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Stanikzai MH, Ishaq N, Zafar MN, Baray AH, Anwary Z, Ahmad M, Stanikzai KA. Depression symptoms among Afghan TB patients: A multi-center study. Indian J Tuberc 2024; 71 Suppl 2:S264-S268. [PMID: 39370194 DOI: 10.1016/j.ijtb.2024.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/01/2024] [Accepted: 08/28/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND Depression in TB patients carries a heightened risk of treatment failure and a lower quality of life. However, no study to date has documented depression prevalence among TB patients in Afghanistan. OBJECTIVES We aimed to assess depression prevalence in TB patients in Southern Afghanistan. METHODS Between February 2023 and May 2024, a sample of 1,003 TB patients aged 18 years and above were randomly sampled in Southern Afghanistan. The questionnaire gathered patients' sociodemographic information, clinical characteristics, social support level, and the PHQ-9 (Patient Health Questionnaire). We fitted a binary logistic regression model to identify correlates of depression symptoms among TB patients. RESULTS Out of 1,003 patients, 69.6% (95% CI: 66.6%-72.4) had depression symptoms. We found that patients with no formal education [AOR = 3.18, 95%CI (2.35-4.30)], those with severe disease [1.84 (1.30-2.59)], patients with medical comorbidity [1.88 (1.29-2.74)], and those with low social support [1.69 (1.22-2.33)] were more likely to have depression symptoms. CONCLUSION TB patients in Afghanistan have high levels of depressive symptoms. Therefore, this study advocates for dedicated mental health screening and counseling services for TB patients in Afghanistan.
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Affiliation(s)
| | - Niamatullah Ishaq
- Radiology Department, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan
| | - Mohammad Nasim Zafar
- Para-Clinic Department, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan
| | - Ahmad Haroon Baray
- Department of Public Health, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan
| | - Zabihullah Anwary
- Clinic Department, Faculty of Medicine, Bost University, Helmand, Afghanistan
| | - Mujeeb Ahmad
- Department of Public Health, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan
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Stanikzai MH, Rahimy N, Baray AH, Anwary Z, Ahmad M, Sayam H. High stigma prevalence and associated factors among TB patients in Southern Afghanistan: A multi-center cross-sectional study. Indian J Tuberc 2024; 71 Suppl 2:S203-S207. [PMID: 39370184 DOI: 10.1016/j.ijtb.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 07/06/2024] [Accepted: 08/12/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND TB stigma represents a growing threat to TB care. Understanding TB stigma distribution and associating factors is crucial for effective TB control in Afghanistan. OBJECTIVES To profile the prevalence of TB-related stigma and its associating factors among TB patients in Southern Afghanistan. METHODS In this multi-center cross-sectional study, we randomly recruited 603 adult TB patients from 2 major TB treatment sites in Southern Afghanistan. A score of >8 on the Stigma Scale for Chronic Illness-8 items (SSCI-8 items) was considered as positive for TB-related stigma. We fitted a binary logistic regression model. RESULTS Out of the 603 TB patients included in this study, 88.3% (95%CI: 85.8-90.9%) had TB-related stigma using the SSCI-8 cutoff (>8). Being in the age group 18-40 years, rural residence, no formal education, severe perception of illness, lack of TB knowledge, and symptoms of depression had positive associations with TB stigma. CONCLUSION A considerable percentage (88.3%) of patients had TB stigma. We identified potential risk factors that could serve as a benchmark for guiding policy efforts and interventions that aim to reduce stigma among TB patients in Afghanistan.
