Impacts of Rural-Urban Migration on Prevalence of Tuberculosis in Monrovia, Liberia

DECLARATION

ACKNOWLEDGEMENT

ABSTRACT

Tuberculosis (TB) is a major issue not only in African countries but also in other countries worldwide. This infectious communicable disease is a major cause of morbidity and mortality, as evidenced by a mortality of 1.5 million people globally. The TB prevalence in Liberia has risen greatly in the past years. The civil war in Liberia that lasted between 1989 and 2003 is majorly to blame for the poor condition of health services and other sectors in the Republic of Liberia. After the civil war, Liberia witnessed a shift in population from the rural to urban areas due to displacement and the search for employment and better living standards among others. The establishment of the TB Annex Hospital in Monrovia, Liberia also contributed to rural urban migration into Monrovia in search of better TB care by TB infected individuals. This main aim of this study was to investigate the impact of rural-urban migration on the prevalence of TB in Monrovia, the capital city of Liberia. The relationship between the independent variables of rural urban migration, efficiency of TB control services and availability of community TB care and the dependent variable of the prevalence of TB in Monrovia between 2008 and 2014. The study was quantitative in nature and used the Health Belief Model. Secondary data from the Ministry of Health and Social Welfare in Liberia, the Liberia Institute of Statistics and Geo-information Services (LISGIS), the Centers for Disease Control (CDC) and the World Health Organization (WHO).

LIST OF ABBREVIATIONS

AIDS -Acquired Immunodeficiency Syndrome

CDC -Centers for Disease Control

DOTS – Direct Observed Treatment Short Course

EPTB -Extrapulmonary Tuberculosis

HBM – Health Belief Model

HIV -Human Immunodeficiency Virus

IRB – Internal Review Board

LISGIS -Liberia Institute of Statistics and Geoinformation Services

NLTCP-National Leprosy and Tuberculosis Control Program

PPD-Purified Protein Derivative

PTB- Pulmonary Tuberculosis

TB- Tuberculosis

SPSS- Statistical Package for Social Sciences

WHO- World Health Organization

CHAPTER 1

1.0 INTRODUCTION TO THE STUDY

1.1 Historical Perspective on Tuberculosis

Tuberculosis (TB) is an infectious disease in humans caused by Mycobacterium tuberculosis, which belongs to the same group of microorganisms as Mycobacterium africanum and Mycobacterium bovis. The bacterium may be as old as the earth itself and has existed in primeval mud since the beginning of time as evidenced by the presence of pathological signs of tubercular decay in the spinal column remains of Egyptian Mummies. The Greeks called it phthisis due to its wasting nature. TB is currently one of the fatal infectious communicable diseases in the world and is present in all parts of the world. Despite the improvements in housing and sanitation, the mortality rate for TB is almost the same as it was a century ago with 50% of the infected with the disease, dying . In 2013, approximately nine million people contracted TB, and about 1.5 million died due to the disease, 360, 000 of these people were HIV positive. About one third of the world’s population has latent TB infection.

The mortality due to TB is still very high despite the availability of a regimen designed to cure the disease. Regimens that are short course and cure the disease are available. However, the existence of other barriers to healthcare access and compliance with medication explain the high mortality rates associated with TB. Africa has the largest TB burden with 281 cases per 100, 000 as compared to the global figure of 133 per 100, 000. In Liberia, TB is a major public health problem with an estimated prevalence rate of 453 and incidence rate of 299 per 100, 000 in 2011.

1.2 Epidemiology of Tuberculosis

Tuberculosis affects populations in all regions around the world. Early in the twentieth century, the prevalence of TB infection declined greatly in the developed nations. The rest of the world however continues to fight persistent high rates of infection through various strategies designed to lower the prevalence and incidence rates of TB. The risk factors for TB fall in two broad categories including environmental and biological risk factors. Environmental risk factors include residence in prisons, nursing homes, homeless shelters and hospitals. Biological risk factors include Human Immunodeficiency Virus (HIV) infection, diabetes mellitus, corticosteroid use, gastrectomy, malnutrition alcohol dependence and intravenous drug use.

TB is primarily a respiratory infection that affects the lungs as pulmonary TB (PTB). It may also affect other organ systems except hair and nails. Spread is through hematogenous or lymphatic pathways and is thus extrapulmonary TB (EPTB). Infection may be active with manifestation of symptoms or latent without symptoms but with immune reactivity to injection of intradermal purified protein derivative (PPD) in the Mantoux Skin test. Treatment of individuals with latent TB eliminates the reservoir and reduce their chances of developing active infection. Management of patients with active TB infection is by use of combination therapy using antibiotics.

Despite the availability of a regimen for treatment of TB infection, there has been an increase in the prevalence and incidence of TB infection in Liberia. There has been a rise from a prevalence rate of 341 per 100, 000 in 1990 to a prevalence rate of 453 per 100, 000 in 2011. There has been an increase in the incidence rate with an estimated annual increase by 2% from the year 2005. The increase in prevalence may be due to the aftermath of civil war in Liberia between 1983 and 2003. There have been significant attempts to restore the health system, including TB control services. The recent shift in the population from rural to urban areas leading to overcrowding may have contributed to increase in prevalence and incidence rates of TB infection. There is need to explore the causes of the increase in prevalence and incidence rates of TB to work towards achievement of high cure rates and a drop in both incidence and prevalence rates of TB in Liberia.

