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1.0 INTRODUCTION
Tuberculosis (TB) is a specific infectious disease caused by Mycobacterium Tuberculosis
(M.tuberculosis) (Park, 2009). It is a historical disease; Evidence of its presence can be found
in the preserved spines of Egyptian mummies (Zink, 2007).TB one of the communicable
disease (WHO, 2000). These communicable diseases of mankind continue to remain a
formidable challenge till this day, all over the world (Dhaar&Robbani, 2006).TB remains an
important cause of death from an infectious agent, second only to the human
immunodeficiency virus, or HIV (WHO, 2004). In 2012, 8.6 million people fell ill with TB
and 1.3 million died from TB (WHO, 2012). People infected with TB bacteria have a lifetime
risk of falling ill with TB of 10 % (WHO, 2012). There are several factors, that are
influencing spreading of tuberculosis among world population, but these factors are not equal
for every region, it will differs place to place.

1.0.1 Tuberculosis control System in Sri Lanka.

The anti-TB campaign was established in 1945. In 1950s, tuberculosis was considered as one
of the most pressing public health problems in the country(Suwasariya, 2014).National
Programme for Tuberculosis Control and Chest Diseases (NPTCCD) is a decentralized unit in
the Ministry of Health which is under the Director NPTCCD; the programme functions under
the Deputy Director General 1(Public Health Services) of the Ministry of Health (Department
of health services, 2012).NPTCCD provides preventive, TB surveillance, diagnostic and
curative services to the population of Sri Lanka; NPTCCD is also a coordinating body
between the central ministry and provincial health sector and other governmental and
nongovernmental organizations (Annual Health Bulletin, 2012). Inward facilities for TB
patients are provided by the chest wards situated in 13 District Hospitals and National
Hospital for Respiratory Diseases (NHRD) situated in Walisara (Annual Health Bulletin,
2012). TB and respiratory disease control activities at the district level are carried out by the
26 District Chest Clinics situated in 25 Districts (Annual Health Bulletin, 2012). In Eastern
province there are three districts includes such as Ampara, Batticaloa and Trincomalee, each
of this districts has one chest clinic. Patients can directly or through a referral by Medical
officer of health (MOH) access these clinics for their treatment. Inward patients in the
relevant hospital will referred by physician or doctor further treatment to chest clinics.

1.1 BACKGROUND
TB occurs in every part of the world; in 2012, the largest number of new TB cases occurred
in Asia, accounting for 60% of new cases globally (WHO, 2012). More than 2,000 million
people, one out of three persons in the world, are infected with M. tuberculosis (WHO, 2012).
In developing countries HIV, increased population, lack of access to health care, poverty, civil
unrest, ineffective TB control programmes, and drug resistance are the factors influencing to
TB (Haslett e, 2002). Park (2009) explained that in many developing countries particularly in
Asia, poverty, economic recession, overcrowding, poor living condition, and malnutrition
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make populations more vulnerable to TB, and recent increase in human migration has rapidly
mixed infected with uninfected communities. Young adults (age limit is 15-54) are more
vulnerable for this infectious disease globally (WHO Annual report, 2012).This age limit is
not only the productive age group in every country but also back bone of the every family. Sri
Lanka is also one of the developing Asian countries; the above factors also contribute to TB.
Social stigma is another big problem in developing countries like Sri Lanka. Sri Lanka is
divided into 9 Provinces, 25 Districts and 331Divisional Secretary Areas (Annual Health
Report, 2012). Every year more than 9000 new TB cases identify in island wide (Annual
Health Bulletin, 2012). Eastern Province (EP) is one of the provinces of Sri Lanka, the
increasing TB cases and TB death rate (Quarterly Report of ChestClinics of EP, 2010, 2011,
2012& 2013). There are four districts has named such as Ampara, Batticaloa, Kalmunai and
Trincomalee in Eastern Province.

