Tuberculosis and stigmatization: pathways and interventions

Major Depression and Stigma among Individuals with Multidrug-Resistant Tuberculosis in South Africa

Stigma is an important social determinant of health-seeking behavior; however, the nature and extent of its association with depression among people living with multidrug-resistant tuberculosis (MDR-TB) are not well-understood. We enrolled 200 microbiologically confirmed MDR-TB inpatients at a TB specialist hospital in KwaZulu-Natal Province, an area considered the epicenter for MDR-TB coinfection in South Africa. Four aspects of stigma and their association with major depression were assessed through individual interviews: 1) community and 2) patient perspectives toward TB, and 3) community and 4) patient perspectives toward HIV. A major depressive episode (MDE), HIV coinfection, and low income were significantly associated with greater stigma subscales. Based on an adjusted regression model, the MDE was the only factor independently associated with (all aspects of) stigma. These results indicate the potential utility of addressing stigma associated with the MDE as an important step in improving health-seeking behavior to promote adherence and retention in care.

Multidrug-Resistant Tuberculosis in Portugal: Patients’ Perception of the Challenges Faced during Treatment

<b><i>Introduction:</i></b> The increase in drug-resistant tuberculosis (TB) threatens global progress in eliminating TB, and constitutes a major challenge for patients, health-care workers and health services. Treatment for multidrug-resistant TB (MDR-TB) can last almost 2 years, and is more expensive, more toxic, and less effective than treating TB caused by drug-sensitive bacilli. This study aims to analyze patients’ narratives about the challenges they face during MDR-TB treatment and identify the support factors that help patients being treated in the most populous district of Portugal. <b><i>Methods:</i></b> Semi-structured interviews were conducted with patients being treated for MDR-TB. The interviews were coded using thematic analysis. They were audio-recorded, transcribed, and transported into NVivo v12 for data management and coding. <b><i>Results:</i></b> Depression, social discrimination, and the side effects of drugs are the main challenges faced by patients with MDR-TB. A good relationship of the patients with the health team, emotional support, and supervised treatment stand out as the factors that generate better adherence and treatment success. <b><i>Conclusion:</i></b> In addition to modern diagnostic techniques and new treatments, MDR-TB can be fought by focusing on the care and needs of patients. We suggest that the Lisbon Tuberculosis Program adopts the following measures: build the health-care team’s capacity to identify symptoms of depression early, increase public awareness of the disease, expand the multidisciplinary team, and expand the options for individualized social support for patients.

Characterizing and Measuring Tuberculosis Stigma in the Community: A Mixed-Methods Study in Cambodia

Background

Stigma is a significant barrier to healthcare and a factor that drives the global burden of tuberculosis (TB). However, there is a scarcity of information on TB stigma in developing countries. We aimed to characterize, measure, and explore the determinants of TB stigma among people with TB in Cambodia.

Methods

We conducted a mixed-methods study between February and August 2019 using a triangulation convergent design—a cross-sectional survey (n = 730) and nested in-depth interviews (n = 31) among people with TB. Quantitative data were analyzed using descriptive statistics and generalized linear regression models. Qualitative transcripts were thematically analyzed.

Results

A total of 56% and 51% of participants experienced self-stigma and perceived stigma by the community, respectively. We found rural dwellers, knowledge of how TB is transmitted, and knowledge that anybody can get TB were associated with higher levels of self-stigma and perceived stigma by the community. Higher scores on knowledge of TB symptoms were inversely associated with both self-stigma and community stigma. Thematic analyses revealed accounts of experienced stigma, acts of intentional distancing and hiding TB diagnosis from others, and feelings of embarrassment and shame.

Conclusions

Tuberculosis stigma was prevalent, suggesting a need for the incorporation of stigma-reduction strategies in the national TB responses. These strategies should be contextualized and developed through community engagement. Future research should continue to measure the levels and dimensions of TB stigma among people with TB through behavioral surveillance using standardized tools.

Knowledge, attitudes, beliefs, and stigma related to latent tuberculosis infection: a qualitative study among Eritreans in the Netherlands

Background

Tailored and culturally appropriate latent tuberculosis (TB) infection screening and treatment programs, including interventions against TB stigma, are needed to reduce TB incidence in low TB incidence countries. However, we lack insights in stigma related to latent TB infection (LTBI) among target groups, such as asylum seekers and refugees. We therefore studied knowledge, attitudes, beliefs, and stigma associated with LTBI among Eritrean asylum seekers and refugees in the Netherlands.

Methods

We used convenience sampling to interview adult Eritrean asylum seekers and refugees: 26 semi-structured group interviews following TB and LTBI related health education and LTBI screening, and 31 semi-structured individual interviews with Eritreans during or after completion of LTBI treatment (November 2016–May 2018). We used a thematic analysis to identify, analyse and report patterns in the data.

Results

Despite TB/LTBI education, misconceptions embedded in cultural beliefs about TB transmission and prevention persisted. Fear of getting infected with TB was the cause of reported enacted (isolation and gossip) and anticipated (concealment of treatment and self-isolation) stigma by participants on LTBI treatment.

Conclusion

The inability to differentiate LTBI from TB disease and consequent fear of getting infected by persons with LTBI led to enacted and anticipated stigma comparable to stigma related to TB disease among Eritreans. Additional to continuous culturally sensitive education activities, TB prevention programs should implement evidence-based interventions reducing stigma at all phases in the LTBI screening and treatment cascade.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12889-020-09697-z.

Reducing HIV- and TB-Stigma among healthcare co-workers in South Africa: Results of a cluster randomised trial

RATIONALE

The HIV and TB co-epidemic has a severe impact on the South African healthcare workforce and health system. HIV- and TB- stigma directed from healthcare workers (HCWs) towards colleagues not only has a negative impact on the mental health and well-being of the HCWs, but has been identified as a barrier to their own health-seeking behaviour. It also increases the strain on the health system due to absenteeism.

OBJECTIVE

This cluster-randomised trial tested an intervention to reduce HIV- and TB-stigma among HCWs. The intervention, based on the theory of Diffusion of Innovations consisted of training healthcare workers as change agents in a Social and Behavioural Change Communication workshop to help them change stigmatising attitudes in the workplace. This was supported by a social marketing campaign.

METHODS

Eight hospitals in the Free State province were randomised into intervention and control group in a stratified study design. 652 respondents randomly drawn from the hospitals were surveyed on aspects of HIV and TB stigma once in 2016 and again in 2018. Since the study only used four hospitals per intervention arm, cluster-based summaries were compared when analysing the intervention effect, using the nonparametric Mann-Whitney test. To explore how the intervention worked, 24 qualitative focus groups were conducted following the intervention.

RESULTS

The quantitative test did not show a significant intervention effect on stigma between intervention and control groups. Qualitative evidence reported new awareness and changed behaviour related to HIV- and TB-stigma among individual HCWs, but a combination of factors including strong social hierarchies in the workplace and the down-scaling of the original version of the intervention seemed to reduce the impact. Conclusion The findings did not indicate a significant intervention effect, but show the potential of using HCWs as change agents to reduce HIV and TB stigma in their local communities.

Burden of stigma among tuberculosis patients in a pastoralist community in Kenya: A mixed methods study

BACKGROUND

Tuberculosis (TB) stigma remains a barrier to early diagnosis and treatment completion. Increased understanding of stigma is necessary for improved interventions to minimise TB stigma and its effects. The purpose of this study is to quantitatively measure TB stigma and to explore qualitatively its manifestation among TB patients in a rural Kenyan community.

METHODS

This hospital based study using explanatory sequential mixed methods approach was conducted in 2016. In the quantitative part of the study, a questionnaire containing socio-demographic characteristics and scales measuring perceived TB stigma and experienced TB stigma, was administered to 208 adult pulmonary TB patients receiving treatment in West Pokot County. Respondents with high stigma were purposively selected to take part in in-depth interviews and focus group discussions. The qualitative data were collected through 15 in-depth interviews and 6 focus group discussions with TB patients. Descriptive and bivariate analysis was done for the quantitative data while the thematic analysis was done for qualitative data.

