Perception and social consequences of tuberculosis: a focus group study of tuberculosis patients in Sialkot, Pakistan

Qualitative study of patient experiences of mental distress during TB investigation and treatment in Zambia

Background

The mental health and TB syndemic is a topic that remains under-researched with a significant gap in acknowledging and recognizing patient experiences, particularly in the sub-Saharan African region. In this qualitative study conducted in Zambia, we aimed to explore the lived mental health experiences of TB patients focusing on their multi-layered drivers of distress, and by so doing highlighting contextual factors that influence mental distress in TB patients in this setting.

Methods

The study draws on qualitative data collected in 2018 as part of the Tuberculosis Reduction through Expanded Antiretroviral Treatment and Screening for active TB trial (TREATS) being conducted in Zambia. The data was collected through in-depth interviews with former TB patients (n = 80) from 8 urban communities participating in the TREATS trial. Thematic analysis was conducted. Additional quantitative exploratory analysis mapping mental distress symptoms on demographic, social, economic and TB characteristics of participants was conducted.

Results

Most participants (76%) shared that they had experienced some form of mental distress during their TB investigation and treatment period. The reported symptoms ranged in severity. Some participants reported mild distress that did not disrupt their daily lives or ability to adhere to their TB medication, while other participants reported more severe symptoms of distress, for example, 15% of participants shared that they had suicidal ideation and thoughts of self-harm during their time on treatment. Mental distress was driven by unique interactions between individual, social and health level factors most of which were inextricably linked to poverty. Mental distress caused by individual level drivers such as TB morbidity often abated once participants started feeling better, however social, economic and health system level drivers of distress persisted during and beyond TB treatment.

Conclusion

The findings illustrate that mental distress during TB is driven by multi-layered and intersecting stresses, with the economic stress of poverty often being the most powerful driver. Measures are urgently needed to support TB patients during the investigation and treatment phase, including increased availability of mental health services, better social security safety nets during TB treatment, and interventions targeting TB, HIV and mental health stigma.

Trial registration ClinicalTrials.gov NCT03739736. Trial registration date: November 14, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00881-x.

Patient and health system level barriers to and facilitators for tuberculosis treatment initiation in Uganda: a qualitative study

BACKGROUND

The WHO END TB strategy targets to place at least 90% of all patients diagnosed with Tuberculosis (TB) on appropriate treatment. In Uganda, approximately 20% of patients diagnosed with TB are not initiated on TB treatment. We sought to identify the patient and health system level barriers to and facilitators for TB treatment initiation in Uganda.

METHODS

We conducted the study at ten public health facilities (three primary care, four district and three tertiary referral hospitals). We carried out in-depth interviews with patients diagnosed with TB and key informant interviews with health managers. In addition, we held focus group discussions with healthcare workers involved in TB care. Data collection and thematic analysis of transcripts was informed by the Capability, Opportunity, Motivation and Behavior (COM-B) model. We identified relevant intervention functions using the Behavior Change Wheel.

RESULTS

We interviewed 79 respondents (31 patients, 10 health managers and 38 healthcare workers). Common barriers at the health facility level included; lack of knowledge about the proportion of patients not initiated on TB treatment (psychological capability); difficulty accessing sputum results from the laboratory as well as difficulty tracing patients due to inadequate recording of patient addresses (physical opportunity). At the patient level, notable barriers included long turnaround time for sputum results and lack of transport funds to return to health facilities (physical opportunity); limited TB knowledge (psychological capability) and stigma (social opportunity). The most important facilitators identified were quick access to sputum test results either on the date of first visit (same-day diagnosis) or on the date of first return and availability of TB treatment (physical opportunity). We identified education, restructuring of the service environment to improve sputum results turnaround time and enablement to improve communication of test results as relevant intervention functions to alleviate these barriers to and enhance facilitators for TB treatment initiation.

CONCLUSION

We found that barriers to treatment initiation existed at both the patient and health facility-level across all levels of the (Capability, Opportunity and Motivation) model. The intervention functions identified here should be tested for feasibility.

Prospective Evaluation of Positivity Rates of Aspergillus-Specific IgG and Quality of Life in HIV-Negative Tuberculosis Patients in Lagos, Nigeria

Background

Pulmonary tuberculosis (PTB) often results in residual anatomical and functional changes despite microbiological cure and may be complicated by chronic pulmonary aspergillosis (CPA). In this study, we determined the perceived health-related quality of life (HRQoL) of patients during and after PTB therapy and compared it with their quantitative Aspergillus-specific IgG positivity rates.

Methodology

We conducted a longitudinal study among TB patients attending two directly observed therapy short-course (DOTS) clinics in Lagos, Nigeria. Two hundred and four confirmed TB patients were recruited over 9 months, with five visits at baseline and 3, 6, 9, and 12 months. They were all acid-fast bacilli smear, GeneXpert, or culture positive for Mycobacterium tuberculosis. Two HRQoL questionnaires translated into Yoruba were self-administered. Chest X-ray and Aspergillus IgG were collected at each visit.

Results

A total of 204 participants were recruited into this study. Most (70.6%) were age 18–39 years, and only 3.9% were above 60 years; 66.7% of all participants were males. A total of 189 (92.6%) participated in the 3-month assessment, 174 (85.3%) at 6 months, 139 (68.1%) at 9 months, and 99 (48.5%) at 12 months. At baseline, only 60.9% scored “good” or “very good” QoL and health on the WHOQOL-Bref, which improved to 77% at 6 months. At baseline, 10.4% had positive Aspergillus IgG levels, 15.1% at 3 months, 11.5% at 6 months, 16.7% at 9 months, and 19.3% at 12 months. Those with a positive Aspergillus IgG at 6 months had worse physical health (p = 0.001), psychological state (p = 0.002), social relationships (p = 0.006), and environmental QoL (p = 0.001) domains of the WHOQOL-Bref. Probable CPA was 10.4% at baseline and 19.3% at 6 months post-PTB therapy. Thirty-eight (18.6%) relocated after 6 months of treatment, 16 (7.8%) were lost to follow-up, and 11 (5.4%) died.

Conclusion

Our findings reveal a significant relationship between the QoL and Aspergillus IgG levels of TB patients. Further follow-up studies and additional imaging are required to determine when patients develop CPA and its clinical impact.

Clinical and Psychosocial Determinants of Patients with Tuberculosis/Human Immunodeficiency Virus Co-Infection: A Structural Equation Model Approach

Background

Tuberculosis (TB)/human immunodeficiency virus (HIV) co-infection is a complex mesh of physical and psychosocial disorders that require a multimodal and multifaceted approach for improved outcomes.

Aims

This study determined the treatment outcomes of patients with TB/HIV co-infection and the clinico-psychosocial predictors of the disease over a 10-year period in resource-limited settings.

Patients and Methods

This study reviewed the 10-year retrospective treatment outcomes of patients with TB/HIV co-infection in a tertiary centre. The data were retrieved from the TB treatment registers and analyzed with STATA 16.0. The effects of latent constructs of high clinical severity, stigmatization, and family stress/burden on treatment outcomes were evaluated using a structural equation model.

Results

Of the 1,321 who met the inclusion criteria, 1,193 had sufficient data. The mean age of the patients was 38.2 ± 16.7 years. The treatment adherence rate over the 10 years was 93.8% (±6.8%) but successful treatment outcome was 75.5% (±8.1%). Stigmatism of TB/HIV infections was experienced by adults and males (β = 0.972; P < 0.001 β = 0.674; P < 0.001, β = -0.770; P < 0.001, respectively), non-adherent to treatment (β = -0.460; P < 0.001) clinical severity of illness (β = 0.940; P < 0.001), and being HIV negative (β = -0.770; P < 0.001). Family Stress/Burden was strongly affected by both Death (β = 1.000; P < 0.001) and higher Stigmatism (β = 0.602; P < 0.001). Clinical severity of illness significantly influenced both Death and Unsatisfactory outcomes (β = 0.207; P < 0.001, β = 0.203; P < 0.05, respectively). Non-Adherence led to potentially unsatisfactory outcome.

