Tuberculosis in Pakistan: socio-cultural constraints and opportunities in treatment

Quality of life and associating factors in pulmonary tuberculosis patients

BACKGROUND

Quality of life is a significant issue among patients with tuberculosis and is used for evaluating treatment responses and therapeutic outcome. This study aimed to assess the quality of life in tuberculosis patients receiving anti-tuberculosis therapy for a short duration in the Vellore district of Tamil Nadu and its associated variables.

METHODS

A cross-sectional study was designed to evaluate pulmonary tuberculosis patients receiving treatment under category -1 registered in the NIKSHAY portal at Vellore. A total of 165 pulmonary tuberculosis patients were recruited from March 2021 to the third week of June 2021. On obtaining informed consent, the data were collected through the telephone interview by administering WHOQOL- BREF structured questionnaire. The data were examined with descriptive and analytical statistics. Multiple regression analysis for independent quality of life variables was done.

RESULTS

The lowest median scores, 31(25,38) & 38(25,44) was, related to psychological and environmental domains, respectively. In addition, the Man-Whitney & Kruskal Wallis showed a statistically significant variation in the mean quality of life for gender, employment status, duration of treatment, persistent symptoms, the location of residence of patients, and the stage of therapy. Age, gender, marital status, and persistent symptoms were the main associating factor.

CONCLUSION

Tuberculosis and its treatment influence psychological, physical functioning, and the environmental domain of patient quality of life. Attention is required in the follow-up and treatment of patients by monitoring their quality of life.

Zoonoses in the margins: environmental displacement and health outcomes in the Indus Delta

BACKGROUND

It remains unclear how human and animal displacement impacts zoonotic disease risk with little contextualized primary data available. This study investigates zoonotic disease dynamics in populations regularly displaced due to slow onset disasters and annual monsoons in the Indus Delta in Sindh province in southeast Pakistan.

METHODS

Using a case study methodology, semi-structured key informant interviews and focus group discussions with 35 participants, as well as observational studies were conducted in seven communities in Thatta district.

RESULTS

Key factors affecting zoonotic disease dynamics in environmental displacement in Thatta identified in the study include disasters and loss of forage, a lack of veterinary and healthcare access, and socio-economic status. Animal and human health are an important consideration in displacement disrupting communities and livelihoods, affecting safety, health, and food security. Displacement results in a poverty spiral whereby the displaced find themselves at continuous peril from poverty and disaster, with zoonotic disease dynamics shifting based on environmental changes, and an expectation of future movement and loss.

CONCLUSION

The precarious conditions generated through the disruption of communities and livelihoods makes environmentally displaced populations vulnerable to zoonotic disease. To prevent further displacement and disease, broader political economy issues need to be addressed, and comprehensive assistance provided to support sustainable livelihoods.

A qualitative exploration of continuity of TB care in clinics after discharge from hospitals in Cape Town, South Africa

BACKGROUND

Continuity of care remains a challenge for TB patients who are discharged from hospital and referred to primary health care clinics in South Africa. The aim of this study was to explore the experiences and perceptions of patients, health care workers and family members regarding continuity of TB care in a Cape Town health district.

METHODS

We conducted one-on-one interviews, using semi-structured interview guides, with TB patients and their families and health care workers. We also conducted focus group interviews with other health care workers who performed similar duties. Field notes were kept and patients' home circumstances were also physically observed. Data saturation was achieved after 31 interviews. We used Miles and Huberman's qualitative data analysis framework to interpret the data.

RESULTS

Themes identified in the interviews were grouped into two categories: (1)  patients' socio-economic circumstances including complex family relationships, good or lack of family support, inadequate income, and agency; and (2) health system challenges, including inadequate referral links between the clinic and the hospital and negative emotions as a result of poor service delivery experienced by patients.

CONCLUSION

Some TB Patients experienced poor continuity of care on discharge from hospitals to primary health clinics and perceived that this resulted from socio-economic conditions and health system-related problems that triggered negative emotions. Proper communication between the hospital and clinic regarding patients' care, adequate counselling, and patient-centred treatment are required to address poor continuity of care among patients with TB down-referred to clinics.

A qualitative study of patients and healthcare workers' experiences and perceptions to inform a better understanding of gaps in care for pre-discharged tuberculosis patients in Cape Town, South Africa

BACKGROUND

Many people diagnosed with Mycobacterium tuberculosis (TB) in tertiary and district hospitals in South Africa do not arrive at their primary care clinic for continued care after they are discharged from the hospital. This loss to follow up is a major, ongoing problem for public health in South Africa, and contributes to drug-resistant TB strains. The objective of this paper was to explore patients' experiences and perceptions of diagnosis and treatment before their discharge from hospital. We use a framework known as patient-centred care to illustrate how these patient narratives point to lapses in these principles within the hospital system, and to show how such lapses may contribute to loss to follow up and inconsistent TB care.

METHODS

We employed a qualitative study using semi-structured interviews to investigate patient and healthcare workers' experiences and perceptions of TB care in two Western Cape hospitals. We purposefully sampled 17 patients, 10 healthcare workers, and two key informant policy makers, all of whom had relevant experiences and insights. Data collection was done between October 2015 and February 2017. Data were analysed using Miles and Huberman's qualitative analysis framework.

RESULTS

Hospitals did not achieve patient-centred care. Newly diagnosed patients were provided with inadequate TB education, diseased-focused approaches were favoured over patient-focused approaches, and there was limited engagement with patients to understand their needs and feelings during the critical period between diagnosis and discharge. Consequently, some patients felt anxious prior to their discharge from hospital. Coupled with their overwhelming socio-economic barriers and complex family situations, some patients felt hopeless and powerless as they prepared for discharge. Finally, there was a lack of patient-provider partnership due to problems including healthcare workers' time constraints and heavy workloads, which detracted from a focus on patients' needs and feelings.

CONCLUSIONS

Improving the three intersecting elements of patient-centred care (health education, engaging with patients' needs and feelings, and shared decision-making) has the potential to positively influence patients' continuity of care for TB in South Africa. It would be helpful to also proactively address how patients plan to stay connected to care, on treatment, and supported, in light of their family situation or socio-economic circumstances. Detailed and unique pre-discharge counselling for each patient may be valuable in this regard.

Reasons for loss to follow-up (LTFU) of pulmonary TB (PTB) patients: A qualitative study among Saharia, a particularly vulnerable tribal group of Madhya Pradesh, India

BACKGROUND

Loss to follow-up (LTFU) among pulmonary tuberculosis (PTB) patients is a significant challenge for TB control. However, there is a dearth of information about the factors leading to LTFU among marginalized communities. This study highlights the factors associated with LTFU in Saharia, a tribe of Madhya Pradesh having high tuberculosis (TB) prevalence.

METHODS

A qualitative study was carried out during January-April 2020 among twenty-two pulmonary TB patients, recorded as LTFU in NIKSHAY, with ten treatment supporters and ten patient's family members. Semi-structured personal interview tools were used to collect the information on the history of anti-tuberculosis treatment, adverse drug events (ADE), social cognitive, behaviors, myths, and misbeliefs. The interviews were transcribed and thematically analysed to examine underlying themes.

