The Effectiveness of the Approach to Integration of Community Leaders in Tuberculosis Detection Chain in Rural Areas

Tuberculosis is a public health problem in Kwango Province . Assessments carried out by a CPLT Kwango (2005-2015) showed the limitations of the health professional-centered approach in detecting TB. this the study is based on the under-detection of tuberculosis observed for more than 10 years in the Kahemba Health Zone. It aimed to determine the effectiveness of the approach of involving community leaders in the detection of tuberculosis. She used a method Comparative quasiexperimental in longitudinal and prospective vision to detect from improvements in TB detection + interventions with the involvement of community leaders (experimental group) vis-à-vis those centered on the health professional (control group). The survey method and the document analysis technique were used to collect the data. Analyzes focused on the comparison test including the chi-square with which the results were compared to two levels: first in the intervention zone at different times and at different areas in the same period. Compared results from two areas revealed a significant increase in detection in the area that integrated the community approach versus the control area (90% vs. 54). The study recommended that health authorities and providers collaborate with community leaders to improve TB + detection .


Introduction
The World Health Organization estimates that about one-third of estimated TB cases are either undiagnosed or undeclared. It is often the most marginalized and disadvantaged populations that are affected, for example the poor [1] women, children, migrants, refugees, minors and drug addicts. Even when suspected cases are identified, the disease is often diagnosed and treated late. As a result, it causes more damage, and treatment may be more difficult and more expensive. Among the diseases that constitute the major problems of public health in the world, tuberculosis is a disease of poverty and sometimes it is found that health services face problems of geographical, financial and sometimes cultural accessibility for the populations. Services [2,3]. Factors that increase the risk of exposure in the community include smoking [4], undernutrition that causes malnutrition. This indeed explains the link between foods and the risk of exposure of TB, which is largely facilitated by a deficiency of immunity [5]. professionals. Hence, [6] believes that reaching out to isolated populations and improving detection and reporting of TB cases requires new and sustainable approaches that do not stop at the institutional level alone. existing health services, but which address community structures and households. The Ninth Report of the World Health Organization Committee of Experts on Tuberculosis has already supported since 1974 that it was very important to involve the community in the implementation of tuberculosis control programs, through opinion leaders and community-based organizations [7,8].
Tuberculosis control concerns all community groups including primary, secondary and university education institutions, politicoadministrative authorities, religious denominations, NGOs, CBOs, public and private enterprises, community relays, groupings young people, even the entire population (Congolese Press Agency, ACP 2018). The strength of this approach lies in the fact that if the message passes through the groupings within the community, the whole population will be informed and sensitized in less time and at a lower cost. For nearly a decade, the Kahemba Health Zone has become a shadow of its own. Under-detection of TB cases has become the rule rather than the exception. The overall annual rate of detection never exceeds 3 0% while the standard set by the NTP requires detection of at least 8 0% of expected TB in the population.
This worrying situation was an irritation for this study. The approach adopted e was to empower the community in this health area, particularly that of the city Kahemba with five health centers grouped in the Diagnosis and Treatment Health Center (TDSB) General Hospital Reference of Kahemba, through these leaders, to control tuberculosis.
The integration of this community-based approach follows the results achieved during the celebration of World TB Day on March 24, 2016, when the CPLT team organized conferences in the city of Kenge. In addition to this, three high schools and members of the provincial government were sensitized. In the aftermath of these activities, a large crowd came to the office of the CPLT.
After consultation, twelve cases of bacteriologically confirmed tuberculosis had been detected in two days. The study conducted in the Kahemba Health Zone was designed to determine the effectiveness of the approach of integrating community leaders into improving the detection of tuberculosis. In particular, it answered the following questions: what is the effectiveness of the approach of integration of community leaders in improving the detection of tuberculosis? Is their contribution significant in guiding patients and detecting TB? To answer these questions, it was first necessary to identify the actors involved in the fight against tuberculosis, namely health service providers and community leaders; second, to demonstrate the contribution of each one in the orientation of patients suspected of having tuberculosis to the screening centers; and finally compare the results obtained in time and space in terms of patient orientation, TB + detections among the oriented and finally compare the evolution of the detection in the two zones.

Literature Paper
Tuberculosis is one of the infectious diseases causing the most deaths in the world. It is also a leading cause of death among people living with HIV, accounting for 35% of deaths among this population in 2015. Tuberculosis and HIV, as well as gender-related challenges and human rights in the fight against these diseases, are therefore closely linked. Tuberculosis is a disease of poverty and inequality. A number of human rights or gender-related factors may hinder the effectiveness, accessibility and sustainability of TB programs and services, as explained in this section. The application of human rights is threatened in the lives of many people living with or at risk of TB. People who face overcrowding, poorly ventilated environments and nutritional deficiencies are vulnerable to the disease and are likely to be at a disadvantage and do not receive reliable information about TB, or no access to good TB services.
Although it is possible that these are free, poverty can affect certain factors such as transport to access or a good diet that is conducive to successful treatment [9][10][11].
Tuberculosis remains a public health problem in sub-Saharan Africa, where health services face problems of geographical, financial and sometimes cultural accessibility for the populations served have not yet included tuberculosis in their activities [13]. Improved screening in rural areas necessarily implies decentralization and the integration of tuberculosis control activities with other primary health care activities. The effective participation of communities in national planning for TB control is neither complex nor difficult to achieve. However, it requires commitment, flexibility and a strong will to build an effective TB response that benefits the entire population. Community involvement enriches the process and adds a special touch in terms of skills, knowledge, diversity and end product integrity that otherwise would not be part of it [6].
There is growing interest in the community's contribution to the provision of care for tuberculosis patients and AIDS patients [14].
Tuberculosis management involves the use of resources outside formal health systems. The involvement of the community through PATB support committees has increased the range of solutions to the problems faced by TB patients and healthcare providers. For community involvement to effectively strengthen the performance of health services, the functional integration of community-based activities into the health care system, a coherent division of tasks among all stakeholders and a balance of power relations between the different contributor's care is essential. Under these conditions, community involvement strengthens the capacity of health centers to better meet the demand for care from chronic patients [7].