Conclusion

TB/HIV co-infection is a complex psychosocial disorder that is significantly and negatively impacted by social determinants of the disease. A holistic approach to treatment intervention that addresses the latent factors of stigmatization, family stress/burden, and high clinical severity is key to achieving a successful treatment outcome.

Risk factors associated with unsuccessful tuberculosis treatment outcomes in Hunan Province, China

OBJECTIVES

Globally, China has the third highest number of tuberculosis (TB) cases despite high rates (85.6%) of effective treatment coverage. Identifying risk factors associated with unsuccessful treatment outcomes is an important component of maximizing the efficacy of TB control programs.

METHODS

Retrospective cohort study to evaluate the outcomes of 306,860 drug-susceptible TB patients who underwent treatment in Hunan Province, China between 2013 and 2018. Univariable and multivariable logistic regression models were used to identify factors associated with unsuccessful TB treatment outcomes.

RESULTS

A successful treatment outcome was recorded for 98.6% of patients, defined as the sum of patients who were cured (36.2%) and completed treatment (62.4%). An unsuccessful treatment outcome was recorded for 1.8% of patients, defined as the sum of treatment failure (1.1%), deaths (0.5%) and lost to follow up (0.2%). The odds of an unsuccessful treatment outcome showed an increasing trend in more recent years of registration (2018 Adjusted Odds Ratio (AOR): 1.43; 95% Confidence Interval (CI) 1.31, 1.57 relative to 2013). Other significant risk factors were male sex (AOR: 1.17; 95% CI 1.10, 1.25); increasing age (AOR:1.02 per year increase; 95% CI 1.02,1.02); being severely ill (AOR: 1.50; 95% CI 1.33, 1.70); having a history of TB treatment (AOR: 2.93; 95% CI 2.69, 3.20); not being under systematic management (AOR: 16.10 (14.49, 17.88) and treatment regimens that differed from full course management.

CONCLUSIONS

The increasing likelihood of an unsuccessful treatment outcome over time necessitates the need for further research.

Tuberculosis prevalence, knowledge of transmission and its association with vaccination of children

Background

Understanding the perceptions of patients regarding tuberculosis (TB) will enable better design of a comprehensive, client-oriented program for the disease.

Methods

This study was conducted district-wise across India in 2015-2016 as part of the National Family Health Surveys (NFHS).

Results

We discovered that the prevalence of TB remains significantly high, with quite a high percentage of people being unaware of the exact cause of disease proliferation. The majority of people believed that touching or sharing utensils can be a source of TB. This perception affected the participants' responses about seeking diagnosis and treatment. However, it is a good sign that most people knew that TB is a curable disease that can be prevented to some extent if immunization with the Bacillus Calmette-Guérin (BCG) vaccine is done at the correct stage. So, a large section of the population had their children vaccinated. In addition, they would go for diagnosis if they had symptoms suggestive of the disease.

Conclusion

Findings from this study are indicative of the fact that a large population is aware that health facilities can make a significant contribution to the treatment of tuberculosis. There is a need to further investigate how this information could potentially be used to enhance early seeking of appropriate services among TB patients.

Gender-based differences in community-wide screening for pulmonary tuberculosis in Karachi, Pakistan: an observational study of 311 732 individuals undergoing screening

We describe gender-based differences in a community-wide TB screening programme in Karachi, Pakistan, in which 311 732 individuals were screened in mobile camps using symptom questionnaires and van-mounted digital chest X-ray, between 1 January 2018 and 31 December 2019. Only 22.4% (69 869) of camp attendees were women. Female attendees were less likely to have sputum collected and tested (31.5% (95% CI 30.4% to 32.7%) vs 38.5% (95% CI 37.6% to 39.1%)) or to initiate TB treatment (75.9% (95% CI 68.1% to 82.6%) vs 82.8% (95% CI 78.9% to 86.2%)), when indicated. Among the participants, the age-standardised prevalence of active TB was higher among women (prevalence ratio 1.4, 95% CI 1.1 to 1.7). These findings underscore the importance of integrating gender into the design and monitoring of TB screening programmes to ensure that women and men benefit equally from this important intervention.

Experiences and needs of patients with MDR/XDR-TB: a qualitative study among Saharia tribe in Madhya Pradesh, Central India

BACKGROUND

Drug-resistant tuberculosis (DR-TB) continues to be a major public health threat posing a critical challenge to TB treatment and control worldwide. The present study was conducted among patients with DR-TB of the Saharia tribe residing in Madhya Pradesh state of Central India to document their experiences and needs, and to identify gaps for treatment adherence as this population is known to be poor because of migration and other factors.

METHODS

We conducted 16 in-depth interviews on purposively selected patients with DR-TB among the Saharia tribe using a predesigned open-ended in-depth interview guide, which included questions on domains like general physical health, diagnosis, treatment adherence, side-effects of drugs and experience related to the health facility. Out of these interviews, various subthemes were extracted. The obtained qualitative data were subjected to thematic analysis.

RESULTS

The study helped to understand the experiences and needs of the patients with DR-TB in various stages from diagnosis to treatment. Also, there was the impact of factors like lack of education and awareness, poor living conditions and lack of healthcare facilities on predominance of the disease in the community. Poor access to a healthcare facility, high pill burden and related side-effects, longer duration of treatment, financial burden, misbeliefs and misconceptions were prominent issues posing a challenge to treatment adherence. The narratives pointed out their struggle at every stage be it with diagnosis, treatment initiation or treatment adherence.

CONCLUSION

It is paramount to address the needs and experiences of patients with DR-TB to develop a patient-centric and context-specific approach conducive to the sociocultural set-up of tribal people. This will scale down the attrition rate of tribal patients while adhering to the complete treatment process and reducing the high burden of TB among the Saharia community. In addition, tribal patients should be counselled at regular intervals to increase their confidence in the treatment.

Quantifying the global number of tuberculosis survivors: a modelling study

BACKGROUND

People who survive tuberculosis face clinical and societal consequences after recovery, including increased risks of recurrent tuberculosis, premature death, reduced lung function, and ongoing stigma. To describe the size of this issue, we aimed to estimate the number of individuals who developed first-episode tuberculosis between 1980 and 2019, the number who survived to 2020, and the number who have been treated within the past 5 years or 2 years.

METHODS

In this modelling study, we estimated the number of people who survived treated tuberculosis using country-level WHO data on tuberculosis case notifications, excluding those who died during treatment. We estimated the number of individuals surviving untreated tuberculosis using the difference between WHO country-level incidence estimates and notifications, applying published age-stratified and HIV-stratified case fatality ratios. To estimate survival with time, post-tuberculosis life tables were developed for each country-year by use of UN World Population Prospects 2019 mortality rates and published post-tuberculosis mortality hazard ratios.

FINDINGS

Between 1980 and 2019, we estimate that 363 million people (95% uncertainty interval [UI] 287 million-438 million) developed tuberculosis, of whom 172 million (169 million-174 million) were treated. Individuals who developed tuberculosis between 1980 and 2019 had lived 3480 million life-years (95% UI 3040 million-3920 million) after tuberculosis by 2020, with survivors younger than 15 years at the time of tuberculosis development contributing 12% (95% UI 7-17) of these life-years. We estimate that 155 million tuberculosis survivors (95% UI 138 million-171 million) were alive in 2020, the largest proportion (47% [37-57]) of whom were in the WHO South-East Asia region. Of the tuberculosis survivors who were alive in 2020, we estimate that 18% (95% UI 16-20) were treated in the past 5 years and 8% (7-9) were treated in the past 2 years.

INTERPRETATION

The number of tuberculosis survivors alive in 2020 is more than ten times the estimated annual tuberculosis incidence. Interventions to alleviate respiratory morbidity, screen for and prevent recurrent tuberculosis, and reduce stigma should be immediately prioritised for recently treated tuberculosis survivors.

FUNDING

UK Medical Research Council, the UK Department for International Development, the National Institute for Health Research, and the European and Developing Countries Clinical Trials Partnership.