1.3 Tuberculosis Diagnosis and Treatment Resources

The diagnosis of active TB infection depends on the identification of the causative microorganism from specimen from affected tissue including sputum in pulmonary TB and tissue biopsy or cerebrospinal fluid for extrapulmonary TB. Methods in use for diagnosis for over a century now include microscopy after staining with Ziehl Neelsen stain or culture of specimen in appropriate culture medium. Gene Xpert is a newer rapid molecular method of diagnosis.

The treatment of active TB infection includes combination therapy for at least six months including an intensive phase using four antibiotics and a continuation phase using two antibiotics. The world Health Organization put forward a global TB strategy dubbed Direct Observed Treatment Short Course (DOTS) in the 1990’s in an attempt to reduce the incidence and prevalence rates of TB. The purpose of this was strategy to guide the administration of TB therapy to TB patients. The components of this strategy were global political commitment to fight TB, case detection using sputum microscopy, standard short course chemotherapy, adequate and regular anti-TB drug therapy supplies, and a standardized reporting and recording system for TB cases. The ‘stop TB strategy’ now succeeds this strategy and aims at ending the TB epidemic globally. The components of this strategy include integrated patient centered care and prevention, bold policies and supportive systems and intensified research and innovation.

Therapy for TB under the DOTS strategy has been effective in reduction of TB prevalence rates globally. This is however not the case for Liberia. Disruption of TB control services due to the civil war in Liberia is one of the major factors that contribute to a rise in prevalence of TB in this country from the 1990’s to 2011. After the war, there were attempts to control TB but accessibility and patient awareness remain low. In Monrovia, there is a high TB notification rate due to increase in factors that favor transmission such as overcrowding and the accessibility of diagnostic facilities. There are gaps in the surveillance systems for detection and treatment of TB cases. Several gaps exist in the TB control services in Liberia including lack of adequate resources for diagnosis, and treatment of TB, poor public awareness, and lack of trained human resource to work in TB control among others.

1.4 Problem Statement

The case notification for TB in 2012 was at 8,132 cases out of which 4, 342 (53%) were smear positive pulmonary TB cases. 60% of these cases were from Monsterrado County in which Monrovia City is located. The mortality rate due to TB is currently at 45 per 100,000 according to the World Health Organization. This is a rise from 35 per 100,000 in the 1990’s. . Currently, there are about 16,050 active TB cases in Liberia, mainly in the rural communities, where majority of people are poor and live in poor conditions. The rural-to-urban migration rate is currently 115/1000 people in the Liberian population. The research done on TB prevalence, incidence and control in Liberia is very scarce and therefore minimal data on these variables is available.

In the recent past, there has been a high increase in the population of Monrovia in relation to its land area, social and economic infrastructure. Census data indicates that there has been an increase in the population of Liberia living in urban areas from 39 percent of the total Liberian population in 1984 to 47 percent in 2008. The census data also reveals that about 28 percent of the total population live in Monrovia. Increase in rural-urban migration is one of the major factors that has led to increased population in the Liberian capital. Among the reasons for the high rate of migration is to flee war, because of internal displacement, to seek higher and better education, for economic and political reasons, and to seek for sources of income and better living standards.

This high rate of migration to bigger towns and cities such as Monrovia has aggravated the incidence and the prevalence of TB in Liberia. People from the densely populated areas are at a high risk of contracting the disease.Accordingly, increase in the number of persons migrating to the city from rural community puts pressure on social infrastructure including, housing, water supply, sanitation and healthcare. All these factors contribute to the increased incidence and prevalence of TB in Liberia city.

Undiagnosed urban migrants from rural communities act as reservoirs and spread the infection to the uninfected urban dwellers. This is likely especially because most urban migrants from rural areas begin from a low socioeconomic level when they first settle in urban areas and these force them to live in poor conditions with poor housing, water and sanitation. Those who were on follow-up in rural healthcare facilities may default on treatment due to difficulty in integration into in the urban healthcare system. Poor linkages between health care facilities in the rural and those in the urban centers may hinder good continuity of care. Migration to urban centers by TB patients may deprive them of the social support structures including support groups. Integration of these individuals into a support group in which they are comfortable may take time for patients with TB.

These individuals are at risk of extra pulmonary involvement and development of multidrug resistant TB. Stigma from the community, and the attitude of healthcare workers in the new urban setting, may affect health seeking behavior, compliance and adherence to treatment by urban migrants from the rural communities. Lack of awareness of the availability of free or subsidized health services by immigrants and negative perception of government services may also has an impact on the prevalence of TB in urban areas. This study will investigate the transition of TB care from follow-up of TB patients in rural health care facilities to continuity of care when the patients migrate to urban centers, and its impact on TB prevalence in Monrovia.