RESULTS

The internal consistency reliability coefficients were satisfactory with Cronbach alphas of 0.87 and 0.86 for the 11-item and 12-item stigma measurement scale. The investigation revealed that TB stigma was high. The key drivers of TB stigma were the association of TB with HIV/AIDS and the fear of TB transmission. TB stigma was exemplified through patients being isolated by others, self-isolation, fear to disclose TB diagnosis, association of TB with human immunodeficiency virus (HIV) and lack of social support. Being a woman was significantly associated with high levels of both experienced stigma (p = 0.007) and perceived stigma (p = 0.005) while age, marital status, occupation and the patient's religion were not.

CONCLUSION

There is a need to implement stigma reduction interventions in order to improve TB program outcomes.

[Barriers and Potential Improvements in the Diagnosis and Treatment of Asylum Seekers with Tuberculosis in Germany: A Qualitative Study]

Since 2014, the number of new cases of tuberculosis (TB) has risen in Germany by about 20%. This coincides with a large number of people applying for asylum in Germany. Some of them are from countries in which TB is much more prevalent than in Germany. The objectives of this contribution are to identify and explain barriers in the diagnosis and treatment of asylum seekers with TB and potential improvements in those fields. Data are derived from 14 problem-centred interviews that were carried out with doctors and staff from public health offices, representing the views of experts in the field of health care. On the one hand, the results suggest that structural factors are responsible for some of the barriers mentioned by the experts. For example, the restricted access to health care for asylum seekers leads to a delayed diagnosis since they visit the doctor too late (if at all). Accordingly, a nationwide implementation of an electronic health card for asylum seekers was proposed. On the other hand, individual and cultural factors play important roles as well. To those belong language barriers: they not only complicate history taking and diagnosis, but also educating patients about their disease and therapy. Moreover, the lack of knowledge concerning the German health care system increases the risk of treatment interruptions. To alleviate those problems, experts propose to carry out train-the-trainer-programmes and to install "guides" who pilot asylum seekers with TB through the German health care system.

Multidrug-resistant tuberculosis in children and adolescents: current strategies for prevention and treatment

INTRODUCTION

An estimated 30,000 children develop multidrug-resistant (MDR) tuberculosis (TB) each year, with only a small proportion diagnosed and treated. This field has historically been neglected due to the perception that children with MDR-TB are challenging to diagnose and treat. Diagnostic and therapeutic developments in adults have improved pediatric management, yet further pediatric-specific research and wider implementation of evidence-based practices are required.

AREAS COVERED

This review combines the most recent data with expert opinion to highlight best practice in the evaluation, diagnosis, treatment, and support of children and adolescents with MDR-TB disease. A literature search of PubMed was carried out on topics related to MDR-TB in children. This review provides practical advice on MDR-TB prevention and gives updates on new regimens and novel treatments. The review also addresses host-directed therapy, comorbid conditions, special populations, psychosocial support, and post-TB morbidity, as well as identifying outstanding research questions.

EXPERT OPINION

Increased availability of molecular diagnostics has the potential to aid with the diagnosis of MDR-TB in children. Shorter MDR-TB disease treatment regimens have made therapy safer and shorter and further developments with novel agents and repurposed drugs should lead to additional improvements. The evidence base for MDR-TB preventive therapy is increasing.

Unmasking the human face of TB- The impact of tuberculosis on the families of patients

BACKGROUND

As per the World Health Organization (WHO) Global Report 2017, among the 9.6 million cases of tuberculosis (TB) that occur annually in the world, 2.8 million are found in India. TB is the biggest killer in the 15 to 49 years age group-an age range during which people are the most productive. It is a disease that creates and thrives in poverty. Several studies have shown that TB has a negative impact on the socioeconomic status of patients. Limited data are available on the long-term impact of this disease on the families of patients.

AIMS

This study aimed to analyze the impact of TB on the socioeconomic condition and educational status of the family members of patients and the nutritional status of children younger than 12 years in the family of the patient.

METHODS

This was a retrospective cohort study conducted in Vellore, Tamil Nadu, India in the month of March 2017. The exposed group consisted of families with a member who completed treatment for TB in the past 5 years obtained from two tuberculosis units under the Revised National Tuberculosis Control Programme. The unexposed group was composed of families in the same neighborhood as the exposed families, matched for the age of one child.

RESULTS

Upon analysis, the multifaceted impact of TB led to an increased risk of "financial crises," delayed and disrupted education among children, and wasting among children younger than 5 years (as measured by weight-for-height Z scores). Older children and adults were also at a higher risk of being undernourished as assessed by BMI-for-age Z scores and BMI, respectively. Reduced social participation as a marker of stigma was found to be higher but not statistically significant.

CONCLUSIONS

This study found that despite the obvious multifaceted impact of TB on the family, the screening and protective measures often fail to encompass the scope of the disease. These are of great importance to the primary physician, often the only contact of the medical fraternity with the family members of patients.

Tuberculosis in migrants - screening, surveillance and ethics

Tuberculosis (TB) is the leading infectious cause of human mortality and is responsible for nearly 2 million deaths every year. It is often regarded as a 'silent killer' because it predominantly affects the poor and marginalized, and disease outbreaks occur in 'slow motion' compared to Ebola or coronavirus 2 (COVID-19). In low incidence countries, TB is predominantly an imported disease and TB control in migrants is pivotal for countries to progress towards TB elimination in accordance with the World Health Organisations (WHO's) End TB strategy. This review provides a brief overview of the different screening approaches and surveillance processes that are in place in low TB incidence countries. It also includes a detailed discussion of the ethical issues related to TB screening of migrants in these settings and the different interests that need to be balanced. Given recognition that a holistic approach that recognizes and respects basic human rights is required to end TB, the review considers the complexities that require consideration in low-incidence countries that are aiming for TB elimination.

Insights into culturally appropriate latent tuberculosis infection (LTBI) screening in NSW: perspectives of Indian and Pakistani migrants

OBJECTIVE

Latent tuberculosis (LTBI) case-finding and treatment are a focus of TB elimination in Australia. We sought the perspectives of migrants from two high-burden countries likely to be targeted by this strategy.

METHODS

To understand perceptions of migrant groups in Australia on LTBI screening, 28 in-depth interviews were conducted with Indian and Pakistani community members recruited purposively through local organisations in the Illawarra region, New South Wales. Drawing on local TB policy, data collected qualitatively was analysed using framework methodologies.

RESULTS

Australia's immigration system prioritises migrants of higher socioeconomic status. Participants supported elimination but perceived TB as a disease of the poor and not relevant to them. Lack of understanding of LTBI and sensitivity to being 'targeted' are further barriers to screening participation.

CONCLUSION

Information provision and targeting rationale are an essential preamble to LTBI screening. Migration appears to modify cultural attitudes to TB, but not significantly. Despite less stigma surrounding TB in Australian contexts, testing privacy and confidentiality, and limiting public identification of specific groups remain important to program acceptability. Implications for public health: Progress towards TB elimination can be enhanced by consulting with targeted communities, using existing networks for communication and service provision; emphasising prevention benefits.

Perspectives and practices of health workers around diagnosis of paediatric tuberculosis in hospitals in a resource-poor setting - modern diagnostics meet age-old challenges

BACKGROUND

Detection of tuberculosis (TB) in children in Kenya is sub-optimal. Xpert MTB/RIF® assay (Xpert®) has the potential to improve speed of TB diagnosis due to its sensitivity and fast turnaround for results. Significant effort and resources have been put into making the machines widely available in Kenya, but use remains low, especially in children. We set out to explore the reasons for the under-detection of TB and underuse of Xpert® in children, identifying challenges that may be relevant to other newer diagnostics in similar settings.

METHODS

This was an exploratory qualitative study with an embedded case study approach. Data collection involved semi-structured interviews; small-group discussions; key informant interviews; observations of TB trainings, sensitisation meetings, policy meetings, hospital practices; desk review of guidelines, job aides and policy documents. The Capability, Opportunity and Motivation (COM-B) framework was used to interpret emerging themes.

