South Gonder Health Department, Debre Tabor, South Gonder, Ethiopia (Getahun); Global Tuberculosis Programme, World Health Organization (Maher)

This study aims to describe the contribution of ‘TB clubs’ (small support groups of patients based on where they live) to the performance of the tuberculosis (TB) control programme in Estie District in Ethiopia. The document offers a descriptive study of the formation of ‘TB clubs’, their contribution to case-based findings, and the treatment outcomes before and after formation of the ‘TB clubs’. The findings showed that community participation through the formation of TB clubs contributed to more effective diagnosis and treatment of TB in the region.

TB clubs were initially formed when, in an effort to simplify organisation, health services requested that tuberculosis patients living in a particular kebele (the smallest administrative subdivision of a district) come to follow-up appointments at the nearest health facility together and on the same day. As a result, the patients got to know each other and began to form 'TB clubs'. A TB club is therefore defined as a number of tuberculosis patients (usually between 3 and 10) living in the same kebele, or adjacent kebeles, who attend out-patient appointments together on the same day. The District Medical Officer promoted the development of the TB clubs and provided advice on organisational arrangements.

The members of each TB club elect a leader, who is usually literate. The leader ensures that all members of the TB club attend the tuberculosis clinic at the local health centre on the appointed day, and informs the clinic staff of the reason if a member is absent. This contributes to the recording of patient attendance. The leader co-ordinates regular meetings of the TB club at least once a week. The purpose of the regular meetings is for members of the TB clubs to provide each other with support in adhering to treatment, to share information about the course of the disease, including recovery and possible drug side-effects, and to help in identifying possible cases of tuberculosis in others. As the meetings are held at social venues, role playing has been encouraged to deliver TB information. The TB club leaders refer possible tuberculosis cases and tuberculosis patients failing to make satisfactory progress or suffering from drug side-effects to the local health facility. TB club leaders may approach other members of the community for help with encouraging and supporting patients to complete their treatment. They may seek the help of community elders, influential priests (so-called ‘spirit fathers’) of the Coptic Orthodox Christian Church, and Mullahs of Islam, to persuade patients who interrupt treatment (referred to as "defaulters" in this study) to begin again and complete their treatment. The District Medical Officer has supplied the TB club leaders with educational materials written in Amharic, the main language of the region. Members of the TB clubs exchange information on tuberculosis with community members through role playing, as mentioned previously, and public reading and dissemination of educational materials. Local health workers and community health agents supervise TB clubs regularly, and contribute to community education activities and the identification and referral of tuberculosis suspects.

According to this report from 2000, the proportion of tuberculosis patients who came for follow-up during treatment at health facilities significantly increased (P < 0.001) after the introduction of the TB clubs. Community elders, community health agents, and local health workers helped TB clubs to refer possible new tuberculosis cases, promote treatment adherence, and trace defaulters as an integral part of a district tuberculosis programme. The TB clubs referred 181 possible tuberculosis cases in the community for investigation, of whom 65% subsequently had a positive diagnosis for tuberculosis. TB clubs identified 69% of all patients and 76% of sputum-smear-positive pulmonary patients diagnosed in the district. Treatment success rates in new sputum-smear-positive, smear-negative, and extra-pulmonary tuberculosis patients were 83%, 79%, and 81% respectively. These treatment success rates are in comparison with those reported in 1996 from different parts of Ethiopia, ranging between 35% and 72% (with rates of treatment interruption of between 15% and 34%).

According to this study, the success of the project can be attributed to community participation. This is described as the process by which individuals and families assume responsibility for their own health and welfare, and for those of the community, and develop the capacity to contribute to their own and the community’s development. The TB club approach makes the patients the principal actors in tuberculosis control efforts. This study shows that even in a remote rural area, and using long-course treatment, high treatment success rates are achievable through a district tuberculosis control programme with community involvement and committed leadership.

In addition, the TB club approach does not incur any extra costs from the perspective of the health service provider. An economic analysis is necessary to assess whether the patients incurred any financial costs or missed any opportunities that would have resulted in losing income (e.g., for a farmer, missing favourable time for working in the fields). The study states that further evaluation of the contribution of the community to tuberculosis control activities in rural Ethiopia through the TB club approach is needed to assess the sustainability of the approach and its feasibility in other settings.

IngentaConnect website on April 22 2008 and July 24 2009.