In Nigeria, tuberculosis (TB) an infectious illness that mostly affects the lungs, is a major public health concern today. In the nation, tuberculosis (TB) continues to be the primary cause of illness and mortality despite worldwide advances in prevention and treatment. Co-infection with HIV, a deficient healthcare system, and socioeconomic constraints that obstruct efficient TB control exacerbate the problem.
This is a significant issue that goes beyond short-term health effects. Nigeria's TB problem is a reflection of larger public health issues that many developing nations confront, such as the influence of socioeconomic disparities on disease prevalence and management, public knowledge, and healthcare accessibility. Therefore, the persistence of tuberculosis in Nigeria necessitates a multimodal strategy that addresses these underlying determinants in addition to a medical intervention.
Through the viewpoint of public health, this essay seeks to critically analyze the TB epidemic in Nigeria. In addition to delving into population demographics and disease trends, it will examine historical viewpoints and evaluate the social justice perspective in public health. It will also assess the ideological and ethical factors that influence policymaking in this particular environment. The methodology includes a thorough examination of tuberculosis (TB) in Nigeria, taking into account interventions at the individual and population levels as well as community development tactics aimed at advancing health. This comprehensive analysis seeks to shed light on the challenges associated with tuberculosis management in Nigeria and make recommendations for future public health initiatives.
Historical Perspectives and Models of Public Health
Public health models and historical views have changed over time, influencing public health issues and reacting to outbreaks. In addition, the miasma idea predominated in the early years of public health, linking illnesses to "bad air" and highlighting the significance of environmental cleanliness. Subsequent to the germ theory, which emerged later in the 1800s, diseases were thought to be caused by tiny organisms and this led to the creation of contemporary epidemiology, vaccinations, and antibiotics. One of the greatest causes of death worldwide and a persistent public health concern is tuberculosis. According to the WHO Global TB report 2021, Nigeria accounted for 4.6% of the global TB burden and had the greatest number of TB cases in Africa with an anticipated 9.9 million cases of TB worldwide in 2020 (WHO, 2021). As per the Minister of Health at the Federal Ministry of Health (FMoH), effective measures has been taken in to consideration in order to prevent the disease. In the first week of the lockdown, Nigeria saw a 30% decrease in GeneXpert testing, and the number of notified TB cases fell by 17%, from 33,119 in Q1, 2020 to 27,353 in Q2, 2020. Creative interventions had to be conceptualized and put into action in order to ensure program sustainability and lessen the impact on TB control efforts. As a result, the number of TB cases notified increased nationwide by 15% in 2020, from 120,266 in 2019 to 138,591 in 2020. This puts us among the few nations that saw an increase in TB notifications in 2020 despite the pandemic.
In the colonial era, public health resources were frequently diverted from tuberculosis (TB) treatment to diseases that were seen as more urgent dangers. As a result of this historical lapse, tuberculosis (TB) is still a serious public health concern and is more common in Nigeria. Furthermore, the TB epidemic in Nigeria is being exacerbated by socioeconomic factors that have historically affected health outcomes that could be seen as poverty, congested living circumstances, and restricted access to healthcare.
Population Perspectives of the Issue
Understanding Nigeria's demographics which are marked by a sizable and diverse population is essential to comprehending the TB pandemic (Teibo, 2023). Nigeria has particular challenges in the control and management of tuberculosis due to its diverse culture, urban-rural divide, and fluctuating socioeconomic conditions. Vulnerable populations are disproportionately affected by the disease: those with HIV/AIDS, those living in poverty, and residents of densely crowded urban areas (Unicef, 2019).
With a population estimated to be over 200 million, Nigeria has a varied demographic makeup. The age distribution of the population of the nation, with a sizable fraction under 30, may have an impact on the dynamics of tuberculosis (Cui et al., 2020). Particularly in metropolitan environments, young adults are frequently more mobile and may be more susceptible to infectious diseases like tuberculosis.
Nigeria has seen a sharp increase in urbanisation, with large population influxes into cities like Lagos and Abuja. These metropolitan areas, which are frequently characterised by densely populated housing, are perfect TB breeding grounds. According to data from the World Bank, 51% of Nigerians lived in cities as of 2020; this percentage has been rising over time, indicating a rising risk of tuberculosis transmission in these environments.
Nigeria has a high prevalence of tuberculosis (TB), as evidenced by the World Health Organization's (WHO) report of 440,000 new cases in 2019 alone (Proquest, 2023). Nigeria is one of the nations with the highest rates of TB/HIV co-infection worldwide. The co-infection rate with HIV is noteworthy. HIV compromises immunity, making the body more vulnerable to tuberculosis, which exacerbates the TB situation (Abrahem et al., 2020).
