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Abstract
Tuberculosis commonly abbreviated as TB is the deadliest single infectious agent after HIV/ AIDS in the world. Tuberculosis has left millions of people dead globally. TB has posed to be a threat to public health in Liberia. This threat mostly applies to immigrants. The main objective of this study was to examine the correlation between the independent variables of the status of immigration, year of residence, and ethnicity or race and the dependent variable of TB infection within Monrovia between 2008 and 2014. In examining these possible relationships, an ecological perspective theory was employed by this quantitative study and thus the study used secondary data that was gotten from the Ministry of Health and Social Welfare. The most significant predictors of TB infection rates according to data analysis via linear regression were the immigrant status, and ethnicity or race. The study provided professionals in health with other resources that assisted in the effective ways of TB intervention and had the highest possibilities in the prevention of spreading TB through relevant data analysis. The research is important because it will help to reduce the incidences of TB, prevalence and best utilization of resources by directing them to the right target group.
Table of Contents
CHAPTER ONE: INTRODUCTION TO THE STUDY
Introduction…………………………………………………………………………
Background of the Study……………………………………………………………
Problem Statement…………………………………………………………………..
Purpose of the study…………………………………………………………………
Research questions and hypotheses…………………………………………………
Theoretical and conceptual framework for the study……………………………….
Nature of the study………………………………………………………………….
Definitions………………………………………………………………………….
Assumptions………………………………………………………………………..
Scope and delimitations………………………………………………………………
Limitations…………………………………………………………………………
Significance of the study……………………………………………………………
Summary……………………………………………………………………………
CHAPTER 2: LITERATURE REVIEW
Introduction…………………………………………………………………………
Literature search strategy……………………………………………………………
Theoretical foundation……………………………………………………………….
Conceptual framework………………………………………………………………
Literature review related to key variables and concepts…………………………….
Summary and conclusions…………………………………………………………..
- CHAPTER ONE: INTRODUCTION TO THE STUDY
Introduction
Tuberculosis is a human infection that is caused by the bacteria. The bacteria that is responsible for tuberculosis is called Mycobacterium tuberculosis. This bacterium is closely compared to Mycobacterium leprae, the bacterium that causes leprosy (Gupta, 2012). Tuberculosis affects anybody although it is more common in those people whom their socioeconomic status is lowest, people living with HIV, and people living in areas where one can get TB easily like psychiatric patients and prison inmates. The two types of TB are extra-pulmonary tuberculosis and pulmonary tuberculosis (Gupta, 2012). The most popular TB type is the pulmonary TB that is throughout the world, and the study will focus on this type of TB. Pulmonary TB occurs when the lungs are colonized by the causing distress in the in the respiratory. The study needs to be conducted so as to intervene on the causes of TB and how it can be prevented. In Liberia, cases of TB reported in 2011 were an estimate of 53%.
Background
Tuberculosis is a human infection caused by the bacteria. The bacteria that is responsible for tuberculosis is called Mycobacterium tuberculosis. According to evidence based on archeology, Mycobacterium tuberculosis appeared firstly around past 20,000 years to 35,000 years (Daniel, Sep 2006). Since then, TB has been a plague and is still a plague to human beings. Other agents that are infectious in the world history can match TB for causing misery and mortality on the human race. Factors such as better housing, income, nutrition and, health have contributed greatly to reduction rates. Despite the advancement of the medical care in the 20th century still the treatment and prevention of TB did not fare as well. In 2013, globally 9,000,000 people contracted TB, and the disease killed an estimate of 1,500,000 people.
Nearly 2/3 of the world population has been infected with tuberculosis in this 21st century. Tuberculosis is an airborne infectious disease and is single deadliest across the world. TB in Liberia poses to be a threat because the case detection rate in 2011 was 54% (LISGIS, 2014). Tuberculosis affects anybody although it is more common in people living with HIV/AIDs, people of low socioeconomic status, and in areas of TB burden setting like psychiatric patients and prison inmates. The two types of TB are extrapulmonary tuberculosis and pulmonary tuberculosis. The most common type of TB is pulmonary tuberculosis that is found all over the world (Gupta, 2012). The study will focus on pulmonary tuberculosis. Pulmonary tuberculosis is caused when the lungs are colonized by the bacteria causing respiratory distress. Extra pulmonary tuberculosis occurs when the bacteria settle outside the lungs. In Liberia, 4/5 cases of tuberculosis are reported to be extrapulmonary tuberculosis.
