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Hayward SE, Vanqa N, Makanda G, Tisile P, Ngwatyu L, Foster I, Mcinziba A, Biewer A, Mbuyamba R, Galloway M, Bunyula S, Westhuizen HM, Friedland JS, Marino-Medina A, Viljoen L, Schoeman I, Hoddinott G, Nathavitharana RR. "As a patient I do not belong to the clinic, I belong to the community." Co-developing a multi-level, person-centred tuberculosis stigma intervention in Cape Town, South Africa. RESEARCH SQUARE 2024:rs.3.rs-3921970. [PMID: 38405783 PMCID: PMC10889064 DOI: 10.21203/rs.3.rs-3921970/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Background Anticipated, internal, and enacted stigma are major barriers to TB care engagement, and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa. Methods Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n=87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed and then further interpreted using the socio-ecological model. Results Intervention components across socio-ecological levels shared common behaviour change strategies, namely education, empowerment, engagement, and innovation. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended. Consideration of how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested to decrease anticipated and enacted stigma. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers. Conclusions Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-informed intervention components should be prioritised by TB programs, including integrated TB/HIV care services.
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Affiliation(s)
| | | | | | | | | | | | | | - Amanda Biewer
- Beth Israel Deaconess Medical Center, Harvard Medical School
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Khan FU, Khan FU, Aqeel MT, Hayat K, Chang J, Rehman AU, Fang Y. A randomized controlled trial to evaluate the impact of pharmacist-led clinical interventions on the health-related quality of life among TB patients. Front Pharmacol 2023; 14:1171985. [PMID: 37292150 PMCID: PMC10246751 DOI: 10.3389/fphar.2023.1171985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/03/2023] [Indexed: 06/10/2023] Open
Abstract
Background: The study was designed to evaluate the impact of pharmacist-led clinical interventions on the health-related quality of life among tuberculosis patients in Pakistan. Methods: A randomized, controlled prospective study was carried out in a Pakistan Institute of Medical Sciences hospital tuberculosis (TB) control center. Participants who visited the TB center between September 2020 and December 2021 were randomly assigned to two clusters, the usual care group (UC group) vs. the intervention group (pharmaceutical care group), in a 1:1 ratio by a simple envelope technique. In the intervention group, a patient received centered care that encompassed informed decision-making, which can increase the quality of care and monitoring of adverse drug events. However, the control group received routine TB treatment at the hospital. The EuroQol-5D-3L instrument was used to assess the health-related quality of life (HRQoL) at the baseline and in the third and sixth months of the treatment time period. Results: A total of 503 patients were eligible, of which only 426 patients were included in this study. At the end of the study, n = 205 of the patients in the intervention group and n = 185 of those in the control group were analyzed. In the intervention group, the EQ-5D-3L health utility score improved significantly (p < 0.001) (from the baseline mean ± SD, 0.40 ± 0.36, to 6 months of treatment, 0.89 ± 0.09, while in the control group from 0.42 ± 0.35 to 0.78 ± 0.27). In multivariate regression analysis, the variables that remained statistically associated (p < 0.001) with the HRQoL (unstandardized β [95% confidence interval]) of the control group were as follows: gender, female vs. male (-0.039 [-0.076 to -0.003]); body weight, less than 40 kg vs. more than 40 kg (-0.109 [-0.195 to -0.024]); patients with any comorbidity vs. without comorbidity (-0.136 [-0.252 to -0.020]); and smokers vs. non-smokers (-0.204 [-0.291 to -0.118]). The study did not find any statistically significant associations between the intervention group's variables and the HRQoL. Conclusion: Patient-centered care interventions led by pharmacists as part of care coordination enhanced the HRQoL for TB patients significantly. According to this study, clinical pharmacists should be included in the interdisciplinary clinical staff for TB patient management.
