of the TB patients belong to the San community, a predominantly nomadic group without fixed addresses and without phones.Cellular phones do not operate in the rural areas.

PROBLEM STATEMENT
TB can be cured with effective treatment, but with ineffective treatment, MDR TB could develop with grave consequences for the patient, his/her family and community as well as for the health care services.MDR TB develops when TB treatment is ineffective and/or inconsistent.By February 2002, 13 cases of MDR TB had been identified in the Omaheke region.TB treatment programmes are available in Namibia as part of the primary health care services, but Namibia has the second largest TB problem of the 14 SADC countries (see Figure 1), and the incidence of MDR TB continues to rise.The purpose of this study was to identify challenges for the implementation of a community-based TB programme, perceived by nurses providing TB treatment in this region, as well as their perceived remedies for these challenges.If such challenges could be identified and addressed, then an effective community-based TB programme could be implemented and the TB outcomes in this area could be improved.

OBJECTIVES OF THE STUDY
The objectives of this study were to: • identify and describe challenges perceived by nurses in providing TB treatment in the Omaheke region of Namibia; • establish nurses' perceived remedies for the identified challenges to enhance the TB programme's treatment outcomes; • determine nurses' perceived advantages/ disadvantages of implementing a community-based TB programme in this area; • identify nurses' perceived requirements for the successful implementation of a community-based TB programme in this area; • make recommendations for implementing an effective community-based TB programme; and • improving TB outcomes in this region.

RESEARCH DESIGN AND METHOD
This was a descriptive quantitative study which ad-dressed the central research question (Trochim, 2001:1), namely to identify the challenges perceived by nurses for providing community-based TB treatment in the Omaheke region of Namibia.A quantitative study uses measurement to record and investigate aspects of social reality (Bless & Higson-Smith, 2000:156).A quantitative design, using structured interviews to gather data, was deemed appropriate as all the nurses could understand and speak English.The interviewer (who was the first author of this article) could not speak any of the local languages (San, Herero, Nama, Tswana or Ovambo), making in-depth qualitative interviews difficult.
Focus group interviews were not feasible as it was impossible to gather a group of nurses involved in TB care for such an exercise during an acute shortage of nurses.Individual structured interviews offered the opportunity to interview each nurse at a convenient time and location, keeping the information confidential and anonymous.As the nurses' home languages did not include English, the interviewer could rephrase questions and ask explanations for unexpected and/or ambiguous answers during the structured interview.No interpreters were used as all the nurses could understand and speak English and as the interviewer promised each nurse that all information would remain anonymous and confidential.

Population
No sampling was done as the population of 40 nurses who worked in clinics and in Gobabis Hospital's medical ward and outpatient department (where TB patients received their treatment) participated in the study.

Ethical considerations
Permission to conduct the study in the

Structured interview schedule
The structured interview schedule was compiled, based on a review of literature pertaining to TB treatment and care.The structured interview schedule comprised the following sections: • Demographic questions, comprising six items, seeking information about the nurses' ages, qualifications, gender and experience.
• Questions about TB challenges encountered in the Omaheke region (four items) and suggestions for addressing these challenges (four items).
• Questions about nurses' perceived advantages and disadvantages of implementing community-based TB care in the Omaheke region (four items).
• Nurses' suggestions for the successful implementation of a community-based TB programme in the Omaheke region.
Most questions were closed, allowing interviewees to select the most appropriate answer, or to organise possible answers into a sequence from most to least important.However, interviewees always had the option of "other… please specify…" where they could provide answers in their own words, which the interviewer recorded verbatim.

Data analysis
Epi Info 2000 was used to capture and analyse the data and Microsoft Excel was used to generate graphs and tables portraying the statistics.Descriptive statistics were used to convert and condense the data into organised tables and figures (Brink, 1999:179-180; coded and analysed quantitatively.

RESEARCH RESULTS
Biographic data about the nurses providing TB services in the Omaheke region were obtained so that the research results could be contextualised against this background knowledge.Subsequent to the presentation of the biographic data, the research results will be presented according to patient-related, access-related, knowledge-related and burden of TB-related challenges encountered by nurses in implementing TB programmes in the Omaheke region of Namibia.(These categories of challenges were derived from the literature review, but were not organised as such on the structured interview schedule, to prevent the creation of mindsets during the interviews.)

Biographic data
A high percentage of the nurses were females, representing 87.5% (n=35) of the respondents, with only 12.5% (n=5) being males.The youngest nurse in the sample was 23 and the oldest was 54 years old, giving the sample a mean age of 40, with a range of 31 years.
As many as 90.0%(n=36) of the participants had worked for five years or more, and 80.0% (n=32) of them had more than 10 years' experience.This has potentially detrimental effects for health education and for adherence to the prescribed TB regimens.