Problem Statement
Tuberculosis (TB)is an infection in humans that is caused by a bacterium called Mycobacterium tuberculosis transmitted through the exchange of air from an infected individual through sneezing, coughing, shouting, and singing (Bynum, 2012). The two types of TB are pulmonary and extrapulmonary, but it is the former that is more common. Few infectious diseases are as deadly as TB. According to Lawn and Zumla (2011), Tuberculosis accounted for about 25% of all deaths in Europe during the 19th century. Even though the situation has improved with better housing and proper sanitation, the mortality rate for TB is still almost the same as it was a century ago (50% of those infected; World Health Organization [WHO], 2014). In 2013, approximately nine million people contracted TB, and about 1.5 million died due to the disease (WHO, 2014). Little knowledge exists about the factors that contribute the prevalence of the TB rate in 2009 -2010 in the capital of Monrovia (Corbett, E.L., et al. (2000) . Patients who visited and tested positive at the TB Annex hospital in Monrovia age range between, 7-12 years (90.91%), 13 – 18 years (88.57), 19 -24 years (90.57), 19 – 24 years (90. 57%), and 31age above was the highest (91.27 % ) sputum positive. (Corbett, E.L., et al. (2000)
Even though Tuberculosis rates have fallen in the developed world, the same cannot be said of developing countries. In most developing nations, like Liberia, TB remains the main cause of deaths in hospitals (Hodes & Azbite, 1993). Liberia, with a population of about 3.8 million people, has a TB prevalence of about 420/100,000, and it is growing at an alarming rate of about 2% per year (WHO, 2010). Presently there are about 16,050 active TB patients in Liberia, mainly in the rural areas where the majority of people are poor and live in squalid conditions, but their migration to bigger towns such as Monrovia leads to the spread of the infectious in Liberia. The rural-to-urban migration rate is currently 115 of every 1000 people in the Liberian population. The high rate of migration are is a result of the rural population traveling to Monrovia to seek medical treatment for tuberculosis . The government created a hub to encourage TB patient to come for treatment for eight weeks, after which the cured individual can return home (Integrated Regional Information Networks [IRIN], 2009). However, the existing hospital space dedicated to TB treatment has proven inadequate.
Significance
The purpose of this research study is to investigate the correlation between trends in TB infections in Monrovia and rural-urban migration. Although a lot of research has examined the effects of refugees and immigrants on the spread of TB, the effects of rural, urban migration has been less studied. This research aims to find that connection. By studying these relationships, public health professionals in Monrovia and Liberia, in general, will have the ability to design interventions that are aimed at addressing the variables that have the highest correlation. The study will help to determine the impact of migration on rates of TB infection, which will be important to the health care system in Monrovia regarding planning for the influx of people that migrate from the rural areas to the city. Further, the results may suggest the utility of intervention measures that can be taken in the rural areas, so that before migrants embark on a journey to Monrovia they can be tested and possibly be medicated to reduce the spread of TB. This study also will help in advocating for behavior changes, because the spread of TB is caused by factors that include lack of access to healthcare, sanitation, clean water or other factors (Stanhop, 2014). The study will aim to raise awareness of the need for TB screening and treatment and improved living conditions, both of which could mitigate the spread of TB.
Research Questions/ Hypothesis
RQ1—What is the relationship between the rate of TB infection and rural-urban migration to Monrovia between 2010 and 2014?
H1o: There is no relationship between TB infection status and migration to Monrovia between 2010 and 2014.
RQ2—Is there any relationship between the years of residence and TB infection rates in Monrovia between 2010 and 2014?
H2o: There is no relationship between the years of residence and TB infection rates among the population of Monrovia between 2010 and 2014.
RQ3—To what extent does income level influence the infection rate of TB among the population of Monrovia between 2010 and 2014?
H3o: Income level does not influence the infection rate of TB among the population of Monrovia between 2010 and 2014
RQ4—To what extent does age influence the infection rate of TB among the population of Monrovia between 2009 and 2011?
H3o: there is a no relationship between the age and the TB infection rate among the population of Monrovia between 2009 and 2011.
Theoretical Framework
The theoretical framework applied was the ecological perspective. It was selected because it helps the researcher to prioritize the most important issues that need to be addressed and at the same time it enables the researcher to determine areas that require emphasis. This model was introduced by Carel Germain in 1973 in an attempt to supplement systems theory and offer alternative hypotheses regarding the interactions of factors on multiple levels (Johnson & Rhodes, 2009, p. 5). She was recognized globally for her exhaustive research regarding the impact of multiple levels of society on human behavior (Johnson & Rhodes, 2009, p. 5).
The ecological perspective looks at the factors that affect one’s health from three levels: intrapersonal, interpersonal and community (CDC, 2015). The intrapersonal level has to do with individual factors such as attitude, lifestyle, beliefs, and behavior, while interpersonal factors are concerned with an individual’s social circles such as friends, peers, and family, and how they influence them and give them a sense of identity and belonging. The community level is broken down into three subcategories: institutional, community, and public policy. The community level encompasses of the category of social networks within defined boundaries, including the building of environment (e.g., community leaders, clinic, employment, church, and school. (Center for Disease Control, 2015). The ecological theory is useful for my study to identify the different levels operative within the spread of TB and implement solutions within a specific community, such as a school or clinic. It also aids the creation of guidelines for public health professional to promote health awareness and interventions to individuals or groups who are at high-risk for diseases such as TB.