RESULTS

At individual level, knowledge, skill, competence and experience, as well as beliefs and fears impacted on capability (physical & psychological) as well as motivation (reflective) to diagnose TB in children and use diagnostic tests. Hospital level influencers included hospital norms, processes, patient flows and resources which affected how individual health workers attempted to diagnose TB in children by impacting on their capability (physical & psychological), motivation (reflective & automatic) and opportunity (physical & social). At the wider system level, community practices and beliefs, and implementation of TB programme directives impacted some of the decisions that health workers made through capability (psychological), motivation (reflective & automatic) and opportunity (physical).

CONCLUSION

We used comprehensive approaches to identify influencers of TB case detection and use of TB diagnostic tests in children in Kenya. These results are being used to design a contextually-appropriate intervention to improve TB diagnosis, which may be relevant to similar low-resource, high TB burden countries and can be feasibly implemented by the National TB programme.

Knowledge and stigma of latent tuberculosis infection in Brazil: implications for tuberculosis prevention strategies

BACKGROUND

Tuberculosis (TB) elimination requires treatment of millions of persons with latent M. tuberculosis infection (LTBI). LTBI treatment acceptance depends on population-wide TB knowledge and low stigma, but limited data are available on the relationship between stigma and knowledge. We assessed knowledge of TB disease and LTBI throughout Brazil and examined their association with TB stigma and incidence.

METHODS

We performed a nationwide survey with multi-stage probability design through AmericasBarometer from April-May 2017; the sample was representative of Brazil at regional and national levels. Knowledge of and stigma toward TB were assessed by validated survey questions.

RESULTS

Survey-weighted responses of 1532 individuals suggest that 57% of the population knew LTBI can occur, and 90% would seek treatment for it. Regarding active TB, 85% knew TB symptoms, 70% reported they should avoid contact with someone with active TB, and 24% had stigma toward persons with TB (i.e., thought persons with tuberculosis should feel ashamed, or deserved their illness). In regression models adjusting for clinical and demographic variables, knowledge of LTBI was associated with increased stigma toward persons with TB (adjusted odds ratio [OR] = 2.13, 95% confidence interval [CI]: 1·25-3.63, for "should feel ashamed"; OR = 1·82, 95% CI: 1·15-2·89, for "deserve illness"). Adjusting for regional TB incidence did not affect this association.

CONCLUSIONS

High proportions of this representative Brazilian population had knowledge of LTBI and were willing to seek treatment for it. However, such knowledge was associated with TB-specific stigma. Strategies to educate and implement treatment of latent tuberculosis must include efforts to decrease TB stigma.

Integrating childhood TB: applying the care delivery value chain to improve pediatric HIV/TB services in Togo, West Africa

The World Health Organization has prioritized integrating tuberculosis (TB) and human immunodeficiency virus (HIV) services. Diagnosis of HIV/TB coinfection in children remains a challenge worldwide for numerous reasons. The care delivery value chain (CDVC) is an effective tool that can be applied as a systemic framework for assessing health care delivery. Our objective was to apply the CDVC framework to improve pediatric HIV/TB care at an HIV center in northern Togo that serves over 130 children and 1000 adults living with HIV. Using the CDVC framework, gaps in HIV/TB care were identified, and services related to screening and diagnosis were prioritized to implement 3 distinct quality improvement cycles. Primary outcomes included percentage of children screened for TB by medical providers and percentage of diagnostic sample results received at the HIV clinic for children and adults. Improvements in the TB diagnostic process were observed, resulting in a change of sputum sample results received for both children and adults from 25% at baseline to >88% at 3 months. Given the relative low associated costs, this QI approach may be applicable and feasible in other settings to target screening and diagnosis of TB for children living with HIV worldwide.

Determinants of delayed diagnosis and treatment of tuberculosis in Cambodia: a mixed-methods study

Background

Cambodia is among the 30 countries in the world with the highest burden of tuberculosis (TB), and it is estimated that 40% of people with TB remain undiagnosed. In this study, we aimed to investigate the determinants of delayed diagnosis and treatment of TB in Cambodia.

Methods

This mixed-method explanatory sequential study was conducted between February and September 2019 in 12 operational districts in Cambodia. It comprised of a retrospective cohort study of 721 people with TB, followed by a series of in-depth interviews. We assessed factors associated with time to TB diagnosis and treatment initiation using Cox proportional hazards model. Subsequently, we conducted in-depth interviews with 31 people with TB purposively selected based on the time taken to reach TB diagnosis, sex, and residence. Transcripts were coded, and thematic analyses were performed.

Results

The median time from the onset of symptoms to TB diagnosis was 49 days (Interquartile range [IQR]: 21–112). We found that longer time to diagnosis was significantly associated with living in rural area (Adjusted hazards ratio [aHR] = 1.25; 95% confidence interval [CI]: 1.06–1.48); TB symptoms—cough (aHR: 1.52; 95% CI: 1.18–1.94), hemoptysis (aHR 1.32; 95% CI: 1.07–1.63), and night sweats (aHR: 1.24; 95% CI: 1.05–1.46); seeking private health care/self-medication (aHR: 1.23; 95% CI: 1.04–1.45); and higher self-stigma (aHR: 1.02; 95% CI: 1.01–1.03). Participants who received education level above the primary level were inversely associated with longer time to diagnosis (aHR: 0.78; 95% CI: 0.62–0.97). The median time from TB diagnosis to the initiation of treatment was two days (IQR: 1–3). The use of smear microscopy for TB diagnosis (aHR: 1.50; 95% CI: 1.16–1.95) was associated with longer time to treatment initiation. Seeking private health care and self-medication before TB diagnosis, lack of perceived risk, threat, susceptibility, and stigma derived qualitatively further explained the quantitative findings.

Conclusions

TB diagnostic delay was substantial. Increasing public awareness about TB and consciousness regarding stigma, engaging the private healthcare providers, and tailoring approaches targeting the rural areas could further improve early detection of TB and narrowing the gap of missing cases in Cambodia.

Initial loss to follow up of tuberculosis patients in South Africa: perspectives of program managers

Background

Tuberculosis (TB) remains a serious public health problem in South Africa. Initial loss to follow up (LTFU) rates among TB patients are high, varying between 14.9 and 22.5%. From the perspective of patients, documented reasons for this include poor communication between patient and staff after testing, not being aware that results are ready and other competing priorities such as preference to go to work as opposed to seeking healthcare. Ward-based Outreach Teams (WBOTs) routinely conduct home visits to ensure adherence to medication for various conditions including TB. We explored reasons for TB initial loss to follow up from the perspectives of TB program managers and WBOT program managers, with a focus on the WBOT’s (potential) role in reducing initial LTFU, in particular.

Methods

Key informant interviews with five WBOT program managers and four TB program managers were conducted. The interviews were audio-recorded, then transcribed and exported to NVivo 11 software for coding. A hybrid analytic approach consisting of both inductive and deductive coding was used to identify themes.

Results

The age of the nine managers ranged between 28 and 52 years old, of which two were male. They had been in their current position for between 2 to 12 years. Prior to treatment initiation, WBOTs screen household members for TB and refer them for TB testing if need be, but integration of the two programs is emphasized only after TB treatment has been initiated. Counseling of patients testing for TB is not guaranteed due to frequent staff rotations and staff shortages. Participants reported that possible dissatisfaction with services as well as stigma associated with the TB diagnosis could explain loss to follow up prior to treatment initiation.

Conclusion

Program managers view health system related factors such as staff rotations, poor communication with patients and lack of counseling as contributing to the problem of initial LTFU among TB patients. The integration of the WBOT and TB programs is limited to referring suspected cases for testing and patients already on treatment.