RESULTS

The study explored various social, behavioral factors leading to loss to follow-up among PTB patients. Drug side effects, alcoholism, social stigma, lack of awareness of the seriousness of the diseases and poor counseling are the main barriers to treatment adherence in this community.

CONCLUSIONS

The study highlights the need to address the issues related to LTFU during TB treatment. The enhanced efforts of treatment supporters, health staff, and family & community persons must motivate and support the 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.

Disaster displacement and zoonotic disease dynamics: The impact of structural and chronic drivers in Sindh, Pakistan

Projected increases in human and animal displacement driven by climate change, disasters and related environmental degradation will have significant implications to global health. Pathways for infectious disease transmission including zoonoses, diseases transmitted between animals and humans, are complex and non-linear. While forced migration is considered an important driver for the spread of zoonoses, actual disease dynamics remain under researched. This paper presents the findings of a case study investigating how disaster displacement affected zoonotic disease transmission risk following the 2010 'superfloods' in Sindh province, Pakistan. We interviewed 30 key informants and 17 household members across 6 rural communities between March and November 2019, supported by observational studies and a review of secondary data. Results were analysed using the ecosocial theoretical framework. Buffalo, cattle and goats were often the only moveable asset, therefore livestock was an important consideration in determining displacement modality and destination location, and crowded locations were avoided to protect human and animal health. Meanwhile however, livestock was rarely included in the humanitarian response, resulting in communities and households fragmenting according to the availability of livestock provisions. We found that rather than a driver for disease, displacement acted as a process affecting community, household and individual zoonotic disease risk dynamics, based on available resources and social networks before, during and after displacement, rooted in the historical, political and socio-economic context. We conclude that in rural Sindh, disaster displaced populations' risk of zoonoses is the result of changes in dynamics rooted in pre-existing structural and chronic inequalities, making people more or less vulnerable to disease through multiple interlinked pathways. Our findings have implications for policy makers and humanitarian responders assisting displaced populations dependent on livestock, with a call to integrate livestock support in humanitarian policies and responses for health, survival and recovery.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Understanding how geographic, demographic and treatment history impact health outcomes of patients with multi-drug-resistant tuberculosis in Pakistan, 2014-2017

Tuberculosis (TB) is one of the top 10 leading causes of morbidity and mortality worldwide [1]. In 2017, approximately 10 million people were infected with TB and 1.3 million patients faced mortality [1]. Patients with active TB can infect up to 10–15 people over a year. There is a greater risk of transmission in overcrowded areas with limited air ventilation including large family units, prisons and slums [1, 2]. Without proper diagnosis and treatment, roughly 45% of non-HIV positive TB patients face mortality [1]. With the help of global organizations and national TB treatment and control programmes, the global incidence of TB is declining by approximately 2% each year [1]. The World Health Organization (WHO) TB-strategy aims to end the TB epidemic and encourages partners to fund national TB programmes to improve diagnosis and treatment of TB. The goal is to ultimately decrease death rates by 90% and decrease incidence rates by 80% [1]. To achieve these goals, the decline in TB incidence needs to reach approximately 4–5% per year [1]. The WHO 2018 TB report identified multidrug resistant TB (MDR-TB) as the leading factor hindering that goal [1]. The incidence and spread of MDR-TB has drastically increased, where approximately 558 000 new cases of MDR-TB were diagnosed in 2017 causing more than 230 000 deaths globally [1]. MDR-TB is identified by resistance to the two most powerful anti-TB treatment drugs including isoniazid and rifampicin [3]. Patients with MDR-TB are required to start second-line anti-TB drugs (SLDs), which are limited, expensive, less effective and more toxic [1,2]. Therapy duration is one of the major limitations of second-line treatments, which may require up to two years of consistent use. Since TB affects mostly developing countries, long treatment durations and associated costs become a major challenge. In 2015, 15% of new TB cases were reported as MDR-TB, which drastically increased to 24% by 2017 [1]. Even with significant improvements in molecular tests and diagnostic methods, MDR-TB is still on the rise where the success rate of treatments is between 50 and 60% [1]. Additional characteristics including socioeconomic and sociocultural factors need to be considered when targeting and treating patients with MDR-TB.

Social stigma associated with TB and HIV/AIDS among Kudumbashree members: A crosssectional study

Introduction:

TB and HIV/AIDS are the two major public health problems. Stigma and discrimination has an enormous impact on the sufferers. The impact is felt at home, in workplace, and at the institutions. The objective of the current study was to measure the stigma and discrimination associated with TB and HIV/AIDS and to determine the underlying factors related to it among women self-help group members in Kochi city Kerala.

Methods:

A cross-sectional study was carried out among the women self-help group members in Kochi city. A total of 135 participants were included in the study. The study tool was a pretested self-administered questionnaire which captured information regarding the sociodemographic profile and stigma towards TB and HIV/AIDS.

Result:

All the respondents were women with mean age group 47.1(SD- 10.7). Majority (60%) belonged to APL category and were Hindus (52.1%). All the members have heard about HIV/AIDS and TB. The respondents reported that they would not send their children for playing with infected people (TB-49.3%; HIV-37.1%), would stay away from infected people (TB-84.3%; HIV-67.1%), and had discomfort while approaching those are infected (TB-62.1%; HIV-59.3%). Stigma toward TB and HIV was found not to have any association with any of the socio demographic factors. Correlation was observed between stigma scores of TB and HIV/AIDS (r = 0.853; P = <0.001).

Conclusion:

Stigma toward TB and HIV still exists as a major issue even among women self-help group members in Kochi. It was observed that those who had stigma toward TB also had stigma toward HIV/AIDS. Therefore is need to create holistic awareness about these diseases among women self-help groups.

A machine learning-based framework for Predicting Treatment Failure in tuberculosis: A case study of six countries

Tuberculosis is ranked as the 2nd deadliest disease in the world and is responsible for ten million deaths in 2017. Treatment failure is one of a main reason behind these deaths. Reasons of treatment failure are still unknown and the death rate due to TB is increasing. Machine learning and data analytics approaches are proved to be useful in healthcare domain in finding the associations among different attributes that can affect the outcome of any disease. Timely identification of reasons can save a patient's life. This study aims to find features that are strongly correlated with treatment failure using feature selection techniques. The validation of features is demonstrated using different classification algorithms. Moreover, this study provides a demographic based feature association of six highly burdened treatment failure countries. A verified real-life patient's dataset gathered from different countries including Azerbaijan, Belarus, Georgia, India, Moldova, and Romania is utilized to address the problem. Two types of experimentation are performed on combined dataset by achieving an average accuracy of 78% and an accuracy of 92% on Romania's data. Results shows the importance of features obtained through this study are highly influential in leading a patient towards treatment failure.

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.

Improving outcomes for multi-drug-resistant tuberculosis in the Peruvian Amazon - a qualitative study exploring the experiences and perceptions of patients and healthcare professionals

BACKGROUND

Management for multi-drug-resistant tuberculosis (MDR-TB) is challenging and has poor patient outcomes. Peru has a high burden of MDR-TB. The Loreto region in the Peruvian Amazon is worst affected for reasons including high rates of poverty and poor healthcare access. Current evidence identifies factors that influence MDR-TB medication adherence, but there is limited understanding of the patient and healthcare professional (HCP) perspective, the HCP-patient relationship and other factors that influence outcomes. A qualitative investigation was conducted to explore and compare the experiences and perceptions of MDR-TB patients and their dedicated HCPs to inform future management strategies.