1.5 Purpose of the Study

The main purpose of this study is to investigate the correlation between the rates of urban migration from rural Liberia to the city of Monrovia and the impact of the urban migration rates on the prevalence of TB in Monrovia. To achieve this, there will be need to obtain data on various variables from relevant sources. These variables include the rates of rural to urban migration into Monrovia by assessing the population of Monrovia before 2008 and the population of Monrovia between 2008 and 2014, prevalence of TB in Monrovia before 2008, TB incidence and prevalence in Monrovia between 2008 and 2014, organization of TB control services and community TB care in Liberia. There are very few studies conducted on TB prevalence and incidence and TB control services in Liberia. Apart from the research carried out by the World Health Organization and the Ministry of Health and Social Welfare in Liberia, minimal information is available concerning TB in Liberia.

Studying these relationships may enable public health professionals in Monrovia to design intervention programs to address the problems regarding accessibility to TB care, continuity of care and follow-up. The study will highlight the need for linkage and the communication between health care facilities in urban and rural Liberia, and the need social support structures for TB patients who migrate to the urban from the rural areas. This study would be important in identifying interventions in both the healthcare sector and by the government, which may reduce the prevalence of TB in this city and the rural areas where the urban migrants came from.

1.6 Research Questions and Hypotheses

RQ1: What is the relationship between rates of rural-urban migration into Monrovia and the prevalence rate of TB in Monrovia between 2008 and 2014?

H10: There is no relationship between the rates of rural-urban migration into Monrovia and the prevalence rate of TB in Monrovia between 2008 and 2014?

H1A: There is a relationship between the rates of rural-urban migration into Monrovia and the prevalence rate of TB in Monrovia between 2008 and 2014?

RQ2: What is the relationship between the efficiency of TB control services in Monrovia and the prevalence rate of TB in Monrovia?

H10: There is a relationship between the efficiency of TB control services in Monrovia and the prevalence rate of TB in Monrovia

H1A: There is no relationship between the efficiency of TB control services in Monrovia and the prevalence rate of TB in Monrovia

RQ3: What is the relationship between the prevalence rate of TB and the availability of Community TB care in Monrovia?

H10: There is a relationship between the prevalence rate of TB and the availability of Community TB care in Monrovia

H1A: There is no relationship between the prevalence rate of TB and the availability of Community TB care in Monrovia

1.7 Theoretical Framework

The theoretical framework used in this study is from the Health Belief Model, which explains why people do or do not engage in the particular health related actions. For instance in a city such as Monrovia, the Liberian capital, this model explains why urban migrants did or did not access free TB screening and care . In addition to this, it explains the health seeking behavior of TB infected urban migrants based on their economic status, perception of the attitude of healthcare workers, accessibility of TB care and stigma associated with TB infection and care. It sheds light on the willingness or unwillingness TB infected urban migrants to seek continuity of care in an urban healthcare facility.

This model holds that engaging in health-related actions depends on the occurrence of three factors

There must be sufficient health motivation to make health issues relevant

There must be a perceived threat to a given disease

The belief that recommended health action will reduce the threat

According to the health belief model, health-seeking behavior depends on the following two variables: the value placed on a given goal, and taking action that will enable an individual attain that goal. As far as health-related behavior is concerned, these variables mean preventing illness, getting well (when ill) and the belief that taking some health-related actions will prevent an illness.

According to HBM posits the following dimensions:

Perceived susceptibility: This is how one perceives vulnerability to a given condition or disease. In this case, it refers to one subjective perception of the chances of contracting TB

Perceived severity: These are feelings about the dangers of contracting a disease and how it might affect an individual socially (losing a job, family and life) or medically (illness, death or disability. Depending on how one perceives it, it can lead taking or not taking some given health-related action.

Perceived benefits: the fact that an individual has perceived vulnerability to a given disease may cause them to take action; another motivating factor is the benefits that one is likely to get by taking some health-related actions.

Perceived barriers: perceived potential negatives of a given health-related action can be the reason why a given recommended health behavior may not be adopted. An individual carefully weighs an option whether it can be beneficial or dangerous and expensive before deciding to engage or not to engage.

With regard to health promotion and all other efforts to educate the population on health issues, HBM holds that these efforts can only be successful and effective depending on the level at which they address and integrate the values and priorities of a target community.

1.8 Definition of Terms

Urban Migrants: the population of Monrovia that moved into the City of Monrovia from the rural areas of Liberia.

Population of Monrovia between 2008 and 2014: individuals, male or female of all ages who either were residents or resided in the city of Monrovia for 6 months or longer between the specified study period with their documentation in public data records at the county and city level.

Tuberculosis (TB): refers to pulmonary TB including both latent and active TB.

Nature of the Study

The nature of this study was quantitative and used multiple linear regression analysis. There was use of a retrospective research design for the quantitative research study. It was quantitative because it can best use the secondary data to evaluate hard data correlations. A retrospective research design is the best design for analyzing data that is already available from records kept or data collected in the past. There is comparison of various sets of data linked to a variable or variables . This quantitative research can help to determine if there is any relationship between the independent variable (rural-urban migration to Monrovia) and the dependent variable (the rate of TB infection among the population of Monrovia).

1.9 Assumptions

This study is non-experimental and utilizes secondary data, which has been analyzed, coded and archived, obtained from sources that have already obtained IRB approval. Testing of All participants for TB was by a public health service. Therefore, there was an assumption that data used had minimal bias to ensure that the results from each group were sound and comparable.