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Affiliation(s)
| | - Najeebullah Rahimy
- Para-Clinic Department, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan
| | - Ahmad Haroon Baray
- Department of Public Health, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan
| | - Zabihullah Anwary
- Clinic Department, Faculty of Medicine, Bost University, Helmand, Afghanistan
| | - Mujeeb Ahmad
- Department of Public Health, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan
| | - Hadia Sayam
- Department of Public Health, Faculty of Medicine, Kandahar University, Kandahar, Afghanistan
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Bhatia V, Rijal S, Sharma M, Islam A, Vassall A, Bhargava A, Thida A, Basri C, Onozaki I, Pai M, Rezwan MK, Arinaminpathy N, Chandrashekhar P, Sarin R, Mandal S, Raviglione M. Ending TB in South-East Asia: flagship priority and response transformation. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 18:100301. [PMID: 38028166 PMCID: PMC10667305 DOI: 10.1016/j.lansea.2023.100301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/29/2023] [Accepted: 10/05/2023] [Indexed: 12/01/2023]
Abstract
Over the decades, the global tuberculosis (TB) response has evolved from sanatoria-based treatment to DOTS (Directly Observed Therapy Shortcourse) strategy and the more recent End TB Strategy. The WHO South-East Asia Region, which accounted for 45% of new TB patients and 50% of deaths globally in 2021, is pivotal to the global fight against TB. "Accelerate Efforts to End TB" by 2030 was adopted as a South-East Asia Regional Flagship Priority (RFP) in 2017. This article illustrates intensified and transformed approaches to address the disease burden following the adoption of RFP and new challenges that emerged during the COVID-19 pandemic. TB case notifications improved by 25% and treatment success rates improved by 6% between 2016 and 2019 due to interventions ranging from galvanising political commitments to empowering and engaging communities. Cumulative TB programme budget allocations in 2022 reached US$ 1.4 billion, about two and a half times the budget in 2016. An ambitious Regional Strategic Plan towards ending TB, 2021-2025, identifies priority interventions that will need investments of up to US$ 3 billion a year to fully implement them. Moving forward, countries in the Region need to leverage RFP and take up intensified, people-centred, holistic interventions for prevention, diagnosis, treatment and care of TB with commensurate investments and cross-ministerial and multi-sectoral coordination.
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Affiliation(s)
- Vineet Bhatia
- Department of Communicable Diseases, WHO South-East Asia Regional Office, India
| | - Suman Rijal
- Department of Communicable Diseases, WHO South-East Asia Regional Office, India
| | - Mukta Sharma
- Department of Communicable Diseases, WHO Country Office, Indonesia
| | | | | | | | - Aye Thida
- Department of Communicable Diseases, WHO South-East Asia Regional Office, India
| | | | | | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
| | - Md Kamar Rezwan
- Department of Communicable Diseases, WHO South-East Asia Regional Office, India
| | | | | | - Rohit Sarin
- Independent Consultant for Tuberculosis, India
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Maroof M, Pamei G, Bhatt M, Awasthi S, Bahuguna SC, Singh P. Drug adherence to anti-tubercular treatment during COVID-19 lockdown in Haldwani block of Nainital district. INDIAN JOURNAL OF COMMUNITY HEALTH 2022. [DOI: 10.47203/ijch.2022.v34i04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background: India saw one of the stringent lockdowns during the COVID-19 pandemic. In the wake of this period, the normal functioning of medical services was affected. People were reluctant to seek medical attention and notification of Tuberculosis dipped. The aim of the study was to estimate the proportion of non-adherence to anti-tubercular treatment and to identify the factors affecting the non-adherence to treatment. Methods: A retrospective community-based study was conducted among 284 tuberculosis patients. They were interviewed using a pre-designed questionnaire consisting of WHO dimensions of non-adherence and lockdown related questions. Results: The proportion of non-adherence to treatment was found to be 5.3%. Factors like chronic diseases, depression, without knowledge on how the disease is transmitted and that medication can be discontinued once the symptoms subsided, alcohol consumption, and trouble accessing medicine were found to be the determining factors in non-adherence to the treatment. Conclusions: Non-adherence to anti-tuberculosis treatment in our study was low but the various dimensions of adherence along with lockdown related factors had significant impact on it. To further minimize non-adherence during emergency like the lockdown due to COVID-19 pandemic, corrective measures must be explored and implemented.