METHOD

Twenty-six, semi-structured in-depth interviews were conducted with 15 MDR-TB patients and 11 HCPs who were purposively recruited from 4 of the worst affected districts of Iquitos (capital of the Loreto region). Field notes and transcripts of the two groups were analysed separately using thematic content analysis. Ethics approval was received from the Institutional Research Ethics Committee, Department of Health, Loreto, and the University of Birmingham Internal Research Ethics Committee.

RESULTS

Four key themes influencing patient outcomes emerged in each participant group: personal patient factors, external factors, clinical factors, and the HCP-patient relationship. Personal factors included high standard patient and population knowledge and education, which can facilitate engagement with treatment by encouraging belief in evidence-based medicine, dispelling belief in natural medicines, health myths and stigma. External factors included the adverse effect of the financial impact of MDR-TB on patients and their families. An open, trusting and strong HCP-patient relationship emerged as a vitally important clinical factor influencing of patient outcomes. The results also provide valuable insight into the dynamic of the relationship and ways in which a good relationship can be fostered.

CONCLUSIONS

This study highlights the importance of financial support for patients, effective MDR-TB education and the role of the HCP-patient relationship. These findings add to the existing evidence base and provide insight into care improvements and policy changes that could improve outcomes if prioritised by local and national government.

Evaluation of treatment outcomes and factors associated with unsuccessful outcomes in multidrug resistant tuberculosis patients in Baluchistan province of Pakistan

BACKGROUND

Evaluating treatment outcomes of a cohort of patients is an effective way for analyzing the effectiveness of a program. Information regarding drug resistance pattern, detailed management, treatment outcomes and factors associated with unsuccessful outcomes in multidrug resistant (MDR-TB) patients is missing from Baluchistan province of Pakistan.

METHODS

This study was carried out at Programmatic Management of Drug Resistant TB unit at Fatimah Jinnah General and Chest Hospital Quetta. All eligible 186 MDR-TB patients enrolled at the study site from January 1, 2012 to April 30, 2016 were retrospectively followed until the treatment outcomes were reported. Data was abstracted through a standardized data collection form and analysed by SPSS 20. Multivariate binary logistic regression (MVBLR) analysis was used to evaluate factors associated with i) death and treatment failure and ii) lost to follow up. A p-value of <0.05 was considered statistically significant.

RESULTS

The study participants were resistant to a median of four drugs (range 2-8) with majority being resistant to any second-line anti-TB drug (SLD) (55.5%). Among SLD, resistance was highest for ofloxacin (52.2%). The study site had an overall treatment success rate of 71.6%. A total of 129 (69.4%) patients were cured, four (2.2%) completed treatment, 37 died (19.9%), 14 (7.5%) were lost to follow up and two (1.1%) were declared treatment failures. In MVBLR analysis, patients' age of >40 years (OR = 4.249, p-value = 0.001) had statistically significant positive and baseline body weight of >40 kg (OR = 0.256, p-value = 0.002) had statistically significant negative association with death and treatment failure. No factor had statistical significant association with lost to follow up.

CONCLUSION

Overall treatment success rate was promising but did not achieve the target success rate (>75%) set by World Health Organization. It can be further improved by paying special attention and providing enhanced management to the patients with risk factors for unsuccessful outcomes.

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.

PROPOSED GUIDELINES TO MINIMISE MULTI-DRUG RESISTANT TUBERCULOSIS TREATMENT DEFAULT IN A MULTI-DRUG RESISTANT UNIT OF LIMPOPO PROVINCE, SOUTH AFRICA

Background:

The increasing prevalence and incidence of Multi Drug Resistant Tuberculosis (MDR-TB) is as a result of the defaulting of treatment by patients. Worldwide, several factors that contribute to patients defaulting to tuberculosis treatment protocol have been identified. This paper aims to develop guidelines to minimise the defaulting rate of MDR-TB patients in MDR unit of Limpopo Province.

Materials and Methods:

The study was conducted using a qualitative approach. Tesch’s open coding method of data analysis was adopted to analyse the data obtained. Reasoning strategies were employed in the development of the guidelines. These include analysis, synthesis, deductive reasoning and inductive reasoning. Synthesis strategy was used to construct relational statements.

Results:

The factors contributing to patients’ default from MDR-TB treatment were identified and organized into four themes. Guidelines were developed to address each factor and give recommendations on possible solutions.

Conclusion:

The guidelines that were developed concluded that co-operation amongst the Department of Health, health practitioners, patient, and family members can help in preventing the defaulting of treatment.

Health-related quality of life among pulmonary tuberculosis patients in Pakistan

PURPOSE

Health-related quality of life (HRQoL) of pulmonary TB patients has not been assessed in Pakistan. We assessed self-reported HRQoL of pulmonary TB patients in Karachi, Pakistan utilizing the EQ-5D and EQ-VAS prior to, during, and after completion of TB treatment.

METHODS

We enrolled 226 pulmonary TB patients in a longitudinal cohort study. Health-utility scores were estimated by the EQ-5D five dimensions and the EQ-Visual Analogue Scale (VAS) at baseline (month 0) and each monthly follow-up visit until treatment completion at month 6. Repeated-measures ANOVA was used to investigate effect of time into treatment on EQ-5D and EQ-VAS scores.

RESULTS

EQ-5D health utility and EQ-VAS scores increase with treatment progression. For the enrolled TB patients, the mean EQ-5D utility scores more than doubled from 0.43 to 0.88, p < .001, effect size η² = 0.40 from treatment initiation to treatment completion.

CONCLUSION

Perceived HRQoL of TB patients improves with treatment progression. This can inform targeted treatment plans as well as TB policy and funding for high-burden countries.

Embedded health service development and research: why and how to do it (a ten-stage guide)

In a world of changing disease burdens, poor quality care and constrained health budgets, finding effective approaches to developing and implementing evidence-based health services is crucial. Much has been published on developing service tools and protocols, operational research and getting policy into practice but these are often undertaken in isolation from one another. This paper, based on 25 years of experience in a range of low and middle income contexts as well as wider literature, presents a systematic approach to connecting these activities in an embedded development and research approach. This approach can circumvent common problems such as lack of local ownership of new programmes, unrealistic resource requirements and poor implementation.We lay out a ten-step process, which is based on long-term partnerships and working within local systems and constraints and may be tailored to the context and needs. Service development and operational research is best prioritised, designed, conducted and replicated when it is embedded within ministry of health and national programmes. Care packages should from the outset be designed for scale-up, which is why the piloting stage is so crucial. In this way, the resulting package of care will be feasible within the context and will address local priorities. Researchers must be entrepreneurial and responsive to windows of funding for scale-up, working in real-world contexts where funding and decisions do not wait for evidence, so evidence generation has to be pragmatic to meet and ensure best use of the policy and financing cycles. The research should generate tested and easily usable tools, training materials and processes for use in scale-up. Development of the package should work within and strengthen the health system and other service delivery strategies to ensure that unintended negative consequences are minimised and that the strengthened systems support quality care and effective scale up of the package.While embedded development and research is promoted in theory, it is not yet practiced at scale by many initiatives, leading to wasted resources and un-sustained programmes. This guide presents a systematic and practical guide to support more effective engagements in future, both in developing interventions and supporting evidence-based scale-up.