Rates of Incidence and Prevalence: According to WHO estimates, in 2019 there would be 219 cases for every 100,000 people. The high prevalence denotes the disease's global distribution.
Death Rates: The death rate from tuberculosis is still quite high, especially in populations with HIV (Canetti et al., 2020). Nigeria suffered an estimated 157,000 TB-related fatalities in 2019.
Treatment Success Rates: When assessing the efficacy of tuberculosis control initiatives, treatment success rates are essential. According to the most recent data, Nigeria has an approximate 85% treatment success rate for both new and recurrent cases (Vo Quang, Shimakawa and Nahon, 2021).
Approaches for Protection and Screening
One of the mainstays of TB prevention initiatives is the administration of the Bacillus Calmette-Guérin (BCG) vaccine, especially to youngsters. Nigeria has a crucial role to play, but getting universal and effective vaccination coverage is not easy. These difficulties include keeping the cold chain intact, distributing vaccines in a timely manner, and guaranteeing that every child receives their inoculation on time (Organization, 2020). Furthermore, there is a need for additional preventative measures in addition to vaccination, as the effectiveness of the BCG vaccine in preventing adult pulmonary tuberculosis is not consistent.
Screening programmes are essential, especially those that focus on high-risk populations like HIV-positive individuals. Nigeria's national TB and HIV programmes have been proactive in incorporating TB screening into HIV services (Ozano, 2022). Given the significant prevalence of HIV/TB co-infection, this strategy is calculated. It guarantees that patients undergoing HIV therapy are also assessed for TB, enabling early diagnosis and treatment.
Enhancing the healthcare system is an additional essential element. This entails improving Nigerian healthcare facilities' ability to handle tuberculosis cases efficiently (Aminu Babayi et al., 2023). Enhancing diagnostic facilities, making sure that necessary TB drugs are available, and providing healthcare personnel with TB management training are important components. These actions are essential for enhancing the results of treatment and halting the disease's spread.
In the battle against tuberculosis, addressing the socioeconomic determinants of health is equally essential. It is imperative to make efforts to reduce poverty, enhance living circumstances, and guarantee food security. In order to lessen the overall burden of the disease, several socioeconomic variables that directly impact population susceptibility to tuberculosis (TB) must be addressed (Cui et al., 2020).
A multisectoral strategy is necessary for a thorough response against tuberculosis. This entails coordinating TB control initiatives across several domains, such as social services, education, health, and government at different levels (Bhargava, Bhargava and Juneja, 2020). By tackling the disease's medical and socioeconomic components, such cooperation guarantees a more efficient and long-lasting response to the TB epidemic.
Social Justice Perspective
There is a strong correlation between the Nigerian TB epidemic and important social, political, and economic issues that have a substantial impact on the health consequences of the impacted communities (Odume et al., 2020). Furthermore, poverty has been found as a widespread problem that is contributing to the TB pandemic as one of the main social determinants of health. There are large economic gaps in Nigeria and a sizable percentage of the populace lives in poverty. Overcrowding in housing, poor access to healthcare, and a lack of educational opportunities are all linked to poverty. As people living in less fortunate environments are more likely to become infected and have difficulty accessing timely and effective healthcare, these factors contribute to the development of tuberculosis. The conditions in which people are born, grow, live, and work are referred to as social determinants of health by the World Health Organization's Commission on Social Determinants of Health (Davidson et al., 2020). These factors primarily lead to health inequities that has been found as the unjust and changeable differences in health between and within nations.
An important contributing element to the TB pandemic in Nigeria is political considerations. The difficulties in TB prevention, diagnosis, and treatment are exacerbated by poor governance that deficient healthcare system has been created and a lack of financing for public health programs has been found. The political climate affects how resources are distributed and past disregard for tuberculosis as a public health emergency has complicated attempts to successfully manage the pandemic. Instability in politics and government exacerbates socioeconomic gaps, fostering a climate conducive to tuberculosis growth.
