FACTORS ASSOCIATED WITH THE IMPLEMENTATION OF THE DIRECTLY

OBSERVED TREATMENT SHORT-COURSE (DOTS) STRATEGY FOR

TUBERCULOSIS CONTROL IN AKKO LOCAL GOVERNMENT AREA, GOMBE
STATE.

BY

AHMAD MUHAMMAD HUZAIFA

NOU242510878

BEING A RESEARCH PROPOSAL SUBMITTED TO THE DEPARMENT OF PUBLIC

HEALTH SCIENCE, NATIONAL OPEN UNIVERSITY OF NIGERIA, IN PARTIAL
FULFILMENT FOR THE AWARD OF MASTERS OF SCIENCE (MSC) IN PUBLIC
HEALTH

SUPERVISOR:

PROF. MUSA DAHIRU

JUNE, 2026
 CHAPTER ONE

INTRODUCTION

1.1 Introduction
Tuberculosis (TB) caused by Mycobacterium tuberculosis is one of the oldest and

most persistent infectious diseases known to humanity (WHO, 2023). For centuries it has

claimed lives across every continent, and despite remarkable advances in medicine, it

continues to do so today. What makes TB particularly difficult to fight is that it thrives

wherever poverty, overcrowding, and weak health systems exist — conditions that

unfortunately remain common in many parts of the world. The World Health Organization

(WHO, 2024) estimates that 10.8 million people fell ill with TB in 2023 and approximately

1.25 million died, making it once again the world’s leading infectious disease killer,

overtaking COVID-19. The African region bears a disproportionate share of this burden,

accounting for approximately 24% of all new cases globally (WHO, 2024).

Nigeria is at the heart of Africa’s TB crisis. According to the WHO Global

Tuberculosis Report 2024, Nigeria ranks first in Africa and sixth globally among high-

burden countries, with an estimated 499,000 new TB cases recorded in 2023 alone,

representing close to 20% of Africa’s entire TB burden (WHO, 2024). Despite over three

decades of implementing control strategies, progress has been frustratingly slow. A large

number of cases go undetected each year, many patients do not complete treatment, and

drug-resistant TB is an increasing threat (FMOH, 2021).

2
 The Directly Observed Treatment Short-Course (DOTS) strategy is the cornerstone of

Nigeria’s approach to TB control. Recommended by the WHO and adopted by Nigeria in

1993, DOTS is built on five pillars: sustained political commitment, quality-assured

bacteriological diagnosis, standardized short-course chemotherapy under direct observation,

a reliable drug supply system, and a functioning recording and reporting system (WHO,

2023). The strategy has been shown to be effective when properly implemented, but its real-

world application is shaped by countless local factors that vary from one community to the

next.

Akko Local Government Area (LGA) in Gombe State is one such community where

TB control faces unique and understudied challenges. The area’s economy is driven largely

by agriculture and artisanal mining — an occupation that significantly raises the risk of TB

through exposure to silica dust and congested living conditions (Abdulkarim et al., 2025).

Beyond these occupational risks, the wider health system in Akko grapples with dispersed

health facilities, varied levels of health-seeking behavior, and socioeconomic hardship that

complicates patients’ ability to stay on treatment (Abdullahi et al., 2024). This study was

born out of the recognition that without locally grounded evidence, interventions designed

for Akko will continue to miss the mark.

1.2 Background to the Study

The history of TB control in Nigeria mirrors the global struggle with the disease.

Nigeria established its National Tuberculosis and Leprosy Control Programme (NTBLCP) in

1993, the same year DOTS was formally adopted as national policy (FMOH, 2021). Over the

subsequent three decades, DOTS services have expanded to cover all 36 states and the

3
Federal Capital Territory. On paper, the framework is in place. In practice, however, the gap

between policy and delivery remains wide.

Nigeria’s TB notification rate has improved in recent years, reaching over 400,000

cases detected in 2024 — the highest ever recorded (WHO African Region, 2025). Yet the

WHO estimates that approximately 63,000 TB cases still go undetected annually, sustaining

community transmission (WHO African Region, 2025). Treatment success rates fall below

the WHO target of at least 90%, and the country continues to struggle with a high burden of

TB/HIV co-infection and multi-drug resistant TB (MDR-TB), which further complicates

patient management (WHO, 2024).

Gombe State, and specifically Akko LGA, sits within this broader context of a

programme that has made gains but still falls short. As the largest LGA in the state, Akko has

a heterogeneous population with differing access to health services, varying levels of

education, and occupational exposures that raise TB risk. Studies from mining communities

in Gombe State have documented poor TB knowledge and high levels of stigmatizing beliefs

among residents (Abdulkarim et al., 2025). These realities point to the need for a focused,

evidence-based assessment of what is actually happening on the ground with DOTS

implementation in this specific locality.

1.3 Problem Statement

Despite the long-standing implementation of the DOTS strategy, TB remains a serious and

unresolved public health problem in Nigeria. The country’s TB programme consistently falls

short of WHO targets, hampered by under-diagnosis, poor treatment adherence, inadequate

funding, and a fragile health system (FMOH, 2021). A scoping review by Ogbuabor and

Onwujekwe (2019) found that the effectiveness of Nigeria’s National TB Programme was
4
constrained by inadequate human resources, dilapidated infrastructure, a weak drug supply

chain, and poor governance at multiple levels. These systemic failures have real

consequences: patients who could be cured are dying, and the cycle of transmission

continues. At the level of individual patients, staying on TB treatment is not easy. Treatment

lasts at least six months, involves multiple drugs with unpleasant side effects, and requires

regular visits to a health facility — a burden that falls heavily on people who are already sick,

often poor, and sometimes stigmatized by their communities (Idoko & Adeyemi, 2022).