Social stigma among tuberculosis patients attending DOTS centers in Delhi

Background:

Every year >9 million people suffer from tuberculosis (TB) and India accounts for >25% of global TB burden. Tuberculosis patients experience both psychological and social suffering. Amongst the problems met by tuberculosis patients, social stigma has been increasingly recognized. This study was done to assess social stigma and associated factors among the tuberculosis patients attending Directly Observed Treatment Short-course (DOTS) centers in South East Delhi.

Material and Methods:

It was a cross-sectional study carried out among tuberculosis patients availing treatment from DOTS centers of South East Delhi. Out of 48 DOTS centers in South East Delhi, 6 centers were selected on the basis of population proportion to size. A total of 270 TB patients were interviewed using a semi-structured, pretested questionnaire consisting of stigma-based questions. Fisher exact and Chi-square test applied.

Results:

The mean age of patients was 31.5 years (SD ± 11.5) with age ranging from 18 to 77 years. Males were higher (57.4%) compared to females (42.6%). 123 (45.5%) perceived stigma with family/friends and 92/158 (58.2%) perceived stigma at workplace. Young patients (<30 years), males faced more stigma at workplace and lower socioeconomic class faced higher stigma with family and friends (P < 0.05).

Conclusion:

There is still higher stigmatization faced by patients with TB at family/friends and at workplace. Motivation by friends/family and support at workplace has been crucial in achieving successful treatment outcomes.

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.

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.

Statistical Modeling of HIV, Tuberculosis, and Hepatitis B Transmission in Ghana

Most mortality studies usually attribute death to single disease, while various other diseases could also act in the same individual or a population at large. Few works have been done by considering HIV, Tuberculosis (TB), and Hepatitis B (HB) as jointly acting in a population in spite of their high rate of infections in Ghana. This study applied competing risk methods on these three diseases by assuming they were the major risks in the study population. Among all opportunistic infections that could also act within HIV-infected individuals, TB has been asserted to be the most predominant. Other studies have also shown cases of HIV and Hepatitis B coinfections. The validity of these comorbidity assertions was statistically determined by exploring the conditional dependencies existing among HIV, TB, and HB through Bayesian networks or directed graphical model. Through Classification tree, sex and age group of individuals were found as significant demographic predictors that influence the prevalence of HIV and TB. Females were more likely to contract HIV, whereas males were prone to contracting TB.

Care and social support from family and community in patients with pulmonary tuberculosis in Pakistan

Objectives

This study aimed to validate the Medical Outcome Study-Social Support Survey (MOS-SSS) instrument in Pakistan and to quantify the nature of care and social support currently extended to patients with pulmonary tuberculosis (TB) in Pakistan.

Design

This is a cross-sectional study design conducted within a period of 3 months from 1 November 2016 to 31 January 2017.

Participants

A total of 269 patients, registered at 11 TB centres and private clinics, were interviewed through an interviewer-administered questionnaire.

Main outcome measures

Cronbach's alpha was used to measure the internal consistency and reliability of the MOS-SSS survey instrument. Univariate and multivariable logistic regressions have been used to explore the association between care and social support, and socioeconomic factors.

Result

This study validated the use of the MOS-SSS among patients with TB in Pakistan. Findings of the study revealed significant differences among the socioeconomic groups of patients in each subscale of social support. Additionally, results of logistic regressions showed that patients who were older (adjusted OR=6.17, 95% CI 1.55 to 24.59, p≤0.01), male (adjusted OR=2.73, 95% CI 1.49 to 4.98, p≤0.01), widow (adjusted OR=0.17, 95% CI 0.04 to 0.80, p≤0.05), and had a larger household size (adjusted OR=5.69, 95% CI 1.32 to 24.65, p≤0.05), higher monthly income (adjusted OR=2.00, 95% CI 1.11 to 3.60, p≤0.05) and house ownership (adjusted OR=1.99, 95% CI 1.10 to 3.60, p≤0.05) were significant factors associated with the extent of care and social support that the participants received.

Conclusion

To cure TB, this study suggests a coordinated approach that includes not only clinical services to address this issue but also a strong social support system based on family and community necessary throughout the treatment process.

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.

Treatment outcomes of drug-resistant tuberculosis in the Netherlands, 2005-2015

Background

Since in low incidence TB countries population migration and complex treatment of drug-resistant tuberculosis (DR-TB) patients are major issues, we aimed to analyse patient risk factors associated with the incidence of poor outcome of TB treatment among DR-TB patients in the Netherlands.

Methods

This retrospective cohort study included adult patients with confirmed DR-TB treated from 2005 to 2015. We obtained data from a nationwide exhaustive registry of tuberculosis patients in the Netherlands. Predictors for unsuccessful TB treatment (defaulted and failed treatment) and TB-associated mortality were analysed using multivariate logistic regression.

Results

Among 10,303 registered TB patients, 545 patients with DR-TB were analysed. Six types of DR-TB were identified from the included patients, i.e. isoniazid mono- or poly-resistance (68%); rifampicin mono- or poly-resistance (3.1%); pyrazinamide mono-resistance (8.3%); ethambutol mono-resistance (0.1%); multidrug-resistance (18.9%); and extensively drug-resistance (0.7%). The majority of patients were foreign-born (86%) and newly diagnosed TB (89%) patients. The cumulative incidence of unsuccessful treatment and mortality were 5 and 1%, respectively. Among all DR-TB cases, patients with Multi Drug-Resistant Tuberculosis (MDR-TB) (OR 4.43; 95%CI 1.70-11.60) were more likely to have unsuccessful treatment, while miliary and central nervous system TB (OR 15.60; 95%CI 2.18-111.52) may also be predictors for TB mortality. Additionally, patients with substance abuse and homelessness tend to have unsuccessful treatment.

Conclusions

In recent years, we identified a low incidence of DR-TB as well as the poor outcome of DR-TB treatment. The majority of cases were primary drug-resistant and foreign-born. To further improve treatment outcome, special attention should be given to the high-risk DR-TB patients.

"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.

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.

Adolescent and young adult couples' views of intravaginal practices: a qualitative analysis of a pilot study

Purpose

In this study, we evaluated the risk behaviors that are drivers of the HIV epidemic among adolescent girls and young women in Zambia using a focus group research technique.

Subjects and methods

Eighteen adolescent couples (n=18 females and 18 males) aged 16–24 participated in six focus groups discussions (3 per gender) convened at three health facilities in Lusaka, Zambia. Focus group moderators utilized a set of open-ended questions to guide the 60-minute sessions. The focus group audio recordings were transcribed, coded, and analyzed using qualitative content analysis in Nvivo 11.

Results

Three themes and four subthemes were identified relating to adolescent and young adult couples’ knowledge, views, and male partner attitudes toward intravaginal practices (IVPs). The first theme, knowledge and rationale for IVPs, consisted of the subthemes relating to why adolescents and young adult couples engage in IVPs and assessed their knowledge of health risks associated with IVPs. The second theme, attitudes toward IVPs, consisted of the subtheme willingness to stop or support partner to discontinue IVP and practices toward IVP and strategies for changing. The third theme, strategies for changing IVPs, consisted of the subtheme raise awareness.

Conclusion

IVPs used for cleaning purposes were perceived as essential to enhancing hygiene, health, and sexual satisfaction for both girls and boys. However, couples expressed concern about the health effects of IVPs used for tightening and a desire for learning more about this practice as well as stopping it.

Treatment outcome of tuberculosis treatment regimens in Kandahar, Afghanistan

BACKGROUND

Tuberculosis (TB) is a chronic disease that mostly affects low-income countries. TB is transmitted through droplet aerosolization from a person with active pulmonary TB. Afghanistan is one of the 22 high TB burden countries where 39,445 people develop this disease and 7840 people die each year. Treatment outcome is one of the best measurements that explain how the current regimen works.

MATERIAL AND METHODS

This was a retrospective cohort study, conducted in Kandahar Province, to find out the treatment outcome of anti-TB drugs regimens in TB patients. Data of pulmonary and extra-pulmonary TB patients, who fulfilled the eligible criteria of the study and were treated from 2005 to 2015, was retrieved from their medical record forms.