Unemployment and underemployment are two economic variables that fuel the TB pandemic in Nigeria (Teibo, 2023b). It is challenging for people in unstable economic situations to prioritize their health or follow long-term treatment programs because they frequently lack access to social safety nets and employment security. In addition to impeding the execution of successful public health initiatives, economic instability makes it more difficult to provide universal access to healthcare services. The TB epidemic in Nigeria has been made worse by economic issues, such as underemployment and unemployment (Abjurnals, 2020). It can be challenging for people in precarious economic conditions to prioritize their health or follow long-term treatment programs because they frequently lack access to social safety nets and employment security. Additionally, unstable economies make it more difficult to execute public health policies that are successful and make it more difficult to provide universal access to healthcare services (Jakovljevic et al., 2021).
Nigeria has made progress against tuberculosis (TB) in 2020, but it still has the greatest burden of any country in Africa and ranks sixth out of 30 countries with a high TB burden worldwide. As a result, in order to lower the disease's burden in the nation by 2030. Furthermore, the federal government, the WHO, and its partners must continuously implement strategic interventions (WHO, 2021).
Figure 1: TB patient cost surveys (as of September 2022)
El Salvador had a higher percentage of TB patients and their households experiencing catastrophic total costs (95% confidence interval (10–17%) than the Solomon Islands, where the percentage was 92% (95%, 86–97%). Catastrophic total costs are defined as exceeding 20% of household expenditure or income. The nigeria has emerged as the tuberculosis epidemic in the year 2017 (WHO, 2021a). However, a methodology for tracking the Sustainable Development Goals (SDGs) connected to tuberculosis (TB) has been created by the World Health Organization (WHO). The framework includes 14 metrics under seven SDGs that could be used to establish a link between TB incidence.
Public Health Ethics and Ideologies
In examining the process of Tuberculosis (TB) in the part of Nigeria by the lens of public health theories and principles, it is more important to understand different aspects such as population dynamics, historical perspectives, social justice, community development approaches, and public health ethics. Historically, the entire country facing different types of challenges related to the understanding and identifying process of TB (Chirinda, Ndlovu and Spangenberg, 2021). influenced by different factors such as limited resources, inadequate healthcare structure and sociocultural barriers in the country contributed to the persistence process of this epidemic. Public health models and ideologies, ranging from social-ecological factors to biomedical have provided a helping hand for the management process of TB in Nigeria (Dada, 2019). Another side Biomedical focuses on the part of the socio-ecological model that helps in TB transmission and controlling process.
Additionally population perspective is also taking a leading role in this aspect to understanding the disease patterns and demographic changes in the part of Nigeria. Urbanization, demographics and lifestyle changes taking a leading role in TB transmission process of the country. Another side perspective holds another prospectus such as the political social and economic factors of Nigeria on the TB transmission process (Ramuhulu, 2021). Numerous types of health disparities embedded in inequality, poverty, and limited healthcare access contributed to a disproportionate burden of Tuberculosis on the marginal population of the country.
Community Development Approaches
Community Health Workers (CHWs) and Directly Observed Treatment (DOT)
Using Community Health Workers is one strategy that works well (CHWs) (Krieger et al., 2021). These people are educated to deliver health education recognizes symptoms of tuberculosis, and monitor treatment compliance. They are members of the local communities. They are essential in bridging the gap that exists between underserved or distant communities and healthcare facilities. Directly Observed Treatment (DOT), in which CHWs watch over patients as they take their medications, is one of their skills (Tseng et al., 2019). Drug resistance has decreased and treatment completion rates have increased thanks to DOT's great success.
Engaging Traditional and Religious Leaders
In Nigerian communities, traditional and religious leaders have a big impact. It can be very beneficial to work together to spread the word about tuberculosis and encourage health-seeking behaviour. They can lessen the stigma attached to tuberculosis, encourage people to seek a diagnosis and treatment, and distribute information at community events. This method is culturally sensitive since it honours regional traditions and customs (Siregar and Yahaya, 2022). Peer education initiatives and support groups enable TB patients to take on the role of health advocates. After successfully completing treatment, TB survivors can inspire others to stick with treatment by sharing their experiences and providing emotional support (Békés et al., 2022). Peer-led treatments have shown promise in lowering treatment discontinuations and fostering a feeling of camaraderie among tuberculosis patients. One of the challenges in TB control is getting to underserved and distant locations. Outreach initiatives and mobile clinics are helpful in providing diagnosis and treatment services to the community on-site (Nayyar et al., 2023). These programmes lower the geographic obstacles to healthcare access by facilitating early detection, treatment initiation, and follow-up care. The reach of TB control initiatives can be increased by cooperation between the public and private sectors (Ananthakrishnan et al., 2019). Involving private healthcare organisations and providers can improve the services provided for case detection and treatment.