Studies across Nigeria report that TB-related stigma — including fear of social rejection, loss

of employment, and relationship breakdown — deters people from seeking care and from

disclosing their diagnosis, even to family members (Junaid et al., 2021). When patients

default from treatment, they not only risk their own health but also fuel the development of

drug-resistant TB strains that are far harder and more expensive to treat. What is particularly

concerning is the near-total absence of local data from Akko LGA specifically. Without

knowing the precise barriers that operate in this community, health authorities cannot design

targeted, effective responses. This study therefore sets out to fill that gap by systematically

assessing the factors associated with DOTS implementation challenges in Akko LGA —

from the perspectives of patients, healthcare workers, and the health system as a whole.

1.4 Purpose / Aim of the Study

The aim of this study is to assess the factors associated with the implementation of

the Directly Observed Treatment Short-Course (DOTS) strategy in the control of tuberculosis

in Akko Local Government Area, Gombe State, Nigeria.

1.5 Specific Objectives

5
 • To identify patient-related challenges affecting adherence to tuberculosis treatment

under the DOTS strategy.

• To determine healthcare worker-related factors influencing effective implementation

of the DOTS strategy.

• To examine health system challenges — including staffing levels, drug availability,

laboratory services, and funding — affecting DOTS implementation.

• To assess community-related factors such as stigma, health literacy, and health-

seeking behavior that influence TB control through DOTS.

1.6 Research Questions

• What patient-related challenges affect adherence to TB treatment under the DOTS

strategy in Akko LGA?

• What healthcare worker-related factors influence the effective implementation of the

DOTS strategy?

• What health system-level challenges affect DOTS implementation in the study area?

• How do community-related factors such as stigma and health literacy influence TB

control in Akko LGA?

• What is the effect of the identified challenges on treatment outcomes among TB

patients in Akko LGA?

1.7 Scope of Study

1.7.1 Subject Scope

6
 This study focuses on the challenges affecting the implementation of the DOTS

strategy in Akko LGA. It covers DOTS-accredited health facilities, healthcare workers

involved in TB diagnosis and management, and TB patients either currently receiving

treatment or who completed treatment within the 1 Year prior to data collection.

1.7.2 Geographical Scope

The study is limited to Akko Local Government Area, Gombe State, Nigeria. Akko is

the largest LGA in Gombe State and covers both urban and rural communities, making it a

representative setting for studying the range of implementation challenges that exist within a

single administrative unit (Abdullahi et al., 2024).

1.7.3 Time Scope

The study covers the period from 2019 to the time of data collection, drawing on

recent facility records, patient experiences, and healthcare worker accounts within that

window to ensure the findings reflect the current state of DOTS implementation.

1.8 Significance of the Study

This study makes a contribution at several levels. For policymakers at the state and

national levels, the findings will provide fresh, locally grounded evidence to guide decision-

making on resource allocation, training, and programme design. For healthcare managers in

Akko LGA, the results will highlight specific operational gaps that can be addressed with

targeted interventions. For community health practitioners, the study sheds light on the social

and behavioral dimensions of TB care that often go unaddressed in clinical settings.

More broadly, this study responds to a recognized gap in the literature. While TB

research in Nigeria has grown considerably, much of it focuses on the south or on large urban

centers. Evidence from the north-east, particularly from states like Gombe that are also
7
dealing with occupational TB risk factors linked to mining, is in short supply. By generating

this evidence, the study strengthens the case for context-specific TB programming across

Nigeria’s diverse regions.

1.9 Theoretical Framework

This study is guided by two program evaluation frameworks that are well suited to

assessing the implementation of a structured health intervention such as DOTS: the

Donabedian Model of Quality of Care and the Logic Model framework.

1.9.1 Donabedian Model of Quality of Care

Developed by Avedis Donabedian (1966, 1988), this model evaluates the quality of

health services through three interconnected dimensions: Structure, Process, and Outcome.

Structure refers to the conditions under which care is delivered — including staffing levels,

drug availability, laboratory infrastructure, and funding. Process refers to what is actually

done in providing care — such as whether medication is genuinely observed, whether

counseling is given, and whether patients are followed up when they miss appointments.

Outcome refers to the results of that care, including treatment success rates, default rates, and

the development of drug-resistant TB.

Applied to this study, the Donabedian Model provides a systematic framework for

categorizing and assessing the challenges affecting DOTS implementation in Akko LGA.

Patient-related and community-related barriers can be understood as factors that affect

process quality, while health system weaknesses — drug stock-outs, understaffing,

inadequate laboratories — represent structural deficiencies that undermine the capacity to

deliver DOTS as intended. Treatment outcomes, including success and default rates, then

reflect the cumulative effect of structural and process-level failures (Donabedian, 1988).

8
1.9.2 The Logic Model Framework
The Logic Model, widely used in public health program evaluation, maps the

relationship between a program’s resources (inputs), its activities, its immediate outputs, and

its longer-term outcomes (W.K. Kellogg Foundation, 2004). It is particularly useful for

evaluating implementation gaps — that is, the distance between what a program is designed

to do and what it actually does in practice.

Applied to the DOTS strategy in Akko LGA, the Logic Model helps trace the chain

from inputs (trained staff, drug supplies, laboratory equipment, funding) through activities

(case detection, direct observation, patient counseling, record-keeping) to outputs (number of

patients registered and treated) and outcomes (treatment success rates, reduction in

community TB burden). When outcomes fall short of targets, the Logic Model directs the

evaluator to examine which link in the chain is broken — whether the problem lies in

insufficient inputs, poorly implemented activities, or external factors disrupting the process.

This makes it an ideal framework for the assessment objectives of this study (Porteous et al.,

2002).