Nature of the Study
The nature of this study will be quantitative and will use multiple linear regression. This quantitative research study will be based on the retrospective research design. It will be 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 has been previously collected and for comparing various sets of data that are linked to a variable or variables (Chumney & Simpson, 2006). 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).
Definitions
Immigrants: The population of the Monrovia (who are here either legally or
illegally) who were not born in the Liberia or Liberia territories. Those who migrate into Liberia but they were not born in Liberia.
Tuberculosis (TB): for the study purpose, when the term TB is used, it refers to pulmonary tuberculosis both LTBI and LTB.
The population of Monrovia between 2008 and 2014: it involves the individuals either male or female who are the residents of Monrovia or have resided in the state for six months or more at the time of the study.
Assumptions
This research is non-experimental and the analysis of the archived secondary data that is coded was obtained from sources that were approved by Ministry of Health and Social Welfare, Liberia. Public Health Services tested all participants for tuberculosis. It was therefore assumed that there was less biased data. Minimum bias was to make sure that each group had sound and comparable results.
Scope and delimitations
The study will cover the following areas; the correlation between trends in TB infections in Monrovia and rural-urban migration, and the effects of refugees and immigrants on the spread of TB. The effects of rural and urban migration are also other areas that will be covered in the study. This study was considered because the increase in the rate of tuberculosis infection and the mortality rate was alarming. Some of the delimitations of the study are; the analysis of data covered a larger cross section of Monrovia, the study was relevant and valid. Lastly is that strong statistical results were because of the type of analysis that was employed.
Limitations
The participants were not selected randomly because the study was retrospective. Nonrandomization only reflected on the population that was used in the study and thus it might fail to reflect the general population. Controlling the numbers that had variables that were confounding was also difficult. Confounding variables have potential impacts on the rates of infection of TB. These variables are the willingness, being available, and or the necessity of what is required to test the study population of the state. The study population covers a wide cross section area that might limit the necessities to carry out the study. The requirements are to facilitate in the test of tuberculosis, testing the area residents comprehensively, and negative test of TB that were false among the study population. Because of these limitations, future researchers should conduct more research on this subject so as to develop it further.
Significance of the study
By investigating the correlation between trends in TB infections in Monrovia and rural-urban migration, the data obtained from the study will help the epidemiologists determine the causes of tuberculosis and how to prevent the disease from spreading. The determinant will not only benefit the study population, but it will be of beneficial to the whole state and across the world. The knowledge acquired from the study will make people be aware of tuberculosis, and thus, they will use that knowledge to refrain from contacting tuberculosis. Results from the study will help initiate positive social change by reducing the rate of TB infection. Lastly, the impact of the study on the public health, economy, and the larger society will be positive.
Summary
Basing on this chapter, TB still poses to be a real threat to all populations. Furthermore, more research needs to be done concerning TB and the status of immigration, years of residence, and ethnicity or race. More research will ensure the certain variables that greatly contribute to TB infection rate and how to avoid these risks. The analysis of these correlations within Monrovia will equip the officials of public health with the necessarily valuable tools that will help them fight against TB. Public health officers will also use these tools to ensure the threats being posed by this disease to all populations are limited. The literature review will follow whereby it will highlight the research that has already been done into this topic for the past 32 years. The literature review also exposes the loops in this literature that the research hopes to fill.
- CHAPTER TWO : LITERATURE REVIEW
Introduction
The problem of the study is the impact of immigration variables on tuberculosis rates in Liberia. The purpose of this research study is to investigate the correlation between trends in TB infections in Monrovia and rural-urban migration. The research also aims to establish the relationship between the years of residence and TB infection rates in Monrovia. The study will find out how the level of income influences the infection rate of TB among the population of Monrovia. The areas in this chapter to be covered are literature search strategy that contains databases and search engines that will be used, detailed information that has searched key terms that are located in the appendix. Literature search strategy also contains the description of the literature scope, citations, and peer review of the current literature. The study will also cover theoretical foundation that contains; theories and their descriptions, sources of these theories. One of the theories will be selected rationally, and a detail description of the theory will be provided. Other areas to be covered in this study are the conceptual framework, literature review, summary, and conclusions.
Literature search strategy
The databases were searched online and thus helped in the accomplishment of the literature review. These databases are; Health and Medical Complete, Google Scholar, Medline, Nursing and Allied Health, CINAHL, PubMed Plus, and Science Direct. There are terms that facilitated the use of databases and they were individually used and at times used in combination. These terms are; Monrovia, Liberia, immigration, race, ethnicity, Western Africa, Buchanan, Zwedru, Ganta, Bensovyle, foreign-born status, year of residence, and or migrant workers. The research and information collected were evaluated, analyzed, recapitulated, and, catalogued so that it can be used in this review.