1.10 Limitations

There was no random selection of participants since the study was retrospective in nature. It is therefore difficult to generalize the findings to the population of study. I could not control a number of confounding variables that affect the prevalence rates of TB. These variables include the willingness of individuals to be tested, the accessibility of testing facilities and the accuracy of these testing methods in the detection of TB.

1.11 Strengths

This study was able to achieve analysis of a large cross-section of data among the general population of the city of Monrovia, validity and rigor of secondary data employed, and the type of analysis used to ensure the statistical strength of the results. This study was able to contribute greatly to the gap in research by providing information about TB in Monrovia, its prevalence and the efficiency of TB control services in the capital city of Liberia.

1.12 Significance of the Study

This research focuses mainly on establishing the impact of urban migration on the prevalence of TB in Monrovia. The study will investigate the system of transition of TB care among TB patients who migrate to the urban center of Monrovia from the rural areas. The study will assess factors that might impact income on health seeking behavior, linkage between the rural and urban health care facilities, follow up and continuity of care for TB patients who migrate to urban areas. In addition, the study will investigate the attitude of health care professionals to these TB patients and the social support structures in place to help the urban migrant TB patients. The study will further establish the contribution of these factors to the high prevalence of TB in Monrovia. This intends to fill the gap in understanding and identifying the availability of transition system for continuity of care for urban migrants and to emphasize the importance of having one in place to ensure that TB patients migrating to urban areas complete their treatment and be free of the infection by achieving complete cure.

Intervention by the ministry of health will ensure that there is screening for TB, and medication to reduce the spread of TB in rural areas. These interventions will reduce the exposure of members of the urban community to TB. The positive social change from the findings obtained from this study may be due to the availability of evidence necessary to support the advocacy for the installation of a transitional care for urban migrants, and to ensure continuation of TB care.

1.13 Ethical Concerns

There are minimal ethical concerns in this study because of the use of secondary data. There was no use of personal information and therefore there is no likelihood for the violation of the privacy and rights of patients. There are minimal concerns about the reliability and validity of the secondary data used in this study. The Institutional Review Board (IRB) gave approval prior to the study. The study strictly followed the policies and regulations of the institutions that provided data.

1.14 Summary and Transition

As evidenced above, TB is a major public health issue not only globally but also in Liberia. The burden of this disease in Liberia is very high as evidenced by the high incidence and prevalence rates. There is minimal research on TB prevalence, TB burden and TB control services in Liberia, Therefore, there is need to find this information through research. there is need to seek evidence used to advocate for change in TB control services and community TB care by the Ministry of Health in Liberia and by international humanitarian organizations. The literature review below explores previous research done on TB and migration in Liberia and the research done in other countries on the effect of urban migration on the prevalence of TB.

CHAPTER 2

2.0 LITERATURE REVIEW

2.1 Urban Migration into Monrovia

Liberia experienced a civil war between 1983 and 2003 that affected the distribution of the population in various parts of the country. Increase in rural-urban migration is one of the major factors that has led to increased population in the Liberian capital, Monrovia.. The citizens of Liberia migrate for many reasons including to flee war, because of internal displacement, to seek higher and better education, for economic and political reasons, and to seek for sources of income and better living standards.

In the recent past, there has been a high increase in the population of Monrovia in relation to its land area, social and economic infrastructure. There has been a shift in the population of Liberia from the rural to urban areas between 2007 and 2013. Census data indicates that there has been an increase in the population of Liberia living in urban areas from 39 percent of the total Liberian population in 1984 to 47 percent in 2008. The census data also reveals that about 28 percent of the total population live in Monrovia. Identification of correlations between various variables is possible through review of a previous study done on prevalence and outcome of TB in TB Annex Hospital in Monrovia, and previous studies done in other countries to explore the impact of rural-urban migration on the prevalence of TB in urban centers. Thorough research reveals that there are no other studies on TB done in Liberia.

2.2 Organization, Strategies and Justification

2.2.1 Organization of the Review

This chapter analyzes the literature regarding correlations the prevalence rates of TB in Monrovia and variables that include increase in the rates of rural-urban migration, the efficiency of TB control services and the availability of Community TB care in Monrovia between 2008 and 2014. The first section of this chapter highlights published literature that has used the Health Belief Model to examine the attitude of populations towards engaging in health related actions. The second section explores the historical perspective of the infection rates of TB at the national level and the study variables over the last 10 years since minimal research is available on TB in Liberia. The third section addresses the efficiency of TB control services in Liberia including barriers to diagnosis and treatment, and the availability of continuity of care and community TB care to urban migrants in Monrovia. In the fourth section of this chapter, I discuss the relationship between the prevalence of TB in urban centers and increase in rates of rural- urban migration, efficiency of TB control services and availability of community TB care. I will obtain this information from research done in other countries due to unavailability of research done in Liberia. A synopsis of these studies and their relation to this research is in the literature and methodology section. I will conclude this chapter with a summary of findings and transition to the next chapter.

2.2.2 Strategies for Searching for Literature

The compilation of this literature review was through research from online databases including Google Scholar, JSTOR, PubMed, Medline, Nursing and Allied Health. Terms used to explore the databases include tuberculosis, Liberia, Monrovia, rural-urban migration, migrants, and qualitative research.