RESULTS

Among 1000 TB patients, 599 (59.9%) were females and 401 (40.1%) males; most of the patients (678/1000 [67.8%]) were from Kandahar city while 322/1000 (32.2%) were from the other districts of Kandahar. Mean age of the patients were 36.1 years with SD of 19.3 years. Main signs and symptoms of fever, cough, and weight loss were present in 949/1000 (94.9%), 880/1000 (88%), and 544/1000 (54.4%) of the patients, respectively. On first visit 459/1000 (45.9%) patients were sputum AFB (acid fast bacilli) positive. Majority (247/459 [53.8%]) of these patients were AFB 2+. After 2 months of intensive anti-TB treatment, 9/459 (1.9%) patients were still AFB positive (1+). Treatment outcome of these 1000 patients showed that 479 (47.9%) completed the treatment, 298 (29.8%) were cured, 35 (3.5%) failed the anti-TB treatment, while 5 (0.5%) patients died.

CONCLUSION

This clearly shows that TB is still one of the major threats to the people of Kandahar Province. There are cases of TB who do not respond to the first line regimens of anti-TB drugs advised by WHO and Afghan Ministry of Public Health (MoPH).

Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India

Background:

Stigma associated with tuberculosis (TB) is still common in many societies, contributing to delays in treatment seeking and treatment non-compliance. India has the highest burden of TB in the world with female TB patients bearing a considerable burden of TB-related stigma.

Objectives:

This study aimed to explore the manifestations and consequences of stigma experienced by female TB patients in an urban setting in India and their strategies to cope with the social stigma of TB.

Methods:

Twenty qualitative interviews were conducted with female TB patients who were either currently on treatment or had undergone treatment at a TB clinic in Kolkata, India. Data were coded and analyzed with the NVivo qualitative software using a thematic approach.

Results:

Our results indicated that TB stigma mainly manifested through social isolation and avoidance due to fear of contagion, gossip and verbal abuse, failed marriage prospects, and neglect from family. Consequences of stigma described by the women included non-disclosure, feelings of guilt, and mental health issues including suicidal ideation. Positive coping strategies used by women to cope with the experiences of stigma included positive reframing, prayer, talking to other patients, focusing on school work, and relaxation activities. Negative coping activities included self-imposed social isolation and anger. In some cases, non-disclosure due to stigma had an impact on TB transmission and control behaviors.

Conclusions:

Stigma-reduction strategies, such as community awareness programs and formation of social support groups to dispel the myths and misconceptions associated with TB, may improve TB treatment seeking and adherence.

Acknowledgement:

Our deepest thanks to the Reverend, St. James’ Church, Dr. Ali Akbar Chowdhury (Medical Officer), staff and participants at the Calcutta Diocesan Tuberculosis Relief Trust, without whom this study would not be possible. We also thank Sushmita Mukherjee for help with translations. Lastly, we thank the Sparkman Center for Global Health at the University of Alabama at Birmingham for providing travel funds for this study.

Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India

BACKGROUND

Stigma associated with tuberculosis (TB) is still common in many societies, contributing to delays in treatment seeking and treatment non-compliance. India has the highest burden of TB in the world with female TB patients bearing a considerable burden of TB-related stigma. Objectives: This study aimed to explore the manifestations and consequences of stigma experienced by female TB patients in an urban setting in India and their strategies to cope with the social stigma of TB.

METHODS

Twenty qualitative interviews were conducted with female TB patients who were either currently on treatment or had undergone treatment at a TB clinic in Kolkata, India. Data were coded and analyzed with the NVivo qualitative software using a thematic approach.

RESULTS

Our results indicated that TB stigma mainly manifested through social isolation and avoidance due to fear of contagion, gossip and verbal abuse, failed marriage prospects, and neglect from family. Consequences of stigma described by the women included non-disclosure, feelings of guilt, and mental health issues including suicidal ideation. Positive coping strategies used by women to cope with the experiences of stigma included positive reframing, prayer, talking to other patients, focusing on school work, and relaxation activities. Negative coping activities included self-imposed social isolation and anger. In some cases, non-disclosure due to stigma had an impact on TB transmission and control behaviors. Conclusions: Stigma-reduction strategies, such as community awareness programs and formation of social support groups to dispel the myths and misconceptions associated with TB, may improve TB treatment seeking and adherence.Acknowledgement: Our deepest thanks to the Reverend, St. James' Church, Dr. Ali Akbar Chowdhury (Medical Officer), staff and participants at the Calcutta Diocesan Tuberculosis Relief Trust, without whom this study would not be possible. We also thank Sushmita Mukherjee for help with translations. Lastly, we thank the Sparkman Center for Global Health at the University of Alabama at Birmingham for providing travel funds for this study.

Predictors of noncompliance to pulmonary tuberculosis treatment: An insight from South America

PURPOSE

To investigate the factors associated with a higher risk of noncompliance to tuberculosis (TB) treatment in Porto Alegre, Brazil.

METHODS

We identified 478 adult patients for this case-control study undergoing treatment for confirmed pulmonary TB. Cases (noncompliance) were defined as patients who stopped treatment for more than 30 consecutive days (n = 118). Controls were defined as all patients who completed treatment and were cured (n = 360). Factors associated with noncompliance were calculated with unadjusted and adjusted odds ratio (OR).

RESULTS

The rate of noncompliance in our study was 25%. The factors of noncompliance after adjustments in the overall population were, in order of magnitude, living in an area of lower income (OR = 4.35, 95%CI: 2.50-7.58), abuse of drugs (OR = 2.73, 95%CI: 1.47-5.09), nonadherence to a previous treatment regimen (OR = 2.1, 95%CI: 1.28-3.45), and history of smoking (OR = 1.72, 95%CI: 1.00-3.00). Age, race, gender, level of education, HIV infection or diabetes status were not associated with a higher risk of noncompliance. In the subgroup of re-treatment cases, poverty (OR = 2.65; 95%CI = 1.06-6.66), smoking history (OR = 2.94; 95%CI = 1.09-7.92), male gender (OR = 3.25; 95%CI = 1.32-8.0), and younger age (OR = 4.3; 95%CI = 1.15-16.07) were also associated with a higher risk of dropout.

CONCLUSION

Predictors of poor compliance to TB treatment were low income, abuse of drugs, re-treatment cases and history of smoking.

Knowledge and perceptions of tuberculosis among patients in a pastoralist community in Kenya: a qualitative study

Introduction

Tuberculosis awareness is crucial to the success of control and prevention of tuberculosis. However, the knowledge and perceptions of tuberculosis patients in rural Kenya is not well documented. The study sought to explore the knowledge and perceptions of TB patients in West Pokot County Kenya.

Methods

This was a qualitative descriptive study conducted between January-March 2016. A total of 61 pulmonary tuberculosis patients took part in the study which comprised 6 focus group discussion and 15 in-depth interviews. Thematic analysis was used to analyse the data.

Results

Participants perceived TB as a serious contagious disease that is hard to diagnose and treat. They attributed tuberculosis to smoking, drinking alcohol, dust, cold air, witchcraft, trauma to the chest, contact with livestock and genetic factors. They believed that TB was transmitted through casual contact with TB patients and sharing of utensils.

Conclusion

The study showed a lot of misperceptions among tuberculosis patients. The tuberculosis program should heighten patient education to improve patient knowledge and put more effort to dispel misinformation about the cause and mode of transmission of the disease.

Knowledge, beliefs, and perceptions of tuberculosis among community members in Ntcheu district, Malawi

Introduction

The global burden of tuberculosis (TB) remains significantly high, with overreliance on biomedical interventions and inadequate exploration of the socioeconomic and cultural context of the infected population. A desired reduction in disease burden can be enhanced through a broader theoretical understanding of people’s health beliefs and concerns about TB. In this qualitative study, we explore the knowledge, beliefs, and perceptions of community members and people diagnosed with TB toward TB in Ntcheu district, Malawi.

Methods

Using a qualitative phenomenological study design, data were obtained from eight focus-group discussions and 16 individual in-depth interviews. The community’s experiences and perceptions of TB were captured without using any preconceived framework. Adult participants who had had or never had a diagnosis of TB were purposively selected by sex and age and enrolled for the study. Discussions and individual interviews lasting about 60 minutes each were audiotaped, transcribed, and translated into English and analyzed using MaxQDA 10 software for qualitative analysis.