Challenges encountered by the nurses in providing TB treatment in the Omaheke region
The data will be discussed according to the patientrelated, access-related, knowledge-related and burden of TB-related challenges as well as the advantages and disadvantages of implementing community-based TB programmes in this area, as perceived by the nurses.
Although only 40 nurses were interviewed, each nurse could supply more than one answer in response to specific questions.Consequently, the total number of responses might exceed 40 in relation to specific items.suggestions for addressing some of these challenges.
The data from Tables 2 and 3 will be discussed successively in the respective subsections.

Access-related challenges (n=104 responses)
The These nurses identified a dire need for transport to do follow-up visits to TB patients.This is indeed a serious shortcoming throughout Namibia's health care services.
However, during March 2007 the MoHSS received 53 vehicles from the United States Centres for Disease Control (CDC) and from the Global Fund against HIV/ AIDS, TB and Malaria to be distributed throughout the 13 regions of Namibia to enhance the rendering of health care services, including to "… help health workers to follow up on the treatment of TB sufferers and to trace people who have abandoned their TB treatment" (Shivute, 2007).

Burden of TB-related challenges (n=68 responses)
The HIV pandemic was mentioned by 25 (36.8%) of the participating nurses as the most daunting challenge which has led to increasing numbers of TB patients (30.9%; n=21), overcrowding of the medical ward at Gobabis Hospital (where TB patients are treated) and an increased workload for the nurses, aggravated by the alleged shortage of nurses (32.4%; n=22) in this area.All 40 (100.0%)nurses recommended that the number of nurses should be increased, but did not recommend ways of addressing the HIV pandemic in the area nor the increased numbers of TB patients.
Reportedly the WHO agreed with these 40 nurses on the severe impact of the HIV/AIDS epidemic on Namibia's health care services: "… the co-infection of TB and HIV/AIDS and the stigma carried by both, as well as the multi-drug resistance to the diseases were major factors leading to the low success rate of the Namibian programme" (Maletsky, 2008:2).The situation is particularly serious, as an estimated 30% of people living with HIV/AIDS could die from TB (Clemens, 2003:97).
Concerning the reported severe shortage of nurses,

Disadvantages of community-based TB care identified by the nurses (n=95)
One way in which the burden-related TB challenges could be addressed in this area is by implementing a community-based TB programme, in addition to the existing hospital and clinic-based programme.Specific questions were asked about the perceived disadvantages of this possibility, as well as about perceived requirements for its successful implementation.
All 40 (100%) nurses replied to this question but as more than one disadvantage could be mentioned, the total number of responses was 95.

Nurses' reported acceptance of community-based TB care
A Likert scale was used to assess the strength of the attitude of the nurses' responses towards the implementation of a community-based TB care strategy.
The scale had five strengths: strongly agree; agree; neutral; disagree; and strongly disagree.The results show that all the respondents agreed with the introduction of the strategy, with 65.0% (n=26) strongly agreeing and 35.0%(n=14) agreeing.No respondents were neutral and none disagreed nor strongly disagreed.
These nurses apparently realised that the resourceand labour-intensive TB treatment of two months' hospitalisation followed by four months' DOTS at the Gobabis Hospital or clinics did not meet the goals of treating TB patients effectively.A community-based TB programme might be better able to meet these goals, provided it had sufficient transport, staff members, TB medicines and community members willing to be involved in the management of TB programmes in their respective areas.

SUMMARY OF THE RESEARCH RESULTS
The research results indicate that the challenges encountered in rendering TB treatment and care in the Omaheke region are multi-faceted and interrelated, as indicated in Figure 2.

LIMITATIONS
The study population was limited to nurses providing

RECOMMENDATIONS
The TB treatment outcomes in the Omaheke region could be improved if the following recommendations were heeded: • TB patients, who are abusing alcohol and/or drugs, should receive treatment for such abuse simultaneously with the TB treatment.• The government of Namibia should consider issuing food parcels with the monthly renewals of TB drugs so that the TB patients can take the TB drugs with food, reducing the severity of side effects, and enhancing the adherence to TB treatment.
• Poverty levels in the area need to be addressed; possible job creation activities should be identified, instituted and maintained.
• Nurses should be enabled to conduct home visits to all TB patients on treatment, and especially to every person who defaults to collect his/her TB drugs at the scheduled times.
• The institution of mobile clinic services should be investigated for the rural areas.
• TB services should be decentralised from hospital and clinic levels to community levels.• The possibility should be investigated that the TB nurses could also provide HIV/AIDS treatment and care, provided that they are regularly updated about both TB and anti-retroviral (ARV) drugs.In this way a more cost-effective service could be provided, potentially enhancing the outcomes of patients using TB and/or ARV drugs.
• Although all TB patients are tested for HIV, it is also essential that all HIV-positive patients be tested for TB.This could enhance the case detection, treatment and cure rates (Wise, 2007:3).
The increase in the number of TB patients indicates that health care workers have not succeeded in reaching all patients to persuade them to successfully complete treatment.Therefore, decentralisation of TB care to community and family level is necessary to reduce the number of people with active TB in the community.
However, this requires nurses to understand communitybased TB care and be aware of its challenges and potential benefits.