Tuberculosis and the sexual and reproductive lives of women in Bangladesh

When they do not meet norms related to sexuality and reproduction, Bangladeshi women often face abandonment and are thus deprived of an active sexual life, a marital relationship, and motherhood. Little is known about how a stigmatised disease such as tuberculosis (TB) may constrain the reproductive health and sexual lives of women. This article, derived from a larger study on the impact of TB on women’s sexual and reproductive health and rights in Narsingdi district and Dhaka, Bangladesh, aims to fill this gap. Based on interviews with nine married women who have or had TB, four husbands, and two mothers-in-law, this article highlights that the ways in which TB impedes on the sexual and reproductive lives of women depends on the stigma within their family and community, their relationships with their husbands, motherhood, their living arrangements, their economic contribution to the family and/or their disclosure of their TB diagnosis. Women with children and supportive husbands retain a stronger position among their in-laws and are less likely to be isolated or rejected. The patients’ narratives revealed that the instructions of health workers influenced their decisions about intercourse or abstinence. Future studies should examine the instructions patients receive from health workers regarding their living and sleeping arrangements, sexual intercourse, and pregnancy, as well as policy documents on TB treatment and prevention.

Patients' experiences and perceptions on associates of TB treatment adherence: a qualitative study on DOTS service in public health centers in Addis Ababa, Ethiopia

Background

Ethiopia is one of the countries with the highest TB burdens in the world. There are multitude of challenges related to the implementation of DOTS and adherence to treatment. This study aimed to assess patients’ experiences and perceptions on associates of TB treatment adherence in Addis Ababa, Ethiopia.

Methods

A phenomenological approach was employed to generate qualitative data through the in-depth interview of TB patients attending DOTS in two public health centers. A total of ten participants, who were purposively selected till conceptual saturation was reached, were interviewed using topic guides prepared in line with the study objectives. Interviews were tape-recorded, transcribed verbatim, and translated to English. Open Code software was used to facilitate analysis. Themes pertaining to patient, health service, therapeutic, and socioeconomic factors were developed, and findings were presented accordingly.

Results

Experience of missing medications was reported by a single participant. Most informants pointed out that TB is transmitted through coughing and expectorate, and prevented by letting in open air in public gatherings. However, most of them stated cold air and few mentioned contaminated food as causes of TB. Perceived risk of non-adherence to medication was among recounted reasons behind treatment adherence. Some informants also recalled to have had the intention of withdrawing medication due to perceived wellness, which they actually did not change into action. Most of the participants generally had smooth relationships with their DOTS service providers. Even if more than half of the patients preferred follow-ups by the same professional, most received DOTS service by two or more service providers.

Conclusions

TB treatment non-adherence was not found to be a major challenge among the study participants. Perceived risk and wellness were implied to be responsible factors for adherence. Albeit the fact that few informants encountered unethical behaviors by some health professionals, interviewed patients generally had positive evaluation of the patient-provider relationship and the DOTS service obtained. There is a need to train and monitor DOTS service providers and ensure the provision of DOTS service by the same provider throughout the treatment period of a given patient.

Patterns of illness disclosure among Indian slum dwellers: a qualitative study

BACKGROUND

Slum dwellers display specific traits when it comes to disclosing their illnesses to professionals. The resulting actions lead to poor health-seeking behaviour and underutilisation of existing formal health facilities. The ways that slum people use to communicate their feelings about illness, the type of confidants that they choose, and the supportive and unsupportive social and cultural interactions to which they are exposed have not yet been studied in the Indian context, which constitutes an important knowledge gap for Indian policymakers and practitioners alike. To that end, this study examines the patterns of illness disclosure in Indian slums and the underpinning factors which shape the slum dwellers' disclosing attitude.

METHODS

In-depth, semi-structured interviews were conducted among 105 men and 113 women who experienced illness in the year prior to the study period. Respondents were selected from four urban slums in two Indian cities, Bangalore and Kolkata.

RESULTS

Findings indicate that women have more confidants at different social levels, while men have a limited network of disclosures which is culturally and socially mediated. Gender role limitations, exclusion from peer groups and unsupportive local situations are the major cause of disclosure delay or non-disclosure among men, while the main concerns for women are a lack of proper knowledge about illness, unsupportive responses received from other people on certain occasions, the fear of social stigma, material loss and the burden of the local situation. Prompt sharing of illness among men is linked with prevention intention and coping with biological problems, whereas factors determining disclosure for women relate to ensuring emotional and instrumental safety, preventing collateral damage of illness, and preventing and managing biological complications.

CONCLUSIONS

The findings reveal that patterns of disclosure are not determined by the acknowledgment of illness but largely depend on the interplay between individual agency, disclosure consequences and the socio cultural environment. The results of this study can contribute significantly to mitigating the pivotal knowledge gap between health policymakers, practitioners and patients, leading to the formulation of policies that maximise the utilisation of health facilities in slums.

Patients pathways to tuberculosis diagnosis and treatment in a fragmented health system: a qualitative study from a south Indian district

BACKGROUND

India's Revised National Tuberculosis (TB) Control Programme (RNTCP) offers free TB diagnosis and treatment. But more than 50% of TB patients seek care from private practitioners (PPs), where TB is managed sub-optimally. In India, there is dearth of studies capturing experiences of TB patients when they navigate through health facilities to seek care. Also, there is less information available on how PPs make decisions to refer TB cases to RNTCP. We conducted this study to understand the factors influencing TB patient's therapeutic itineraries to RNTCP and PP's cross referral practices linked to RNTCP.

METHODS

We conducted in-depth interviews on a purposive sample of 33 TB patients and 38 PPs. Patients were categorised into three groups: those who reached RNTCP directly, those who were referred by PPs to RNTCP and patients who took DOT from PPs. We assessed patient's experiences in each category and documented their journey from initial symptoms until they reached RNTCP, where they were diagnosed and started on treatment. PPs were categorised into three groups based on their TB case referrals to RNTCP: actively-referring, minimally-referring and non-referring.

RESULTS

Patients had limited awareness about TB. Patients switched from one provider to the other, since their symptoms were not relieved. A first group of patients, self-medicated by purchasing get rid drugs from private chemists over the counter, before seeking care. A second group sought care from government facilities and had simple itineraries. A third group who sought care from PPs, switched concurrently and/or iteratively from public and private providers in search for relief of symptoms causing important diagnostic delays. Eventually all patients reached RNTCP, diagnosed and started on treatment. PP's cross-referral practices were influenced by patient's paying capacity, familiarity with RNTCP, kickbacks from private labs and chemists, and even to get rid of TB patients. These trade-offs by PPs complicated patient's itineraries to RNTCP.

CONCLUSIONS

India aims to achieve universal health care for TB. Our study findings help RNTCP to develop initiatives to promote early detection of TB, by involving PPs and private chemists and establish effective referral systems from private sectors to RNTCP.