1.10 Conceptual Framework

The conceptual framework for this study illustrates the relationship between the

independent variables (implementation challenges) and the dependent variable (DOTS

implementation effectiveness/treatment outcomes). The independent variables are grouped

into four domains: (1) Patient-Related Factors — including socioeconomic status, stigma,

medication side effects, and health literacy; (2) Healthcare Worker-Related Factors —

including training, attitudes, workload, and knowledge gaps; (3) Health System Factors —

including drug supply, laboratory services, staffing, and funding; and (4) Community-

9
Related Factors — including stigma, awareness, and health-seeking behavior. These four

domains collectively influence the quality of DOTS implementation, which in turn

determines TB treatment outcomes (success, default, failure, or death).

Fig 1.1: Conceptual Framework on Challenges Affecting the Implementation of DOTS

Strategy

1.11 Operational Definition of Terms

 Directly Observed Treatment Short-Course (DOTS): The WHO-

recommended strategy for TB control in which a trained healthcare or

community worker directly supervises a patient taking each dose of anti-TB

10
 medication, combined with quality-assured diagnosis, an uninterrupted drug

supply, and a recording and reporting system.

 Implementation Challenges: Any patient-related, healthcare worker-related,

health system-related, or community-level factor that hinders the effective

delivery of the DOTS strategy.

 Treatment Adherence: The degree to which a TB patient takes anti-

tuberculosis medications as prescribed, attends all scheduled appointments,

and completes the full course of treatment.

 Treatment Default: Failure to collect prescribed anti-TB drugs for two or

more consecutive months after a patient has been registered for treatment.

 Drug-Resistant TB (MDR-TB): Tuberculosis that does not respond to at

least isoniazid and rifampicin, the two most powerful first-line anti-TB drugs.

 Stigma: Negative social attitudes, beliefs, and behaviors directed toward

individuals with tuberculosis, which may lead to discrimination, social

exclusion, and avoidance of healthcare services.

11
 CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction
The literature on tuberculosis control in sub-Saharan Africa is extensive, but much of

it points to the same uncomfortable conclusion: knowing what to do is not the same as being

able to do it. The DOTS strategy has been available for decades, and its effectiveness under

ideal conditions is not in question. What researchers have spent years trying to understand is

why, in places like Nigeria, the strategy continues to underperform despite widespread

adoption. This chapter reviews what is currently known about the DOTS strategy, the

challenges that affect its implementation, and the specific factors at play in Nigeria and in

settings similar to Akko LGA. It also outlines the theoretical frameworks that guide this

study.

2.2 The DOTS Strategy: Concept and Components

The Directly Observed Treatment Short-Course (DOTS) strategy was formalized by

the WHO in the 1990s as a response to the worsening global TB epidemic. At its core, DOTS

is built around five mutually reinforcing components: sustained political and financial

commitment from governments; quality-assured bacteriological confirmation of TB

diagnosis, primarily through sputum-smear microscopy or GeneXpert molecular testing;

standardized short-course anti-TB treatment given under direct observation; an uninterrupted

and reliable supply of quality-assured anti-TB drugs; and a standardized recording and

reporting system to monitor outcomes and programme performance (WHO, 2023).

12
 The direct observation component is the element that sets DOTS apart from simple

self-administered treatment. A trained observer — who may be a nurse, a community health

worker, or a trusted community member — watches the patient swallow each dose of

medication. This is intended to prevent the kind of irregular or incomplete treatment that

allows drug-resistant TB strains to develop (Serapelwane et al., 2016). When properly

implemented, DOTS has been shown to achieve treatment success rates above 85%, the

WHO’s minimum target. As of 2005, 187 countries had adopted DOTS, and the strategy was

credited with treating close to five million TB cases in that year alone (Serapelwane et al.,

2016).

However, the strategy’s success depends on a functioning health system able to

support all five components simultaneously. When any one element is weak — when drugs

run out, when staff are absent, when laboratory equipment breaks down, or when political

commitment translates into no actual funding — the whole system is compromised. This is

the central challenge that has characterized DOTS implementation in Nigeria and in much of

sub-Saharan Africa.

2.3 Implementation of DOTS in Nigeria

Nigeria adopted the DOTS strategy in 1993 through its National Tuberculosis and

Leprosy Control Programme (NTBLCP). Since then, DOTS services have been scaled up

progressively to cover all 36 states and the FCT, operating through a network of primary,

secondary, and tertiary health facilities (FMOH, 2021). The programme is coordinated at the

federal level by the NTBLCP, with state-level TB control programmes responsible for

implementation at the LGA level.

13
 Despite this broad coverage, Nigeria’s programme results have consistently fallen

short of WHO targets. The FMOH (2021) National Strategic Plan for TB Control

acknowledges that under-diagnosis and under-reporting are among the primary drivers of low

treatment coverage, noting that a significant proportion of estimated TB cases remain

undetected each year. This is partly because many Nigerians with TB symptoms seek care

first from patent medicine vendors, traditional healers, or private clinics that are not plugged

into the national TB reporting system, creating an invisible reservoir of untreated cases that

fuel ongoing transmission (Ogbuabor & Onwujekwe, 2019).

A systematic scoping review of TB governance in Nigeria by Ogbuabor and

Onwujekwe (2019) found that while the structural framework for TB control is largely in

place, the real-world performance of the programme is undermined by poor governance at

multiple levels. Key findings included weak stewardship from local government authorities,

poor awareness of service entitlements among both providers and users, a weak public-

private mix for service delivery, and insufficient or delayed government funding that creates

heavy dependence on external donors. The review concluded that governance failures — not

just resource constraints — are at the root of Nigeria’s TB control challenges.

The country’s highest-ever TB case notification — over 400,000 cases detected in

2024 — reflects genuine improvement in case finding (WHO African Region, 2025).

However, the WHO (2024) estimates that approximately 499,000 new cases occurred in

Nigeria in 2023, meaning a meaningful detection gap still persists. MDR-TB, TB/HIV co-

infection, and the persistence of TB in marginalized communities such as mining settlements,

prisons, and informal urban settlements continue to complicate the national response.