2.2.3 Justification of the Study

During the preliminary review of the research topic, it was evident that there exists a wide gap in the knowledge on TB in Liberia with regard to the various variables discussed earlier. Minimal documented research on TB in not only Monrovia but also the entire republic of Liberia was available. The information obtained in this study is valuable in the war against TB in both Monrovia and the entire republic of Liberia. The research will fill the gap in knowledge in TB prevalence and control; provide evidence for advocacy for positive social change and raise awareness for TB prevention.

2.3 Theoretical Framework

The Health Belief Model is widely used in medical and public health research to explain health behavior. It is a specific social cognition model. American Psychologists Hochbaum, Rosenstock and Kegels developed this model in the 1950’s in response to the failure of a free TB screening program. Since then there has been utilization of this model to explore various short and long-term behaviors including sexual risk behaviors and the transmission of HIV/AIDs. This research utilizes the Health Belief Model to establish correlations between the health behavior of individuals and other variables that directly determine their health seeking behavior. These variables include the availability and accessibility of TB control services and community TB care among urban migrants. The components of the model may provide an understanding of the impact of social, economic and environmental factors on the health behavior of an individual.

Hochbaum’s original concern was the uptake of TB screening opportunities provided through mobile X-ray units. It was evident that beliefs concerning susceptibility to the infection and benefits of the screening heavily depended on the acceptance of an individual to have a chest x-ray. From Hochbaum’s research, it is apparent that several variables including the availability of disease control services, socio-economic status and intrapersonal beliefs, directly affect the rates of infection with a particular etiological agent such as Mycobacterium tuberculosis.

In their study, used the Health Belief Model to analyze TB related behavior among rural to urban migrant workers in China. The purpose of the study was to find out the factors that affect migrant workers, TB prevention behavior and health seeking intention with an aim to improve the behavior of migrants and to provide TB-related recommendations. Through the utilization of the Health Belief Model, the researchers in this study were able to find out the variables that affected the rates of TB among migrant workers in China and to propose interventions to minimize the rates of infection with this disease.

2.4 Historical perspective

The study of the relationship between rural-urban immigration and its impact on the health of immigrants has been the subject of many studies in other countries including China, India, Vietnam and Bangladesh. The studies done in China focused on the impact of rural urban migration on the incidence and prevalence rates of TB in these countries. This is however not the case in Liberia. There has been no previous research to establish the relationship between increase in rural-urban migration and the prevalence of TB in urban areas in Liberia. The study by in Monrovia, Liberia between 2009 and 2010 is the only study that I found has investigated the prevalence of TB among patients who visited the TB Annex Hospital in Monrovia, Liberia between July 2009 and July 2010. The study used a cross-sectional descriptive study design. The results indicated that the prevalence of TB was very high among individuals who visited the TB Annex Hospital. The exact binomial test was used with P<0.05 and CI (0.864-0.934). The monthly incidence of TB was very high ranging between 75% and 100% respectively.

In a study conducted by to determine the contribution of migration to case burden and drug resistance rates of urban cities in China, it was evident that there was a great impact of urban migration on the incidence and prevalence of drug-resistant TB. This study utilized a facility-based epidemiological study and a conclusion was made that appropriate treatment regimens should be sustained to prevent the transmission of drug-resistant TB among migrants and residents.

Another study done in China is that conducted by to investigate the health seeking behavior of and health systems responses to migrants and permanent urban residents suffering from chronic cough to identify the factors influencing delays in receiving a TB diagnosis in urban China. There was a combination of prospective cohort study of adult suspect TB patients and qualitative method to carry out the study. There was an analysis of the health seeking behavior of TB suspects among migrants and urban residents and factors influencing their decisions and responses by general health providers using the Piot model. The results from this study indicated that 68% of migrants delayed for more than two weeks before they sought care for symptoms that suggested TB. Migrants were 1.5 times more likely to use less expensive, community health services as compared to urban residents. In the follow up survey, 61% of migrants and 41% of urban residents who had persistence of symptoms gave up continuing to seek professional care with a statistically significant difference between the two groups(p<0.05). The findings from this study indicated that rural to urban migrants are more susceptible to delays in seeking care for symptoms suggestive of TB in urban Chongqing. It was evident that there was an interaction between patient and provider related factors to pose barriers to diagnosis of TB among migrants. These factors include low awareness and poor knowledge among the public and suspects about the TB control program low financial capacity to pay for care and diagnostic tests.

2.5 Barriers to Tuberculosis Diagnosis and Treatment among Urban Migrants.

The health system in Liberia is on recovery phase after disruption during the civil war between 1989 and 2003. Consequently, the TB control services are not well established. The government of Liberia established a hospital in Congo Town, Monrovia, which focusses on the management of TB cases. This hospital is the TB Annex Hospital. This may be one of the reasons for the increase in the prevalence of TB in Monrovia due to movement of people to this city to seek TB treatment. Currently, estimates indicate that there are less than 1300 professional health workers in all professional categories in the health sector in Liberia. Increase in rural-urban migration is one of the major factors that has led to increased population in the Liberian capital. In his research, enumerates some of the reasons for the high rate of migration from rural areas to urban areas among Liberians to include the need to flee war, because of internal displacement, to seek higher and better education, for economic and political reasons, and to seek for sources of income and better living standards.