1.2 JUSTIFICATION OF THE STUDY

Although TB is a curable and preventable disease (Park, 2009), the number of TB cases and
deaths (due to TB) rise annually in the EP (Quarterly Reports of Case Finding of Chest
Clinics of EP). These reports reveal that TB affects economically productive age groups of 15
-45 years. In 2012, 13 patients died due to TB in Batticaloa district alone and the number of
death increased to 23, in 2013. If the existing factors continue to facilitate the spread and
occurrence of TB, the TB burden will increase in future. To control and prevent TB in this
region, it is necessary to identify the factors that influence to TB in EP. This actual health
problem needs a study to finds the factors that influence to TB. The study finding will
provide guidelines to stop TB in this region.

1.3 SIGNIFICANCE OF THE STUDY

The factors identified by this study can be given more priority in planning TB control
program. The study finding will guide the National TB Control programme, the Non-
Governmental Organizations and other volunteers in providing their help in meaningful way
to the people in this community. The identified factors will be included in teaching content
while planning the health teaching session to the people in the region. The TB screening
program can give more priority to the area where the identified factors are prevalence.

1.4 PROBLEM STATEMENT

The National programme for TB Control and other public health services provides
preventive, diagnostic, curative services to the population of Sri Lanka. If so, the incidence of
TB should decrease in EP. But in EP, TB cases continue to rise. TB is a one of the real health
problem in EP. In future TB will affect more people when the existing factors are unknown.
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To provide holistic health care to these people all the component of TB affected people and
their environment should be identified. In this region, there is no clear picture about the
existing factors that influence to TB. These unknown factors need to be studied. The problem
of the study is identifying the factors that influence to TB in EP. This qualitative study will
describe the factors that influence to TB in EP.

1.5 PURPOSE OF THE STUDY

The purpose of the study is to describe the factors that influence to Tuberculosis (TB) in
Eastern Province (EP).

1.6 RESEARCH OBJECTIVES OF THE STUDY

1.6.1 GENERAL OBJECTIVES

Examine the factors that influencing for tuberculosis among patients at T.B clinics in EP.

1.6.2 SPECIFIC OBJECTIVES OF THE STUDY

1. Identify the knowledge and attitude about TB at chest clinic in EP

2. Identify the socio economic factors of the affective patients at chest clinic in EP.

3. Identify the nutritional factors of the people at chest clinic in EP.

4. Identify the existing medical condition of the patient at chest clinic in EP.

5. Develop an educational session for public who live in selected area for study.

2.0 Literature review

One of the control study conducted by Shetty, Sempko, at el(2006) , in India to evaluate
potential social demographic risk factors for TB,which by using 189 cases, findings were;
low education, not having separate kitchen and chronic disease mainly diabetes and
concluded that TB associated with low level education, and diabetes.

Another study was conducted by Soham Gupta, Vishnu Prasad, Indra and Sethumadhavan,
(2011) in South India to role of risk factors and socio-economic status in pulmonary
tuberculosis, which using 207 clinically and microbiologically diagnosed patients with
pulmonary TB. Results Diabetic mellitus 30%, smoking 16.9%, alcoholism 12.6%, HIV
10.6%, malignancy 5.8%, chronic liver disease 3.9%, history of contact with TB 3.4%,
chronic corticosteroid therapy 2.9%, chronic kidney disease and malnourishment 1.5% finally
39.6% there were no underlying risk factors.

Above two studies were done in India. India is our very nearest sub-continent and both
countries have long and very same similarities in many ways. Above studies results may
compromise with Srilankan situation regarding the factors which is influencing Tuberculosis.
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Existing medical conditions such as diabetic mellitus, chronic liver disease and malignancy
may influence TB in Srilanka also. Socio economic factors such as smoking and tobacco use
also influence TB in Sri Lanka as much as possible EP also.

Anothercase control study conducted by Hill, (2006) in Gambia(South Africa)examined the

identification risk factors for pulmonary TB in those attending a general out patients clinic,
use of 100 sputum smear positive TB cases, the researcher came under conclusion that house
hold crowding past house hold exposure to a known TB cases are the main risk factors of TB.
In different places, different factors were associated for TB.