Challenges in accessing and utilising health services for women accessing DOTS TB services in Kolkata, India

Challenges in accessing and utilising TB treatment are a major reason for the existing gaps in tuberculosis (TB) control in India. Twenty qualitative interviews were conducted with women who were attending or had attended a directly observed treatment short course (DOTS) clinic in Kolkata, India. The resulting data were analysed using a thematic approach. Our results indicated that women experienced several challenges categorised as (1) DOTS specific challenges, (2) lack of client friendly services, and (3) resource constraints. DOTS specific challenges included having to come to the clinic for medicines, lack of privacy, providers minimising contact with patients, length of treatment, drug side effects and pill burden. Lack of client friendly services led to mistrust in government services and a preference for private providers, which was compounded by corruption in the medical system. Inability to complete household duties due to inflexible clinic hours, long lines and overcrowded spaces, and mistreatment from providers were further challenges faced by women. Lastly, resource constraints meant women faced financial difficulties with additional treatment costs and suffered from lack of adequate food and nutrition. Our findings lead to several recommendations for addressing these challenges that should help improve women's experiences with DOTS TB treatment.

HIV and tuberculosis: The paradox of dual illnesses and the challenges of their fighting in the history

Tuberculosis is an ancient infectious disease caused by the bacillus Mycobacterium tuberculosis that is still nowadays afflicting humans all over the world. It causes ill-health for 10 million people each year. Tuberculosis (TB) has been the leading cause of death from a single infectious agent, ranking above HIV/AIDS. In recent years, infection with HIV represents a major risk factor predisposing for infection and TB is the most common cause of AIDS-related death. Despite the treatment of HIV-associated TB has essentially retraced that recommended in HIV-negative cases, it has disclosed some additional challenges over the years. The association of delayed and missed diagnoses, logistic accidents and some well-known complications of HIV and TB treatment co-administration has contributed to 300,000 people living with HIV died from a preventable and curable disease like TB in 2017. The evaluation of new diagnostic and therapeutic approaches with the struggle to erase stigma are essential to successfully manage HIV-TB coinfection.

Stigma matters in ending tuberculosis: Nationwide survey of stigma in Ethiopia

BACKGROUND

Tuberculosis (TB) affects, and claims the lives of, millions every year. Despite efforts to find and treat TB, about four million cases were missed globally in 2017. Barriers to accessing health care, inadequate health-seeking behavior of the community, poor socioeconomic conditions, and stigma are major determinants of this gap. Unfortunately, TB-related stigma remains unexplored in Ethiopia.

METHODS

This mixed methods survey was conducted using multistage cluster sampling to identify 32 districts and 8 sub-cities, from which 40 health centers were randomly selected. Twenty-one TB patients and 21 family members were enrolled from each health center, and 11 household members from each community in the catchment population.

RESULTS

A total of 3463 participants (844 TB patients, 836 from their families, and 1783 from the general population) were enrolled for the study. The mean age and standard deviation were 34.3 ± 12.9 years for both sexes (34.9 ± 13.2 for men and 33.8 ± 12.5 for women). Fifty percent of the study participants were women; 32.1% were illiterate; and 19.8% came from the lowest wealth quintile. The mean stigma score was 18.6 for the general population, 20.5 for families, and 21.3 for TB patients. The general population of Addis Ababa (AOR: 0.1 [95% CI: 0.06-0.17]), those educated above secondary school (AOR: 0.58 [95% CI: 0.39-0.87]), and those with a high score for knowledge about TB (AOR: 0.62 [95% CI: 0.49-0.78]) had low stigma scores. Families of TB patients who attended above secondary school (AOR: 0.37 [95% CI: 0.23-0.61]) had low stigma scores. TB patients educated above secondary school (AOR: 0.61 [95% CI: 0.38-0.97]) had lower stigma scores, while those in the first (AOR: 1.93: 95% CI 1.05-3.57) and third quintiles (AOR: 1.81: 95% CI: 1.08-3.05) had stigma scores twice as high as those in the highest quintile. Fear of job loss (32.5%), isolation (15.3%), and feeling avoided (9.3%) affected disclosure about TB.

CONCLUSIONS

More than a third of Ethiopians have high scores for TB-related stigma, which were associated with educational status, poverty, and lack of awareness about TB. Stigma matters in TB prevention, care, and treatment and warrants stigma reduction interventions.

Unpacking the dynamics of double stigma: how the HIV-TB co-epidemic alters TB stigma and its management among healthcare workers

BACKGROUND

HIV and tuberculosis (TB) are intricably interlinked in South Africa. The social aspects of this co-epidemic remain relatively unexplored. More specifically, no research has quantitatively explored the double stigma associated with HIV and TB in this context, and more specifically the impact of the co-epidemic on [1] the stigmatisation of TB and [2] the TB stigma mangement strategy of covering (i.e. the use of TB as a cover for having HIV). The current study aims to address this research gap by disentangling the complex mechanisms related to HIV-TB stigma.

METHODS

Using Structural Equation Modelling (SEM), data of 882 health care workers (HCWs) in the Free State province, South Africa, are analysed to investigate the link between the stigmatization of HIV and TB and the stigma management by those affected. The current study focuses on health care workers (HCWs), as both TB and HIV have a severe impact on this professional group.

RESULTS

The results demonstrate that the perceived link between the epidemics is significantly associated with double HIV-TB stigmatization. Furthermore, the link between the illnesses and the double stigma are driving the stigmatization of TB. Finally, the link between HIV and TB as well as the stigmatization of both diseases by colleagues are associated with an increased use of covering as a stigma management strategy.

CONCLUSIONS

This is the first quantitative study disentagling the mediating role of double stigma in the context of the co-epidemic as well as the impact of the co-epidemic on the social connotations of TB. The results stress the need for an integrated approach in the fight against HIV and TB recognizing the intertwined nature of the co-epidemic, not only in medical-clinical terms, but also in its social consequences.

TRIAL REGISTRATION

South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.

Comorbidities between tuberculosis and common mental disorders: a scoping review of epidemiological patterns and person-centred care interventions from low-to-middle income and BRICS countries

Background

There is increasing evidence that the substantial global burden of disease for tuberculosis unfolds in concert with dimensions of common mental disorders. Person-centred care holds much promise to ameliorate these comorbidities in low-to-middle income countries (LMICs) and emerging economies. Towards this end, this paper aims to review 1) the nature and extent of tuberculosis and common mental disorder comorbidity and 2) person-centred tuberculosis care in low-to-middle income countries and emerging economies.

Main text

A scoping review of 100 articles was conducted of English-language studies published from 2000 to 2019 in peer-reviewed and grey literature, using established guidelines, for each of the study objectives. Four broad tuberculosis/mental disorder comorbidities were described in the literature, namely alcohol use and tuberculosis, depression and tuberculosis, anxiety and tuberculosis, and general mental health and tuberculosis. Rates of comorbidity varied widely across countries for depression, anxiety, alcohol use and general mental health. Alcohol use and tuberculosis were significantly related, especially in the context of poverty. The initial tuberculosis diagnostic episode had substantial socio-psychological effects on service users. While men tended to report higher rates of alcohol use and treatment default, women in general had worse mental health outcomes. Older age and a history of mental illness were also associated with pronounced tuberculosis and mental disorder comorbidity. Person-centred tuberculosis care interventions were almost absent, with only one study from Nepal identified.

Conclusions

There is an emerging body of evidence describing the nature and extent of tuberculosis and mental disorders comorbidity in low-to-middle income countries. Despite the potential of person-centred interventions, evidence is limited. This review highlights a pronounced need to address psychosocial comorbidities with tuberculosis in LMICs, where models of person-centred tuberculosis care in routine care platforms may yield promising outcomes.

Barriers for tuberculosis case finding in Southwest Ethiopia: A qualitative study

BACKGROUND

Ethiopia is one of the countries with a high burden of tuberculosis (TB). Jimma Zone has the lowest TB case notification rate compared to the national and World Health Organization's (WHO) targets. The aim of the present study was to identify barriers, and explore the origin of these barriers in relation to TB case finding.