Theoretical foundation
The type of theory that was used in this chapter was the ecological perspective theory. Traditional theories dealing with the investigation and control of diseases involves examining of the epidemiological triad of the host, it’s surrounding, and the host(Ogilvie, 2012). However, by the use of the ecological perspective theory, the researchers have acquired tools in examining other factors that are not in the traditional triad so that they can intervene diseases effectively and how they can control these diseases strategically. “Episystem of disease” is a term that was used to convey the approach of the whole system offered through how the ecological perspective was utilized. However, it is indicated that information from the episystem of the disease was majorly based on how the change in climate can have an impact on the disease, assertions of how the surrounding of an organism can influence its biological makeup applies to all environments. These assertions can be applied to this research in many ways but basically during the analysis of the rates of TB infection to the geographical area.
There are diseases that can be managed when two or three factors are considered, but there are many more diseases like tuberculosis whose examination should be conducted on a holistic level. Every factor that contributes to the risk of acquiring this disease must be researched and evaluated for the provision of eradication campaign and how to manage this disease effectively. As it has been stated previously, there are some factors from the society that have had effects on TB risk factors. In an article (Austin, 2007)has adopted the use of ecological perspective in evaluating how SES multiple levels affect the rate of TB of countries that have acquired membership in WHO Africa region. SES consists of the health care accessibility, gross domestic product, and the rate of migration. Authors were able to identify the correlation between high rates of TB and low SES within the examined countries and this dissertation correlates directly with their findings. Through analyzing the rate of TB by the use of ecological perspective theory in the African countries that were chosen, authors were given the opportunity to examine the risk factors for TB beyond the ones that are known for prevalence. They were also allowed to think more homogeneously for the purpose of future studies on TB including this one.
Conceptual framework
The relation between immigration and tuberculosis rates can be conceptualized at generally fair level. The conceptualization of this relationship has been shown in the figure below depicting causes of migration and the final outcomes from these causes. The independent variables in this study are; rural-urban migration, years of residence, and race or ethnicity. Dependent variables of rural-urban migration are; high prevalence, difficulties in tracking the status of TB infection in the immigrants because of certain reasons. These reasons are their illegal status and or lacking financial resources and insurance. In years of residence, immigrants who had settled in Liberia for less than a year recorded highest levels of TB infection, lack of TB testing among the larger population of immigrants. The benefit of this study is that it will offer comparisons in the rate of TB among the Monrovia immigrants when working out the relationship between the years of residence in the rate of TB infection within Liberia. The concept has helped previous research in better ways of effective TB intervention and had the highest possibilities in the prevention of the spread of TB through relevant data analysis. The dependent variable for race or ethnicity is immigrants from high TB burden areas spreading TB to the Liberian natives.
The figure below shows a conceptual framework for linking immigration and the rate of TB infection.
Independent variables
Dependent variables
Literature review related to key variables and or concepts.
There are some reasons that may contribute to increasing in TB infection rate in Liberia. One of the main reasons that cause the rate infection of TB to be high is when people from low SES countries migrate in the Liberia(John D H Porter, 2007). Mostly, high rate of infection in Liberia is achieved when these immigrants come from countries where these countries are 55 times higher of being infected with TB than in Liberia. TB has been a major problem in Monrovia as it has greatly affected the agriculture industry since the industry relied heavily on immigrants to provide labor force. These immigrants were from African countries such as Sierra Leone, Ghana, Ivory Coast and Guinea states. Many of these countries are categorized to contain a high burden of TB. A larger population of Liberia is not tested for TB and neither do they seek the treatment for TB symptoms because of certain setbacks. These setbacks are; misconception on TB, social stigma, and lack of trust in the medical system. Information to overcome such setbacks may be gained when the previous studies that examined the TB historical perspective are reviewed.
Retrospective cross-sectional studies have been conducted to examine the relationship between the status of immigration and or residential years in Liberia and the rate of infection of TB infection in the study population. Since retrospective design study was employed by dissertation, articles, and analysis that are valuable were produced by these articles that are relevant to this study. A sensitivity analysis was conducted for the purpose of determining how effective is the program for Ministry of Public Health TB detection and also identify loops that will be reviewed and be evaluated in future studies(Skolnik, 2011). Sensitivity analysis was also to determine how the status in immigration affects the rate of TB infection at the state level. Time series decomposition analysis was also conducted to determine the seasonal rates and the areas of Liberia that are highly affected by the rates of TB.