Effective communication approaches in tuberculosis control: Health workers' perceptions and experiences

BACKGROUND

Health workers' experiences and understanding of the myths, misconceptions, beliefs about TB, and patients in the community (and effective communication methods) can be useful in designing effective IEC materials and strategies.

OBJECTIVE

To study the perceptions and experiences of health workers regarding TB disease, patients, and effective communication strategies in TB control.

METHODS

A survey was conducted among health workers involved in Directly Observed Treatment Short (DOTS) course. Data regarding general health beliefs, prevalent myths and misconceptions about TB in their respective localities, knowledge level among patients, and utilization of various communication strategies were collected.

RESULTS

There is a significant increase in knowledge about TB during DOTS among patients, as observed by about half of the health workers. TB patients are aware about how TB spreads to others and their responsibilities. Regular interaction with patients is required for treatment adherence. Two thirds of the health workers believe that media-mix strategy can be very effective in creating awareness among the patients as well as the public. Health workers realized that the video player facility on their mobile phones is useful for showing health-related videos.

CONCLUSION

A combination of mass media and interpersonal communication could be effective for TB control. Face-to-face communication with community members, patient-provider discussions, and information through television could be very effective techniques. Exclusive communication materials should be designed for family members of the patients. Smart phones can be used for effective implementation of TB control programs.

Factors associated with knowledge about tuberculosis and attitudes of relatives of patients with the disease in Ribeirão Preto, São Paulo, Brazil

OBJECTIVE

To investigate the knowledge regarding tuberculosis among relatives of patients with tuberculosis and the possible factors associated with this event and also to conduct comparative analyses between groups of relatives with or with few knowledge regarding tuberculosis, considering their attitudes in both groups.

METHODS

Cross-sectional study in which the sample was obtained through simple and randomized method. The data were collected by trained interviewers and validated tool. Logistic regression analyses were done using statistical software SPSS, version 22.0.

RESULTS

Among the 110 subjects recruited for the study, 85 (87.5%) were women, and the mean age was 49 years. Regarding common symptoms of tuberculosis, 102 relatives (90.9%) pointed the chronic cough; regarding the knowledge about tuberculosis transmission modes, 100 (90.9%) of them pointed symptomatic respiratory as the probable infection source. The relatives also reported other tuberculosis transmission models: sharing of clothes (n = 87; 79.1%) and household utensils (n = 66; 60%); sexual relations (n = 50; 50%). Illiterate relatives (adjusted OR = 4.39; 95%CI 1.11 - 17.36), those who do not watch or watch little television (adjusted OR = 3.99; 95%CI 1.2 - 13.26), and also those who do not have the Internet access (adjusted OR = 5.01; 95%CI 1.29 - 19.38) were more likely to have low knowledge regarding tuberculosis. Regardless the group, with or without tuberculosis knowledge, the attitudes of both were satisfactory.

CONCLUSION

There are evidences that social inequity is associated to the tuberculosis knowledge of patient relatives.

Qualitative interviews with non-national tuberculosis patients in Cairo, Egypt: understanding the financial and social cost of treatment adherence

Limited data are available about the challenges of non-national TB patients undergoing long-term treatment courses in an urban setting. This study aimed to understand the financial and social cost of adherence of non-national TB patients in Cairo, Egypt as a means to inform the development of context-specific interventions to support treatment adherence. In 2011, 22 in-depth interviews were conducted with TB patients from Sudan, Ethiopia, Eritrea, Somalia and Djibouti to obtain qualitative data. Analysis was based on thematic analysis that aimed to identify recurrent themes and codes from the narratives. The study identified a number of factors that influence TB treatment adherence. Uncertain financial status due to limited or no employment was frequently discussed in interviews, which resulted in fear of not being able to support family, loss of pride, dependence on family and friends, fear of losing housing, food insecurity and limited food options. Respondents also feared infecting other household members and longed for opportunities to discuss their illness and treatment experiences with other individuals but their social networks were often limited. TB-related stigma was driven by shame and blame of infection. Respondents also believed stigma was based on their foreign origin. Stigma manifested in distancing and exclusion in various ways, resulting in isolation, psychological distress and reluctance to disclose TB status to others. Poverty-related factors and social context with a special focus on stigma should be considered when developing strategies for supporting long-term treatment courses for non-national patients in Cairo and other similar urban settings.

Coping with tuberculosis and directly observed treatment: a qualitative study among patients from South India

BACKGROUND

In India, the Revised National TB control programme (RNTCP) offers free diagnosis and treatment for tuberculosis (TB), based on the Directly Observed Treatment Short course (DOTS) strategy. We conducted a qualitative study to explore the experience and consequences of having TB on patients enrolled in DOTS and their caretakers in Tumkur district, located in a southern state of India, Karnataka.

METHODS

We conducted 33 in-depth interviews on a purposive sample of TB patients from three groups: (1) patients who reached RNTCP directly on their own and took DOTS at RNTCP; (2) patients who were referred by private practitioners (PPs) to RNTCP and took DOTS at RNTCP; and (3) patients diagnosed by RNTCP and took DOTS from PPs. Data was analyzed using a thematic approach with the support of NVivo9.

RESULTS

The study revealed that TB and DOTS have a large impact on patient's lives, which is often extended to the family and caretakers. The most vulnerable patients faced the most difficulty in accessing and completing DOTS. The family was the main source of support during patient's recovery. Patients residing in rural areas and, taking DOTS from the government facilities had to overcome many barriers to adhere to the DOTS therapy, such as long travelling distance to DOTS centers, inconvenient timings and unfavorable attitude of the RNTCP staff, when compared to patients who took DOTS from PPs. Advantages of taking DOTS from PPs cited by the patients were privacy, flexibility in timings, proximity and more immediate access to care. Patients and their family had to cope with stigmatization and fear and financial hardships that surfaced from TB and DOTS. Young patients living in urban areas were more worried about stigmatisation, than elderly patients living in rural areas. Patients who were referred by PPs experienced more financial problems compared to those who reached RNTCP services directly.

CONCLUSION

Our study provided useful information about patient's needs and expectations while taking DOTS. The development of mechanisms within RNTCP towards patient centered care is needed to enable patients and caretakers cope with disease condition and adhere to DOTS.

Evaluation of Health-Related Quality of Life among Tuberculosis Patients in Two Cities in Yemen

Background

The health-related quality of life (HRQoL) of Tuberculosis (TB) patients is important because it directly influences the outcome of TB patients in several aspects. The current study aims to evaluate and to find the factors influencing the HRQoL of TB patients in two major TB-prevalent cities (Taiz and Alhodidah) in Yemen.