Results

Most participants believed that TB was curable and would go for diagnosis if they had symptoms suggestive of the disease. However, based on their beliefs, individuals expressed some apprehension about the spread of TB and the social implications of being diagnosed with the disease. This perception affected participants’ responses about seeking diagnosis and treatment.

Conclusion

A supportive and collective approach consisting of a combination of mass media, interactive communication campaigns, emphasizing TB symptoms, transmission, and stigma could be useful in addressing barriers to early diagnosis and care-seeking behavior.

Diagnostic delay and associated factors among patients with pulmonary tuberculosis in Kerala

Introduction

Delay in the diagnosis of tuberculosis (TB) can lead to an increased infectivity period, delayed treatment, and increased severity of the disease. The objective of this study was to estimate the diagnostic delay and factors associated with the delay in diagnosis among the newly diagnosed smear-positive pulmonary TB patients in Kerala, India.

Materials and Methods

A cross-sectional study was conducted among TB patients who were in the intensive phase of directly observed treatment short-course treatment in four randomly selected TB units in a district in Kerala during the years 2012-2013. Diagnostic delay was defined as the delay between the onset of symptoms and diagnosis. Data collection using a modified World Health Organization questionnaire was done by interviewing 302 participants.

Results

Mean age of the participants was 48.6 ± 14.5 years. Males constituted 76.5% of the study population. The mean diagnostic delay was 43.5 ± 29.1 days (median: 37 days). The median patient and health system delays were 16 days and 15 days, respectively. Patient delay (55.6%) contributed more than health system delay (44.4%). Poor knowledge about TB, first consulting a private physician, and increased number of consultations were found to be significantly associated with diagnostic delay.

Conclusion

The diagnostic delay in tuberculosis reported in this study was lower than other studies in India but it needs further reduction. Both patients and health providers play a role in a delay in diagnosis, and poor knowledge about the disease among the patients was one of the main risk factors. Interventions to improve knowledge and awareness of the disease and to increase the suspicion of chest symptomatic by health-care providers in the private sector are vital to reduce diagnostic delay.

Public health and public trust: Survey evidence from the Ebola Virus Disease epidemic in Liberia

Trust in government has long been viewed as an important determinant of citizens' compliance with public health policies, especially in times of crisis. Yet evidence on this relationship remains scarce, particularly in the developing world. We use results from a representative survey conducted during the 2014-15 Ebola Virus Disease (EVD) epidemic in Monrovia, Liberia to assess the relationship between trust in government and compliance with EVD control interventions. We find that respondents who expressed low trust in government were much less likely to take precautions against EVD in their homes, or to abide by government-mandated social distancing mechanisms designed to contain the spread of the virus. They were also much less likely to support potentially contentious control policies, such as "safe burial" of EVD-infected bodies. Contrary to stereotypes, we find no evidence that respondents who distrusted government were any more or less likely to understand EVD's symptoms and transmission pathways. While only correlational, these results suggest that respondents who refused to comply may have done so not because they failed to understand how EVD is transmitted, but rather because they did not trust the capacity or integrity of government institutions to recommend precautions and implement policies to slow EVD's spread. We also find that respondents who experienced hardships during the epidemic expressed less trust in government than those who did not, suggesting the possibility of a vicious cycle between distrust, non-compliance, hardships and further distrust. Finally, we find that respondents who trusted international non-governmental organizations (INGOs) were no more or less likely to support or comply with EVD control policies, suggesting that while INGOs can contribute in indispensable ways to crisis response, they cannot substitute for government institutions in the eyes of citizens. We conclude by discussing the implications of our findings for future public health crises.

Patients infected by tuberculosis and human immunodeficiency virus facing their disease, their reactions to disease diagnosis and its implication about their families and communities, in Burkina Faso: a mixed focus group and cross sectional study

Background

Patients facing tuberculosis (TB) and human immunodeficiency virus (HIV) infection receive particular care. Despite efforts in the care, misconceptions about TB and HIV still heavily impact patients, their families and communities. This situation severely limits achievement of TB and HIV programs goals. This study reports current situation of TB patients and patients living with HIV/AIDS (PLWHA) facing their disease and its implications, by comparing results from both qualitative and quantitative study design.

Methods

Cross sectional study using mixed methods was used and excluded patients co-infected by TB and HIV. Focus group included 96 patients (6 patients per group) stratified by setting, disease profile and gender; from rural (Orodara Health District) and urban (Bobo Dioulasso) areas, all from Hauts-Bassins region in Burkina Faso. Quantitative study included 862 patients (309 TB patients and 553 PLWHA) attending TB and HIV care facilities in two main regions (Hauts-Bassins and Centre) of Burkina Faso.

Results

A content analysis of reports found TB patients and PLWHA felt discriminated and stigmatized because of misconceptions with its aftermaths (rejection, emotional and financial problems), mainly among PLWHA and women patients. PLWHA go to healers when facing limited solutions in health system. There are fewer associations for TB patients, and less education and sensitization sessions to give them opportunity for sharing disease status and learning from other TB patients. TB patients and PLWHA still need to better understand their disease and its implication. Access to care (diagnosis and treatment) remains one of the key issues in health system, especially for PLWHA. Individual counseling is centered among PLWHA but not for TB patients. With research progress and experiences sharing, TB patients and PLWHA have some hope to implement their life project, and to receive psychosocial and nutritional support.

Conclusion

Despite international aid, TB patients and PLWHA are facing misconceptions effects. There is a need to reinforce health education towards patients and healers, inside community, health centers and associations, and for specific settings. International aid must be adapted to specific targets and strategies implementing programs. Maintaining psychosocial and nutritional support is crucial for better outcomes of medication adherence. Individual counseling has to be centered among TB patients and PLWHA.

Tuberculosis patient and family education through videography in El Salvador

Background

Tublosis (TB) and the approaches to successful management are commonly misunderstood health topics among patients and family members within resource-limited settings. Such public misconceptions often result in delayed diagnoses of afflicted patients, suboptimal compliance with prescribed therapies and a negative community social stigma that hinders effective contact investigations.

Objective

To determine through an observational field pilot study if videography-based TB education program can be implemented in busy resource-limited outpatient TB clinic settings and improve both patient and family understanding of TB and its treatment, as well as, improve the efficiency of TB medical evaluations and corresponding contact investigations.

Methods

We produced and implemented a videography-based health educational pilot strategy in 14 TB clinics within El Salvador to supplement the discussions between health providers, patients and families. Field observations and impressions after the first year of implementation were recorded.

Results

After viewing the video, patient impressions revealed greater understanding of TB including how it's transmitted and successfully treated, as well as, a more optimistic outlook of the diagnosis. Family members viewing the video displayed less fear and greater interest in TB and also exhibited more support for relatives undergoing evaluation or treatment. Salvadorian TB health providers reported improvements in patient compliance with treatment, contact investigations of suspected patients, delivery of sputum samples for testing, clinic time-efficiency spent with patients, and an observed reduction of negative family stigma of TB.

Conclusions

Our findings suggest that videography-based TB education can be successfully implemented in busy and resource-limited outpatient settings, and can provide a potentially efficient and low-cost effective strategy towards optimizing patient understanding, acceptance and compliance with TB treatment recommendations. This feasibility pilot study provides an opportunity within underresourced clinics for further evaluation regarding the favorable educational and sustainable impact of videography-based health education.

"My Favourite Day Is Sunday": Community Perceptions of (Drug-Resistant) Tuberculosis and Ambulatory Tuberculosis Care in Kara Suu District, Osh Province, Kyrgyzstan

OBJECTIVES

Kyrgyzstan is one of the 27 high multidrug-resistant tuberculosis (MDR-TB) burden countries listed by the WHO. In 2012, Médecins Sans Frontières (MSF) started a drug-resistant tuberculosis (DR-TB) project in Kara Suu District. A qualitative study was undertaken to understand the perception of TB and DR-TB in order to improve the effectiveness and acceptance of the MSF intervention and to support advocacy strategies for an ambulatory model of care.

METHODS

This paper reports findings from 63 interviews with patients, caregivers, health care providers and members of communities. Data was analysed using a qualitative content analysis. Validation was ensured by triangulation and a 'thick' description of the research context, and by presenting deviant cases.