This collaboration is essential for effective TB control in Nigeria, since the private sector provides a large share of healthcare services. Campaigns for community-based health education use a variety of media platforms to spread knowledge about tuberculosis symptoms, prevention, and services that are available (Li et al., 2021). These initiatives seek to lessen stigma, increase public knowledge, and promote early health-seeking behaviour. The key to success is consistent community participation and message that is adapted to the local culture.Optimising resource utilisation and broadening the accessibility of TB services can be achieved by integrating TB control initiatives with already-existing community programmes, such as nutrition or maternity and child health services (Li et al., 2021). It guarantees that TB is seen as a component of general community health rather than in isolation.
The DOTS Strategy
Nigeria has achieved progress in tuberculosis control by implementing the Directly Observed Treatment, Short-Course (DOTS) approach (Ogbonna, Alabere and Tobin-West, 2020). This internationally recognised technique includes patient observation, a strict treatment plan, and improvements to the health system. DOTS has been successfully adopted in numerous locations throughout the nation and has helped to enhance the outcomes of TB treatment (PsycNet, 2021).
Using community development initiatives is essential to combating Nigeria's tuberculosis pandemic. Engaging CHWs, traditional and religious leaders, adopting the DOTS model, integrating with current programmes, mobile clinics, public-private partnerships, peer education, and health education campaigns are examples of successful strategies. These strategies lessen stigma, enable communities to take charge of their health, and support efforts to combat tuberculosis. Maintaining community involvement, cultural sensitivity, and effective execution are critical for long-term success in Nigeria's TB fight (PsycNet, 2021).
Models of Behaviour Change
Population-Level Behavior Change Models
Social Ecological Model promotes that a variety of factors, including individual, interpersonal, communal, and societal influences, impact behaviour at different levels (Hawkins et al., 2021). It suggests that, when it comes to tuberculosis, interventions ought to take into account not just personal preferences but also the social and environmental factors that influence health (Hawkins et al., 2021).
Campaigns to prevent tuberculosis (TB) can focus on a range of issues, from personal knowledge and attitudes to social policies and community awareness (Ryan et al., 2020). For example, establishing community-based supportive environments for tuberculosis testing and treatment can enhance attempts to modify individual behaviour. According to this concept, people are more likely to take preventive action if they think they are at risk for a disease, think it will have negative effects, and understand the advantages of doing so. Educational campaigns can draw attention to the risk factors for tuberculosis (TB) and the serious implications of leaving the disease untreated (Ryan et al., 2020). People may seek healthcare services if the advantages of early identification and treatment are emphasised.
Individual-Level Behavior Change Models
According to the Transtheoretical Model, changing one's behaviour involves a series of steps that people can focus on pre contemplation, contemplation, preparation, action, and maintenance. It acknowledges that individuals are not all ready for change at the same time. Depending on a person's stage of change, TB therapies might customise their messaging and support. People in the pre-contemplation stage, for instance, might benefit from awareness-raising campaigns, but people in the action stage require assistance to stick to their treatment plan. According to the Theory of Planned Behaviour, a person's conduct is influenced by their goals, attitudes, subjective norms, and sense of behavioural control (Hagger et al., 2020). A major factor in predicting behaviour is intention. The goal of TB interventions may be to alter people's perceptions of their own behavioural control and attitudes towards getting a TB diagnosis and treatment. Taking care of perceived impediments and social norms might influence behaviour and intentions (Hagger et al., 2020).
Informing Interventions for TB in Nigeria
A comprehensive strategy for combating the tuberculosis (TB) epidemic in Nigeria must include customised messaging, community participation, shifting views, incorporating culture and values, and empowering healthcare providers.
Customised messaging recognises that people vary in their readiness to modify their behaviour with regard to tuberculosis. Informative ads that emphasise the benefits of early TB detection could be beneficial in encouraging those who are in the contemplation stage to take action (Abbasiah et al., 2023). On the other hand, those who are in the action stage need assistance and resources in order to continue attending to their treatment plan and effectively finish their recommended course of action.
Under the direction of the Social Ecological Model, community engagement acknowledges that communities, as well as people, have an impact on behaviour change. Through addressing TB-related social norms, increasing public awareness of the illness, and creating conditions that support TB diagnosis and treatment, TB interventions can involve communities (Ali et al., 2019). This strategy lowers stigma and encourages group action by including the entire community in the fight against tuberculosis.