METHODS

A qualitative study was conducted by using different data collection methods and sources. Sixty in-depth interviews with TB treatment providers, program managers and TB patients were included. In addition, 42 governmental health facilities were observed for availability of resources. Data obtained from the in-depth interviews were transcribed, coded, categorized and thematized. Atlas.ti version 7.1 software was used for the data coding and categorizing.

RESULTS

Inadequate resources for TB case finding, such as a shortage of health-care providers, inadequate basic infrastructure, and inadequate diagnostic equipment and supplies, as well as limited access to TB diagnostic services such as an absence of nearby health facilities providing TB diagnostic services and health system delays in the diagnostic process, were identified as barriers for TB case finding. We identified the absence of trained laboratory professionals in 11, the absence of clean water supply in 13 and the electricity in seven health facilities. Furthermore, we found that difficult topography, the absence of proper roads, an inadequate collaboration with other sectors (such as education), a turnover of laboratory professionals, and a low community mobilization, as the origin of some of these barriers.

CONCLUSION

Inadequate resources for TB case finding, and a limited access to diagnostic services, were major challenges affecting TB case finding. The optimal application of the directly observed treatment short course (Stop TB) strategy is crucial to increase the current low TB case notification rate. Practical strategies need to be designed to attract and retain health professionals in the health system.

Perceived discrimination among tuberculosis patients in an urban area of Kolkata City, India

Context and Aims:

Tuberculosis (TB) in India is a leading public health problem plagued by social determinants such as stigma and discrimination, which may affect treatment seeking, adherence, and possibly treatment outcome. This study was conducted to elicit the perceived discrimination, its determinants, as well as to determine whether perceived discrimination is predicting treatment outcome among TB patients registered in an Urban Health District, Kolkata City, India.

Settings and Design:

An institutionbased follow-up study was conducted where all the TB patients registered within the 1^st 4 months of data collection were followed up for their current course of treatment.

Subjects and Methods:

Perceived discrimination was assessed at treatment initiation, after intensive period and after continuation phase using a predesigned and pretested questionnaire.

Statistical Analysis Used:

Multivariable logistic regression analyses were performed to identify the determinants of perceived discrimination as well as the treatment outcome.

Results:

Perceived discrimination by family members, neighbors, and colleagues was reported by 9.4%, 36.5%, and 34.2% participants, respectively, overall discrimination being 37.9%. Multivariable analysis revealed that discrimination was significantly more among patients with older age group, females, and from joint families. Perceived discriminated was found to be significantly predicting unfavorable treatment outcome even after adjustment with background and treatment-related variables.

Conclusions:

Sensitization programs should incorporate measures to address stigma and discrimination and more emphasis needs to be placed on women and elderly patients.

Tuberculosis infectious pool and associated factors in East Gojjam Zone, Northwest Ethiopia

Background

Globally, tuberculosis (TB) lasts a major public health concern. Using feasible strategies to estimate TB infectious periods is crucial. The aim of this study was to determine the magnitude of TB infectious period and associated factors in East Gojjam zone.

Methods

An institution-based prospective study was conducted among 348 pulmonary TB (PTB) cases between December 2017 and December 2018. TB cases were recruited from all health facilities located in Hulet Eju Enesie, Enebse Sarmider, Debay Tilatgen, Dejen, Debre-Markos town administration, and Machakel districts. Data were collected through an exit interview using a structured questionnaire and analyzed by IBM SPSS version25. The TB infectious period of each patient category was determined using the TB management time and sputum smear conversion time. The sum of the infectious period of each patient category gave the infectious pool of the study area. A multivariable logistic regression analysis was used to identify factors associated with the magnitude of TB infectious period.

Results

Of the total participated PTB cases, 209(60%) were male, 226(65%) aged < 30 years, 205(59%) were from the rural settings, and 77 (22%) had comorbidities. The magnitude of the TB infectious pool in the study area was 78,031 infectious person-days. The undiagnosed TB cases (44,895 days), smear-positive (14,625 days) and smear-negative (12,995 days) were major contributors to the infectious pool. The overall average median TB management time was 142.4 days (IQR, 98–238 days). Similarly, the average sputum smear conversion time of PTB cases (new and repeat) was 46 days. Residence, knowledge, form of TB, smoking, alcohol history, distance from the facility, comorbidity history and stigma were statistically significant factors TB infectious period (p-value< 0.05).

Conclusions

The magnitude of the TB infectious pool is high even if it is lower than the findings of previous studies. This might be an indicator of poor access to TB services, service delays, low community awareness, impaired facility readiness, and poor transportation. Improving personal awareness and behavior, timely management of commodities, and using the TB management time in TB control are crucial to improving TB control activities.

Quality of life with tuberculosis

Tuberculosis diagnosis and treatment currently revolves around clinical features and microbiology. The disease however adversely affects patients’ psychological, economic, and social well-being as well, and therefore our focus also additionally needs to shift towards quality of life (QOL). The disease influences all QOL domains and substantially adds to patient morbidity, and these complex and multidimensional interactions pose challenges in accurately quantifying impairment in QOL. For this review, PubMed database was queried using keywords like quality of life, health status and tuberculosis, and additional publications identified by a bibliographic review of shortlisted articles. Both generic and specific QOL scales show a wide variety of derangements in scores, and results vary across countries and patient groups. In particular, diminished capacity to work, social stigmatization, and psychological issues worsen QOL in patients with tuberculosis. Although QOL has been consistently shown to improve during standard anti-tubercular therapy, many patients continue to show residual impairment. It is also not clear if specific situations like presence of comorbid illnesses, drug resistance, or co-infection with human immunodeficiency virus additionally worsen QOL in these patients. There is a definite need to incorporate QOL assessment as adjunct outcome measures in tuberculosis control programs. Governments and program managers need to step up socio-cultural reforms and health education, and provide additional incentives to patients, to counter impairment in QOL.

Delayed diagnosis and treatment of pulmonary tuberculosis in high-burden countries: a systematic review protocol

INTRODUCTION

Countries identified to bear the highest tuberculosis (TB) incidence account for approximately 85% of the global TB burden. TB is curable, yet nearly 40% of TB cases remained undiagnosed hence delaying treatment and perpetuating transmission. This systematic review aimed to review current evidence on factors associated with delayed diagnosis and treatment of TB in the high TB-burden countries.

METHODS AND ANALYSIS

This systematic review will incorporate qualitative and observational study designs published between 2008 and 2018. Articles will be retrieved from major databases including PubMed, EMBASE, CINAHL and PsycINFO. Reference lists of key articles, including relevant systematic reviews and meta-analysis, will be screened for additional studies. Two independent reviewers will screen and select studies, extract data and assess the quality and risk of bias of each study. Study-specific estimates will be pooled by meta-analysis, and effect sizes will be presented as OR and their 95% CI. Levels of heterogeneity will be evaluated using chi-square statistic Q and I2. Publication bias will be assessed using forest plots and Egger's tests. Qualitative findings and sample quotes will be extracted. Textual references to the topics of interest will be retrieved and categorised using qualitative thematic analysis. We will triangulate quantitative and qualitative findings for a complete understanding of the reasons for delayed TB diagnosis and treatment. Results will be presented by geographical region.

ETHICS AND DISSEMINATION

This study will be conducted based on published data. This systematic review may provide insights into the reasons for delayed TB diagnosis in high-burden countries. These findings will also inform future research and key stakeholders in developing interventions to reach these undiagnosed cases effectively. Findings from this review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018107237.

"Who Will Marry a Diseased Girl?" Marriage, Gender, and Tuberculosis Stigma in Asia

In a qualitative study on the stigma associated with tuberculosis (TB), involving 73 interviews and eight focus groups conducted in five sites across three countries (Bangladesh, Nepal, and Pakistan), participants spoke of TB's negative impact on the marriage prospects of women in particular. Combining the approach to discovering grounded theory with a conceptualization of causality based on a realist ontology, we developed a theory to explain the relationships between TB, gender, and marriage. The mechanism at the heart of the theory is TB's disruptiveness to the gendered roles of wife (or daughter-in-law) and mother. It is this disruptiveness that gives legitimacy to the rejection of marriage to a woman with TB. Whether or not this mechanism results in a negative impact of TB on marriage prospects depends on a range of contextual factors, providing opportunities for interventions and policies.

