Epidemiology Essay Samples

Health promotion(HP)is defined as “raising the health status of individuals and communities”(Scriven 2010, p.17).Globally, tuberculosis(TB) is a major health concern in the 21st century that requires much effort in terms of prevention and health promotion (Gupta et al.2004).Tuberculosis is an infectious disease caused by a type of bacterium called Mycobacterium tuberculosis and usually affects the lung but also may attack other body parts(kidney, spinal cord and brain)(Centers for Disease Control and Prevention( CDC)2014).TB can be latent (bacteria can live in the body without making a person sick)or active (where bacteria affects the immune system, which develops a TB infection in the body)(CDC 2014).
TB remains as a major health problem worldwide(World Health Organization(WHO) 2013a). Therefore, the WHO considers TB the second worst infectious disease after HIV/AIDS around the world (WHO 2014a).According to Oman’s Ministry of Health (2014)pulmonary TB was showing a sharp decline of 60% in 2010 compared to 1991 and the evidence was obtained from negative sputum cases. On the other hand, no change was noticed in extra pulmonary cases over the years(Ministry of Health( MOH) 2014).In addition, the number of cases declined from 375 cases in 2012 to 325 cases in 2013(Bhattacharjee 2014).Furthermore,the death rate dropped from 7.4% in 1991 to 5.3% in 2012 due to the establishment of treatment under direct control(DOTS)(MOH 2014).However, the vision of 2020–2050 mentioned that serious activities are required in order to avoid the possibility of rolling back TB disease in Oman(MOH 2014). Accordingly, in 2007 the Oman Governorate introduced a policy for TB prevention and management and a national control programme started to eradicate TB(MOH 2007). Similarly, a WHO policy established early detection and aimed to decrease morbidity and mortality rates by enhancing quality of life and disease prevention(WHO 2009a). Therefore, this report will be about the prevention of tuberculosis disease.
In addition, this topic was also selected because tobacco smoking increased the risk of becoming infected with TB bacteria and active TB(Draper 2014).Furthermore, internationally, more than 20% of TB incidence is attributable to smoking(WHO 2009b).
In 1986 the Ottawa charter stated five strategic actions for implementing health promotion(WHO 2008).These strategies are build a policy for public health, create a supportive environment, reinforce community action, develop personal skills and reorient health facilities(WHO 2008).There are different health promotion models(Naidoo and Wills 2009).Downie, Tannahill and Tannahill’s model(1996) is one of the models and will be used to structure this report. This model is commonly used by health care professionals because it emphasises positive health and aims to prevent disease through three stages of health promotion: health protection, prevention and education (Naidoo and Wills 2009).It emphasises the realities in practice of health promotion as an overlapping activity. For example, in practice community nurses tend to carry out preventive and educational activities but can also be involved in health policy(Duaso 2000).
This report also focuses on the epidemiology of TB, relevant policy, evidence-based information about the prevention of TB by avoiding risk factors, and examining the role of community nurses in raising awareness of TB and its risk factors.

The global TB report by the WHO(2014b)estimated that around 9 million were affected by TB in 2013; half of them were from South-East Asia and Western Pacific regions, while more than one quarter were from African regions, which had the highest cases and deaths in relation to population size(WHO 2014b).China and India alone accounted for 24% and 11% of total cases, respectively (WHO 2014b).Approximately 60% of affected cases and the highest death rate occurred among men; nevertheless, the burden of disease is also high among women. In 2013 there were 510,000 female deaths from TB, and more than one third of them were HIV positive cases because of immune deficiency(WHO 2014b).In addition, a UK TB report in 2014 reported that the highest number of cases was from non-UK born populations at around 94.3 per 100,000; for those born in the UK the figure was 6.6 per 100,000 (Public Health England 2014).In Oman in 2012 a report by the MOH found that the total number of cases was 375. The highest number was in the Muscat governorate (120 cases) followed by North Batinah and Dofar with 72 and 65, respectively, and 118 cases in the remaining governorates(MOH 2012a).