It is imperative to alter people's perspectives, in accordance with the Health Belief Model, in order to motivate them to treat and prevent tuberculosis. Campaigns for education should stress the seriousness of tuberculosis and the vital significance of early detection and treatment. People are more likely to seek medical attention as soon as possible if attitudes are changed and tuberculosis is given priority (Haldane et al., 2021).
Given the variety of cultures and customs in Nigeria, it is imperative that TB interventions take cultural considerations and beliefs into account. TB interventions ought to be considerate of cultural differences and local traditions. By building trust and ensuring that initiatives are meaningful to the community, this strategy increases the likelihood that they will be welcomed and accepted. Providing behaviour modification concepts to healthcare providers improves their capacity to engage with tuberculosis patients (Acha-Anyi et al., 2020). This entails encouraging candid dialogue, attentive hearing, and compassion. Strong patient-provider relationships are essential to enhancing treatment adherence and patient outcomes, and can be developed by healthcare professionals who have received training in the application of behaviour modification principles.
Scope for Improving Population Health
Considering the Nigerian tuberculosis (TB) epidemic, there is undoubtedly room for improvement in public health via a multimodal strategy. Key conclusions and insights from the analysis show that Nigeria has a significant TB burden, which is driven by socioeconomic determinants, healthcare system issues, demographic factors, and behaviour change models (Ananthakrishnan et al., 2019). Several tactics and suggestions can be implemented to solve these issues and improve population health.
Furthermore, it is important to fortify the healthcare system, emphasising the development and enhancement of diagnostic centres and guaranteeing the steady supply of tuberculosis drugs. This will help stop the disease from spreading by enabling early detection and quick treatment commencement. Furthermore, community-based initiatives that use Community Health Workers (CHWs) with training can be extremely effective in informing populations about tuberculosis (TB), doing screenings, and overseeing treatment in isolated locations (World Health Organization, 2020).
Targeted screening programmes are crucial to early detection of tuberculosis cases and the prevention of transmission, especially among high-risk populations such as individuals living with HIV, convicts, and healthcare workers. Public awareness programmes that highlight the seriousness of tuberculosis, fight stigma, and emphasise the value of early diagnosis and treatment are also crucial. These advertisements ought to be targeted at different demographic groups and attentive to cultural differences.
Behaviour modification programmes based on theories like the Theory of Planned Behaviour and Transtheoretical Model should be created in order to support behaviour change at the individual and community levels (Abrash Walton et al., 2022). Individuals should receive support and messages from these programmes according to their level of readiness to modify their behaviour about tuberculosis prevention and treatment.
Working together with traditional and religious leaders can be quite effective because of their wide-ranging influence over community attitudes and behaviours around tuberculosis (Tabong et al., 2021). A complete approach to health is ensured by integrating TB control efforts with already-existing community programmes, such as maternity and child health services.
Furthermore, improving patient-provider relationships and treatment adherence can be achieved by educating healthcare professionals on how to implement behaviour change concepts. Lastly, in order to evaluate the effectiveness of interventions, pinpoint areas in need of development, and make evidence-based modifications for more efficient tuberculosis control, it is imperative to put in place strong monitoring and evaluation mechanisms (García-Basteiro et al., 2023). Nigeria can greatly enhance population health and combat the tuberculosis epidemic by putting these tactics and recommendations into practise. This all-encompassing strategy takes into account Nigeria's distinct demographic and cultural environment, guaranteeing that efforts are not only significant but also inclusive and sensitive to cultural differences.
Conclusion
In conclusion, this essay has examined the current public health problem of tuberculosis (TB) in Nigeria by applying several public health theories and concepts. It started by presenting the topic, setting the scene for its importance, and summarising the goal and methodology of the essay. The investigation of population views on the tuberculosis pandemic in Nigeria examined the factors that have contributed to the current state of affairs, including illness patterns, population shifts, and demographics. The impact of health and disease on the population was measured, and strategies for screening and protecting the public were covered. Important elements like immunisation, screening programmes, bolstering the healthcare system, addressing social determinants, and utilising a multi-sectoral approach were highlighted.
The importance of Community Health Workers (CHWs), interaction with traditional and religious leaders, peer education and support groups, mobile clinics, public-private partnerships, health education campaigns, and integration with already-existing community programs were among the many community development strategies for health promotion that were also looked into. To inform effective interventions for tuberculosis control, the examination of behaviour modification models at the population and individual levels highlighted the significance of customised messaging, community participation, shifting attitudes, embracing culture and values, and empowering healthcare practitioners.