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Pradhan A, Koirala P, Bhandari SS, Dutta S, García-Grau P, Sampath H, Sharma I. Internalized and Perceived Stigma and Depression in Pulmonary Tuberculosis: Do They Explain the Relationship Between Drug Sensitivity Status and Adherence? Front Psychiatry 2022; 13:869647. [PMID: 35664495 PMCID: PMC9161274 DOI: 10.3389/fpsyt.2022.869647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/20/2022] [Indexed: 11/30/2022] Open
Abstract
Background Adherence to medication for tuberculosis (TB) has been found to be deleteriously affected by psychosocial issues, including internalized and perceived stigma (IPS) and depression, usually resulting in the emergence of multidrug-resistant TB (MDR-TB). The objective of the study was to find the prevalence of depression among patients receiving treatment for pulmonary TB, and how stigma and depression affect the relationship between drug sensitivity status (DSS) and treatment adherence. Method It was a cross-sectional observational study conducted between January 2019 and July 2020 in two centers in Sikkim, India. The Patient Health Questionnaire-9 (PHQ-9), Internalized Social Stigma Scale (ISSS), and Tuberculosis Medication Adherence Scale were used to assess depression, IPS, and medication adherence, respectively. A path analysis was performed with DSS, treatment adherence, IPS, and depression. Education in years was included in the model as it was significantly correlated with IPS. Results A total of 71 patients who were on drug-sensitive TB (DS-TB) regimen (n = 26) and MDR-TB regimen (n = 45) participated in the study. Notably, 56.3% (n = 40) of the participants were found to have depression. Among the depressed participants, 32.5% were on the DS-TB regimen and 67.5% were on the MDR-TB regimen. The path analysis indicated that IPS and depression were serially mediating the relationship between DSS and treatment adherence (β = -0.06, p < 0.05, 95% CI = -3.20, -0.02). Finally, years of education had an exogenous predictor role, not only directly affecting IPS (β = -0.38, p < 0.001, 95% CI = -0.99, -0.31) but also affecting treatment adherence through IPS and depression (β = 0.08, p = 0.02, 95% CI = 0.03, 0.47). This indicated that with more years of education, the IPS decreases, which decreases depression and ultimately leads to better adherence. Conclusion We found an important relationship between different psychosocial factors which may affect treatment adherence. Patients who have higher IPS are more likely to develop depression which negatively affect adherence. Patients on the MDR-TB regimen have higher stigma. There is an urgent need to integrate mental health services with TB Control Programs.
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Affiliation(s)
- Anmol Pradhan
- Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, India
| | - Prakash Koirala
- Department of Respiratory Medicine, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, India
| | - Samrat Singh Bhandari
- Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, India
| | - Sanjiba Dutta
- Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, India
| | - Pau García-Grau
- Programa de Maestro de Educación Infantil, Universidad Católica de Valencia, Valencia, Spain
| | - Harshavardhan Sampath
- Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, India
| | - Indralal Sharma
- Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, India
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Pampalia N, Waluyo A, Yona S. Knowledge, stigma and health-seeking behavior of patients co-infected with HIV and tuberculosis in Jakarta. ENFERMERIA CLINICA 2021. [PMID: 33849184 DOI: 10.1016/j.enfcli.2020.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose was to identify knowledge and TB stigma, as well as its relationship with health-seeking behavior in HIV and TB co-infection patients. A cross-sectional study was conducted with 115 HIV and TB co-infection patients who visited the VCT Polyclinic in five hospitals in Jakarta. This study was using instruments: Brief HIV-Knowledge Questionnaire (HIV-KQ-18), Knowledge TB survey Questionnaire, Berger HIV stigma Scale, Tuberculosis-Related Stigma Scale. This study showed that respondents had good knowledge of TB (69.6%) and had a low stigma of TB (55.7%), and had a health-seeking behavior that did not delay consultation (55.7%). There was a significant relationship between TB knowledge (p-value: 0.042) and TB stigma (p-value: 0.026) with health-seeking behavior. The results of this study can be used as guidelines to improve education and counseling about TB knowledge and TB stigma in HIV and TB co-infection patients.
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Affiliation(s)
- Novi Pampalia
- Faculty of Nursing Universitas Indonesia, Depok, West Java, Indonesia; Mohammad Hoesin Cental General Hospital, South Sumatera, Indonesia
| | - Agung Waluyo
- Faculty of Nursing Universitas Indonesia, Depok, West Java, Indonesia.