14
2.4 Patient-Related Challenges Affecting DOTS Implementation
Patient adherence is critical for the success of the DOTS strategy. Several factors influence

adherence, including socio-demographic characteristics such as age, gender, and educational

level (Worgu et al., 2023). Economic barriers, including the cost of transportation to DOTS

centers and the loss of income due to illness, are significant challenges (Ohamaeme et al.,

2020).

Treatment default is also driven by health factors including medication side effects and the

long duration of treatment (Idoko & Adeyemi, 2022). Stigma is a particularly powerful

barrier. A Ugandan study found that self-stigma, public stigma, and anticipated stigma were

significantly associated with missed treatment submissions under video directly observed

therapy (DOT Selfie RCT, 2020-2021). Culturally influenced misconceptions about TB

transmission — including beliefs that it is spread through kissing or shared utensils - also

contribute to care avoidance and social isolation (Frontiers, 2024).

Furthermore, patient-related psychological factors like forgetfulness and a lack of

understanding of the treatment duration often lead to non-adherence (Iweama et al., 2021).

2.4.1 Socioeconomic Factors

Economic hardship is one of the most consistently reported barriers to TB treatment

adherence in Nigeria. Although anti-TB drugs are provided free of charge through the public

health system, patients must still bear indirect costs — transportation to DOTS centers, lost

working hours, and the cost of food needed to take medication safely (Ohamaeme et al.,

2020). For daily wage earners, smallholder farmers, and the unemployed, these indirect costs

can be prohibitive. Idoko and Adeyemi (2022) found in their retrospective study at the

University of Nigeria Teaching Hospital that unemployment was significantly associated

15
with non-compliance with the DOTS treatment plan, with unemployed patients showing the

highest rates of non-adherence. This points to the reality that for many patients, staying on

treatment is not simply a matter of willpower but of economic survival.

Distance to DOTS centers is a related barrier, particularly in areas like Akko LGA

where health facilities are unevenly distributed and transport infrastructure is poor. Iweama

et al. (2021) identified distance as a significant predictor of TB treatment non-adherence in

their cross-sectional study across DOTS centers in Kano and Kaduna States, noting that

patients who lived far from facilities were significantly more likely to miss doses or default

entirely. Community-based DOT models, where trained community volunteers observe

treatment at or near the patient’s home, have been proposed and piloted as a response to this

challenge, though coverage remains inconsistent (WHO African Region, 2025).

2.4.2 Medication Side Effects and Treatment Duration

Anti-tuberculosis drugs, while effective, are not without side effects. First-line drugs

including rifampicin, isoniazid, pyrazinamide, and ethambutol can cause nausea,

hepatotoxicity, peripheral neuropathy, and a range of gastrointestinal symptoms. Idoko and

Adeyemi (2022) noted that medication side effects were among the key drivers of treatment

default in their study population, particularly during the intensive phase of treatment when

the drug burden is highest. The duration of treatment — a minimum of six months and up to

20 months for drug-resistant TB — is itself a barrier. Patients who feel better after the first

two months often see little reason to continue, especially when they are experiencing side

effects and treatment is disrupting their daily lives (Iweama et al., 2021).

2.4.3 Stigma and Its Effect on Adherence

16
 Stigma is, without question, one of the most damaging forces acting against TB

control in Nigeria. It operates at multiple levels: self-stigma, in which patients internalize

negative beliefs about themselves because they have TB; public stigma, driven by

community misconceptions about how TB spreads and who it affects; and anticipated stigma,

in which patients imagine the negative reactions of others and adjust their behavior to avoid

exposure — sometimes by not seeking care at all (Junaid et al., 2021).

A study among urban community members in Surulere, Lagos found that while most

participants were aware of TB, knowledge levels were poor and stigmatizing attitudes were

common, with a significant proportion believing that TB was a disease of the dirty or the

immoral (Junaid et al., 2021). In Gombe State specifically, Abdulkarim et al. (2025) found

that stigmatizing attitudes toward TB were prevalent in mining communities, creating a

social environment in which patients feared disclosure and often delayed seeking care. These

findings align with a broader Nigerian pattern: the fear of being labeled a TB patient, and the

social consequences that follow, keeps many people away from healthcare and undermines

adherence among those who do seek treatment.

A qualitative study published in Frontiers in Sociology examined beliefs and myths

surrounding TB among patients in Oyo State who had delayed seeking care (Okonkwo et al.,

2024). Participants described widespread beliefs that TB was spread through sharing utensils

or kissing, that it was a punishment or curse, and that revealing a TB diagnosis would lead to

social rejection. These misconceptions, deeply embedded in community culture, drive

delayed health-seeking and treatment avoidance — challenges that standardized DOTS

protocols alone cannot address.

17
2.4.4 Knowledge, Attitudes, and Health Literacy
Poor knowledge of TB — its causes, symptoms, transmission, and treatability —

contributes to both delayed diagnosis and poor adherence. Patients who do not understand

why they must take medication for months after feeling better are far more likely to stop

early. Research across Nigerian settings consistently finds gaps in TB knowledge at the

community level, and these gaps are particularly pronounced in rural areas and among people

with limited formal education (Worgu et al., 2023). Traditional healing practices represent an

additional challenge: many Nigerians consult herbalists, traditional healers, or religious

leaders before or alongside formal healthcare, which can delay the start of anti-TB treatment

and create confusion about prescribed medication regimens (Okonkwo et al., 2024).

2.5 Healthcare Worker-Related Factors

The effectiveness of DOTS is heavily dependent on the knowledge and attitudes of

healthcare workers. Challenges include a shortage of trained personnel, leading to high

workloads and long waiting times for patients (Ohamaeme et al., 2020). Inadequate training

and retraining of health workers on current TB management guidelines can result in poor

service delivery and a lack of proper patient counseling (Abdulkarim et al., 2025).