CONCLUDING REMARKS
Community-based TB programmes should recognise the fact that "…former patients make the best advocates for TB control … those who had tuberculosis and are now cured are 'living proof' of the effectiveness of directly observed therapy, short course (DOTS) and their stories put a human face to the disease … personal perspectives … underscore the power of personal stories in raising awareness of tuberculosis and the need to improve detection and treatment" (Larkin, 2003:176).Subsequent to the completion of this and other exploratory studies, a community-based TB programme has been implemented in the Omaheke region, with the financial and technical support of Oxfam Canada and later also from the United Nations' Global Fund.This programme, known as OHEP (Omaheke Health Education Project), was established to enhance the quality of health services provided by Namibia's MoHSS, "… to provide outreach to people living in rural areas and the squatter settlements through … community health committees and a program of travelling health promoters … the cure rate for TB has risen from 28% to 90%" (Oxfam, 2008:1).This is a significant cure rate because Namibia's average cure rate for TB patients is reported to remain around 50% (Maletsky, 2008:1).

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few facilities with microscopy services and trained staff to use these facilities for diagnostic purposes, making it difficult to determine whether a specific patient's sputum remains directly microscopic positive (DM+ve), implying that live TB bacteria are present in the sputum, and/or whether the patient responds to TB treatment; • poor data management, poor record keeping and poor follow-up systems of non-adherent TB patients; • training in TB treatment was not considered a priority and supervision of TB-related activities had not been performed effectively; • lack of transport for TB treatment related activities; • TB advocacy was not a priority; • lack of an official TB research agenda; • centralisation of TB services in the Omaheke region, with patients admitted to hospitals for the initial two months of TB treatment and receiving the remaining four months of treatment at outpatient departments or at clinics (MoHSS, 2000b:14-19); • use of the services of doctors who are not necessarily familiar with the country and its people, as the University of Namibia has no medical faculty; • "The multitude of medical doctors from dozens of different nations [are] not oriented on the Namibian TB guidelines and often do not provide what the NTCP (Namibia's TB Control Programme) considers 'gold standard clinical practice'"