| | - Sri Yona
- Faculty of Nursing Universitas Indonesia, Depok, West Java, Indonesia
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Tuberculosis related stigma. MARMARA MEDICAL JOURNAL 2021. [DOI: 10.5472/marumj.854373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Chen X, Du L, Wu R, Xu J, Ji H, Zhang Y, Zhu X, Zhou L. Tuberculosis-related stigma and its determinants in Dalian, Northeast China: a cross-sectional study. BMC Public Health 2021; 21:6. [PMID: 33397334 PMCID: PMC7780403 DOI: 10.1186/s12889-020-10055-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 12/11/2020] [Indexed: 11/22/2022] Open
Abstract
Background The stigma of tuberculosis (TB) poses a significant challenge to TB control because it leads to delayed diagnosis and non-adherence. However, few studies on TB-related stigma have been completed in China. The aim of the current study was to explore the status of TB-related stigma and its associated predictive factors among TB patients in Dalian, Northeast China. Methods An institution-based, cross-sectional survey was conducted among outpatients at Dalian Tuberculosis Hospital in Liaoning Province, Northeast China. Data were collected by using a questionnaire that measured TB-related stigma, treatment status, anxiety, social support, doctor-patient communication and so on. A multiple linear regression model was used to determine the predictors of TB-related stigma. Results A total of 601 eligible participants were recruited. The mean score for TB-related stigma was 9.07, and the median score was 10. The average scores for anxiety, social support and doctor-patient communication were 4.03, 25.41 and 17.17, respectively. Multiple linear regression analysis revealed that patients who were female (β = 1.19, 95% CI: 0.38–2.01, P < 0.05), had self-assessed moderate or severe disease (β = 1.08, 95% CI: 0.12–2.03 and β = 1.36, 95% CI: 0.03–2.70, respectively, P < 0.05), and had anxiety (β = 0.38, 95% CI: 0.30–0.46, P < 0.001) were more likely to have a greater level of TB-related stigma than their counterparts. However, a significantly lower level of TB-related stigma was observed in patients with good social support (β = − 0.25, 95% CI: − 0.33--0.17, P < 0.001) and doctor-patient communication (β = − 0.14, 95% CI: − 0.29--0.00, P < 0.05). Conclusions This study showed that stigma among TB patients was high. Targeted attention should be paid to female patients and patients with moderate or severe disease in TB stigma-related interventions. Moreover, the important role of social support and doctor-patient communication in reducing TB-related stigma should also be emphasized. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-020-10055-2.
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Affiliation(s)
- Xu Chen
- School of Public Health, Dalian Medical University, 9 Western Section, Lvshun South Street, Lvshunkou District, Dalian, People's Republic of China, 116044
| | - Liang Du
- School of Public Health, Dalian Medical University, 9 Western Section, Lvshun South Street, Lvshunkou District, Dalian, People's Republic of China, 116044
| | - Ruiheng Wu
- School of Public Health, Dalian Medical University, 9 Western Section, Lvshun South Street, Lvshunkou District, Dalian, People's Republic of China, 116044
| | - Jia Xu
- School of Public Health, Dalian Medical University, 9 Western Section, Lvshun South Street, Lvshunkou District, Dalian, People's Republic of China, 116044
| | - Haoqiang Ji
- School of Public Health, Dalian Medical University, 9 Western Section, Lvshun South Street, Lvshunkou District, Dalian, People's Republic of China, 116044
| | - Yu Zhang
- School of Public Health, Dalian Medical University, 9 Western Section, Lvshun South Street, Lvshunkou District, Dalian, People's Republic of China, 116044
| | - Xuexue Zhu
- School of Public Health, Dalian Medical University, 9 Western Section, Lvshun South Street, Lvshunkou District, Dalian, People's Republic of China, 116044
| | - Ling Zhou
- School of Public Health, Dalian Medical University, 9 Western Section, Lvshun South Street, Lvshunkou District, Dalian, People's Republic of China, 116044.
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Thomas BE, Stephen A. Tuberculosis related stigma in India: roadblocks and the way forward. Expert Rev Respir Med 2020; 15:859-861. [PMID: 33021117 DOI: 10.1080/17476348.2020.1826314] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Beena E Thomas
- Department of Social and Behavioural Research (DSBR), Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
| | - A Stephen
- Department of Social and Behavioural Research (DSBR), Indian Council of Medical Research-National Institute for Research in Tuberculosis, Chennai, India
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Controle ineficaz da saúde em pessoas vivendo com AIDS: análise de conteúdo. ACTA PAUL ENFERM 2020. [DOI: 10.37689/acta-ape/2020ao0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Datiko DG, Jerene D, Suarez P. Stigma matters in ending tuberculosis: Nationwide survey of stigma in Ethiopia. BMC Public Health 2020; 20:190. [PMID: 32028914 PMCID: PMC7006204 DOI: 10.1186/s12889-019-7915-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 11/07/2019] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Daniel G Datiko
- Challenge TB/Ethiopia and Management Sciences for Health/Ethiopia, P.O. Box 1157, Code 1250, Addis Ababa, Ethiopia.
| | - Degu Jerene
- Challenge TB/Ethiopia and Management Sciences for Health/Ethiopia, P.O. Box 1157, Code 1250, Addis Ababa, Ethiopia
| | - Pedro Suarez
- Management Sciences for Health, Senior Director Infectious Diseases Cluster, Arlington, USA
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Abstract
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.
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Affiliation(s)
- Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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