Furthermore, the motivation and commitment of healthcare workers are essential for the

rigorous “direct observation” component of the strategy, which is often poorly implemented

(Idoko & Adeyemi, 2022).

2.5.1 Staff Shortage and Workload

Nigeria faces a chronic shortage of health workers, particularly in primary healthcare

facilities. In DOTS centers, this shortage translates into high patient-to-staff ratios, long

waiting times, and an inability to provide the individualized attention that effective DOTS

18
requires. Ohamaeme et al. (2020), in their comparative analysis of DOTS implementation

across facilities in Anambra State, found that understaffing was one of the most commonly

cited system challenges by both healthcare workers and patients, and was directly linked to

compromised direct observation practices. When staff are overwhelmed, observation of

medication intake becomes cursory or is skipped entirely, undermining the very core of the

DOTS strategy.

2.5.2 Knowledge Gaps and Training Deficits

The technical knowledge of healthcare workers managing TB is not always current.

Guidelines for TB diagnosis and treatment have evolved — incorporating GeneXpert testing,

revised drug regimens, and updated MDR-TB protocols — and not all frontline staff receive

timely training on these changes. Abdulkarim et al. (2025) noted in their study of TB

knowledge among healthcare providers in Gombe State that gaps in provider knowledge

were a contributing factor to suboptimal service delivery. Inadequate counseling is a related

problem: patients who are not properly educated about what to expect from treatment are

more likely to be alarmed by side effects, confused about the duration of therapy, and

ultimately non-adherent.

2.5.3 Provider Attitudes and Stigma

Poor staff attitudes toward TB patients have been documented as a significant barrier

to care in Nigerian settings. Ogbuabor and Onwujekwe (2019) identified poor staff attitude to

patients, lack of privacy during consultations, and inadequate management of adverse drug

reactions as ethical breaches that damaged patient trust in DOTS services. When patients feel

judged, disrespected, or embarrassed during clinic visits, they are less likely to return. The

Nigerian Medical Journal (2022) reported that patient satisfaction at DOTS centers was

19
below 90%, with poor staff attitudes and lack of social support identified as key drivers of

dissatisfaction. A healthcare system that stigmatizes the very patients it is trying to help

creates a vicious cycle that fuels treatment default.

2.6 Health System Challenges

Systemic issues within the healthcare infrastructure including Weak procurement and supply

management systems are major barriers to TB control (Bello et al., 2020). Drug and

laboratory consumables stock-outs disrupt patient adherence and contribute to the emergence

of drug-resistant TB (MDR-TB) (Governance of TB Control, 2019). Inadequate laboratory

services, such as non-functional microscopes or limited access to GeneXpert machines, delay

diagnosis and treatment initiation (Ohamaeme et al., 2020). Poor funding and a lack of

sustained political commitment at the local level also affect the quality of TB services

(Abdulkarim et al., 2025).

In 2022, there were 410,000 MDR-TB cases globally, with 62,000 rifampicin-resistant cases

in the African Region alone (Frontiers Microbiology, 2025). MDR-TB requires longer, more

expensive treatment courses and worsens outcomes when health systems are already

stretched. Integration of TB services into primary healthcare, along with community-based

DOT models, has been proposed as a sustainable strategy for improving access (WHO Policy

Brief, 2025).

2.6.1 Drug Supply and Laboratory Services

An uninterrupted supply of quality anti-TB drugs is one of the non-negotiable pillars

of the DOTS strategy. Drug stock-outs, however, are a recurring reality in many Nigerian

facilities. When a patient arrives for their medication and is told it is unavailable, the

disruption to their treatment course can be severe — creating gaps that promote treatment

20
failure and, in the worst cases, the emergence of drug resistance (Ogbuabor & Onwujekwe,

2019). Ohamaeme et al. (2020) specifically identified weak procurement and supply

management as a critical operational gap in DOTS facilities, a finding that echoes reports

from across the country.

Laboratory services face similar challenges. Sputum-smear microscopy, the most

widely available diagnostic tool, has limited sensitivity, particularly in HIV-positive patients.

GeneXpert machines, which provide faster and more accurate diagnoses, have been

introduced in many Nigerian facilities, but access remains uneven, maintenance is

inconsistent, and cartridge supplies are not always reliable (FMOH, 2021). Delayed diagnosis

means delayed treatment, which means more time for transmission in the community.

2.6.2 Funding and Infrastructure

Nigeria’s TB programme is heavily dependent on external donor funding. The FMOH

(2021) National Strategic Plan noted that domestic spending on TB control is low relative to

need, and that the programme’s sustainability is threatened by fluctuating donor

commitments. This reliance on external funding creates vulnerability: when donor priorities

shift or funding is delayed, programme activities — including community outreach, patient

support, and staff training — are the first to be cut. Infrastructure at many DOTS centers is

inadequate, with poor infection control, limited space for confidential consultations, and

unreliable electricity that compromises refrigeration and laboratory equipment (Ogbuabor &

Onwujekwe, 2019).

Recent warnings from the WHO (2024) about funding cuts to the Global Fund and

USAID-supported programmes are particularly alarming in this context. Nigeria is among the

countries most exposed to these cuts, and any reduction in external support for community

21
engagement, sample transport, and drug supply chains could reverse hard-won gains in case

detection and treatment success.

2.6.3 Drug-Resistant Tuberculosis

The emergence of MDR-TB is both a consequence and a driver of health system

failure. Globally, an estimated 390,000 people developed MDR-TB in 2024, and the WHO

African Region accounted for approximately 57,000 of these cases (WHO African Region,

2025). MDR-TB requires treatment regimens that are longer, more toxic, more expensive,

and harder to administer than standard first-line therapy. In settings where the health system

is already stretched, managing MDR-TB places enormous additional demands on resources,

infrastructure, and staff. Nigeria carries a significant share of this burden, and the FMOH

(2021) has identified MDR-TB as one of the most pressing challenges facing the national TB

programme.