Figure 1 :
Figure 1: Estimated TB prevalence per 100 000 of general population in 14 SADC countries in 2000.(WHO 2001a) Omaheke region was granted by Namibia's Ministry of Health and Social Services (MoHSS).The research proposal was also approved by the Research and Ethics Committee of the Department of Health Studies of the University of South Africa.The researcher obtained informed consent from each nurse prior to the interview.The purpose of the interview, namely to identify nurses' perceived challenges in providing TB treatment in the Omaheke region, was explained as well as the individual nurses' right to decline participation, or to withdraw from participation at any stage during the interview, without incurring any negative consequences whatsoever.To enhance anonymity and confidentiality, no signed consent was obtained.No names were indicated on the structured interview schedules or in any reports emanating from this data.The interviewer had a list of the names of the 40 nurses providing TB care in the Omaheke region and merely ticked off each nurse's name after the nurse was interviewed.This list was destroyed once all 40 nurses had been interviewed.Information collected was kept in the strictest confidence and the completed structured interview schedules were available to the researchers and the statistician only, and were destroyed subsequent to publication of the research report.
lack of transport for nurses to carry out communitybased TB work was mentioned most often under access challenges.The results disclosed that 92.5% (n=37) of the nurses involved in TB work never visited their communities.They did not have vehicles and would need special training to drive four-wheeled drive cars through the heavy Kalahari sands.The sparse population was spread out over vast distances without proper roads or maps and without telephone or cellular contact, posing challenges to trace any TB defaulters in the rural areas.Poor access to health services by patients, owing to long distances between the patients and the health facilities, and an absence of public transport, were also challenges in providing effective TB care in the Omaheke region.Many TB patients were nomadic, moving from farm to farm, which posed a great challenge for follow-up visits.Centralisation of TB services at the Gobabis Hospital and at a number of clinics in the region further aggravated the inaccessibility of these services for many TB patients.The nurses made 83 recommendations for addressing access-related challenges, including providing transport (39.8%; n=33) to health workers for rendering community-based TB work, establishing communitybased structures to deal with TB at community level (39.8%; n=33) and decentralising TB control to community levels (20.5%; n=17) from hospital and clinic levels.
The 103 remedies suggested by the nurses to address knowledge-related challenges included community education (38.2%; n=38), improved training of nurses (29.1%; n=30), enhanced supervision of clinic nurses (19.4%; n=20) and TB promotion to gain consensus that communities assume responsibility for TB control (16.5%; n=17).No remedy was suggested for enhanced political support for TB programmes in the area.Based on the results of this survey, all 40 nurses who participated in this study attended an in-service education programme about TB and about guidelines for Namibia's national TB programme.A number of clinic committees were established and the committee members as well as other community members were trained in the major aspects of TB and DOTS (Zvavamwe, 2006: Annexures I, K and M).Although the nurses did not mention the doctors' lack of knowledge, this might be a possibility because Namibia has no medical school and relies on doctors trained in other countries McCourt and Awases (2007:2) agree that Namibia, like other African countries, faces a shortage of health human resources, indicating that "… while Africa is estimated to have 25% of the world's diseases, it has only 1.3% of its health staff".However, the CDC has increased the number of nurses trained by the MoHSS from 50 to 200.By 2003, Namibia's MoHSS, with the assistance of CDC and USAID, had hired additional staff (13 doctors, 10 nurses, 10 pharmacists and 10 data clerks) with prospects of increasing these numbers in future (McCourt & Awases, 2007:12).These authors indicate that during 2003 an estimated 210 000 (or 1:10) people were living with HIV/AIDS in Namibia, which would affect the number of HIV-positive health care workers (McCourt & Awases, 2007:3) and possibly further deplete the number of caregivers in Namibia.
These requirements are shown in Table5.This question allowed room for multiple answers, yielding a total of 231 possible requirements.The most important perceived requirements for the successful implementation of a community-based TB programme in the Omaheke region were that the number of nurses should be increased, as was indicated by all 40 (100%) interviewees, transportation for patient follow-up visits should be provided (82.5%; n=33) and patients as well as their families should be educated about TB (77.5%; n=31).Based on the results of this and other subsequent surveys, health education programmes were offered to nurses, clinic committee members, school children and community members prior to and during the eventual implementation of a community-based TB programme in the Omaheke region of Namibia(Zvavamwe, 2006:98-  104).
TB treatment and care in the Omaheke region of Namibia only.Therefore the results of this study cannot be generalised to nurses working in other areas of Namibia, or in other countries, without duplicating this study in the area(s) concerned.Structured interviews were used to collect quantitative data.More in-depth data might be obtained by conducting individual and/or focus group interviews.The research results portray only the nurses' views, not those of the TB patients and/or their families, or those of the communities concerned or of the MoHSS.CONCLUSIONS The 40 nurses who were interviewed identified the major patient-related challenges for the successful implementation of TB treatment and care in the Omaheke region as alcohol and drug abuse, defaulting from treatment, poverty and lack of food to eat after taking the TB drugs.The major access-related challenges concerned nurses' inability to visit TB patients in the community and patients' difficulties in reaching the TB services centralised at the hospital or clinics.The nurses indicated that they required more knowledge about TB but that the communities should also be educated about TB.The major challenges related to TB's burden of disease were the HIV epidemic leading to overcrowding of the medical ward at the Gobabis Hospital and increasing the workloads of nurses in the hospital and clinics.All 40 nurses were in favour of instituting communitybased TB treatment programmes in the Omaheke region, but identified the possible disadvantages of such a programme (which could impact negatively on adherence to TB treatment) as defaulting by TB patients, poor drug maintenance and patients' alcohol and drug abuse.The nurses' requirements for instituting a successful community-based TB programme involved the employment of more nurses specifically for providing TB-related services, the supply of transport for the nurses to visit TB patients and the education of TB patients as well as their families.

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Community structures should be instituted to enhance the successful implementation of community-based TB care, especially DOTS.• In cases where DOTS supervisors operate satisfactorily, more than one month's supply of TB drugs should be issued, obviating the need for monthly visits to the clinic or hospital.• Nurses providing TB care in the Omaheke region should be educated about TB generally and about community-based TB care specifically.• Regular TB awareness campaigns should be held in the area and communities' knowledge about TB should be enhanced.• TB patients should commence TB treatment in their communities, without the initial two months' admission period to the hospital.• Nurses providing TB care should receive regular updates about TB drugs.• Nurses working in TB clinics should maintain meticulous records and should be visited regularly by nurses from both district and MoHSS levels.• More nurses should be appointed specifically to provide TB treatment and care, and to support the community members supervising, as well as the patients receiving TB treatment, and to sustain community-based health education drives about TB (and possibly also about HIV/AIDS).

Table 1 : Nurses' qualifications, workplaces and years of experience (n=40)
no nurses from the San ethnic group.As most TB patients in the Omaheke region are from the San communities, nurses cannot communicate with the majority of the TB patients in their own (San) language.

Table 2
summarises the nurses' responses about challenges encountered in rendering TB services in the Omaheke region, and Table3summarises the nurses'