Chronic Hepatitis B stigma in Ghana: a qualitative study with patients and providers

OBJECTIVE

This study explored beliefs contributing to Hepatitis B stigma, and the ways in which Hepatitis B stigma manifests, from the perspectives of people with chronic Hepatitis B as well as healthcare providers in Northern and Southern Ghana.

DESIGN

We used an exploratory qualitative design with a purposive sampling technique. Face-to-face interviews and focus group discussions were conducted. Data were processed using QSR Nvivo V.10.0 and analysed using inductive thematic analysis.

SETTINGS

Participants were recruited from one tertiary and one regional hospital in Ghana between February and November 2017.

PARTICIPANTS

Overall, 18 people with chronic Hepatitis B (PWHB) and 47 healthcare providers (primary care physicians, nurses and midwives) between the ages of 21 and 57 years participated in the study.

RESULTS

PWHB face stigma in their sociocultural context and the healthcare environment. Three main beliefs underlying stigma were found: (1) the belief that Hepatitis B is highly contagious; (2) the belief that Hepatitis B is very severe and (3) the belief that Hepatitis B is caused by curses. Stigmatisation manifested as avoidance and social isolation (discrimination). In healthcare settings, stigmatisation manifested as excessive cautiousness, procedure postponement or avoidance, task-shifting and breaches of confidentiality.

CONCLUSIONS

Given the prevalence of incorrect knowledge, as reflected in the beliefs about Hepatitis B, we recommend public awareness campaigns that emphasise Hepatitis B transmission routes. Also, given the manifestations of the stigma in healthcare settings, we recommend the development and implementation of a continuing professional development programme on Hepatitis B and adjusted policy on Hepatitis B vaccination for Healthcare providers (HCPs).

Understanding illness perception in pulmonary tuberculosis patients: One step towards patient-centered care

BACKGROUND

Assessing the illness perception of patients with tuberculosis (TB) could improve our understanding of their beliefs about disease and help address problems in their health-seeking behavior.

STUDY AIM

We assessed illness perception in patients with pulmonary TB in association with patients' demographic, socioeconomic, and clinical features.

METHODS

Adult patients who were newly diagnosed with pulmonary TB at three tertiary hospitals in South Korea were included from November 2016 and September 2018. Participants' illness perception was assessed using the Brief Illness Perception Questionnaire (BIPQ) at the start of anti-TB treatment.

RESULTS

In total, 390 patients with pulmonary TB completed this survey. The mean BIPQ score was 31.6 ± 13.2, and that was positively correlated with clinical TB scores. Patients were highly concerned about their illness, but believed in the treatment. Unhealthy eating habits were mentioned as the most prevalent perceived cause. Coughing for more than one month and alarming symptoms were significantly associated with BIPQ scores ≥ 33. Non-adherent patients had significantly higher BIPQ scores.

CONCLUSIONS

Assessing the illness perceptions of those with severe TB-related symptoms and signs may help to identify TB patients with vulnerable to poor treatment outcomes.

Predictors of isoniazid preventive therapy completion among HIV-infected patients receiving differentiated and non-differentiated HIV care in rural Uganda

Rates of Isoniazid Preventive Therapy (IPT) completion remain low in programmatic settings in sub-Saharan Africa. Differentiated HIV care models may improve IPT completion by addressing joint barriers to IPT and HIV treatment. However, the impact of differentiated care on IPT completion remains unknown. In a cross-sectional study of people with HIV on antiretroviral therapy in 5 communities in rural Uganda, we compared IPT completion between patients receiving HIV care via a differentiated care model versus a standard HIV care model and assessed multi-level predictors of IPT completion. A total of 103/144 (72%) patients received differentiated care and 85/161 (53%) received standard care completed IPT (p < 0.01). Adjusting for age, gender and community, patients receiving differentiated care had higher odds of completing IPT (aOR: 2.6, 95% CI: 1.5-4.5, p < 0.01). Predictors of IPT completion varied by the care model, and differentiated care modified the positive association between treatment completion and the belief in the efficacy of IPT and the negative association with side-effects. Patients receiving a multi-component differentiated care model had a higher odds of IPT completion than standard care, and the model's impact on health beliefs, social support, and perceived side effects to IPT may underlie this positive association.

Dynamic and game theory of infectious disease stigmas

Stigmas are a primal phenomena, ubiquitous in human societies past and present. Some evolutionary anthropologists have argued that stigmatization in response to disease is an adaptive behavior because stigmatization may help people and communities reduce the risks they face from infectious diseases and increase reproductive success. On the other hand, some cultural anthropologists and social critics argue that stigmatization has strong negative impacts on community health. One recent analysis resolved this conflict by hypothesizing that stigmas had individual and group-evolutionary benefits in the past but are now maladaptive because of intervening societal transitions. Here, we present a quantitative theory of infectious disease stigmatization. Using a four-compartment model of stigmatization against a chronic disease, we show a stigma ratio, being the ratio of net transmissions by stigmatized people to net transmissions by unstigmatized people, predicts the impact of stigmatization on lifetime infection risk. When stigmatized people are segregated from the rest of the population and there are no alternative interventions that reduce transmission, stigmatization can reduce prevalence and infection risk. When stigmas do not lead to segregation but do discourage behavior change and reduce access to medical interventions, stigmatization acts to increases the lifetime risk of infection in the community. We further show that fear of stigmas can create policy resistance to healthcare access. The societal consequences of fear are worse when effective medical treatment is available. We conclude that stigma's can be adaptive, but good healthcare and leaky ostracism can make stigmas against chronic infectious disease maladaptive, and that the deprecation of stigmas is a natural transition in the modern urban societies.

Waiting to inhale: factors associated with healthcare workers' fears of occupationally-acquired tuberculosis (TB)

Background

Fear of TB infection is rooted in historical and social memories of the disease, marked by stigma, segregation and exclusion. Healthcare workers (HCWs) face these same fears today, and even seek to hide their TB status when infected. This study sought to investigate factors associated with HCWs fears of acquiring TB while at work, including selected biographic characteristics, TB knowledge, infection control and perceptions that their colleagues stigmatise co-workers with TB/ presumed to have TB.

Methods

In the Free State Province, South Africa, a representative sample of 882 HCWs from eight hospitals completed self-administered questionnaires on issues related to fear of occupationally acquired TB, infection control, TB knowledge and workplace TB stigma. The data were analysed using descriptive statistics as well as binomial logistic regression.

Results

Most of the HCWs (67.2%) were concerned about contracting TB at work. Support staff were less likely to worry about acquiring TB than clinical staff (OR = 0.657, P = 0.041). Respondents who indicated that there were inadequate numbers of disposable respirators at work, were 1.6 times more likely to be afraid of contracting TB at work (P = 0.040). With every unit increase on the TB stigma scale, respondents were 1.1 times more likely to fear acquiring TB at work (P = 0.000).

Conclusions

Being a professional clinical HCW, not having adequate disposable respirators available and seeing/perceiving co-workers stigmatise colleagues with (presumptive) TB were all significantly associated with the fear of occupationally-acquired TB. It is recommended that campaigns to destigmatise TB, as well as appropriate TB infection control education and measures, are necessary to alleviate HCWs fears of acquiring the disease in the workplace. Ultimately this should create a health-enabling working environment, where HCWs are not afraid to function and are free to seek treatment and support when necessary.

Perceived Stigma and Associated Factors among Patient with Tuberculosis, Wolaita Sodo, Ethiopia: Cross-Sectional Study

Background

Tuberculosis is a historically stigmatized disease and the stigma associated with it affects the institution, community, and interpersonal factors. Therefore, understanding tuberculosis-related perceived stigma has importance in improving quality of the patients.

Objective

The aim of this study was to assess prevalence and factors associated with perceived stigma among patients with tuberculosis attending Wolaita Sodo University Referral Hospital, Ethiopia.