2.7 Community-Related Factors

TB control cannot succeed within the four walls of a health facility alone. The

community from which patients come — its beliefs, its social structures, its relationship with

formal healthcare — plays a decisive role in whether people seek care, how quickly they do

so, and whether they complete treatment.

2.7.1 Community Awareness and Health-Seeking Behavior

Community awareness about TB remains limited in many parts of Nigeria,

particularly in rural and semi-urban areas. Worgu et al. (2023) found in their study of TB

patients at DOTS centers across Nigerian states that a significant proportion of patients had

poor baseline knowledge of TB transmission and treatability, which delayed their initial

health-seeking. Many patients in these studies reported visiting patent medicine vendors,

22
traditional healers, or private clinics for months before being correctly diagnosed and

referred to a DOTS center. This diagnostic delay means that by the time patients reach a

DOTS center, they may have already infected others and their disease may have progressed.

Stigma remains a pervasive challenge in TB control, often leading to delayed health-seeking

behavior and social isolation of patients (Abdulkarim et al., 2025). Community awareness

regarding TB symptoms and the availability of free treatment is often low, particularly in

rural and underserved areas (Worgu et al., 2023). Cultural beliefs and the use of traditional

medicine as a first line of treatment also contribute to delays in diagnosis and poor treatment

outcomes (Iweama et al., 2021).

Breakthrough ACTION (2024) documented through qualitative research with

Nigerian communities that myths and misconceptions about TB are widespread, and that

stigma is a major driver of delayed care-seeking behavior. People with TB symptoms often

know something is wrong but choose to manage it quietly at home or through informal

providers rather than risk a TB diagnosis and the social consequences that follow. This

pattern — of awareness without action — is a critical gap that community-level interventions

need to address.

2.7.2 The Role of Community and Family Support

While community stigma is a barrier, community and family support can also be a

powerful enabler of treatment completion. Patients who have a family member, friend, or

community health worker supporting them through treatment are significantly more likely to

adhere (Iweama et al., 2021). Community-based DOT, in which a trusted community

member rather than a health facility worker observes medication intake, has been shown to

improve adherence in resource-limited settings by reducing the travel burden and placing the

23
patient in a supportive rather than clinical environment. However, the success of community-

based DOT depends on proper training, supervision, and support for community volunteers

— elements that require sustained programme investment (WHO African Region, 2025).

2.8 Empirical Review of Studies in Nigeria

Several studies conducted across Nigeria’s diverse geopolitical zones provide

important empirical grounding for this research.

Idoko and Adeyemi (2022) conducted a retrospective study at the University of

Nigeria Teaching Hospital and found that only 50% of TB patients were fully compliant with

the DOTS treatment plan. Occupation and marital status were significant predictors of

adherence, with unemployed patients and those who were single showing higher rates of non-

compliance. The study recommended the establishment of more DOTS centers closer to

communities and more frequent programme reviews as strategies to improve compliance.

Iweama et al. (2021) enrolled 712 TB patients from 25 DOTS centers in Kano and

Kaduna States in a facility-based cross-sectional study. They reported a non-adherence rate

of 30.5% and identified distance to health facilities, TB/HIV co-infection, and prolonged

treatment duration as the strongest predictors of non-adherence. Their findings underline the

logistical and clinical complexity of maintaining DOTS adherence in the north-west, a region

with geographical and socioeconomic characteristics similar to Gombe State.

Ohamaeme et al. (2020) assessed DOTS implementation across 32 accredited

facilities in Anambra State, combining questionnaire surveys with observation checklists and

in-depth interviews. They found adherence rates of 86.2% in rural facilities and 87.6% in

urban facilities — figures that, while above the national average, still fall below the WHO

24
target. Critical system gaps identified included drug stock-outs, understaffing, and inadequate

infection control measures. The use of a mixed-methods approach and an observation

checklist in this study is particularly relevant to the methodology of the current research.

Ogbuabor and Onwujekwe (2019), through their comprehensive scoping review of

TB governance in Nigeria, synthesized the structural and governance factors that undermine

the national TB programme. Their finding that public spending on TB is low, governance at

the local level is weak, and the programme is highly dependent on external donors provides

the structural backdrop against which all facility and patient-level challenges must be

understood.

In Gombe State, Abdulkarim et al. (2025) examined TB knowledge, attitudes, and

practices among mining community members in Gombe and found significant gaps in TB

literacy combined with high levels of stigmatizing attitudes. Workers in mining communities

showed higher rates of respiratory symptoms consistent with TB but were reluctant to seek

formal healthcare, both because of stigma and because of the disruption that a TB diagnosis

would cause to their employment. This study provides directly relevant local context for the

present research, given that mining is a major economic activity in Akko LGA.

Together, these studies paint a picture of a programme that is structurally present

across Nigeria but functionally compromised by a combination of patient-level, provider-

level, system-level, and community-level barriers. What is missing from this body of

literature is a focused assessment from Akko LGA — a gap this study directly addresses.

25
 CHAPTER THREE

METHODOLOGY

3.1 Methodology
This study uses a quantitative research methodology with a descriptive, cross-

sectional survey design. Quantitative methods are appropriate here because the study aims to

measure the prevalence of specific implementation challenges, identify their distribution

across different stakeholder groups, and examine statistical associations between identified

challenges and treatment outcomes. A cross-sectional design allows data to be collected from

multiple respondent groups at a single point in time, providing a contemporaneous snapshot

of DOTS implementation in Akko LGA (Polit & Beck, 2021).