References
Abbasiah, A., Handayani, Gusti Lestari, Dewi, V., & Fahmi, I. (2023). Revolutionizing Healthcare Awareness: Empowering the Masses with m-Health Media through “Health Corner” for Comprehensive Tuberculosis Screening and Effective Treatment Insights. Health Education and Health Promotion, 11(4), 1001–1012. https://hehp.modares.ac.ir/browse.php?a_id=71557&sid=5&slc_lang=fa
Abjurnals. (2020). THE IMPACT OF GLOBAL INFECTIOUS DISEASES ON NIGERIA’S SOCIO- ECONOMIC DEVELOPMENT. 3(6), 232. https://abjournals.org/ajsshr/wp-content/uploads/sites/9/journal/published_paper/volume-3/issue-6/AJSSHR_T2IDVUZL.pdf
Abrahem, R., Chiang, E., Haquang, J., Nham, A., Ting, Y.-S., & Venketaraman, V. (2020). The Role of Dendritic Cells in TB and HIV Infection. Journal of Clinical Medicine, 9(8), 2661. https://doi.org/10.3390/jcm9082661
Abrash Walton, A., Nageotte, N. L., Heimlich, J. E., & Threadgill, A. Victoria. (2022). Facilitating behavior change: Introducing the Transtheoretical Model of Behavior Change as a conservation psychology framework and tool for practitioners. Zoo Biology, 41(5). https://doi.org/10.1002/zoo.21704
Acha-Anyi, A., Acha-Anyi, P. N., Asongu, S. A., & Tchamyou, V. S. (2020). Social media for health promotion: A visual analysis of “TB proof” South Africa’s Facebook page. Technology in Society, 63, 101386. https://doi.org/10.1016/j.techsoc.2020.101386
Ali, S. M., Anjum, N., Ishaq, M., Naureen, F., Noor, A., Rashid, A., Abbas, S. M., & Viney, K. (2019). Community Knowledge about Tuberculosis and Perception about Tuberculosis-Associated Stigma in Pakistan. Societies, 9(1), 9. https://doi.org/10.3390/soc9010009
Aminu Babayi, Bethrand Odume, Chidubem Ogbudebe, Ogoamaka Chukwuogo, Nwokoye, N. N., Cyril Chukwudi Dim, Sani Useni, Nongo, D., Eneogu, R., Obioma Chijioke-Akaniro, & Chukwuma Anyaike. (2023). Improving TB control: efficiencies of case-finding interventions in Nigeria. Public Health Action, 13(3), 90–96. https://doi.org/10.5588/pha.23.0028
Ananthakrishnan, R., Richardson, M. D., van den Hof, S., Rangaswamy, R., Thiagesan, R., Auguesteen, S., & Kamp, N. (2019). Successfully Engaging Private Providers to Improve Diagnosis, Notification, and Treatment of TB and Drug-Resistant TB: The EQUIP Public-Private Model in Chennai, India. Global Health: Science and Practice, 7(1), 41–53. https://doi.org/10.9745/ghsp-d-18-00318
Békés, V., Belleville, G., Lebel, J., Ouellet, M.-C., Chen, Z., Morin, C. M., Bergeron, N., Campbell, T. S., Ghosh, S., Bouchard, S., Guay, S., & MacMaster, F. P. (2022). Trainee Therapists’ Perceptions of a Blended Intervention to Promote Resilience after a Natural Disaster: A Qualitative Case Study. Journal of Clinical Medicine, 11(15), 4361. https://doi.org/10.3390/jcm11154361
Bhargava, A., Bhargava, M., & Juneja, A. (2020). Social determinants of tuberculosis: context, framework, and the way forward to ending TB in India. Expert Review of Respiratory Medicine, 15(7), 1–17. https://doi.org/10.1080/17476348.2021.1832469
Canetti, D., Riccardi, N., Martini, M., Villa, S., Di Biagio, A., Codecasa, L., Castagna, A., Barberis, I., Gazzaniga, V., & Besozzi, G. (2020). HIV and tuberculosis: A historical perspective on conflicts and challenges. Tuberculosis, 122(63), 101921. https://doi.org/10.1016/j.tube.2020.101921
Chirinda, B., Ndlovu, M., & Spangenberg, E. (2021). Teaching Mathematics during the COVID-19 Lockdown in a Context of Historical Disadvantage. Education Sciences, 11(4), 177. https://doi.org/10.3390/educsci11040177
Cui, Y., Shen, H., Wang, F., Wen, H., Zeng, Z., Wang, Y., & Yu, C. (2020). A Long-Term Trend Study of Tuberculosis Incidence in China, India and United States 1992–2017: A Joinpoint and Age–Period–Cohort Analysis. International Journal of Environmental Research and Public Health, 17(9). https://doi.org/10.3390/ijerph17093334