The analysis according to the conclusion was that the areas that had many people who had settled for less than a year recorded the highest number of TB infection rate including Monrovia City (Smith, 2013). Recent and relevant statistics were offered by authors that showed that the number of people migrating into Monrovia from the countries that experience a high rate of TB infection over the last two hundred years was high. This article did not only deal with the rate of TB infection rates, but it also gave reliable data on race or ethnicity within the city of Monrovia and the interaction of these groups with each other that could have a relationship with the increase in the rate of TB infection in this population. Liberia has employed certain practices for screening those who migrate into the state for different diseases and ailments on various levels and degrees.
These practices have been enhanced since the 18th century. However, screening the immigrants was minimized before the 21st century (Verver, 2008). Sometimes the process of health screening was being skipped depending on what time the immigrants got into the country and also if the resources were limited in the sense that they could not facilitate the health screening process. Establishment of an industrial revolution at the beginning of the 10th century made the government of Liberia begin placing public health workers at strategic immigration points. Placement of the public health workers at strategic immigration points by the government was because of the high immigration in the country that was caused by the establishment of these industries. There was the establishment of large health facilities by the public health workers at these immigration points. Some of these facilities in Liberia that were established include; Cavalla medical center, Ganta Hospital, Liberia Government Hospital, and, Duside Hospital among others.
In Liberia, the institution that deals with the collection and analysis of data on tuberculosis, the rate of infection, and the spread of tuberculosis is called Liberia Demographic and Health Survey. Those people who are not ready to be treated or be tested against TB are at a high risk to contract TB(Amor, 2008). The rate of infection can be justified by those people who migrate into Liberia, and they fear to be deported or lack the necessary resources to access medical services and care. Since 2011, the cases of TB have risen to 64% among the immigrants in Liberia. Since the rate of TB infection is two times less among the general populations than in immigrants, it is essential to identify the causes of resistance to immigrants to testing of TB and treatment. The historical retrospective study majorly focuses on how the screening of TB has evolved among the human beings and the effectiveness of those techniques.
Kruk, M.E & Williams, E.A (Kruk, 2010) discussed that early screening was mostly used to stop the immigrants who were infected because they could subject the public health system to burdens of taking care of them. The early screening was also used on those people who were unable to work and sustain themselves in the society. However, early screening in Liberia was mostly focused on stopping these immigrants into the country other than preventing the disease from getting and spreading into the country. However, the treatment of TB infections by the use of antibiotics on a large scale in the 19th century, the reason TB was being screened among the immigrants evolved was to offer treatment to those who were infected so as not to allow the disease from spreading to the Liberian natives. In an article by(Gwenigale, 2011), the authors also looked for the causes that prevent immigrants from being tested and or treated for TB. These are some of the findings that they came up with; wrong information about TB symptoms and treatments, social stigmas, and their ultimate desire to get into Liberia for the betterment of their lives and their families.
According to (Grossman, 2013), the authors examined the disparity between the rates of TB infection among immigrants and to the general population of Liberia. As the authors have pointed out, the Liberia’s National Leprosy and TB Control program recommend testing those people from countries that are characterized by high rates of TB for the disease immediately when they get into Liberia. However, follow-ups for this practice have not been consistent, and this is because of limited resources, funding, staffing, and insufficient knowledge or immigrants’ participations in the testing of TB and the care of the follow-ups. Social organization and behavior pattern of a group of immigrants was analyzed by authors. The analysis was done on those immigrants who go for adult education in Monrovia. The authors conducted a qualitative study by the use of Health belief model principle. The study used both oral and written questionnaire for the purpose of identifying those participants that were afraid of being screened for TB, and if they were diagnosed to contain the disease, why the few of those who are diagnosed would seek treatment.
The study had 53 participants and out of the 53 participants, many of them stated that they did not seek to be tested nor treated for TB because they did not have sufficient knowledge about the dangers and the risks that are associated with TB. Some of the participants said that TB does not exist in Liberia, and so they cannot be worried about the disease. Other participants expressed their worry concerning the social stigma that are relating to TB and their perception on TB that the disease is fatal. Therefore, they felt that it was better for them not to know their status. For those who were tested and found to suffer from TB, offered resistance to the treatment because they perceived that the treatment for TB was too expensive, inaccessible, or they suspected and did not trust the doctors and their medication. The authors in an article by(Grossman D. B., 2013) came up with several ways of overcoming the barriers that have been aforementioned to the education of TB and offering treatment among immigrants. Some of these ways of overcoming include sufficient knowledge about, the causes, symptoms, options on treatment, and the available resources for patients suffering from TB. This education incoherent with similar methods that are implemented will ensure that misconceptions and stigmas on TB are overcome. There will also be positive outcomes both among the immigrants and the overall population of Liberia as well.