The National Tuberculosis and Leprosy Control Program (NTLCP) coordinates TB control services in Liberia since 1989. Use of the DOTS strategy recommended by the World Health Organization began in Liberia in 1999. Regardless of this, the TB prevalence in Liberia has been rising in the recent past. Undiagnosed urban migrants from rural communities become reservoirs and spread the infection to the uninfected urban dwellers. According to research by , this is likely especially because most urban migrants from rural areas begin from a low socioeconomic level when they first settle in urban areas and these force them to live in poor conditions with poor housing, water and sanitation.

In the study by to investigate the barriers to accessing TB diagnosis and treatment among urban migrants in Chongqing, China, the researchers found out the several barriers. These barriers included low awareness and poor knowledge among the public and TB suspects about TB as a disease and about the TB control program; low financial capacity to pay for care and diagnostic tests and inadequate use of diagnostic tests and referral to TB dispensaries by general health providers. This may shed light on some of the likely barriers to access of TB treatment by urban migrants with chronic cough.

An article by indicates that urban migrants who were on follow-up in rural healthcare facilities may default on treatment due to difficulty in integration into in the urban healthcare system. Poor linkages between health care facilities in the rural and those in the urban centers may hinder good continuity of TB care for rural to urban migrants. Migration to urban centers by TB patients may deprive them of the social support structures including support groups. Integration of these individuals into a support group in which they are comfortable may take time for patients with TB. It is important of find out the efficiency of TB control services and the availability of community TB care in Monrovia in order to propose interventions to reduce the incidence and prevalence rates of TB in this city.

2.6 Study Variables

These variables include the rates of rural to urban migration into Monrovia, TB incidence and prevalence in Monrovia between 2008 and 2014, organization of TB control services and community TB care in Liberia.

2.6.1 Rural to urban migration into Monrovia

The TB Annex Hospital established in Monrovia by the Liberian government is the only facility for comprehensive and focused TB management in the country. A study conducted by to investigate the prevalence and outcome of TB patients who visited this hospital between July 2009 and July 2010 revealed that there is a high prevalence of TB among patients who visited the TB Annex Hospital in Monrovia. The fact that there has been evidence of increase in rural to urban migration into Monrovia according to the study by supports the assumption that increase in rural to urban migration into Monrovia has led to an increase in the prevalence of TB in Monrovia.

An article by the international organization for migration describes the migration process and TB epidemiology. This article highlights the avenues where migrants contract TB during migration and after arrival at their destination, mostly urban centers. This article explains that migrants may have difficulty integrating in the health system at their destination. This, along with the poor socioeconomic status of most migrants are the major factors that increase the chances of migrants contracting TB.

, in their study, describe the social determinants of Tuberculosis to include global socioeconomic inequalities, high levels of population mobility and rapid urbanization and population growth. These authors argue that the conditions provided by these social determinants result in unequal distribution of key social determinants of TB including food insecurity and malnutrition, poor housing and environmental conditions. They also lead to financial and geographic barriers to healthcare access among TB infected individuals.

2.6.2 TB control services

The NTLCP strategic plan by the Ministry of Health and Social Welfare of Liberia for between 2014 and 2018 in Liberia states clearly that the TB control services in Liberia are not the best since the country is on a recovery phase after the Civil war of between 1989 and 2003. This is among the factors that needs investigation to assess the accessibility and efficiency of TB control services in Liberia. Individuals infected with TB who move from rural Liberia into Monrovia, who may be undiagnosed or on treatment for TB need diagnosis through a screening system.

A study by to understand the barriers to TB care among migrant patients in Shanghai after the introduction of the free TB treatment policy applied to Migrants since 2003, revealed that the health system, which describes the TB control services, caused the biggest barrier to the access to TB care among migrant patients. The study used cross sectional study design whereby there were conduction of in depth interviews among 34 migrant patients registered on the Shanghai TB program.

In their study to investigate the barriers to accessing TB diagnosis for rural to urban migrants with chronic cough in Chongqing, china, used a mixed methods study using the PIOT model. This study analyzed the health seeking behavior of TB suspects among migrants and permanent urban residents. The findings from this study revealed that patient and provider related factors interact to pose barriers to the diagnosis of TB among migrants. These factors include low awareness and poor knowledge about TB as a disease and about the TB control program, and low financial ability to cater for diagnostic and treatment. Among the health care providers, barriers included inadequate use of diagnostic tests and referral to facilities where TB treatment was available.

Another study by to investigate the diagnosis and treatment of TB among migrants reveals that there is difficulty in access to healthcare services among TB infected urban migrants. The study further reveals that the lack of or poor organization of linkages between health facilities in rural and urban areas prevents access of TB care among rural to urban migrants. Continuity of care should be available to ensure complete cure of patients on medication. Tb control services should include linkages between facilities in rural areas with those in urban centers to ensure continuity of care for patients on medication.

2.6.3 Community TB care

The strategic plan for 2014-2018 by the NTLCP also reveals that community TB care is minimal in Liberia. This type of care aims at the provision of social support through counselling and integration of newly diagnosed TB patients into a support group. This form of TB care aims at ensuring compliance and adherence to TB medication and therefore promote cure of the disease. Integration into a support group enables patients susceptible to stigma to cope better and resist stigma.