Description of the Mi Place of Study
This study was conducted mainly in the city of Kahemba, locat-

Sampling Methods and Technique Collection of Donations
This study is comparative longitudinal in nature prospect.
It is based on a quasi-experimental design aimed at identifying improvements resulting from TB + detection interventions with the involvement of community leaders (Experimental Group) vis-à-vis those focused on the health professional alone (Control Group) . The Tuberculosis Screening and Treatment Center (TCSC) at Kahemba General Referral Hospital (HGR) was considered to be an intervention area (Experimental Group) and CSDT Tshiweka was the control area. A health survey method based on a simple random probability sample and the literature review were used to collect the data used as the basis for the analysis. Community leaders were selected based on an established list of community groupings. The procedure was to identify the first community groups each with its leaders from which a list used for the selection of these was prepared. As a result of this selection , 10 community groups were identified from where 207 community leaders were selected . The

S Technical Analysis Data
The collected data were analyzed using computer software  there is 3.86% for civil society coordinators and neighborhood leaders respectively; there are 1.45% for the directors general of higher education and university institutions and finally 0.97% for the chiefs of the markets (Table 1).  coughers were directed to health training by community leaders.   In control zone 98 out of 259, 38% of coughers were referred by community relays and health workers using the traditional approach .

Involvement of Community Leaders in the Orientation of Tuberculosis Patients
These results clearly indicate that s years the involvement of  (Table 3). Source: Authors (2017).

Effectiveness of Involvement of Community Leaders in
Approach Detection TB leaders, the number of detected TB + is 80 but with their involvement their TB + 62 more that were added on the 80 for a total of 142. As can be seen, the contribution of community leaders has increased significantly detection (Table 4). Source: Authors (2017). to nearly 44% in the detection because without this contribution, detection in the intervention zone would remain at 56% (Table 5). Source: Authors (2017). 28.75% and in the control area it was 21.19%. In 2017, the intervention zone reached the detection rate of 90 % but in the control zone this detection remained at 55%. It should be noted that these two areas were in a particular context. For more than ten years with the conventional approach, no structure has reached a screening rate of at least 80% as a national standard. It's a great performance for the first time in over 10 years to see that e HGR Kahemba TDSB has tracked over 80% and reach the following standard to the introduction of the approach community leaders ( Table 6). Source: Authors (2017).

Discussion on the Profile of Community Leaders
The composition of the different community groups that have Communities are not just recipients of services. They are also actors whose contribution to the improvement of health is vital.
Thus, as communities participate, programs gain a greater impact.
They expand the reach of services, involve people in health care, and overcome social rejection and discrimination [15].

Discussion on the Involvement of Community Leaders
The The results of the Table 3

Effectiveness of News has Approach Compared to the Traditional Approach to Detection TB +
The results of Table 4 [20].
The Global Plan stresses that the objectives of the Eliminate Tuberculosis program will not be achieved if current efforts continue without a paradigm shift. Of the eight areas where a paradigm shift is needed , the fourth is a community and patient-centered approach. The Global Plan requires additional and important efforts for real engagement and collaboration with key populations, people living with TB, civil society and the private sector. The plan presents an approach to identify, reach and work with key populations. Civil society and community-based organizations must play a key role in planning and delivering TB care through advocacy; actively seeking cases; improving access to care; encouraging accession; providing psychosocial support and reducing stigma; setting up monitoring programs; and facilitating community engagement in research and development [21][22][23][24][25][26].

Conclusion
The utter against tuberculosis is a challenge and should not be considered as an issue of are medical professionals only . This study , which was based on WHO recommendations summary E by E approach engage-TB , has evaluated the effectiveness of the approach involving the art community leaders in the detection of TB. The results obtained make it possible to affirm that the involvement of community leaders in the fight against tuberculosis to control tuberculosis. If properly applied, it significantly improves detection by systematically targeting coughers to health facilities for screening and management. One of the strengths of this approach is that it reaches all levels of society in less time and at a lower cost.
The results clearly show that there has been improvement in the detection rate in the intervention area compared to the year before compared to that of the intervention but also compared to the area control ( Table 6).

Recommendations
In view of the results obtained in this research, it is strongly recommended to the peripheral level health authorities, in particular the Central Office of the Health Zone (BCZS) and the Health Centers (CS) to be able to disseminate the community approach in the fight against tuberculosis. To do this, they should encourage associations to broad community-based to integrate TB + messages to other fight against TB activities in their daily activities.
Finally, encourage the sponsorship of tuberculosis patients and the creation of association of former tuberculosis patients who can well drain the others to consult the CS.