Methods

Institution based cross-sectional study was conducted among a total of 417 tuberculosis patients who had treatment follow-up at TB clinics and were recruited for the study. Systematic random sampling technique was used to recruit study participants. A 12-item perceived TB stigma scale was used to assess tuberculosis-related perceived stigma. In addition, Oslo social support scale was used to assess social support related factors.

Results

Prevalence of tuberculosis-related perceived stigma by using perceived tuberculosis stigma scale was 42.4%. Patients who had pulmonary TB [AOR=2.49, (95% CI: 1.24, 4.87)], being intensive phase category [AOR=1.42, (95% CI: 1.19, 2.58)], TB/HIV coinfection [AOR= 3.54, (95% CI: 1.37, 9.12)], poor social support [AOR=2.45, (95% CI: 1.18, 5.09)], and using substance (alcohol, khat and cigarette) [AOR=1.78, (95% CI: 1.28, 3.17)] were more likely to have perceived TB stigma when compared to their counter parts.

Conclusion

Health education programs should be conducted to reduce TB stigma and improve patients' compliance.

Preventing Tuberculosis in a Low Incidence Setting: Evaluation of a Multi-lingual, Online, Educational Video on Latent Tuberculosis

Treating latent tuberculosis infection (LTBI) in those at risk is an important yet challenging cornerstone of TB elimination. We evaluated a culturally-tailored, multi-lingual, 4.5-min, health promotional video on LTBI. Mixed methods study assessed use of the video with web-analytics, acceptability of content through interviews and survey questions, and compared knowledge scores in viewers and non-viewers using a survey. The video was viewed 6999 times in six languages over 1 year. Of 1598 survey respondents, 193 viewers had a mean knowledge score of 59%, compared to 38% in non-viewers. Eighty-four percent of viewers rated the video as helpful. When controlling for other factors, viewing the video was associated with a 1.04 (95% CI 0.85-1.26) or a 21% increase in a knowledge score. Qualitative data suggested the video was acceptable and may facilitate behavior change. This online, educational video shows promise as a tool to supplement clinical care.

More Than Malnutrition: A Review of the Relationship Between Food Insecurity and Tuberculosis

Despite a significant reduction in tuberculosis (TB) mortality over the past decade, TB remains a leading cause of death worldwide. Food insecurity-through pathways such as malnutrition, mental health impact, and high-risk health behaviors-affects the risk of TB disease, treatment failure, and mortality. We searched the literature for studies reporting on the links between food insecurity and TB. In contrast to the well-documented interactions between food insecurity and HIV/AIDS, we found that the association between food insecurity and TB remains largely understudied-this is especially true with regard to non-nutritional correlations. Mental health and behavioral linkages between TB and food insecurity deserve further attention. An improved understanding of the pathways through which food insecurity impacts TB is crucial to inform evidence-based integration of interventions such as psychological counseling, psychiatric care, harm reduction programs, and efforts to address social determinants of disease within current TB programs.

Patient predictors of health-seeking behaviour for persons coughing for more than two weeks in high-burden tuberculosis communities: the case of the Western Cape, South Africa

Background

This study aimed to analyse the patient predictors of health-seeking behaviour for persons coughing for more than 2 weeks to better understand this vulnerable and important population.

Methods

The study analysed data from a cohort study (SOCS - Secondary Outcome Cohort Study) embedded in a community randomised trial ZAMSTAR (Zambia and South Africa TB and AIDS Reduction Study) in eight high-burden TB communities in the Western Cape, South Africa. These datasets are unique as they contain TB-related data as well as data on health, health-seeking behaviour, lifestyle choices, employment, socio-economic status, education and stigma. We use uni- and multivariate logistic regressions to estimate the odds ratios of consulting for a cough (of more than 2 weeks duration) for a range of relevant patient predictors.

Results

Three hundred and forty persons consulted someone about their cough and this represents 37% of the 922 participants who reported coughing for more than 2 weeks. In the multivariate analysis, respondents of black ethnic origin (OR 1.99, 95% CI 1.28–3.12, P < 0.01), those with higher levels of education (OR 1.05 per year of education, 95% CI 1.00–1.10, P = 0.05), and older respondents (OR 1.02 per year, 95% CI 1.01–1.04, P < 0.01) had a higher likelihood of consulting for their chronic cough. Individuals who smoked (OR 0.63, 95% CI 0.45–0.88, P < 0.01) and those with higher levels of socio-economic status (OR 0.81, 95% CI 0.71–0.92, P < 0.01) were less likely to consult. We find no evidence of stigma playing a role in health-seeking decisions, but caution that this may be due to the difficulty of accurately and reliably capturing stigma due to, amongst other factors, social desirability bias.

Conclusions

The low levels of consultation for a cough of more than 2 weeks suggest that there are opportunities to improve case-finding. These findings on health-seeking behaviour can assist policymakers in designing TB screening and active case-finding interventions that are targeted to the characteristics of those with a chronic cough who do not seek care.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3992-6) contains supplementary material, which is available to authorized users.

Being safe, feeling safe, and stigmatizing attitude among primary health care staff in providing multidrug-resistant tuberculosis care in Bantul District, Yogyakarta Province, Indonesia

INTRODUCTION

Patient-centered care approach in multidrug-resistant tuberculosis care requires health worker safety that covers both being safe and feeling safe to conduct the services. Stigma has been argued as a barrier to patient-centered care. However, there has been relatively little research addressing the issues of safety and stigma among health staff. This paper explored the issue of being safe, feeling safe, and stigmatizing attitude among health staff working with multidrug-resistant tuberculosis cases in primary health care facilities in Indonesia.

METHODS

Using a mixed methods research design, data was collected with structured questionnaires among 123 staff, observations of infection control in 17 primary health care facilities, and in-depth interviews among 22 staff.

RESULTS

The findings showed suboptimal infection control infrastructures for the primary health care facilities. The knowledge and motivation to follow multidrug-resistant tuberculosis care protocols are suboptimal. Feeling unsafe is related to stigmatizing attitude in providing multidrug-resistant tuberculosis care.

CONCLUSION

Being safe, feeling unsafe, and stigmatizing attitude are challenges in providing patient-centered multidrug-resistant tuberculosis care in primary health care facilities in Indonesia. Serious efforts are needed on all levels to ensure safety and prevent irrational stigma.

Spatially targeted screening to reduce tuberculosis transmission in high-incidence settings

As the leading infectious cause of death worldwide and the primary proximal cause of death in individuals living with HIV, tuberculosis remains a global concern. Existing tuberculosis control strategies that rely on passive case-finding appear insufficient to achieve targets for reductions in tuberculosis incidence and mortality. Active case-finding strategies aim to detect infectious individuals earlier in their infectious period to reduce onward transmission and improve treatment outcomes. Empirical studies of active case-finding have produced mixed results and determining how to direct active screening to those most at risk remains a topic of intense research. Our systematic review of literature evaluating the effects of geographically targeted tuberculosis screening interventions found three studies in low tuberculosis incidence settings, but none conducted in high tuberculosis incidence countries. We discuss open questions related to the use of spatially targeted approaches for active screening in countries where tuberculosis incidence is highest.

Stigma in health facilities: why it matters and how we can change it

Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health. This correspondence article seeks to assess how developments over the past 5 years have contributed to the state of programmatic knowledge-both approaches and methods-regarding interventions to reduce stigma in health facilities, and explores the potential to concurrently address multiple health condition stigmas. It is supported by findings from a systematic review of published articles indexed in PubMed, Psychinfo and Web of Science, and in the United States Agency for International Development's Development Experience Clearinghouse, which was conducted in February 2018 and restricted to the past 5 years. Forty-two studies met inclusion criteria and provided insight on interventions to reduce HIV, mental illness, or substance abuse stigma. Multiple common approaches to address stigma in health facilities emerged, which were implemented in a variety of ways. The literature search identified key gaps including a dearth of stigma reduction interventions in health facilities that focus on tuberculosis, diabetes, leprosy, or cancer; target multiple cadres of staff or multiple ecological levels; leverage interactive technology; or address stigma experienced by health workers. Preliminary results from ongoing innovative responses to these gaps are also described.The current evidence base of stigma reduction in health facilities provides a solid foundation to develop and implement interventions. However, gaps exist and merit further work. Future investment in health facility stigma reduction should prioritize the involvement of clients living with the stigmatized condition or behavior and health workers living with stigmatized conditions and should address both individual and structural level stigma.