Justification of the study
It was noted that the gaps in the research were significant on the rate of TB infection in Monrovia when conducting a preliminary study on what topic to select. The research knowledge concerning the rate of TB infection in respect to the variables as mentioned earlier was insufficient. The quantitative research that was discovered was very little, and it discovered the exploration in the relationship between the variables that were proposed by this study and the rate of TB infection in the population of Monrovia between 2008 and 2014. The concerns were raised by this significant gap. Therefore, this study was initiated for the purpose of awareness creation of the variables that results in the rate of TB infection, facilitate social change positively, and reduce the prevalence and incidences of TB among the population.
Research variables
- Immigration Status
Kruk (2010) analyzed the sensitivity of Liberia’s National Leprosy and TB Control Program on detection program of TB. He focused his analysis among the immigrants who had migrated from countries that experience a high burden of TB. Even though the TB cases were reported to have reduced by 56% from 1993 to 2008, 74% of the reduction were cases reported that were from Liberian natives. The TB infection rate was12 times higher among the immigrant population than the native population of Liberia. Austin (2007) conducted an assessment of the data that was collected from 168,500 participants who were tested for TB in the Liberia’s National Leprosy and TB Control program so as to explore on how effective the program was from March 2001 to December 2008. Although of the TB tests conducted, 17% were from the foreign-born residents, but their rate of the incident was disproportionally higher (33%) than the Liberian population (6%).
In the study, one of the flaws was acknowledged by the authors that it is not easy to track the status of TB infection of immigrants because of lack of financial resources or illegal status and insurance that makes them not to seek medical care (Skolnik, 2011). However, the authors did not suggest on how this gap should be addressed. The study in this article by (John D H Porter, 2007) explores the status of TB infection on foreigners in a state that corresponds to Monrovia, its location, and SES. The state of the study corresponding to Monrovia makes it relevant to this dissertation. The author (Gwenigale, 2011) evaluated on the rates of TB deactivation among the immigrant population in Liberia between 2004 and 2008. The authors identified 38,650 cases of TB by conducting a retrospective cross-sectional study from the Liberian National Center for Biotechnology Information. The reason this study was conducted was to identify the similarities and the differences of the reactivation rates of TB among those who were born in Liberia and the immigrants living in Liberia.
The finding of the authors showed that the study population of the foreign born whom their current infection had been contracted by TB from reactivation had not contracted the disease within Liberia, but instead they contracted the disease outside Liberia. The authors drew conclusions that the resources should be used well in screening the immigrants who come to Liberia for TB. The use of these valuable resources in screening TB helps to minimize reactivation if those people who were tested were positive for the disease. Screening of TB also helps to reduce the risk of the contagion being spread to the people. One of the study findings(Skolnik, 2011) showed that among the population that was being studied was that, immigrants from Ghana accounted for 24% of the reported cases of TB in Liberia during the last decade of the 21st century. A higher percentage of immigrants from Ghana and other West African countries are characterized to contain high burden of TB thus making the findings relevant to this dissertation. Therefore, the findings that will be obtained from this study will help to identify the correlation between the status of immigration and the rates of TB that will be collected from the study population within Monrovia.
The data and analysis from this article (Skolnik, 2011) will be used to infer and compare the rates of TB infection among the immigrants in Monrovia. The author (Smith, 2013) tested and made follow-ups to the employees of a certain workplace by the use of the retrospective, cross-sectional studies. The use of the retrospective, cross-sectional study was to examine the effects of testing and follow-ups among the low-SES labors. 320 employees were screened for HIV and TB by researchers at their places of work in Montserrado County in Monrovia. The study indicated that 23% of the study population was foreign-born, and 5% of the study population was Basa community from Monrovia, Liberia. According to the study, 21% of those who were tested for TB among the general study population were positive. 54% was the percentage of the immigrants to the population that tested positive.
The percentage of the people who were born in Liberia that tested positive after the test for TB was 12% according to the study population. One main reason the gap in the article was significant is because many of those who were tested for TB and tested positive did not return for follow ups and to be diagnosed for the second time for the purpose of confirming the initial diagnosis. The authors also acknowledged another gap that was on whether or not the people who had migrated into the state had received BCG vaccinations in their native countries for TB. The results obtained from this study further supports the fact that the correlation is high between the rates of TB infection and immigrants from countries that experience high burdens of TB. The major hypothesis of this dissertation is supported by this high correlation.
- Years of residence
TB always follows seasonal trends like many other diseases that are infectious like the common cold and influenza. The rates TB incidences are high in the fall and winter months as compared to the months of summer and spring. The focus is precisely on the article by (Gwenigale, 2011)on which an analysis was made by authors on how seasonal trends affect the rates of TB in Liberia. An analysis of time series decomposition was conducted by the authors for the purpose of supporting their hypothesis of the cases of TB that were reported to the Liberia’s Ministry of Public Health and Social Welfare between 1995 and 2010. A cohort of 243,567 patients was confirmed by the medical laboratory to contain TB, and this was according to the study population. Monrovia was reported to contain the majority of the cases of TB (29%). The population was broken down into years of residence and race in Liberia by the authors.