Methods

A prospective study was conducted, and all TB patients meeting the HRQoL criteria were asked to complete the HRQoL SF-36 survey. The records of TB patients were examined for disease confirmation, and a follow-up was consequently performed for patients during treatment between March 2013 and February 2014 in Taiz and Alhodidah Cities. HRQol scores were calculated by using QM scoring software version 4.5, in which the physical component score (PCS) and mental component score (MCS) were obtained. The scores obtained between 47–53 normal based score (NBS) were considered equivalent to the US normal score. Low scores indicate the poor health situation of TB patients

Results

A total of 243 TB patients enrolled in the study at the beginning of the treatment. A total of 235 and 197 TB patients completed the questionnaire at the end of the intensive phase (I.P.) and continuation phase (C.P.), respectively. The final dropout rate was 16.2%. The mean PCS and MCS scores at the beginning of treatment were low, thus showing the poor health situation of TB patients. The mean PCS scores at the beginning of treatment, end of I.P., and end of treatment were (36.1), (44.9), and (48), respectively. Moreover, the mean MCS score at the beginning of treatment, end of I.P., and end of treatment were (35.1), (42.2), and (44.3), respectively. The result shows that significant increases are observed at the end of I.P. for PCS and MCS because of the treatment and slight changes at the end of C.P. Despite this finding, the MCS score remains below the normal range (47), thus indicating a significant risk of depression among TB patients. Furthermore, general linear repeated measure ANOVA was performed for selected variables, to examine the changes of PCS and MCS over time. It was found that Alhodiah city, chewing khat habit, stigmatization, and duration of treatment more than six months were greatly associated with low mean MCS score of TB patient, indicating great risk of depression which may result in poor treatment outcome.

Conclusion

TB patients in Yemen were found to have poor QoL, with a significant likelihood of depression. Highly risk depression was found among TB patients in Alhodiah city, khat chewers, stigmatization and having a duration of treatment more than 6 months. Therefore, additional efforts should be made to improve their QoL because it may affect the final clinical outcome of patients.

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.

Preliminary validation of an instrument to assess social support and tuberculosis stigma in patients' families

SETTING

Ribeirão Preto, São Paulo, Brazil.

OBJECTIVE

To develop and validate a preliminary instrument for assessing social support and tuberculosis (TB) stigma in families of TB patients.

DESIGN

A literature review on social support and TB stigma was used to generate the theoretical domains for the instrument. A focus group was then conducted with TB patients and their families to revise the domains. Reviewers were invited to judge the appropriateness of the items in the instrument. A cross-sectional survey was carried out among 110 family members to assess the factorial structure using principal component analysis and confirmatory factor analysis to assess construct validity. Reliability was assessed in terms of internal consistency using Cronbach's alpha.

RESULTS

After semantic validation and a pilot study, 23 items were selected for the scale. Examination of the factorial structure of the 16 items that were factorable using principal component analysis led to the extraction of two factors. The 16-item instrument was assessed for construct validity with confirmatory factor analysis, which confirmed a model with four items for each dimension.

CONCLUSION

The study analysed the psychometric properties of an instrument that is still in its preliminary stages. Other studies on a similar scale in the Brazilian setting are required.

Health care seeking behavior and patient delay in tuberculosis diagnosis

Delays in diagnosis of TB cases are major impeding factors in the control of TB. The objectives of this study were to describe the health care seeking behavior of TB patients, assessing patient delay and the number of health care facilities visited before the start of TB treatment. A cross-sectional study was carried out with adult patients with pulmonary TB presenting to two TB facilities to start treatment. We found a median patient delay of 20 days. The factors associated negatively with patient delay in multivariate analysis were weight loss, and have sought treatment because of the first symptom. We also demonstrated that 44.8% of patients incorrectly reported the mode of transmission of TB. In addition, the local of first attendance was an emergency room of public hospitals in 37.3% of patients. We demonstrated that the median patient delay in TB diagnosis in two TB services in a region with a high prevalence of TB was 20 days, and the protective factors associated with this delay in multivariate analysis were weight loss, and have sought treatment because of the first symptom.

SOCIAL, HISTORICAL AND CULTURAL DIMENSIONS OF TUBERCULOSIS

Tuberculosis (TB) researchers and clinicians, by virtue of the social disease they study, are drawn into an engagement with ways of understanding illness that extend beyond the strictly biomedical model. Primers on social science concepts directly relevant to TB, however, are lacking. The particularities of TB disease mean that certain social science concepts are more relevant than others. Concepts such as structural violence can seem complicated and off-putting. Other concepts, such as gender, can seem so familiar that they are left relatively unexplored. An intimate familiarity with the social dimensions of disease is valuable, particularly for infectious diseases, because the social model is an important complement to the biomedical model. This review article offers an important introduction to a selection of concepts directly relevant to TB from health sociology, medical anthropology and social cognitive theory. The article has pedagogical utility and also serves as a useful refresher for those researchers already engaged in this genre of work. The conceptual tools of health sociology, medical anthropology and social cognitive theory offer insightful ways to examine the social, historical and cultural dimensions of public health. By recognizing cultural experience as a central force shaping human interactions with the world, TB researchers and clinicians develop a more nuanced consideration of how health, illness and medical treatment are understood, interpreted and confronted.

Barriers to completing TB diagnosis in Yemen: services should respond to patients' needs

Objectives and Background

Obtaining a diagnosis of tuberculosis (TB) is a prerequisite for accessing specific treatment, yet one third of estimated new cases are missed worldwide by National Programmes. This study investigated economic, geographical, socio-cultural and health system factors hindering adults' attendance and completion of the TB diagnostic process in Yemen, to inform interventions designed to improve patient access to services.

Methodology

The study employed a mixed methods design comprising a cross-sectional survey and In-Depth-Interviews (IDIs) and Focus Group Discussions (FGDs) among patients abandoning the diagnosis or registering for treatment. Adults with cough of ≥2 weeks attending a large governmental referral centre in Sana'a, Yemen, between 2009 and 2010, were eligible to participate.

Results

497 and 446 (89.7%) participants were surveyed the first and second day of attending the services and 48 IDIs and 12 FGDs were also conducted. The majority of patients were disadvantaged and had poor literacy (61% illiterate), had travelled from rural areas (47%) and attended with companions (84%). Key barriers for attendance identified were clinic and transport costs (augmented by companions), distance from home, a preference for private services, strong social stigma and a lack of understanding of the diagnostic process. There were discrepancies between patient- and doctor-reported diagnosis and 46% of patients were unaware that TB treatment is free. Females faced more difficulties to attend than men. The laboratory practice of providing first-day negative smear results and making referrals to the private sector also discouraged patients from returning. Strategies to bring TB diagnostic services closer to communities and address the multiple barriers patients face to attend, will be important to increase access to TB diagnosis and care.

Knowledge, care-seeking behavior, and factors associated with patient delay among newly-diagnosed pulmonary tuberculosis patients, Federal Capital Territory, Nigeria, 2010

INTRODUCTION

Early treatment of Tuberculosis (TB) cases is important for reducing transmission, morbidity and mortality associated with TB. In 2007, Federal Capital Territory (FCT), Nigeria recorded low TB case detection rate (CDR) of 9% which implied that many TB cases were undetected. We assessed the knowledge, care-seeking behavior, and factors associated with patient delay among pulmonary TB patients in FCT.

METHODS

We enrolled 160 newly-diagnosed pulmonary TB patients in six directly observed treatment short course (DOTS) hospitals in FCT in a cross-sectional study. We used a structured questionnaire to collect data on socio-demographic variables, knowledge of TB, and care-seeking behavior. Patient delay was defined as > 4 weeks between onset of cough and first hospital contact.