A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries

BACKGROUND

Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions.

METHODS

We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations.

RESULTS

Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes.

CONCLUSIONS

Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs.

Community Knowledge about Tuberculosis and Perception about Tuberculosis-Associated Stigma in Pakistan

Tuberculosis- (TB) associated stigma is a well-documented phenomenon with various factors, both individual and societal, manifesting its role in shaping health-seeking behavior and contributing to suboptimal TB care in Pakistan. The objective of this study was to assess TB-related knowledge and perceived stigma among community members. This was a cross-sectional survey using a convenience sample of 183 individuals recruited between October and December 2017. A validated stigma measurement tool developed by Van Rie et al. was adapted. Data was analyzed using SPSS version 20.0. A clear majority was aware that TB is curable disease and that it is transmitted by coughing. However, respondents also thought that TB spread through contaminated food, sharing meals, sharing utensils, and by having sexual intercourse with a TB patient. In addition, females, unemployed, and persons having less than six years of education were also more likely to associate stigma with TB. We found an association between the lack of knowledge about TB and perceived stigma. This study highlights the need for improved TB-related education among communities.

Challenges and opportunities for eliminating tuberculosis - leveraging political momentum of the UN high-level meeting on tuberculosis

Background

As demonstrated by the United Nations High-Level Meeting on tuberculosis (TB) held in September 2018, the political momentum for TB has been increasing. The aim of this study was to analyze the current challenges and opportunities for global TB control and, with specific focus on policies surrounding TB control, to reveal what kinds of efforts are needed to accelerate global TB control.

Methods

We organized two expert meetings with the purposes of assessing the current situation and analyzing challenges regarding TB control. By applying Shiffman and Smith’s framework which contains four categories; Actor, Ideas, Political context, and Issue characteristics, we analyzed the challenges and opportunities for global TB control based on the findings from the two expert meetings.

Results

In the Actor Category, we found that although there has already been active engagement by non-governmental organizations (NGOs), civil society organizations (CSOs) and private sectors, there still remained an area with room for improvement. In particular, the complexities behind varying drug regulatory and procurement systems per country hindered the active participation of the private sector in this area. As for the Ideas category, due to an increasing threat of antimicrobial resistance and growing number of global migrations, TB is now widely recognized as a health security issue rather than a purely health issue. This makes TB an easier target for political attention. As for the Political category, having the UN High-Level Meeting itself is not enough; such meetings must be followed up by actual commitments from heads of states. Lastly the issue characteristic indicates that the amount of funding for R&D for new drugs, vaccines and diagnostics for TB is not at an adequate level, and investment in childhood TB and missing cases are particularly in need.

Conclusions

This study provides important insight into the current status of global efforts toward end TB epidemic. The outcomes from the UN high-level meeting on TB need to be closely monitored will be crucial for the progress towards this goal.

Stigma and the in(visible) perspectives and expectations of home oxygen therapy among people with chronic breathlessness syndrome: A qualitative study

Background:

Chronic breathlessness syndrome in the context of advancing disease is distressing for all concerned. Oxygen is commonly prescribed in this setting; however, little is known about the perspectives of breathless people who either are on oxygen or are yet to have it prescribed.

Aim:

To understand and describe the perspectives and experiences of breathless people towards oxygen use at home.

Design:

This qualitative study utilised an interpretive description approach using semi-structured interviews and thematic analysis.

Setting/participants:

A total of 19 people with chronic breathlessness syndrome living in South Australia participated in semi-structured interviews. Participants were divided into sub-groups according to whether they were chronically breathless and (1) not using home oxygen ( n = 6), (2) using funded home oxygen for severe hypoxaemia ( n = 7) and (3) using home oxygen for palliation outside of funding guidelines ( n = 6).

Results:

Three main themes were identified: (1) managing distress and living with chronic breathlessness syndrome, with or without oxygen, requires a range of self-management strategies; (2) expectations of oxygen use: ‘Not as good as I thought it would be’; and (3) the stigma of using oxygen: the visible and invisible.

Conclusion:

People living with chronic breathlessness struggle daily with both the progression of the underlying disease and the distressing nature of the syndrome. While oxygen does provide benefit for some people, its use and the perceptions of its use are often associated with both the visible and invisible manifestations of stigma. Clinicians need to promote self-management strategies and give careful thought to the prescribing of home oxygen, especially outside the current funding guidelines.

Assessment of Health-Related Quality of Life among Tuberculosis Patients in a Public Primary Care Facility in Indonesia

Background and Objectives:

Evaluation of health-related quality of life (HRQoL) among tuberculosis (TB) patients could improve understanding about the burden associated with the diseases. There is a paucity of research regarding evaluation of HRQoL among TB population in Indonesia. This study aimed to investigate HRQoL among TB patients in Ciamis, Indonesia.

Methods:

This was a cross-sectional study conducted at one primary health-care facility in Ciamis, Indonesia. HRQoL was measured using the World Health Organization (WHO) QoL-BREF instrument which covers assessment on physical, psychological, social relationship, and environmental health domains. Multiple regression analysis was used to investigate the association between domain scores with demographic factors of the participants such as age, sex, education years, and types of treatment. Statistical analysis was conducted using SPSS software version 21.

Results:

Eighty-one participants were recruited in the present study. The total mean score for all domains was 45.35 (±23.3). The mean scores for physical, physiological, social relationship, and environmental health domains were 20.5 (±9.9), 76.4 (±11.9), 36.9 (±9.2), and 46.9 (±10.4), respectively. Education years were significantly associated with improved HRQoL in environmental health domain (P < 0.05).

Conclusion:

TB had remarkable negative impacts on patients HRQoL, with physical domain was the most affected. This finding calls upon strategies addressing HRQoL problems in the management of TB patients.

Pre-treatment loss to follow-up among patients with rifampicin-resistant tuberculosis in Baluchistan, Pakistan, 2012-17: a retrospective cohort study

Background: Patients with rifampicin-resistant TB (RR-TB) pretreatment loss to follow-up continue to be a global health challenge. Although the accuracy of diagnosis significantly increased with the implementation of Xpert MTB/RIF assay, which is a rapid molecular based test and more sensitive than conventional microscopy which detects MTB even present in small limit of 136 MTB/ml of sputum, but still data suggest a wide treatment initiation gap among diagnosed. This study was done to assess the proportion of patients with RR-TB pretreatment lost to follow-up and the socio-demographic factors associated with this in Balochistan, Pakistan. Methods: This was a retrospective cohort study based on review of the routinely managed program records. The data included all patients with RR-TB detected at Fatima Jinnah Chest & General Hospital Quetta and District Head Quarter Hospital Loralai, Xpert sites and enrolled at programmatic management of drug resistant TB (PMDT) sites during 2012-2017. Data collected was double-entered, validated and analyzed using EpiData. Results: Of the 396 patients with RR-TB detected during 2012-17, 78 (19.8%) underwent pre-treatment lost to follow-up. The mean age of those detected with RR-TB was 37 years (SD ±16.98); 189 (48%) were of age group 15-34, while 60% were female. Among 84 individuals referred out to other facilities, only 6 started treatment. Almost half of the ‘pretreatment lost to follow-up’ patients were from age group 15-34, while 43 were from within the Quetta and Loralai districts. Conclusions: The high proportion of patients with RR-TB that were pre-treatment lost to follow-up in Balochistan needs immediate strategies to establish linkages between Xpert and PMDT sites for the timely management of patients to prevent the spread of RR-TB infection.