Another multicentre case control study done by Lienhart, Fielding, Sillah, Bah,
Guftafson,warndoff,Lisse, Donkor,Diallo, Manneh,Adegbola, Aaby, Bennett(January 1999
March 2001) in three countries in (Guinee, Guinea Bissau, Gambia) West Africa to
investigation of the risk factors for tuberculosis. In Guinee;regarding host-related factors,
univariate analysis by conditional logistic regression of 687 matched pairs of cases and
household controls showed that TB was associated with male sex, family history of TB,
absence of a BCG scar, smoking, alcohol, anaemia, HIV infection, and history and treatment
of worm infection: In Guinea Bissau. In a multivariable model based on 601 matched pairs,
male sex, family history of TB, smoking, and HIV infection were independent risk factors of
TB. In Gambia the investigation of environmental factors based on the comparison of 816
cases/community control pairs showed that the risk of TB was associated with single marital
status, family history of TB, adult crowding, and renting the house.

From the research among these three countries shows TB was associated with male sex, HIV
infection, smoking (with a dose-effect relationship), and history of asthma, family history of
TB, marital status, adult crowding, and renting the house influence TB. First two studies
contrast with third study regarding the factor of HIV and asthma. Two new factors identify
through this study. HIV patients are more vulnerable for TB infection (WHO, 2008).

Another study which was descriptive cross sectional one, was conducted by Siddique,M.S,
Moizefakin,H.A et al(2011),in Pakistan to concluded multiple environmental and host related
factors are present in sputum smear positive cases of Karachi, with 250 sputum smear
positive cases. According to the finding of this study, 54persentage for male sex,25
percentage for diabetes, 10 percentage for smoking(20 cigarettes per day), 69.6 percentage
for live in over crowd.

Another study was conducted by Berhe, Enquselassie, Aseffa,(2011) in Tigray of

Ethiopia.This study result indicated the house hold food shortage HIV zero positive, literacy,
being married, smoking and alcohol consumption substantially increased risk of increasing
tuberculosis. In this study nutritional factors involve as a key role for influencing factors of
TB.

Above two studies mentioned overcrowding, smoking and alcohol, but they contrast with
nutritional factors. Nutritional factors are one of the main causes for infections in any kind of
disease. In the eastern province this factor may influence TB spreading among patients.
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In another case control study, conducted by Ladefoged, K, Rendal,T et al(2011), in Green

land, to disclose risk factors for TB by using 146 cases. Researchers concluded from this
study as risk factors of tuberculosis associated with living in a settlement. From this study,
researchers found risk factors for TB not only living settlement of people but also
unemployment and no access of tap water.

3.0 RESEARCH METHODOLOGY

3.1 STUDY DESIGN

The researchers select a quantitative approach and descriptive design to describe the
influencing factors of TB in EP.

3.2 PERIOD OF STUDY

This study will be carried out over a two (02) month period.
3.3 STUDY POPULATION

The study population of this study is the all diagnosed TB patients who live in Eastern
Province of Sri Lanka.

3.4 SAMPLING
The researchers will use convenience sampling method for this study. The expected total
number of sample is 150 from the sample frame of the TB patients who are following
treatment at chest clinics in EP. TB patients who are following treatment at Teaching Hospital
Batticaloa, General Hospital Trincomalee and Ashroff Memorial Hospital are selected for
convenient sampling.

3.4.1 INCLUSION CRITERIA

1. The patients who give informed consent to participate in the study

2. The patients who have diagnostic document or records that confirm TB

3. The patients who live and stay in eastern province continuously

3.4.2 EXCLUSION CRITERIA

1. The patients who refuse to give informed consent, and mentally ill patients.

2. The patients who are in severe chest conditions, such as frequent cough and

difficulty in breathing.
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3. The patient who stays or lives out of the eastern province even though they are

belongs to Eastern province. This is may be due to their job or conveniences.

3.5 DATA COLLECTION

The questionnaire will be prepared with the help of the supervisor. The patients will be
explained thoroughly about the study and consent will be obtained before the data collection.
Patients who refuse to participate in the study will be excluded.

3.6 PILOT STUDY

Pilot study will be done among 10 TB patients. The results will be analyzed and alteration
will be made on the questionnaire if necessary.

3.7 DATA COLLECTION INSTRUMENT

The questionnaire prepared in English. It will be translated into Tamil.