Dada, A. A. (2019). Factors affecting maternal health seeking behaviour in a Yoruba community of Nigeria: an analysis of socio-cultural beliefs and practices. Ukzn-Dspace.ukzn.ac.za. https://ukzn-dspace.ukzn.ac.za/handle/10413/17652
Davidson, K. W., Kemper, A. R., Doubeni, C. A., Tseng, C.-W., Simon, M. A., Kubik, M., Curry, S. J., Mills, J., Krist, A., Ngo-Metzger, Q., & Borsky, A. (2020). Developing Primary Care–Based Recommendations for Social Determinants of Health: Methods of the U.S. Preventive Services Task Force. Annals of Internal Medicine, 173(6), 461–467. https://doi.org/10.7326/m20-0730
García-Basteiro, A. L., Eyüboglu, F. Ö., & Rangaka, M. X. (2023). The Challenge of Tuberculosis in the 21st Century: ERS Monograph 101. In Google Books. European Respiratory Society. https://books.google.com/books?hl=en&lr=&id=KOveEAAAQBAJ&oi=fnd&pg=PA178&dq=+Lastly
Haldane, V., Zhang, Z., Ma, Q., Yin, T., Zhang, B., Li, Y., Pan, Q., Dainty, K. N., Rea, E., Pasang, P., Wei, X., & Hu, J. (2021). A qualitative study of perspectives on access to tuberculosis health services in Xigaze, China. Infectious Diseases of Poverty, 10(1). https://doi.org/10.1186/s40249-021-00906-4
Hawkins, M. M., Schmitt, M. E., Adebayo, C. T., Weitzel, J., Olukotun, O., Christensen, A. M., Ruiz, A. M., Gilman, K., Quigley, K., Dressel, A., & Mkandawire-Valhmu, L. (2021). Promoting the health of refugee women: a scoping literature review incorporating the social ecological model. International Journal for Equity in Health, 20(1). https://doi.org/10.1186/s12939-021-01387-5
Jakovljevic, M., Liu, Y., Cerda, A., Simonyan, M., Correia, T., Mariita, R. M., Kumara, A. S., Garcia, L., Krstic, K., Osabohien, R., Toan, T. K., Adhikari, C., Chuc, N. T. K., Khatri, R. B., Chattu, V. K., Wang, L., Wijeratne, T., Kouassi, E., Khan, H. N., & Varjacic, M. (2021). The Global South political economy of health financing and spending landscape – history and presence. Journal of Medical Economics, 24(sup1), 25–33. https://doi.org/10.1080/13696998.2021.2007691
Krieger, M. G. M., Wenham, C., Nacif Pimenta, D., Nkya, T. E., Schall, B., Nunes, A. C., De Menezes, A., & Lotta, G. (2021). How do community health workers institutionalise: An analysis of Brazil’s CHW programme. Global Public Health, 1–18. https://doi.org/10.1080/17441692.2021.1940236
Li, Y., Liu, G., Egolet, R. O., Yang, R., Huang, Y., & Zheng, Z. (2021). Knowledge, Attitudes, and Practices Related to COVID-19 Among Malawi Adults: A Community-Based Survey. International Journal of Environmental Research and Public Health, 18(8), 4090. https://doi.org/10.3390/ijerph18084090
Nayyar, S., Chakole, S., Taksande, A. B., Prasad, R., Munjewar, P. K., Wanjari, M. B., Nayyar, S., Chakole, S., Taksande, A. B., Prasad, R., Munjewar, P. K., & Wanjari, M. (2023). From Awareness to Action: A Review of Efforts to Reduce Disparities in Breast Cancer Screening. Cureus, 15(6). https://doi.org/10.7759/cureus.40674
Odume, B., Falokun, V., Chukwuogo, O., Ogbudebe, C., Useni, S., Nwokoye, N., Aniwada, E., Olusola Faleye, B., Okekearu, I., Nongo, D., Odusote, T., & Lawanson, A. (2020). Impact of COVID-19 on TB active case finding in Nigeria. Public Health Action, 10(4), 157–162. https://doi.org/10.5588/pha.20.0037
Ogbonna, V. I., Alabere, D. I., & Tobin-West, C. I. (2020). Treatment Outcomes and Associated Factors of Tuberculosis Patients on Directly Observed Treatment (Short Course) in a Tertiary Hospital in Port Harcourt, Nigeria. Nigerian Journal of Medicine, 29(4), 707–713. https://www.ajol.info/index.php/njm/article/view/204278