Risk factors

There are some factors which may increase the spread of tuberculosis disease infection among the population(Brunner et al.2010).These include close contact with active TB patients, homelessness, alcoholism, tobacco smoking, ethnic minority groups being immunocompromised(HIV),elderly patients with special conditions such as haemodialysis, diabetes and gastrostomy, and immature children(Draper 2014). According to the WHO(2012a), the Oman Global Youth Tobacco Survey(2010) aimed to monitor the prevalence of tobacco smoking, as it is considered to be one of the risk factors that increases the transmission of TB. In total, 1620 school students aged 13 to 15 years were surveyed, and the findings are as follows:1.8% were current cigarette smokers,1.5% smoke shisha,1.8% used smokeless tobacco products and 2.2% used other tobacco products. In addition, there were other risk factors such as exposure to second-hand smoke(WHO 2012).
There is a strong relation between smoking tobacco and tuberculosis(Kolappan & Gopi 2002).A smoker can develop active TB in three ways after being infected with bacteria. Firstly, smoking causes damage to the lungs and this makes smokers more susceptible to infection. Secondly, smoking affects the immune system, which results in easily acquired TB infections. Finally, smoking interferes with the effectiveness of treatment, which leads to long periods of infection and increases the severity of disease (Public Health Agency of Canada 2012).In developing countries, tobacco smoking and TB are considered two major health problems as per the estimate that by 2020 the number of deaths from tobacco consumption will be approximately 8.4 million, which is double of what it was in 1990 (Kumar & Behera 2012).A systematic review and meta-analysis was done by Bates et al.(2007) to quantify the association between TB infections and active tobacco smoking. They included 24 studies with differing methodologies, and the findings demonstrated that smoking is a risk factor for TB infection with an RR(relative risk) of around 1.7 and for TB disease with an RR of about 2.3 to 2.7. However, it is not clear if smoking causes an additional mortality risk in persons who already have active TB. Therefore, further studies in more countries are needed in order to draw an ultimate conclusion between TB mortality rate and smoking (Bates et al.2007).Another cohort study done by Lin et al.(2009) in Taiwan investigated the relationship between tobacco smoking and active TB in a cohort of the common population. The National Health Interview Survey(NHIS) was used to collect standard information from participants like smoking status and sociodemographic and behavioural factors using in-person interviews and it ran from 2001 to 2004. The participants numbered 17,699(recent smokers n=3,893, previous smokers n=552, have never smoked n=13,254). The sample size was large, which helps to generalise the result to whole populations(Fain 2009). A major strength of this study is that it is unlike previous cohort studies, which included only high-risk people. This study included the general population from a typical sample and was generalisable to the population of Taiwan (Lin et al.2009).The finding shows a twofold increase in the risk of active tuberculosis in those currently smoking compared to those who have never smoked. The researcher concluded that tobacco smoking was associated with an increased risk of active TB in the Taiwanese population. One limitation found in this study was that deaths were not recorded in the National Health Interview (NHI) database because smokers have a greater mortality rate than those who have never smoked, which results in a bias towards a smaller relationship between smoking and TB (Lin et al.2009).It may be useful to reproduce this study or conduct a similar study in Oman to assess if the results are similar and then to aim to improve clinical practice and promote health promotion in order to avoid such behaviours which can contribute to an increase in the rate of TB disease.
It is not only smokers who are at risk of being infected by TB, as the studies also confirmed that passive smoking and being exposed to environmental tobacco is considered another contributing factor that leads to active TB(Kumar & Behera 2012). Leung et al.(2010) conducted a cohort study in Hong Kong to assess the relationship between passive smoking and the development of TB. The sample was 15,486 women (aged 65 to 74) living with their husbands who were never exposed to active or passive smoke and were enrolled in 18 health institutions for the elderly from 2000 to 2003. The sample was retrospectively assembled. This design is good for studying multiple outcomes (Rees 2011).The result shows that the number of passive smokers reflects those who actively smoke and that the TB cases in both groups were similar. They conclude that passive smoking was similar to active smoking in affecting people’s predisposition to development of TB (Leung et al.2010).