The study by to investigate barriers to diagnosis and treatment of TB also reveals that migrants infected with TB are susceptible to stigmatization by the community in the urban setting, when they know their TB infection status. Migration into urban areas according to this study deprives the migrants of the social support structures that they had in the rural setting. In Liberia, the citizens refer to TB as Grave Yard Cough. This creates a negative perception among TB infected patients, who may not seek TB care, and may not know that TB is a curable disease.

The study by reveals that stigma from the community, which despises and avoids people on TB care, negatively affects the health seeking behavior of rural to urban migrants diagnosed with TB. According to the approach and attitude of healthcare workers in the new urban setting, affects health seeking behavior and compliance and adherence to treatment by urban migrants from the rural areas.

CHAPTER 3

3.0 RESEARCH METHODOLOGY

3.1 Chapter Overview

The purpose of this study is to investigate the relationship between the high prevalence of TB in Monrovia and various variables between 2008 and 2014. This chapter focuses on highlighting the methods of data collection and analysis. In the first section, there will be a description of the research design, approach and rationale used. The second section explores the methodology used in the study and is composed of population, sampling and sampling methods, information on obtaining archived data, instrumentation, plan of data analysis and ethical issues. The conclusion of this chapter is a summary of the information provided in the entire chapter.

3.2 Research Design and Rationale

The study was non-experimental quantitative type. Collection of secondary data that has been coded, archived and maintained was from the Liberia Institute of Statistics and Geo-Information Services (LISGIS) and the Ministry of Health and Social Welfare in the republic of Liberia. I chose to collect secondary data as opposed to primary data since it is impractical for me to collect primary data on this subject of study. The use of secondary data to conduct this study is superior to using primary data because using secondary data is economical since the researcher does not have to avail themselves physically in the field of study. Use of secondary data was time saving since collection is already done and time is only spent on data analysis enabling the researcher to recognize factors such as patterns of change in data collected from a common population. Use of secondary data was also advantageous in that there is ability to access a bulky amount of data from various different sources. The data collection process of secondary data involves expertise and professionalism that may not be available to smaller research projects such as this.

The databases on TB infection rates and Factsheets on the disease in the republic of Liberia were accessible and secondary data was therefore readily available. The fact that data was already collected, coded, tabulated and archived by the LISGIS and the Ministry of Health and Social Welfare in Liberia, the data was reliable and viable. Bias of this secondary data was minimal. It would be impractical for me to collect this data and analyze it on my own to be able to draw conclusions and generalizations from it.

3.3 Methodology

3.3.1 Setting and Participants

There was an analysis on the effect of various variables including rural to urban migration, efficiency of TB control services and community TB care on prevalence rates of TB infection in Monrovia between 2008 and 2014 in this study. Preliminary investigation of statistics in the LISGIS database and the Ministry of Health through the National TB and Leprosy Control Program provided data on the prevalence rates of TB infection in the specific counties of Liberia, including Monsterrado County, which Monrovia is part. This program provided data on the efficiency of TB control services and the availability of community TB care, while LISGIS database provided data on rural to urban migration through a comparison of population from various census carried out in various years. Data from these databases proved to be the most recent data concerning TB in the country. Since these databases provided data from previous years, it was easy to compare and correlate variables based on specific periods in which the study focused. The period chosen is likely to provide a good overview of the relationship between prevalence rates of TB infection and the variables in the study.

3.3.2 Sampling and Sampling Procedures

The study was quantitative and non-experimental and utilized secondary data which was collected, coded and archived by the Ministry of Health and Social Welfare in Liberia, and the LISGIS as well as international organizations including the CDC and WHO. This data highlighted the prevalence rates of TB infection in Monrovia and the rates of rural to urban migration into Monrovia, the efficiency of TB control services and the availability of community TB care for rural to urban migrants in Monrovia. There was access to data upon approval by the IRB and a study population derived based on stratified sampling. I established two strata composed of male and female sex. Selection of participants was at random from these strata. From the strata, there was generation of a sample size of insert sample size here.

3.3.3 Procedures for Data Collection

Data for this study was from various sources. The major source being the Ministry for Health and Social Welfare in Liberia. Other sources include the LISGIS, which conducts the Liberia Demographic Health Survey. Some of the data was from databases including the WHO and CDC databases, especially data concerning TB prevalence and incidence rates in Liberia. The data was publicly accessible and there was no need for special permission to access it. Data collection and analysis only commenced once there was approval of the proposal for this study by IRB.

3.3.4 Instrumentation and Materials

Before data collection, there was assumption that data used would be secondary and would be already collected and analyzed by LISGIS and the Ministry of Health in Liberia. I compiled data that was in the archives from different databases according to the variables I was interested in in this study in this study. The population of Monrovia between 2008 and 2014 was from the LISGIS database. Data on the prevalence of TB in Monrovia, the organization and efficiency of TB control services and availability of community TB care in Monrovia was from the database of the Ministry of Health and Social Welfare of Liberia. There was analysis of the efficiency of TB control services based various parameters. They included the number of facilities that offer treatment for TB, the patients newly enrolled for TB treatment in health facilities in Monrovia between 2008 and 2014 and the number of qualified medical doctors attending to patients in these hospitals. Another parameter is the presence of a system to link the facilities in rural areas to facilities in urban areas to facilitate the transition of TB care rural to urban migrants and finally, the incidence and prevalence rates of TB in the city of Monrovia between 2008 and 2014. Data on the availability of community TB care was from analysis data by the Ministry of Health and Social Welfare in Liberia through the NTLCP.