3.8 DATA ANALYSIS

The collected data will be analyzed and processed by using SPSS (Version- 19.0),

3.9 ETHICAL CONSIDERATION

Permission for conducting the research will be obtained from the Department of Natural
Science, Faculty of Bachelor of Nursing, and Open University Sri Lanka and discussed with
supervisor. The permission will also be obtained from the Hospital Directors of who are
working at Teaching Hospital Batticaloa, General Hospital Trincomalee and Ashroff
Memorial Hospital. Consent will be taken from the patient before data collection. Results will
be used for our research purpose only. There will be no personal identification in order to
maintain the confidentiality. The proposal will be submitted and ethical clearance obtained
from Ethical Review Committee of Faculty of HealthCare Sciences, Eastern University Sri
Lanka. Participants have the freedom to refuse or withdraw at any time without any risk.

3.10 MAINTENANCE AND DISPOSAL OF DATA

Collected data will be processed and saved in personal computer. The saved data will be
password protected. The processing and analysis will be carried out only by us and used only
for our research. The data and questionnaires shall be handled with care and will be handed
over to the department of Department of Natural Science after the evaluation will be
completed. Saved data in the personal computer also will be deleted.

3.11 TIME
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TIME April MAY JUNE JULY AUG SEP

FRAME 2017 2017 2017 2017 2017 2017

0 Heading
1 selection,
preparing
proposal and
questionnaire
0 Approval
2
0 Collection of
3 data
0 Data
4 processing
and analysis
0 Writing
5 report

0 Typing and
6 Binding
0 Submission
7 of report

4.0 REFERENCES

1. Anti malaria campaign. (2010). (www.statistics.gov.lk).

2. Dhaar, G. M., &Robbani, I. (2006).Foundation of community medicine: Natural
history of respiratory route infection (1st Ed.). India: Elsevier.
3. Haslett, C., Chilvers, E. R., Boon, N. A., Colledge, N. R., & Hunter, J. A.
(Eds.). (2002). Davidsonss principles and practice of medicine: Respiratory
Disease (19th ed.). London: Churchill Livingstone.
4. Hill, P.C. et al (2006) Bio Med Public Health 6: 156; 1471- 2458.
5. Ladefoged, K., Rendal, T et al (2011) International Journal of Tuberculosis And
Lung Disease. 2011. Jan; 15(1): 44-49.
6. Lienhardt, C., Fielding, K. et al(2005) International Journal of Epidemiology
2005; 34; 914-923.
7. Park, K. (2009). Preventive and social medicine: Epidemiology of
Communicable diseases (20th ed.). India: M/S BanarsidasBhanot Publishers.
8. PDHS, EP. (2007 & 2008).Health status & Health services provisional
indicators. (http://www.ep.gov.lk).
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9. Porta M (editor). A dictionary of Epidemiology.5th. Edition. New York: Oxford

University Press, 2008. Edited by Miquel Porta
10. Shetty ,N.,Shemko,M et al(2006) The International Journal of Tuberculosis and
lung disease 10(1); 80-86.
11. Siddique, M. S, Moizefakin, H.A et al (2011) Journal of Pakistan Medical Study
1 (1); 13- 18.

Appendix I

Permission letter

Address: Teaching Hospital Batticaloa

Date :2017 04 10

To: Director,
Through: Medical officer in charge, chest clinic,
Through: The Special Grade Nursing Officer,
Through: The Nursing officer incharge,
Chest clinic,
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Teaching Hospital,
Batticaloa.
Dear Sir/Madam,
Request for permission to collect data for a research study on, An examination of the
factors influencing for tuberculosis among patients atchest clinics inEastern province.

I am Mr. J.Perananthamj working as nursing officers in Medical intensive Care Unit,

at theTeaching Hospital Batticaloa interested in conducting a research onAn examination of
the factors influencing for tuberculosis at chest clinics in Eastern province as a partial
fulfillment of the requirements for the degree of bachelor of science in Nursing at the Lincoln
University College Malaysia.
The purpose of the study is to describe the factors that influence to TB in EP, and I
wish to invite nursing officers for voluntary participation and plan to collect data from a
selected sample. Our research proposal and the interview questionnaire are annexed for your
information.
We kindly request our permission to conduct this study in thechest clinic,Teaching
Hospital Batticaloa

Thank you.

Yours faithfully,

..

..

..