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Affiliation(s)
- Farman Ullah Khan
- Department of Pharmacy Administration and Clinical Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, Xi’an, China
- Faculty of Pharmacy, Hamdard University Islamabad Campus, Islamabad, Pakistan
| | - Faiz Ullah Khan
- Department of Pharmacy Administration and Clinical Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, Xi’an, China
| | | | - Khezar Hayat
- Department of Pharmacy Administration and Clinical Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, Xi’an, China
| | - Jie Chang
- Department of Pharmacy Administration and Clinical Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, Xi’an, China
| | - Asim ur Rehman
- Department of Pharmacy, Faculty of Biological Sciences, Quaid-i-Azam University, Islamabad, Pakistan
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, Xi’an, China
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3
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Soemarko DS, Halim FA, Kekalih A, Yunus F, Werdhani RA, Sugiharto A, Mansyur M, Wingfield T, Fuady A. Developing a tool to measure tuberculosis-related stigma in workplaces in Indonesia: An internal validation study. SSM Popul Health 2023; 21:101337. [PMID: 36660173 PMCID: PMC9842934 DOI: 10.1016/j.ssmph.2023.101337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/09/2022] [Accepted: 01/07/2023] [Indexed: 01/11/2023] Open
Abstract
Workers with tuberculosis (TB) are often stigmatized, negatively impacting their socioeconomic position, mental health, and TB treatment outcomes. There is a dearth of validated tools to assess stigma in the worker population. This study aimed to develop and validate a novel, culturally adapted tool to measure TB-related stigma among workers in Indonesia. We translated, adapted, applied, and internally validated Van Rie's TB-Stigma Scale to the worker population in varying sizes businesses (formal and informal business sectors) in Indonesia. Psychometric evaluation using exploratory and confirmatory factor analyses (EFA and CFA) was performed to check the tool's internal consistency and reliability. The translation and cultural adaptation phases resulted in a final 11-item tool. From 172 participant responses, the EFA found two loading factors relating to responses on isolation and exclusion from the workplace. The CFA confirmed that the developed model had moderate fit with R2 values for each item ranging from 0.37 to 0.84. The tool was reliable (Cronbach's alpha 0.869). This validated, consistent and reliable adapted tool is ready to use in larger scale evaluations of TB-related stigma amongst workers in formal and informal business sectors of Indonesia to develop strategies to eliminate TB-related stigma from the workplace.
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Affiliation(s)
- Dewi Sumaryani Soemarko
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jl. Pegangsaan Timur No.16, Jakarta, 10310, Indonesia
| | - Frisca Aprillia Halim
- Master of Occupational Medicine Study Program, Faculty of Medicine, Universitas Indonesia, Jl. Pegangsaan Timur No.16, Jakarta, 10310, Indonesia
| | - Aria Kekalih
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jl. Pegangsaan Timur No.16, Jakarta, 10310, Indonesia
| | - Faisal Yunus
- Department of Pulmonology and Respiration, Faculty of Medicine, Universitas Indonesia, Jl. Persahabatan Raya No.1, Jakarta, 13230, Indonesia
| | - Retno Asti Werdhani
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jl. Pegangsaan Timur No.16, Jakarta, 10310, Indonesia
| | - Agus Sugiharto
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jl. Pegangsaan Timur No.16, Jakarta, 10310, Indonesia
| | - Muchtaruddin Mansyur
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jl. Pegangsaan Timur No.16, Jakarta, 10310, Indonesia
- South East Asian Ministers of Education Organization Regional Center for Food and Nutrition, Jakarta, 13120, Indonesia
| | - Tom Wingfield
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
- Department of Global Public Health, WHO Collaborating Centre on Tuberculosis and Social Medicine, Karolinska Institute, Stockholm, 171 76, Sweden
- Tropical and Infectious Disease Unit, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, L7 8XP, UK
| | - Ahmad Fuady
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jl. Pegangsaan Timur No.16, Jakarta, 10310, Indonesia
- Primary Health Care Research and Innovation Center, Indonesian Medical Education and Research Institute, Faculty of Medicine Universitas Indonesia, Jl. Salemba Raya No.6, Jakarta, 10430, Indonesia
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Patient- and Health-System-Related Barriers to Treatment Adherence for Patients with Drug-Resistant Tuberculosis in the Philippines: A Mixed-Methods Study. Tuberc Res Treat 2022; 2022:6466960. [PMID: 36444334 PMCID: PMC9701125 DOI: 10.1155/2022/6466960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 08/01/2022] [Accepted: 10/26/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose In the Philippines, drug-resistant tuberculosis (DRTB) is a growing concern. Healthcare workers face challenges in retaining patients with DRTB in care. This study intends to understand their perspectives on the factors that influence patient treatment outcomes and to propose potential programmatic solutions for strengthening care services for the patients. Methods A mixed-methods study was conducted in the Philippines between December 2017 and March 2018 to understand the major barriers for healthcare workers to provide quality care to DRTB patients across the care continuum. In the quantitative phase, healthcare workers participated in an online survey; in the qualitative phase, in-depth interviews were conducted with a select number of the survey respondents to better understand their survey responses. Results 272 healthcare workers participated in the survey, and of those, 11 were interviewed. Survey results identified economic constraints, patient perceptions of care, family-related concerns, and limited accessibility to healthcare services as the major patient-related barriers across the care continuum. Major health-system-related barriers were insufficient human resources, lack of financial and political support, and limited knowledge about DRTB by healthcare providers. Interviews revealed more elaborate, contextualized, and nuanced aspects of each of the major challenges. The elaborated patient-related barriers included expenses needed during treatment (e.g., transportation); fear of being stigmatized by family, community, or healthcare staff; worries about adverse drug reactions from medication; a lack of family support; and the location of patients' homes. The health-system-related barriers revealed through interviews included the limited capacities of facility staff to provide DRTB care due to insufficient human resources; the shortage of funds to support treatment completion (e.g., transportation allowance and food package for patients, service vehicles and mobile phone costs for outreach actions at the facility level); and discrimination by healthcare staff against patients with DRTB attributed to the staff's limited knowledge and experiences of treating the patients. Conclusion This study identified the main barriers for DRTB facility staff in the Philippines from the perspectives of providers. Further exploration of the barriers and best practices in facilities may be useful for improving DRTB care in the Philippines.