3.2 Research Design

The study adopts a descriptive cross-sectional survey design. This design is well-

suited to the research objectives because it permits the simultaneous collection of data from

patients, healthcare workers, and facility-level records without the time and resource

demands of a longitudinal study. Descriptive cross-sectional designs are widely used in

health systems research to assess programme implementation and identify priority areas for

intervention (Polit & Beck, 2021). The study does not manipulate any variable or assign

participants to interventions; it observes and describes conditions as they exist.

26
3.3 Study Population
The study population consists of three groups:

1. TB patients currently receiving treatment or who completed treatment within the six

months prior to data collection at any DOTS-accredited facility in Akko LGA.

2. Healthcare workers (including nurses, community health officers, laboratory

technicians, and TB focal persons) directly involved in TB management at DOTS

centers in Akko LGA.

3. Health facility managers and TB focal persons at DOTS-accredited facilities within

the LGA.

3.4 Sample Size and Sampling Design

The sample size for TB patients will be calculated using the Cochran (1977) formula

for cross-sectional surveys:

2
Z P(1−P)
n=
d2

Where:

n = required sample size

Z = confidence level at 95% (1.96)

P = estimated prevalence of treatment adherence or challenges (50%/0.5 for maximum

sample size)

d = margin of error (0.05)

27
 Using these values, the minimum sample size is approximately 384 TB patients. To

account for possible non-responses and incomplete records, a 10% addition will be applied,

bringing the target to 423 participants. For healthcare workers and facility managers, all

available staff directly involved in DOTS services at selected facilities will be included

through purposive sampling, with an estimated target of 60–80 respondents.

A multi-stage sampling technique will be used for patient selection:

1. Stage 1 — Facility selection: All DOTS-accredited health facilities in Akko LGA

will be identified from the Gombe State TB Control Programme register.

Facilities will then be stratified into urban and rural categories, and a sample will

be drawn from each stratum using simple random sampling to ensure

representativeness across geographic settings.

2. Stage 2 — Patient selection: From each selected facility, eligible TB patients will

be identified from facility registers. Systematic random sampling will then be

used to select patients, with the sampling interval calculated based on the total

registered patient population and the required sample size.

3. Stage 3 — Healthcare worker selection: All healthcare workers directly involved

in DOTS service delivery at selected facilities will be included through census

sampling, given the relatively small size of this population.

3.4 Data Source

Primary data will be used. Primary data will be collected directly from TB patients

and healthcare workers using structured questionnaires.

28
3.4. 3.5 Data Collection Instruments
Structured Questionnaire: A researcher-administered questionnaire will be used with

both TB patients and healthcare workers. The patient questionnaire will cover

sociodemographic information, treatment experience, knowledge of DOTS, and perceived

barriers to adherence. The healthcare worker questionnaire will cover training history,

knowledge of TB management guidelines, workload, attitudes toward patients, and self-

assessed challenges in delivering DOTS services.

3.4.2 Ethical Considerations

Ethical approval will be obtained from the appropriate Institutional Review Board

and the Gombe State Ministry of Health. All participants will provide written informed

consent. Confidentiality and anonymity will be maintained throughout. Participation will be

voluntary, and participants may withdraw at any time without penalty.

3.6 Measurement of Variables

The key variables and their measurement approaches are as follows: level of DOTS

implementation will be measured through facility observation checklists scored against a

standardized rubric; patient adherence will be measured through self-reported behavior and

facility treatment records; patient-level barriers will be measured using validated barrier

scales adapted for the Nigerian context; healthcare worker knowledge and attitudes will be

assessed using scored questionnaires; health system challenges including drug availability

and staffing will be measured through checklist scores and records review; and community-

level factors including stigma and awareness will be assessed using Likert-scale items from

validated TB stigma and knowledge tools.

29
3.7 Validity and Reliability of Research Instrument
Content validity will be established through expert review: the questionnaires and

checklists will be reviewed by at least three public health specialists and TB programme

experts for relevance, clarity, and comprehensiveness before finalization. A pilot study will

be conducted at a DOTS facility in Gombe LGA — a setting with similar characteristics to

Akko LGA but not included in the main study — to test instrument clarity and completion

time. Internal consistency of the questionnaire scales will be assessed using Cronbach’s alpha

coefficient, with a minimum acceptable threshold of 0.70. Any items with poor item-total

correlation will be revised or removed before the main data collection.

3.8 Data Processing and Analysis

Completed questionnaires will be reviewed for completeness and accuracy in the

field. Data will be entered into SPSS version 26.0 for analysis. Descriptive statistics —

including frequencies, percentages, means, and standard deviations — will be used to

summarize the characteristics of respondents and the distribution of identified challenges.

Chi-square tests will be used to examine associations between categorical variables, such as

the relationship between healthcare worker training status and self-reported DOTS

compliance. Where applicable, logistic regression will be used to identify independent

predictors of poor treatment outcomes. A significance level of p < 0.05 will be used

throughout.

3.9 Limitations and Problems Anticipated

Several limitations are anticipated. First, self-reporting bias may affect both patient

and healthcare worker responses: patients may over-report adherence behavior, and

healthcare workers may describe their practices in more favorable terms than the reality

30
warrants. Second, patients who have defaulted from treatment entirely are unlikely to be

present at facility clinics and may therefore be underrepresented, which could lead to an

underestimate of the true non-adherence burden. Third, as a cross-sectional study, the design

cannot establish causality — only associations between identified challenges and outcomes.

Fourth, the findings will be specific to Akko LGA and may not be directly generalizable to

other Nigerian LGAs, although they will be informative for settings with similar

characteristics. These limitations will be acknowledged in the discussion of findings and

taken into account in the interpretation of results.