RESULTS

Mean age was 32.8 years (± 9 years). Sixty two percent were males. Forty seven percent first sought care in a government hospital, 26% with a patent medicine vendor and 22% in a private hospital. Forty one percent had unsatisfactory knowledge of TB. Forty two percent had patient delay. Having unsatisfactory knowledge of TB (p = 0.046) and multiple care-seeking (p = 0.02) were significantly associated with patient delay. After controlling for travel time and age, multiple care-seeking was independently associated with patient delay (Adjusted Odds Ratio = 2.18, 95% CI = 1.09-4.35).

CONCLUSION

Failure to immediately seek care in DOTS centers and having unsatisfactory knowledge of TB are factors contributing to patient delay. Strategies that promote early care-seeking in DOTS centers and sustained awareness on TB should be implemented in FCT.

Emotional representation of tuberculosis with stigma, treatment delay, and medication adherence in Russia

This descriptive cross-sectional study aimed to explore emotional representation and illness coherence, the understanding a person has about an illness which helps them make sense of the experience, in Russians with tuberculosis. In a secondary analysis of questionnaires from 105 Russians treated for pulmonary tuberculosis, social isolation and disease consequences were predictors of negative emotions related to tuberculosis and accounted for 49 percent of the variance. Participants who scored higher on illness coherence were less likely to experience negative emotions. Development of programs to help patients understand tuberculosis and to manage emotional responses and stigma is suggested.

Long distance travelling and financial burdens discourage tuberculosis DOTs treatment initiation and compliance in Ethiopia: a qualitative study

Background

Timely tuberculosis treatment initiation and compliance are the two key factors for a successful tuberculosis control program. However, studies to understand patents’ perspective on tuberculosis treatment initiation and compliance have been limited in Ethiopia. The aim of this study is to attempt to do that in rural Ethiopia.

Methods

This qualitative, phenomenological study conducted 26 in-depth interviews with tuberculosis patients. A thematic content analysis of the interviews was performed using the Open Code software version 3.1.

Results

We found that lack of geographic access to health facilities, financial burdens, use of traditional healing systems and delay in diagnosis by health care providers were the main reasons for not initiating tuberculosis treatment timely. Lack of geographic access to health facilities, financial burdens, quality of health services provided and social support were also identified as the main reasons for failing to fully comply with tuberculosis treatments.

Conclusions

This study highlighted complexities surrounding tuberculosis control efforts in Dabat District. Challenges of geographic access to health care facilities and financial burdens were factors that most influenced timely tuberculosis treatment initiation and compliance. Decentralization of tuberculosis diagnosis and treatment services to peripheral health facilities, including health posts is of vital importance to make progress toward achieving tuberculosis control targets in Ethiopia.

Factors associated with patient and health care system delay in diagnosis for tuberculosis in the province of Luanda, Angola

Background

Tuberculosis (TB) is still a great challenge to public health in sub-Saharan Africa. Most transmissions occur between the onset of coughing and initiation of treatment. Delay in diagnosis is significant to disease prognosis, thus early diagnosis and prompt effective therapy represent the key elements in controlling the disease. The objective of this study was to investigate the factors influencing the patient delay and the health system delay in TB diagnosis in Angola.

Methods

On a cross-sectional study, 385 TB patients who visited 21 DOTS clinics in Luanda were included consecutively. The time from the onset of symptoms to the first consultation of health providers (patients’ delay) and the time from the first consultation to the date of diagnosis (health system’s delay) were analysed. Bivariate and logistics regression were applied to analyse the risk factors of delays.

Results

The median total time elapsed from the onset of symptoms to diagnosis was 45 days (interquartile range [IQR]: 21–97 days). The median patient delay was 30 days (IQR: 14–60 days), and the median health care system delay was 7 days (IQR: 5–15 days). Primary education (AOR = 1.75; CI [95%] 1.06–2.88; p <0.029) and the health centre of the first contact differing from the DOTS centre (AOR = 1.66; CI [95%] 1.01–2.75; p <0.046) were independent risk factors for patient delay >4 weeks. Living in a suburban area (AOR = 2,32; CI [95%] 1.21–4.46; p = 0.011), having a waiting time in the centre >1 hour (AOR = 4.37; CI [95%] 1.72–11.14; p = 0.002) and the health centre of the first contact differening from the DOTS centre (AOR = 5.68; CI [95%] 2.72–11,83; p < 0,00001) were factors influencing the system delay.

Conclusions

The results indicate that the delay is principally due to the time elapsed between the onset of symptoms and the first consultation. More efforts should be placed in ensuring the availability of essential resources and skills in all healthcare facilities other than the DOTS centres, especially those located in suburban areas.

SF-36v2 norms and its' discriminative properties among healthy households of tuberculosis patients in Malaysia

BACKGROUND

The aim of the study was to obtain norms of the SF-36v2 health survey and the association of summary component scores with socio-demographic variables in healthy households of tuberculosis (TB) patients.

DESIGN

All household members (18 years and above; healthy; literate) of registered tuberculosis patients who came for contact tracing during March 2010 to February 2011 at the respiratory clinic of Penang General Hospital were invited to complete the SF-36v2 health survey using the official translation of the questionnaire in Malay, Mandarin, Tamil and English. Scoring of the questionnaire was done using Quality Metric's QM Certified Scoring Software version 4. Multivariate analysis was conducted to uncover the predictors of physical and mental health.

RESULTS

A total of 649 eligible respondents were approached, while 525 agreed to participate in the study (response rate = 80.1 %). Out of consenting respondents, 46.5 % were male and only 5.3 % were over 75 years. Internal consistencies met the minimum criteria (α > 0.7). Reliability coefficients of the scales were always less than their own reliability coefficients. Mean physical component summary scale scores were equivalent to United States general population norms. However, there was a difference of more than three norm-based scoring points for mean mental component summary scores indicating poor mental health. A notable proportion of the respondents was at the risk of depression. Respondents aged 75 years and above (p = 0.001; OR 32.847), widow (p = 0.013; OR 2.599) and postgraduates (p < 0.001; OR 7.865) were predictors of poor physical health while unemployment (p = 0.033; OR 1.721) was the only predictor of poor mental health.

CONCLUSION

The SF-36v2 is a valid instrument to assess HRQoL among the households of TB patients. Study findings indicate the existence of poor mental health and risk of depression among family caregivers of TB patients. We therefore recommend that caregivers of TB patients to be offered intensive support and special attention to cope with these emotional problems.

Socio economic position in TB prevalence and access to services: results from a population prevalence survey and a facility-based survey in Bangladesh

BACKGROUND

In Bangladesh DOTS has been provided free of charge since 1993, yet information on access to TB services by different population group is not well documented. The objective of this study was to assess and compare the socio economic position (SEP) of actively detected cases from the community and the cases being routinely detected under National Tuberculosis Control Programme (NTP) in Bangladesh.