3.3.5 Data Analysis

I used version 21.0 of the Statistical Package for Social Sciences (SPSS) to analyze secondary data obtained for the study. I used descriptive statistics via linear regression models to compare and analyze the independent variables both individually and comparatively against the dependent variable of prevalence rates of TB infection. This would enable sufficient exploration and analysis of the cohort under evaluation. There was production of multiple linear regression models to enable analysis of the associated variables and to obtain inferential statistics to test the null and alternative hypotheses.

The linear regression model is the model of choice for the investigation of the probability of a health outcome or a disease as a function of non-dichotomous covariate, or risk factor as it allows for the isolation of exposures and analysis of their impact on the independent and dependent variables. This is therefore the appropriate choice for exploring associations between different variables. Majority of the studies explored in the literature review employed linear regression analysis. This makes this type of analysis suitable for this study. The use of descriptive statistics in various studies enables thorough analysis and description of the specific characteristics of the study population. Inferential statistics are an invaluable entity as they enable the researcher to establish parameters and to test hypotheses.

The research questions and their hypotheses analyzed for this study are:

RQ1: What is the relationship between rates of rural-urban migration into Monrovia and the prevalence rate of TB in Monrovia between 2008 and 2014?

H10: There is no relationship between the rates of rural-urban migration into Monrovia and the prevalence rate of TB in Monrovia between 2008 and 2014?

H1A: There is a relationship between the rates of rural-urban migration into Monrovia and the prevalence rate of TB in Monrovia between 2008 and 2014?

There was utilization of a multiple linear regression model to test the null hypothesis for RQ1 for the evaluation of the relationship between the rates of rural to urban migration into Monrovia between 2008 and 2014. Before conducting the procedure, there was statistical analysis to define the degree to which the assumptions of the multiple linear regression were true.

RQ2: What is the relationship between the efficiency of TB control services in Monrovia and the prevalence rate of TB in Monrovia?

H10: There is a relationship between the efficiency of TB control services in Monrovia and the prevalence rate of TB in Monrovia

H1A: There is no relationship between the efficiency of TB control services in Monrovia and the prevalence rate of TB in Monrovia

Testing the null hypothesis for RQ2 was by the multiple linear regression model to evaluate the relationship between the efficiency of TB control services in Monrovia and the prevalence rates of TB in Monrovia between 2008 and 2014. Before conducting the procedure, there was utilization of statistical procedures to define the degree of achievement of the assumptions of the multiple linear regression model.

RQ3: What is the relationship between the prevalence rate of TB and the availability of Community TB care in Monrovia?

H10: There is a relationship between the prevalence rate of TB and the availability of Community TB care in Monrovia

H1A: There is no relationship between the prevalence rate of TB and the availability of Community TB care in Monrovia

Testing of the null hypothesis for RQ3 was by the multiple linear regression model to investigate the relationship between the availability of community TB care for patients in each facility and the prevalence rates of TB in Monrovia between 2008 and 2014. Before conducting the procedure, there was utilization of statistical procedures to define the degree of achievement of the assumptions of the multiple linear regression model.

3.3.6 Threats to Internal and External Validity

The only threat to external validity in this study is the probability that collection, coding and archiving of the secondary data used in the study was not by the appropriate recommended standards. Secondary data used is however highly reliable since its collection was from government databases in the republic of Liberia. It is therefore likely that data collection, coding and storage was as required and that external threat should be minimal and may not present a risk to the reliability of this study.

3.3.7 Ethical Procedures

Upon submission of a insert name of university here Internal Review Board Application, I gained approval by the institution in insert date here via approval number insert approval number here. Data collection and analysis for this study began only after approval by IRB.

3.3.8 Protection of Human Participants

During this study, I did not collect any personal identifying information apart from TB infection status and urban migrant status. The data cannot be used to link back to individuals whose information is utilized in the study. There was no potential risks conferred to the individuals whose information featured in the study. I gained IRB approval from Walden University prior to data collection. Data collection, analysis and storage was through strict adherence to recommended procedures. Storage of data was in a password-protected computer located at my residence. Storage and access of data collected will be in a secure location for five years, after which there will be destruction by permanent deletion from my computer’s hard drive.

3.3.9 Summary and Transition

This study was a quantitative study that involved the use of coded archived secondary data from databases including the Ministry of Health and Social Welfare and the LISGIS. Data analysis was by use of SPSS version 21.0. There was use of statistical analysis and multiple linear regression tests to test the null and alternative hypotheses. Collection of secondary data was by strict adherence to recommended standards and procedures to safeguard the integrity and security of data. These include the need for information, ensuring data security, confidentiality and anonymity of participants. There will be a presentation of the results of data analysis in Chapter 4 and finally in Chapter 5, there will be a discussion of results and conclusions and recommendations for further scholarly research will follow.

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