TB policy

As a consequence of their previous statement the World Health Organization established a strategy to stop TB worldwide and aimed to implement it from 2006 to 2015 (WHO 2006).The vision of this strategy plan was “A world free of tuberculosis” (MOH 2007, p.2).In Oman the national tuberculosis programme was introduced in 1981. The purpose of this programme was to decrease mortality, morbidity and work effectively to eliminate TB (MOH 2007,Royal Number 73/92).The programme advises implementation of direct observation treatment via a short-course(DOTS) strategy (MOH 2007).According to the WHO(2006),this strategy stated that TB patients with positive sputum must stay in the hospital for 2 months under the direct observation of health professionals. All over Oman regional hospitals are following this strategy and it is mandatory to consider TB whenever health professionals examine any patient with a continuous cough for two weeks or more (MOH 2007).In addition, all investigations must be undertaken to rule out TB, for example a sputum test and culture, chest x-ray and Mantoux test (MOH 2007).

Health protection

Health protection comprises legislation and policy, which is important to promote and protect the community’s health(Naidoo and Wills 2009). According to the WHO(2014c) Oman approved a convention on tobacco control in 2005. The rules and regulations of tobacco control include restrictions and now a ban on smoking in the workplace and also in public places (WHO 2014c).In addition, the sultanate decided to use tax as a weapon in the war on tobacco as a step in the right direction, and this was also endorsed by the World Bank (Mitra 2014).It says that some studies have shown that increased taxes on tobacco smoking have resulted in decreased numbers of smokers and also smoking-related deaths, while price increases have forced some smokers to quit and prevented others from being persistent smokers (Mitra 2014).In comparison, the Department of Health(2011) in the UK developed a plan to control tobacco, which includes not displaying tobacco products in shops, plain packaging of tobacco products, legislation to stop the sale of tobacco from vending machines, the use of e-cigarettes, and taxes to maintain high prices; consequently, the number of smokers was reduced (DH 2011). A cross-sectional study using a telephone survey was done by MacFarlane et al.(2010) to evaluate the effect of cost as a motivating reason for quitting smoking before and after the tax increase in 2010. Data was collected from August to October 2009 and compared to data collected in July 2010. The sample was 750 smokers. This sample size was small so it is not helpful to generalise the result to the whole population(Fain 2009). The finding shows that, compared to 2009, cost was the main reason for quitting smoking in 2010 due to taxes, which were raised from 25% in 2009 to 50% in 2010 (MacFarlane et al.2010).The strength of this study was that it was a national sample despite a very low sample size. There were some limitations in this study, as it included smokers only and did not present data on the smokers who quit after taxes were raised. In addition, they conducted the survey three months after the tax increases, and in order to assess the abstinence rates of smoking in the long term, a longer period is needed.

Health prevention

According to Downie, Tannahill and Tannahill(1996), the purpose of health prevention is to avoid any risk factors to help prevent the disease(Naido and Wills 2009).In the Sultanate of Oman, there are two specialist clinics for smoking cessation that promote healthy lifestyles. Around 6% of smokers cannot tolerate the withdrawal symptoms, and therefore these clinics provide them with guidance and support. Furthermore, nicotine replacement therapy is available for those who are seeking to quit smoking, and nicotine patches, gum and lozenges are offered, which have minimal side effects compared to cigarettes(Pourmohammadi 2014).In terms of TB prevention, in 1970 the Omani Ministry of Health introduced a Bacille Calmette–Guerin (BCG) vaccine for newborn babies in order to protect them from being infected (MOH 2003).Also, there are measures in the secondary hospitals to follow up with all contacts of patients with TB in the community in order to avoid the spread of the disease to other family members(MOH 2007). Mandatory hospitalisation was implemented for TB patients, who are placed in isolation rooms until the sputum test becomes negative(MOH 2007).Similarly, in the UK a positive TB test means immediately shifting the patient to an isolation ward in a room with negative pressure and with the door closed(National Health Services 2012).
Roy et al.(2014)conducted systematic reviews and a meta-analysis that examines 14 studies to assess the effectiveness of the BCG vaccine against Mycobacterium TB infection as evaluated by interferon release assays in children. The sample was 3,855 children aged under 16 years (vaccinated and non-vaccinated with BCG) who had recently had contact with TB patients. The results of all 14 studies showed that BCG provided significant protection from TB infection and also protection in the progression from infection to disease (Roy et al.2014).This result provides evidence of effectiveness of BCG vaccine in protect against TB infection which enhance the importance of vaccinating the children with BCG vaccine.