RESULTS

Findings show that the general population interprets TB as the 'lungs having a cold' or as a 'family disease' rather than as an infectious illness. From their perspective, individuals facing poor living conditions are more likely to get TB than wealthier people. Vulnerable groups such as drug and alcohol users, homeless persons, ethnic minorities and young women face barriers in accessing health care. As also reported in other publications, TB is highly stigmatised and possible side effects of the long treatment course are seen as unbearable; therefore, people only turn to public health care quite late. Most patients prefer ambulatory treatment because of the much needed emotional support from their social environment, which positively impacts treatment concordance. Health care providers favour inpatient treatment only for a better monitoring of side effects. Health staff increasingly acknowledges the central role they play in supporting DR-TB patients, and the importance of assuming a more empathic attitude.

CONCLUSIONS

Health promotion activities should aim at improving knowledge on TB and DR-TB, reducing stigma, and fostering the inclusion of vulnerable populations. Health seeking delays and adherence problems will be countered by further implementation of shortened treatment regimens. An ambulatory model of care is proposed when convenient for the patient; hospitalisation is favoured only when seen as more appropriate for the respective individual.

Close to community health providers post 2015: Realising their role in responsive health systems and addressing gendered social determinants of health

Universal health coverage is gaining momentum and is likely to form a core part of the post Millennium Development Goal (MDG) agenda and be linked to social determinants of health, including gender; Close to community health providers are arguably key players in meeting the goal of universal health coverage through extending and delivering health services to poor and marginalised groups; Close to community health providers are embedded in communities and may therefore be strategically placed to understand intra household gender and power dynamics and how social determinants shape health and well-being. However, the opportunities to develop critical awareness and to translate this knowledge into health system and multi-sectoral action are poorly understood; Enabling close to community health providers to realise their potential requires health systems support and human resource management at multiple levels.

Improving access to effective care for people with chronic respiratory symptoms in low and middle income countries

Chronic respiratory symptoms are amongst the most common complaints among low and middle-income country (LMICs) populations and they are expected to remain common over the 10 to 20 year horizon. The underlying diseases (predominantly chronic obstructive pulmonary disease, asthma and tuberculosis) cause, and threaten to increasingly cause, substantial morbidity and mortality. Effective treatment is available for these conditions but LMICs health systems are not well set up to provide accessible clinical diagnostic pathways that lead to sustainable and affordable management plans especially for the chronic non communicable respiratory diseases. There is a need for clinical and academic capacity building together with well-conducted health systems research to underpin health service strengthening, policy and decision-making. There is an opportunity to integrate solutions for improving access to effective care for people with chronic respiratory symptoms with approaches to tackle other major population health issues that depend on well-functioning health services such as chronic communicable (e.g. HIV) and non-communicable (e.g. cardiovascular and metabolic) diseases.

Determinants of Default from Tuberculosis Treatment among Patients with Drug-Susceptible Tuberculosis in Karachi, Pakistan: A Mixed Methods Study

Purpose

Non-adherence to tuberculosis therapy can lead to drug resistance, prolonged infectiousness, and death; therefore, understanding what causes treatment default is important. Pakistan has one of the highest burdens of tuberculosis in the world, yet there have been no qualitative studies in Pakistan that have specifically examined why default occurs. We conducted a mixed methods study at a tuberculosis clinic in Karachi to understand why patients with drug-susceptible tuberculosis default from treatment, and to identify factors associated with default. Patients attending this clinic pick up medications weekly and undergo family-supported directly observed therapy.

Methods

In-depth interviews were administered to 21 patients who had defaulted. We also compared patients who defaulted with those who were cured, had completed, or had failed treatment in 2013.

Results

Qualitative analyses showed the most common reasons for default were the financial burden of treatment, and medication side effects and beliefs. The influence of finances on other causes of default was also prominent, as was concern about the effect of treatment on family members. In quantitative analysis, of 2120 patients, 301 (14.2%) defaulted. Univariate analysis found that male gender (OR: 1.34, 95% CI: 1.04–1.71), being 35–59 years of age (OR: 1.54, 95% CI: 1.14–2.08), or being 60 years of age or older (OR: 1.84, 95% CI: 1.17–2.88) were associated with default. After adjusting for gender, disease site, and patient category, being 35–59 years of age (aOR: 1.49, 95% CI: 1.10–2.03) or 60 years of age or older (aOR: 1.76, 95% CI: 1.12–2.77) were associated with default.

Conclusions

In multivariate analysis age was the only variable associated with default. This lack of identifiable risk factors and our qualitative findings imply that default is complex and often due to extrinsic and medication-related factors. More tolerable medications, improved side effect management, and innovative cost-reduction measures are needed to reduce default from tuberculosis treatment.

Factors Associated with Health-Related Quality of Life in Tuberculosis Patients Referred to the National Research Institute of Tuberculosis and Lung Disease in Tehran

Background

In tuberculosis (TB) patients, health-related quality of life (HRQoL) is significant in self-management, which in turn can be effective in therapeutic acceptance and prevention of treatment failure due to multi-drug resistant TB. This study was conducted to evaluate HRQoL and associated factors in TB patients referred to the National Research Institute of Tuberculosis and Lung Disease (NRITLD).

Methods

In this study, patients were selected from TB clinics of the NRITLD in Tehran. In addition to an Iranian version of the Short-Form Health Survey (SF-36), demographic and disease characteristic questionnaires were used for data collection. The data were then analyzed using SPSS software.

Results

Two hundred five TB patients, with the average age of 42.33±17.64 years, participated in this study. The HRQoL scores in different domains ranged from 14.68±11.60 for role limitations due to emotional problems to 46.99±13.25 for general health perceptions. The variables of sex, marital status, education, job status, place of residence, and cigarette smoking, influenced the HRQoL scores in different dimensions.

Conclusion

According to the study findings are the important variables that influenced the HRQoL of TB patients. The consideration of its can improve the HRQoL of TB patients.

Is tuberculosis treatment really free in China? A study comparing two areas with different management models

Objective

China has implemented a free-service policy for tuberculosis. However, patients still have to pay a substantial proportion of their annual income for treatment of this disease. This study describes the economic burden on patients with tuberculosis; identifies related factors by comparing two areas with different management models; and provides policy recommendation for tuberculosis control reform in China.

Methods

There are three tuberculosis management models in China: the tuberculosis dispensary model, specialist model and integrated model. We selected Zhangjiagang (ZJG) and Taixing (TX) as the study sites, which correspond to areas implementing the integrated model and dispensary model, respectively. Patients diagnosed and treated for tuberculosis since January 2010 were recruited as study subjects. A total of 590 patients (316 patients from ZJG and 274 patients from TX) were interviewed with a response rate of 81%. The economic burden attributed to tuberculosis, including direct costs and indirect costs, was estimated and compared between the two study sites. The Mann-Whitney U Test was used to compare the cost differences between the two groups. Potential factors related to the total out-of-pocket costs were analyzed based on a step-by-step multivariate linear regression model after the logarithmic transformation of the costs.

Results

The average (median, interquartile range) total cost was 18793.33 (9965, 3200-24400) CNY for patients in ZJG, which was significantly higher than for patients in TX (mean: 6598.33, median: 2263, interquartile range: 983–6688) (Z = 10.42, P < 0.001). After excluding expenses covered by health insurance, the average out-of-pocket costs were 14304.4 CNY in ZJG and 5639.2 CNY in TX. Based on the multivariable linear regression analysis, factors related to the total out-of-pocket costs were study site, age, number of clinical visits, residence, diagnosis delay, hospitalization, intake of liver protective drugs and use of the second-line drugs.

Conclusion

Under the current “free of diagnosis and treatment” policy, the financial burden remains heavy on tuberculosis patients. Policy makers need to consider appropriate steps to lessen the burden of out-of-pocket costs for tuberculosis patients in China and how best to improve service delivery for poor patients.