Organization, P. A. H. (2020). Immunization Newsletter, v.42, n.4, Dec. 2020. Immunization Newsletter (EPI Newsletter);V.42, 2020. https://iris.paho.org/handle/10665.2/53230
Ozano, K. (2022). Cross Country Study on Integration of HIV, TB and Malaria in Uganda, Nigeria, Mozambique, DRC, Zimbabwe and Tanzania. Opendocs.ids.ac.uk. https://doi.org/10.19088/K4D.2022.066
Proquest. (2023). Tuberculosis-Associated Knowledge, Stigma, and Health Seeking Behavior Among Traders in Onitsha Main Market, Anambra State, Nigeria - ProQuest. Www.proquest.com. https://search.proquest.com/openview/8eda670650fa818e08105c0ede02fca2/1?pq-origsite=gscholar&cbl=18750&diss=y
PsycNet. (2021). APA PsycNet. Psycnet.apa.org. https://psycnet.apa.org/record/2021-56319-001
Ramuhulu, T. C. (2021). The prospectus and challenges of rural urban migration in South African cities: perceptions from integrated development plans. Ukzn-Dspace.ukzn.ac.za. https://ukzn-dspace.ukzn.ac.za/handle/10413/20144
Ryan, G., Avdic, L., Daly, E., Askelson, N., Farris, P. E., Shannon, J., McRee, A.-L., Hanson, J., Kenyon, D. B., & Seegmiller, L. (2020). Influences on HPV vaccination across levels of the social ecological model: perspectives from state level stakeholders. Human Vaccines & Immunotherapeutics, 17(4), 1006–1013. https://doi.org/10.1080/21645515.2020.1839290
Siregar, I., & Yahaya, S. R. (2022). Semiotic Exploration of Roti Buaya as a Cultural Ornament. British Journal of Applied Linguistics, 2(1), 06-13. https://doi.org/10.32996/bjal.2022.2.1.2
Tabong, P. T.-N., Akweongo, P., & Adongo, P. B. (2021). Community beliefs about tuberculosis in Ghana: Implications for the end tuberculosis global agenda. Cogent Medicine, 8(1), 1870069. https://doi.org/10.1080/2331205x.2020.1870069
Teibo, T. K. A. (2023a, June 7). Time series and spatial distribution of tuberculosis in Oyo state Nigeria. Www.teses.usp.br. https://www.teses.usp.br/teses/disponiveis/22/22133/tde-31082023-092906/en.php
Teibo, T. K. A. (2023b, June 7). Time series and spatial distribution of tuberculosis in Oyo state Nigeria. Www.teses.usp.br. https://www.teses.usp.br/teses/disponiveis/22/22133/tde-31082023-092906/en.php
Tseng, Y., Griffiths, F., Kadt, J. de, Nxumalo, N., Rwafa, T., Malatji, H., & Goudge, J. (2019). Integrating community health workers into the formal health system to improve performance: a qualitative study on the role of on-site supervision in the South African programme. BMJ Open, 9(2), e022186. https://doi.org/10.1136/bmjopen-2018-022186
Unicef. (2019). Mitigating the socio-economic impacts of COVID-19 in Ethiopia, with a focus on vulnerable groups Annex I -Vulnerability Impact Fiches. https://www.unicef.org/ethiopia/media/3546/file/Annex%20I%20%E2%80%93%20Vulnerability%20Impact%20Fiches.pdf
Vo Quang, E., Shimakawa, Y., & Nahon, P. (2021). Epidemiological projections of viral?induced hepatocellular carcinoma in the perspective of WHO global hepatitis elimination. Liver International, 41(5), 915–927. https://doi.org/10.1111/liv.14843
WHO. (2021a). 6.2 National surveys of costs faced by TB patients and their households. Www.who.int. https://www.google.com/url?q=https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/uhc-tb-determinants/6-2-national-surveys-of-costs-faced-by-tb-patients-and-their-households&sa=D&source=docs&ust=1700082408262554&usg=AOvVaw1ou3OtHYKYjA4bPjjGdb8E
World Health Organization. (2020). Health policy and system support to optimize community health worker programmes for HIV, TB and malaria services: an evidence guide. https://apps.who.int/iris/bitstream/handle/10665/340078/9789240018082-eng.pdf?sequence=1