METHODS AND FINDINGS

SEP was assessed by validated asset item for each of the 21,427 households included in the national tuberculosis prevalence survey 2007-2009. A principal component analysis generated household scores and categorized in quartiles. The distribution of 33 actively identified cases was compared with the 240 NTP cases over the identical SEP quartiles to evaluate access to TB services by different groups of the population. The population prevalence of tuberculosis was 5 times higher in the lowest quartiles of population (95.4, 95% CI: 48.0-189.7) to highest quartile population (19.5, 95% CI: 6.9-55.0). Among the 33 cases detected during survey, 25 (75.8%) were from lower two quartiles, and the rest 8 (24.3%) were from upper two quartiles. Among TB cases detected passively under NTP, more than half of them 137 (57.1%) were from uppermost two quartiles, 98 (41%) from the second quartile, and 5 (2%) in the lowest quartile of the population. This distribution is not affected when adjusted for other factors or interactions among them.

CONCLUSIONS

The findings indicate that despite availability free of charge, DOTS is not equally accessed by the poorer sections of the population. However, these figures should be interpreted with caution since there is a need for additional studies that assess in-depth poverty indicators and its determinants in relation to access of the TB services provided in Bangladesh.

Conhecimento e percepção sobre tuberculose das famílias de pacientes em tratamento diretamente observado em um serviço de saúde de Ribeirão Preto-SP, Brasil

Pesquisa epidemiológica descritiva que objetivou descrever o perfil demográfico das famílias de pacientes em Tratamento Diretamente Observado em um serviço de saúde de Ribeirão Preto-SP, analisar o contexto em que estavam inseridas, no que refere ao grau de parentesco e aspectos clínico-epidemiológicos do familiar portador da tuberculose, e avaliar o conhecimento e a percepção dessas famílias em relação à tuberculose. Os dados foram coletados em julho de 2010, utilizando-se um questionário semiestruturado com 16 familiares, sendo analisados por meio da estatística descritiva. O perfil demográfico dos familiares corrobora com a associação da tuberculose às condições de pobreza e má distribuição de renda. Verificou-se um número substancial de comunicantes no domicílio, sendo a tuberculose pulmonar a forma clínica predominante. O conhecimento das famílias foi satisfatório, entretanto, alguns sujeitos associam a transmissão da doença, ao uso compartilhado de utensílios domésticos. Os resultados apontam fragilidades relacionadas à gestão do cuidado às famílias.

Health-seeking behaviour in Pakistan: a narrative review of the existing literature

INTRODUCTION

This narrative review was carried out to collate the work of researchers on health-seeking behaviour in Pakistan, to discuss the methods used, highlight the emerging themes and identify areas that have yet to be studied.

STUDY DESIGN

Review.

METHODS

An overview of studies on health-seeking behaviour in Pakistan, found via searches on scholarly databases intended to locate material of medical and anthropological relevance.

RESULTS

In total, 29 articles were reviewed with a range of different methodologies. A retrospective approach was the most common. A variety of medical conditions have been studied in terms of health-seeking behaviour of people experiencing such conditions. However, a wide range of chronic illnesses have yet to be studied. Nevertheless, some studies highlighting unusual issues such as snake bites and health-seeking behaviour of street children were also found. In terms of geographical area, the majority of studies reviewed were performed in the provinces of Sind and Punjab, with little research targeting the people from the two other provinces (Balochistan and Khyber Pakhtunkhwa) of Pakistan. Predominant utilization of private healthcare facilities, self-medication, involvement of traditional healers in the healthcare system, women's autonomy, and superstitions and fallacies associated with health-seeking behaviour were found to be the themes that repeatedly emerged in the literature reviewed.

CONCLUSIONS

The sociocultural and religious background of Pakistan means that health-seeking behaviour resembles a mosaic. There is a need to improve the quality of service provided by the public healthcare sector and the recruitment of female staff. Traditional healers should be trained and integrated into the mainstream to provide adequate healthcare. Serious efforts are required to increase the awareness and educational level of the public, especially women in rural areas, in order to fight against myths and superstitions associated with health-seeking behaviour.

[Financial challenges to access tuberculosis treatment in Ribeirão Preto - São Paulo]

The objective of this study was to analyze the financial challenges that patients have to deal with to access the Tuberculosis (TB) Care Reference Centers in Ribeirão Preto. Adjustments were made to the Primary Care Assessment (PCAT) and an opinion poll was made with one-hundred patients following treatment and 16 health care professionals working at TB Reference Centers in Ribeirão Preto. Anova, Kruskall Wallis and chi-square tests were used. Most patients were males and most health care professionals were female. Differences were found between Centers C and A, in that Center C (p=0.028) offers a bus pass, and in A (p=0.010) patients paid for their own transportation. The indicator medical appointment in 24 hours showed a satisfactory level. There were disagreements between the reports from patients and health professionals as to the center offering the bus pass. Patients face challenges in their treatment, such as costs with transportation or being late for work, which result in losses in the family income.

[Functioning of the concept of vulnerability to tuberculosis amongst university students]

The objective of this study was to identify aspects that characterize the vulnerability to tuberculosis in resident students at the Residential Rooms of the University of Sao Paulo (CRUSP). The data relative to individual vulnerability were collected by using a questionnaire during the period of October to November, 2002. The theoretical reference and the interpretation frame to analize the issue of tuberculosis were given in the theoretical frame of vulnerability .The study sample completed 106 students being 69.8% graduated students and 30.2% postgraduated students. The proportion of emigrants (internal and external) reached 43.4%. Seventy-nine students (74.5%) answered that the disease can be cured. Nearly 60 (56.6%) answered that they did not know the causal agent of the disease and 72 (67.9%) said that they had already heard about tuberculosis, and for 5 of them (6.9%) it happened at health institutions. It was also asked if they knew where to ask in order to get tests to verify the presence of the disease and 48 (45.3%) did not know. Although some results are positive it is identified the individual vulnerability of the students especially as they are apparently a well differentiated group, because in thesis they would have more favourable conditions to acced to the information related to the disease.

Care seeking and attitudes towards treatment compliance by newly enrolled tuberculosis patients in the district treatment programme in rural western Kenya: a qualitative study

Background

The two issues mostly affecting the success of tuberculosis (TB) control programmes are delay in presentation and non-adherence to treatment. It is important to understand the factors that contribute to these issues, particularly in resource limited settings, where rates of tuberculosis are high. The objective of this study is to assess health-seeking behaviour and health care experiences among persons with pulmonary tuberculosis, and identify the reasons patients might not complete their treatment.

Methods

We performed qualitative one-on-one in-depth interviews with pulmonary tuberculosis patients in nine health facilities in rural western Kenya. Thirty-one patients, 18 women and 13 men, participated in the study. All reside in an area of western Kenya with a Health and Demographic Surveillance System (HDSS). They had attended treatment for up to 4 weeks on scheduled TB clinic days in September and October 2005.

The nine sites all provide diagnostic and treatment services. Eight of the facilities were public (3 hospitals and 5 health centres) and one was a mission health centre.

Results

Most patients initially self-treated with herbal remedies or drugs purchased from kiosks or pharmacies before seeking professional care. The reported time from initial symptoms to TB diagnosis ranged from 3 weeks to 9 years. Misinterpretation of early symptoms and financial constraints were the most common reasons reported for the delay.

We also explored potential reasons that patients might discontinue their treatment before completing it. Reasons included being unaware of the duration of TB treatment, stopping treatment once symptoms subsided, and lack of family support.

Conclusions

This qualitative study highlighted important challenges to TB control in rural western Kenya, and provided useful information that was further validated in a quantitative study in the same area.