Lifestyle, attitudes and needs of uncured XDR-TB patients living in the communities of South Africa: a qualitative study

OBJECTIVE

Patient-level data are required to inform strategies interrupting transmission and default in patients with extensively drug-resistant TB (XDR-TB) to improve models of care and identify potential routes of transmission. We therefore explored the experiences, lifestyle, attitudes and needs of patients with uncured XDR-TB, who failed or interrupted therapy, living without treatment in the community.

METHODS

We conducted in-depth interviews with 12 community-based patients from South Africa. Family members were interviewed when patients were unavailable. Interviews were analysed using inductive thematic analysis.

RESULTS

The thematic experiences identified from the interviews were as follows: (i) living with but not being cured of XDR-TB, (ii) altered lifestyle in the community, (iii) experiences with community health care, (iv) local community members, and (v) wants and needs. Patients identified mistrust in health care, futility of treatment regimens, a need for a purpose in life and subsistence as major concerns. Restriction of living in the community for patients whose treatment had failed resulted in self-imposed isolation. Defaulters focused more on the never-ending drug regimen and bad experiences with health care contributing to non-adherence. Family members emphasised an under-recognised experience of unforeseen burden, obligation, worry and discomfort. Lack of knowledge and lack of concern about transmission was evident.

CONCLUSION

Current models of care are not adequately meeting the needs of patients with uncured XDR-TB and relatives. These data inform the need for community-based palliative care, vocational facilities to improve economic opportunities, home-based infection control and improved psychosocial support to increase patient adherence, reduce transmission, provide income and relieve the burden on family members.

Knowledge and Attitudes About Tuberculosis Among U.S.-Born Blacks and Whites with Tuberculosis

Non-Hispanic blacks represent 13% of the U.S.-born population but account for 37% of tuberculosis (TB) cases reported in U.S.-born persons. Few studies have explored whether this disparity is associated with differences in TB-related knowledge and attitudes. Interviews were conducted with U.S.-born, non-Hispanic blacks and whites diagnosed with TB from August 2009 to December 2010 in cities and states that accounted for 27% of all TB cases diagnosed in these racial groups in the U.S. during that time period. Of 477 participants, 368 (77%) were non-Hispanic black and 109 (23%) were non-Hispanic white. Blacks had significantly less knowledge and more misconceptions about TB transmission and latent TB infection than whites. Most TB patients in both groups recalled being given TB information; having received such information was strongly correlated with TB knowledge. Providing information to U.S.-born TB patients significantly increased their knowledge and understanding of TB. More focused efforts are needed to provide TB information to U.S.-born black TB patients.

Is there a need to mitigate the social and financial consequences of tuberculosis at the individual and household level?

This paper reviews evidence on social and economic costs of tuberculosis. Key socio-economic consequences include stigma, social isolation, increased out-of-pocket expenditures for medical and non-medical costs and reduced income. Many of the financing methods that households use have long-term negative impacts and the poor are most vulnerable to these costs. Together, these negative consequences adversely affect TB control, in terms of delayed diagnosis, delayed initiation of treatment, suboptimal adherence and failure to complete treatment, as well as the coping and well being of the individual and household. There are two ways to reduce treatment costs for the patient; one can either reduce the direct and indirect costs of seeking a diagnosis and obtaining treatment and/or provide income transfers to offset some of those costs incurred. Social transfers in the form of food, cash or vouchers can mitigate the negative effects by enabling the individual to seek a diagnosis, protecting minimum food expenditures, reducing the need to accumulate debt and reduce productive assets and reducing the negative impacts on other household members, particularly young children and school-age children.

Gender-related barriers and delays in accessing tuberculosis diagnostic and treatment services: a systematic review of qualitative studies

Background. Tuberculosis (TB) remains a significant global public health problem with known gender-related (male versus female) disparities. We reviewed the qualitative evidence (written/spoken narrative) for gender-related differences limiting TB service access from symptom onset to treatment initiation. Methods. Following a systematic process, we searched 12 electronic databases, included qualitative studies that assessed gender differences in accessing TB diagnostic and treatment services, abstracted data, and assessed study validity. Using a modified “inductive coding” system, we synthesized emergent themes within defined barriers and delays limiting access at the individual and provider/system levels and examined gender-related differences. Results. Among 13,448 studies, 28 studies were included. All were conducted in developing countries and assessed individual-level barriers; 11 (39%) assessed provider/system-level barriers, 18 (64%) surveyed persons with suspected or diagnosed TB, and 7 (25%) exclusively surveyed randomly sampled community members or health care workers. Each barrier affected both genders but had gender-variable nature and impact reflecting sociodemographic themes. Women experienced financial and physical dependence, lower general literacy, and household stigma, whereas men faced work-related financial and physical barriers and community-based stigma. Conclusions. In developing countries, barriers limiting access to TB care have context-specific gender-related differences that can inform integrated interventions to optimize TB services.

Barriers and delays in tuberculosis diagnosis and treatment services: does gender matter?

Background. Tuberculosis (TB) remains a global public health problem with known gender-related disparities. We reviewed the quantitative evidence for gender-related differences in accessing TB services from symptom onset to treatment initiation. Methods. Following a systematic review process, we: searched 12 electronic databases; included quantitative studies assessing gender differences in accessing TB diagnostic and treatment services; abstracted data; and assessed study validity. We defined barriers and delays at the individual and provider/system levels using a conceptual framework of the TB care continuum and examined gender-related differences. Results. Among 13,448 articles, 137 were included: many assessed individual-level barriers (52%) and delays (42%), 76% surveyed persons presenting for care with diagnosed or suspected TB, 24% surveyed community members, and two-thirds were from African and Asian regions. Many studies reported no gender differences. Among studies reporting disparities, women faced greater barriers (financial: 64% versus 36%; physical: 100% versus 0%; stigma: 85% versus 15%; health literacy: 67% versus 33%; and provider-/system-level: 100% versus 0%) and longer delays (presentation to diagnosis: 45% versus 0%) than men. Conclusions. Many studies found no quantitative gender-related differences in barriers and delays limiting access to TB services. When differences were identified, women experienced greater barriers and longer delays than men.

Tuberculosis in indigenous communities of Antioquia, Colombia: epidemiology and beliefs

Morbidity and mortality caused by tuberculosis are increased in most of the Latin-American indigenous communities. Factors that could explain this situation are poverty and limited health services access due to social conflicts and geographical isolation. We determined the frequency of tuberculosis in Colombian indigenous communities and described their knowledge related to transmission and control. We developed a descriptive study and health survey. Interviews were performed to find ancestral knowledge about tuberculosis. Sputum samples from patients with respiratory symptoms were analyzed. 10 indigenous communities were studied, which tuberculosis incidence was 291/100,000. Communities believe that tuberculosis is a body and spirit disease, which transmission is by direct contact or by witchcraft. Tuberculosis incidence in the studied communities was ninefold higher than that of the general population from Antioquia Department. Knowledge exchange could facilitate the community empowerment and implementation of educational activities which might improve the control of the disease.

Experiences of the diagnosis and management of tuberculosis: a focused ethnography of Somali patients and healthcare professionals in the UK

AIM

To explore experiences of the diagnosis and management of tuberculosis from the perspective of Somali patients and healthcare professionals involved in their care.

BACKGROUND

The Somali population has the third highest incidence of tuberculosis occurring in persons born outside the UK. Tuberculosis is a disease with sociocultural as well as physical consequences. Nurses should understand how the disease is experienced by people from different ethnic backgrounds to implement strategies for prevention and management of tuberculosis.

DESIGN

A focused ethnography.

METHOD

Individual interviews with 14 Somali patients and 18 healthcare professionals with experience of providing care to Somalis were undertaken in 2008-2009. Interviews explored the patient experience from onset of symptoms to completion of treatment. Data were analysed using Framework approach.

FINDINGS

Despite presenting in primary care early, patients experienced diagnostic delays due to low clinical suspicion of tuberculosis among general practitioners. Although patients reported felt and enacted stigma, it did not adversely affect concordance with treatment. Patients were reticent about sharing their diagnosis among wider networks due to perceived stigma. Psychological support from families and specialist nurses was valued highly. Healthcare professionals perceived that stigmatization of tuberculosis was diminishing among Somalis leading to improved management of tuberculosis. Patients and healthcare professionals raised concerns about the longer term physical and psychosocial implications of tuberculosis once treatment was completed.