3.10 Expected Outcome

This study is expected to produce a detailed, evidence-based profile of the patient-

related, healthcare worker-related, health system-level, and community-level challenges

affecting DOTS implementation in Akko LGA. Specifically, the study expects to: identify

the most prevalent barriers to DOTS adherence from the perspectives of both patients and

healthcare workers; document the gaps in health system readiness at DOTS-accredited

facilities in the LGA; quantify the relationship between identified challenges and treatment

outcomes; and generate a set of practical, context-specific recommendations for the Gombe

State Ministry of Health, the NTBLCP, and community health stakeholders to act on. These

recommendations will be grounded in the evidence collected and informed by what has

worked in comparable Nigerian and sub-Saharan African settings.

31
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34
 APPENDIX I

RESEARCH QUESTIONNAIRE

Dear Respondent,

I am AHMAD MUHAMMAD HUZAIFA, a Master of Science (MSc) in Public Health

student at the National Open University of Nigeria (NOUN). I am conducting a research
study on the FACTORS ASSOCIATED WITH THE IMPLEMENTATION OF THE
DIRECTLY OBSERVED TREATMENT SHORT-COURSE (DOTS) STRATEGY
FOR TUBERCULOSIS CONTROL IN AKKO LOCAL GOVERNMENT AREA,
GOMBE STATE, NIGERIA. Your participation in this study is entirely voluntary. The
information you provide will be treated with the utmost confidentiality and used strictly for
academic research purposes. Please answer the questions as honestly as possible.

Do you consent to participate in this study? [ ] Yes [ ] No (If no, please return the
questionnaire)

SECTION A: SOCIO-DEMOGRAPHIC CHARACTERISTICS

(Please tick [√] the appropriate box or fill in the blank spaces)

Age (in years): [ ] 18 - 25 [ ] 26 - 35 [ ] 36 - 45 [ ] 46 - 55 [ ] 56 and above

Gender: [ ] Male [ ] Female

Marital Status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed

Highest Level of Education: [ ] No formal education [ ] Primary education [ ] Secondary

education [ ] Tertiary education

Occupation: [ ] Farming [ ] Artisanal Mining [ ] Civil Servant [ ] Trading/Business [ ]

Unemployed [ ] Others (Please specify): ___________________________

35
Estimated Monthly Income (Naira): [ ] Less than ₦30,000 [ ] ₦30,000 - ₦50,000 [ ]
₦51,000 - ₦100,000 [ ] Above ₦100,000

Category of Respondent: [ ] TB Patient (Currently on treatment or completed within the last

1 year) [ ] Healthcare Worker (Involved in TB management)

(If you are a TB Patient, please answer Sections B, D, and E. If you are a Healthcare
Worker, please answer Sections C, D, and E.)

SECTION B: PATIENT-RELATED CHALLENGES AFFECTING ADHERENCE TO

TB TREATMENT

(For TB Patients Only) Please indicate your level of agreement with the following
statements. (SA = Strongly Agree, A = Agree, N = Neutral, D = Disagree, SD = Strongly
Disagree)

S/N Statement SA A N D SD

8 The distance from my home to the DOTS center

makes it difficult to attend appointments.

9 The cost of transportation to the health facility is a

major burden for me.

10 The side effects of the TB medications make me

want to stop taking them.

11 I sometimes forget to take my medications at the

right time.

12 I feel that taking many pills every day is too

stressful.

13 I stopped taking my drugs when I started feeling

better before completing the 6 months.

36
 14 Lack of adequate food makes it difficult for me to
take my TB drugs.

SECTION C: HEALTHCARE WORKER-RELATED FACTORS INFLUENCING

DOTS IMPLEMENTATION

(For Healthcare Workers Only) Please indicate your level of agreement with the following
statements. (SA = Strongly Agree, A = Agree, N = Neutral, D = Disagree, SD = Strongly
Disagree)

S/N Statement SA A N D SD

15 I have received adequate and up-to-date training on

the DOTS strategy.

16 The workload at the DOTS center is too heavy for

the available staff.

17 I have enough time to properly counsel each TB

patient during their visits.

18 Fear of contracting TB affects my attitude towards

treating TB patients.

19 There is a lack of motivation or incentives for staff

working in the TB unit.

20 I am able to effectively follow up with patients who

miss their appointments.

SECTION D: HEALTH SYSTEM CHALLENGES AFFECTING DOTS

IMPLEMENTATION

(For Both Patients and Healthcare Workers) Please indicate your level of agreement with
the following statements. (SA = Strongly Agree, A = Agree, N = Neutral, D = Disagree, SD
= Strongly Disagree)

37
 S/N Statement SA A N D SD

21 Anti-TB drugs are always available at the health

facility without stock-outs.

22 The laboratory services for TB diagnosis (e.g.,

GeneXpert, sputum smear) are reliable and fast.

23 The health facility has adequate infrastructure (e.g.,

waiting areas, ventilation) for TB care.

24 There are enough healthcare workers at the facility

to attend to TB patients promptly.

25 The recording and reporting system for TB cases is

efficient and well-maintained.

26 Funding for TB control activities at the local

government level is adequate.

SECTION E: COMMUNITY-RELATED FACTORS (STIGMA AND HEALTH

LITERACY)

(For Both Patients and Healthcare Workers) Please indicate your level of agreement with
the following statements. (SA = Strongly Agree, A = Agree, N = Neutral, D = Disagree, SD
= Strongly Disagree)

S/N Statement SA A N D SD

27 People in my community avoid interacting with

individuals known to have TB.

28 Fear of being stigmatized or rejected prevents people

from seeking TB testing.

29 TB patients often hide their diagnosis from family

members and friends.

30 There is a general belief in the community that TB is

38
 caused by witchcraft or a curse.

31 People in the community have a good understanding

of how TB is transmitted and cured.

32 Community leaders actively support and encourage

TB patients to complete their treatment.

Thank you for your time and cooperation.

39