The rate of TB infection was the highest among the Kru and the Grebo ethnic communities in Liberia (30% and 27%) respectively of the study population. In regards on how the rate of TB is being affected by the status of immigration, the study stated that those people who had migrated into Liberia and had settled for less than a year recorded the highest rates of TB infection. Authors did not only offer the data on how the status of immigration affects the rates of TB but also provided insights to the correlation between the rates of TB infection and residence in years. One of the hypotheses in this dissertation corresponds to that correlation. A certain researcher used across, sectional retrospective analysis to assess on how the rate of TB infection is affected by the length of time immigrants spent in a certain location in Liberia between 2002 and 2009. The data he used in the retrospective cross-sectional analysis was from Liberia Demographic and Health Survey.
The percentage that this population had accounted for among the study population was highest (42%). The main setback that the authors acknowledged in the study is that there were no reporting and screening among all immigrants, and they ascertained that this was the main obstacle for them to come up with solid conclusions basing on how the status of immigration and residence in years affect the rates of TB infection in Liberia. However, the hypothesis of the study of (Berger, 2015) is supported by the findings of the study. The hypothesis stated that immigrants from countries that experience a high burden of TB and have settled in Liberia for less than twelve months are at the greatest probability of being exposed to TB than the general population of the state. The conclusions are drawn from these studies will help to compare the rates of TB among the immigrants in Liberia when conducting an evaluation of the correlation between residence years on infection of TB rates within Liberia.
- Race/ Ethnicity
As it has been indicated previously, the degree of TB burdens varies from one country to another. Certain countries experience high burdens of TB than others. The general population of Liberia is at a high risk of being infected with TB from immigrants who come from these countries that experience high burdens of TB. Authors (Verver, 2008) conducted a study of a quantitative cohort that examined the immigrants from Ghana, who entered Liberia through Monrovia between 2002 and 2003. The authors indicated that Ghana is a country that is characterized by a high burden of TB the percentage the immigrants from this country represents is significant. Over 56% of the immigrants from Ghana origin are approximated to contain LTBI, and they are one of the largest race/ ethnicity that recorded the highest rates of TB. Furthermore, the rates of TB among the immigrants from Ghana do not reduce over the residence years in Liberia.
The authors drew a conclusion stating that states, locals and, Departments of Federal Health of Liberia should be more alert in diagnosing and making follow-ups among the immigrants from countries that experience high burdens of TB. Addressing this issue does not only involve services such as caring and providing them with treatments but it also helps in controlling and preventing the spread of TB to the general population of Liberia. Kruk, M.E and Rockers, P.Cs (Kruk, 2010) in their articles conducted a qualitative study that was community-based with an objective of assessing the history of Kru ethnic community in Monrovia and the growth of this community resulted in changes in the 21st century. The authors stated that the population of the Kru community in Monrovia was 0.8% before 1990’s. However, because of growth in agriculture and increase in jobs that are low paying in the state, Ikru ethnic community was ranked as the second fastest growing ethnic community in Liberia. Kru ethnic community had grown from 0.8% to 7.4%. The growth of this ethnic community seemed to be correlating with the increase in the rate of TB infection during the same period in Liberia.
Qualitative data was gathered by the authors from 65 participants from Liberia’s Cash for Work Temporary Employment on some of the perceived variables. These variables are SES, accessing community resources, and race or ethnicity. Some of the limitations the study had according to the acknowledgment of the authors were that there was low participation, and data was reported that contributed to biases in comparison to the general Ikru community individually. Although TB was not specifically addressed in this study, the research is of great importance to this dissertation because it shows population increase in Monrovia among ethnicities or race that come from countries that are characterized by high burden of TB.
Literature and methodology
Amor, A.B and Yenser, A(Amor, 2008) used retrospective, cross-sectional studies in the evaluation of the status of immigration and or years of residence in Liberia, and the rates of TB infection within the population that is being studied. Since the design employed in this dissertation is retrospective study design, guidelines and analysis that are valuable were provided by these articles that are relevant to this research. For the purpose of analyzing how the status of immigration affects the rates of TB, Gwenigale, W.T (Gwenigale, 2011) conducted an analysis of the Liberia’s Ministry of Public Health and Social Welfare. The analysis was to determine the effectiveness of that ministry in the state and in the identification of loops that will be reviewed and evaluated in future programs. John D H Porter(John D H Porter, 2007)conducted an analysis of time series decomposition in determining the seasonal TB rates, and the areas of Liberia that had the highest rates of TB and he drew a conclusion that stated that immigrants who had settled in Liberia for less than a year contribute greatly in affecting the rate of TB infection in Monrovia. Statistics that are relevant and recent were offered by authors, and they showed that there was a significant increase in the immigrants who had migrated into Monrovia from countries that had experienced high burdens of TB.