CONCLUSION

Nurses have a role in promoting early presentation, timely diagnosis, and treatment adherence through supporting Somali patients and raising awareness of the disease among primary care practitioners.

Patient views on determinants of compliance with tuberculosis treatment in the eastern cape, South Africa: an application of q-methodology

BACKGROUND

: Tuberculosis (TB) constitutes one-quarter of all avoidable deaths in developing countries. In the Eastern Cape, South Africa, TB is a public health problem of epidemic proportion. Poor compliance and frequent interruption to treatment are associated with increased transmission rates, morbidity, and costs to TB control programs. This study explored determinants of (non-)compliance from the patients' perspective.

METHODS

: Semi-structured interviews were conducted with patients (33 treatment compliers and 34 treatment non-compliers) and 14 community health workers from local community clinics and the hospital in the township of Grahamstown, Eastern Cape, South Africa. Q-methodology was used. Patients rank ordered 32 opinion statements describing determinants of treatment compliance from the TB adherence model. By-person factor analysis was used to explore patterns in the rankings of statements by compliers and non-compliers. These patterns were interpreted and described as patient views on determinants of compliance with treatment. Patients and community health workers selected the top five determinants of compliance and non-compliance.

RESULTS

: Compliers believed that completing treatment would cure them of TB. Economic prospects were crucial for compliance. Compliers felt that the support of the government disability grant helped with compliance. Non-compliers believed that stigmatization had the greatest impact on non-compliance, together with the burden of disease, the arrangements involved with receiving treatment, restrictions accompanying treatment, and the association of TB with HIV/AIDS infection.

CONCLUSIONS

: Stigmatization makes TB a 'social disease'. Individual motivation and self-efficacy appear to have a considerable effect on compliance, but, for non-compliers, the general lack of job prospects and being able to provide for themselves or their family also makes TB very much an 'economic disease'.

Socioeconomic impact of TB on patients registered within RNTCP and their families in the year 2007 in Chennai, India

Background:

Tuberculosis patients are registered in government clinics under Directly Observed Treatment Short-course (DOTS) program in Chennai city catering to 4.34 million population. With the entire country geographically covered under the DOTS program, research into socioeconomic impact of TB on patients and their households is crucial for providing comprehensive patient-friendly TB services and to document the benefits of DOTS.

Objective:

To assess the social and economic impact of TB on patients registered under DOTS program and their families.

Materials and Methods:

A cross-sectional study of 300 TB patients was done using a pre-coded semi-quantitative questionnaire between March and June 2007 in all the Tuberculosis Units (TUs) of Chennai city.

Results:

Social and economic impact was perceived by 69.0% and 30.3% patients, respectively. About 24.3% suffered from both social and economic impact, while 75% patients suffered from any one form of impact. Social impact was perceived by more female patients as compared to males (80.7% vs. 62%; P < 0.001). More patients with extra-pulmonary disease (44.4%) and patients belonging to joint families (40.7%) perceived economic impact (P < 0.05).

Conclusion:

After 8 years of DOTS implementation, the present study has shown that with the availability of DOTS, percentage of patients who mortgaged assets or took loans has reduced. Social impact of TB is still perceived by two-thirds of the patients (69%). Elimination or reduction of social stressors with specific, focused, and intense social support services, awareness generation, and counseling to patients and families need to be built into the program.

Socio-demographic determinants and prevalence of Tuberculosis knowledge in three slum populations of Uganda

Background

Knowledge of tuberculosis has been shown to influence health seeking behaviour; and urban slum dwellers are at a higher risk of acquiring tuberculosis than the general population. The study aim was to assess knowledge of tuberculosis and identify the associated socio-demographic determinants, in order to inform tailored interventions for advocacy, communication and social mobilisation in three urban-slum communities of Uganda.

Methods

A cross-sectional survey of 1361 adults between April and October 2011. Data was analyzed by descriptive statistics. Adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) of potential determinants of tuberculosis (TB) knowledge were estimated by multivariable ordinal logistic regression using Stata 11.2 software.

Results

We found low knowledge of TB cause (26.7%); symptoms (46.8%), transmission (54.3%), prevention (34%) and free treatment (35%). Knowledge about TB treatment (69.4) and cure (85.1) was relatively high. Independent determinants of poor knowledge of TB in the multivariable analysis included (aOR, 95% CI) lack of formal education (0.56; 0.38 – 0.83, P = 0.004), unemployment (0.67; 0.49 – 0.90, P = 0.010) and never testing for HIV (0.69; 0.51 – 0.92, P < 0.012). Whilst, older age (1.73; 1.30 – 2.29, P < 0.001) and residing in Lira (2.02; 1.50 – 2.72, P < 0.001) were independent determinants of higher knowledge of TB.

Conclusion

This study revealed deficiencies in the public health knowledge about TB symptoms, diagnosis and treatment among urban-slum dwellers in Uganda. Tuberculosis control programmes in similar settings should consider innovative strategies for TB education, advocacy, communication and social mobilisation to reach the youth, unemployed and less-educated; as well as those who have never tested for HIV.

Gender differences in treatment outcomes of tuberculosis patients in Taiwan: a prospective observational study

Gender disparities in tuberculosis (TB) cases are reported worldwide, and socio-cultural factors have been proposed as possible causes. To date, gender differences in treatment outcomes of TB patients remain controversial. In this prospective observational study, newly diagnosed, culture-proven TB patients from six hospitals in Taiwan were enrolled for analysis. Gender differences in demographic characteristics and treatment outcomes, including sputum conversion and on-treatment mortality, were analysed accordingly. From January 2007 through to December 2009, a total of 1059 patients were enrolled, including 819 (77.3%) males and 240 (22.7%) females. The ratio of male gender was around 50 ~ 60% in TB patients below 35 years and >80% for those older than 65 years. When compared with the female patients, the male patients were older, more likely to have the habit of smoking, chronic obstructive pulmonary disorder, malignancy and liver cirrhosis, and more likely to present with haemoptysis, body weight loss and pleural effusion. Regarding treatment outcomes, male gender is associated with a lower 2-month sputum culture conversion rate (78.8% vs. 89.3%, p 0.002) and higher on-treatment mortality (21.1% vs. 12.1%, p 0.002). Kaplan-Meier survival analysis demonstrated significantly higher mortality in the men (p 0.005). In multivariate analysis, male gender was an independent risk factor for 2-month sputum culture un-conversion (OR, 1.96; 95% CI, 1.12-3.41). Our findings suggest that male gender is associated with older age, more co-morbidities and worse treatment outcomes. Gender-specific strategies, including active case finding in elderly women and smoking cessation in male patients, are warranted to optimize TB management.

Study of tuberculosis and AIDS stigma as barriers to tuberculosis treatment adherence using validated stigma scales

BACKGROUND

Adherence to tuberculosis (TB) treatment is important for TB control. The effect of stigma on adherence has not been well quantified.

OBJECTIVE

To identify the effects of TB and acquired immune-deficiency syndrome (AIDS) stigma on missed doses during TB treatment.

DESIGN

Validated TB and AIDS stigma scales assessing perceived and experienced/felt stigma were administered in a prospective cohort of 459 TB patients at TB treatment initiation and after 2 months. Repeated measures and multivariable models estimated the effects of stigma on the rate of missed doses.

RESULTS

Fifty-six per cent of patients missed no doses, and associations between stigma and missed doses were minimal. Heterogeneity of effects was observed, how- ever, with higher experienced and felt TB stigma increasing missed doses among women (adjusted RR 1.22, 95%CI 1.10-1.34) and human immunodeficiency virus (HIV) co-infected patients (aRR 1.39, 95%CI 1.13-1.72). Experienced and felt AIDS stigma also increased missed doses among HIV co-infected patients (aRR 1.43, 95%CI 1.31-1.56).

CONCLUSION

Stigma has a minimal effect in this population with good adherence. Among women and HIV co-infected patients, however, experienced and felt stigma, and not perceived stigma, increased the rate of missed doses. Further research is needed to determine if stigma or coping interventions among these subgroups would improve adherence.