Health education

According to Downie, Tannahill and Tannahill (1996) the aim of health education is to provide knowledge or change the behaviours and attitudes of the public and society in order to enhance their general health(Naidoo and Wills 2009).Every year around the world TB day is universally celebrated on the 24th of March(WHO 2013b).This day is taken as a chance to raise awareness about the international burden of TB and provide information about the control and prevention of the disease (WHO 2013b).This day also includes the distribution of pamphlets or leaflets to communities in order to increase awareness of the seriousness of the disease. Health educators in each health institution in Oman celebrate this day and offer health education to everyone attending the institutions(MOH 2000).In terms of health awareness of tobacco smoking, there is a mass-media campaign about the prevention of tobacco use, the main goal being to decrease the prevalence of smoking and reduce morbidity and mortality(Levy&Friend 2002).Furthermore, tobacco can be responsible for a great part of the total illness burden of TB; therefore, awareness of smoking cessation is very important to prevent the further spread of disease (Siddiqi et al.2013).

Role of community nurses

The community health nurse plays a major role in the prevention of TB by conducting health promotion through health education in order to increase awareness among the public (Newberry 2011).The nurses’ focus of care is the patient, which extends to the patient’s family and includes an assessment of their capability to continue the therapy at home (Oman Nursing and Midwifery Council 2011).Advice is given to the patient and family about infection control procedures, such as proper disposal of tissues, covering the mouth during coughing, and frequent hand washing (MOH 2007).In addition, assessment of the patient’s adherence to the medication regimen is essential because of the risk of developing resistance if the regimen is not followed consistently (Brunner et al.2010).Further, the nurse evaluates the patient’s environments, including the home, workplace and social setting, in order to identify the other people who may have been in contact with the patient during the infectious stage. It is important to arrange follow-up screenings for those who had contact with the patient(Brunner et al.2010). Furthermore, another aspect of the nursing role is to prevent smoking by warning all people about its dangers by conducting campaigns to encourage smokers to quit, educating them about the harmful effects of smoking, the risk factors and encouraging them to make changes in their attitudes and beliefs in order to decrease smoking prevalence(Kolappan&Gopi 2002).

Recommendations

It is recommended that the governorate include health education on smoking in the educational curriculum in order to increase students’ awareness, impose a complete ban on cigarette advertisements (on television,in newspapers and magazines) to emphasise the restriction in public places, and continuously raise the taxes on smoking products to encourage people to give up smoking(Poureslami 2001).Oman’s future plan and recommendations for TB aim to introduce an Electronic Nominal Registration system in all regions over the next five years, involving the private sector in the national TB control programme’s activities, such as health promotion activities for the public, strengthen the surveillance system to help eliminate TB and follow up on TB contact effectively(MOH 2012b).

Conclusion

The WHO recommended that health educators, community leaders, community health professionals and civil society advocates offer essential voices in promoting awareness of TB. This report appraised the epidemiology of TB disease and the risk factors that lead to more disease prevalence. It is focused on tobacco smoking, as the evidence clearly demonstrates a strong association between TB and both passive and active smoking. The Downie,Tannahill and Tannahill(1996) model of health promotion was used to demonstrate how the three elements of it (prevention, protection and health education) can be utilised to discuss the relationship between TB and tobacco smoking and the importance of the strategies to reduce smoking. In addition, the community nurses have a vital role in relation to both subjects.