However, this article did not only deal with the rates of TB infection; it provided data that was valuable in regards to race/ ethnicity within Monrovia and the interaction among the ethnic communities with each other. The interaction among these communities could have a correlation with an increase in the rate of TB infection in this population. Apart from how the variables affect the rates of TB infection in Monrovia as it is indicated by some articles that are highlighted in this chapter, these articles also demonstrated on how the general population may be exposed to such risks. Regarding these articles, all of the variables are correlated directly with the objective of this dissertation. Furthermore, the databases that were used by these articles in the literature review use secondary data that is coded and archived, and the type of data that was used in this dissertation is same to the one that was used in these articles. These articles ensured that the data was reliable and valid, and thus this dissertation had a strong foundation that was established by these articles.
Summary and transition
Statistics and information from previous studies have always proved TB to be a dangerous disease. TB still poses to be a disease that is relevant and very dangerous to all populations. It is important to examine the TB risk factors and study its correlations so as to prevent the future outbreak of the disease. Correlations have been drawn after examining these variables in the studies that have been mentioned above. These variables are effects of immigration, race and or ethnicity, and residence in years. The correlations that have been drawn support the scholarship and efficiency of exploring more in these variables about the population of Monrovia. Although the findings that are in this literature review are not new, the foundation they have established for this dissertation is very strong. The studies as mentioned above have contributed greatly to providing information that acts as a strong foundation for this dissertation. The articles in the studies that have been mentioned above have also helped in identifying gaps in the current research that may be addressed this dissertation.
No definitive explanation that has been offered that supports the design that they used in the study according to Authors in an article by (John D H Porter, 2007). As mentioned earlier, the research design that was employed by this dissertation is retrospective study design so as to compare data that are from various sets and they were connected to a variable or variables that are common all of which that could be applied in this study. In an article,(Gwenigale, 2011) authors drew conclusions on how certain variables could affect the health status of an individual. They drew conclusions from the data they had obtained from Liberia’s Cash For Temporary Employment. However, there are no indicators from authors on whether they used data from state, local, or at the state level that will offer support to their hypotheses and justification of their methodology. If the relevant data is missing, although considered perfect, and there is no accountability of the missing data, then their findings are always questioned.
Since the secondary data that has been collected and gathered by this dissertation is relevant and valid and also accounts for the study conducted in states, then the data in this study can be compared to data from other territories and states. The findings in this dissertation are efficient and statistically right, and thus, it will address information that is not found in this existing literature. An author,(Verver, 2008)identified a connection that is significant between the immigrants from Ghana and the rates of TB information in Liberia between 2006 and 2010 regarding the study variables. These study variables are the countries these immigrants come from, their age, and time they have spent in Liberia. As previously mentioned in the study, the variables in that study make it relevant to this dissertation. The study provides a strong foundation for the variables to be studied in this dissertation but since the study population entailed all of the TB cases to all those people that were immigrating into Liberia, then a larger population could have been considered to be used in the study.
The use of a small study population in examining all cases of TB raises questions for this study. Since room for error, sample results, and results skewing were smaller in this dissertation, and then it resulted in doubtable statistical results. The sample size was also an issue that was present in an article bySkolnik Richard(Skolnik, 2011). 325 employees were screened TB and HIV by the study at their places of work in Gabacounty in Monrovia, and the results indicated that the prevalent of TB was higher among the immigrant population than the general population of Monrovia. However, it is not clear if the sample size of the study population is appropriate to be used in drawing assumptions about the rate of TB infection among immigrants from all parts of the state. As all the data containing individuals with TB within Monrovia was collected and gathered by this dissertation between 2008 and 2014, it is therefore assumed that the results obtained from this dissertation contain a thorough and applicable statistics that can be used in the whole of Monrovia and beyond. Additionally, statistics has been examined that were conducted by certain researchers. These statistics have antedated the analyzed data in the study.
Therefore, a loop in the current literature has been addressed by this dissertation regarding the update of research references to the rates of TB infection and how they affect the general population of Liberia. Relevance and the validity of this dissertation may result to the extrapolation of the information it disseminates to the larger population or across the nation. As this chapter has been previewed through the analysis of the existing literature, TB still poses to be a real threat both to the immigrants in Monrovia and the general population of the state. The literature review in this chapter has also identified that it is important for officials of public health to understand the risks that are involved with these variable that affect the rate of TB infection. These variables include the status of migration, race or and ethnicity, and residence in years. Understanding the risks in these variables will help to fight these diseases. In Chapter 4, the research design, methodology, and rationale will be reviewed regarding the models and the gaps that have been mentioned in this chapter.
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