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Sabin LL, Thulasingam M, Carwile M, Babu SP, Knudsen S, Dong L, Stephens J, Fernandes P, Cintron C, Horsburgh CR, Salgame P, Ellner JJ, Sarkar S, Hochberg NS. 'People listen more to what actors say': A qualitative study of tuberculosis-related knowledge, behaviours, stigma, and potential interventions in Puducherry, India. Glob Public Health 2022; 17:2898-2910. [PMID: 34657567 DOI: 10.1080/17441692.2021.1990372] [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: 12/15/2022]
Abstract
India has made substantial advancements in reducing the burden of tuberculosis (TB), but persons living with active TB (PLWATB) still face myriad challenges in seeking and receiving care, including TB-related stigma. To meet the END TB targets, it is critical that PLWATB engage in care and are able to adhere to treatment. This qualitative study aimed to understand TB-related stigma (perceived, enacted, and internalised) and possible interventions to reduce stigma in Puducherry and Tamil Nadu, India. We conducted 47 in-depth interviews with PLWATB and household members and eight focus group discussions: two each with PLWATB, their household members, healthcare workers, and key informants. We found varying TB-related knowledge: the vast majority of interview participants reported incorrect modes of transmission, although most were also aware that TB is curable. Participants reported high levels of perceived stigma, with nearly two-thirds of PLWATB choosing to hide their disease to avoid being stigmatised in their community. Participants supported interventions including celebrity advocacy and school-based programming to increase community knowledge and reduce enacted stigma as well as support groups and counselling to reduce internalised stigma in PLWATB. This study has the potential to inform future interventions to reduce TB-related stigma in India.
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Affiliation(s)
- Lora L Sabin
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | | | - Madeline Carwile
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | | | - Selby Knudsen
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Lijia Dong
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Jessie Stephens
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Priyanka Fernandes
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Chelsie Cintron
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - C Robert Horsburgh
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | | | | | - Sonali Sarkar
- Department of Preventive and Social Medicine, JIPMER, Puducherry, India
| | - Natasha S Hochberg
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.,Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Foster I, Galloway M, Human W, Anthony M, Myburgh H, Vanqa N, Wademan DT, Makanda G, Tisile P, Schoeman I, Hoddinott G, Nathavitharana RR. Analysing interventions designed to reduce tuberculosis-related stigma: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000989. [PMID: 36962638 PMCID: PMC10022226 DOI: 10.1371/journal.pgph.0000989] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 08/08/2022] [Indexed: 03/17/2023]
Abstract
Stigma is a critical barrier for TB care delivery; yet data on stigma reduction interventions is limited. This review maps the available literature on TB stigma reduction interventions, using the Health Stigma and Discrimination framework and an implementation analysis to identify research gaps and inform intervention design. Using search terms for TB and stigma, we systematically searched PubMed, EMBASE and Web of Science. Two independent reviewers screened all abstracts, full-texts, extracted data, conducted a quality assessment, and assessed implementation. Results were categorized by socio-ecological level, then sub-categorized by the stigma driver or manifestation targeted. After screening 1865 articles, we extracted data from nine. Three studies were implemented at the individual and interpersonal level using a combination of TB clubs and interpersonal support to target internal and anticipated stigma among persons with TB. Two studies were implemented at the interpersonal level using counselling or a video based informational tool delivered to households to reduce stigma drivers and manifestations. Three studies were implemented at the organizational level, targeting drivers of stigma among healthcare workers (HW) and enacted stigma among HWs. One study was implemented at the community level using an educational campaign for community members. Stakeholder consultation emphasized the importance of policy level interventions and education on the universality of risk to destigmatize TB. Review findings suggest that internal and anticipated TB stigma may be addressed effectively with interventions targeted towards individuals using counselling or support groups. In contrast, enacted TB stigma may be better addressed with information-based interventions implemented at the organizational or community level. Policy level interventions were absent but identified as critical by stakeholders. Implementation barriers included the lack of high-quality training and integration with mental health services. Three key gaps must be addressed in future research: consistent stigma definitions, standardized stigma measurement, and measurement of implementation outcomes.
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Affiliation(s)
- Isabel Foster
- TB Proof, Cape Town, South Africa
- Global Health, International Development Research Centre, Ottawa, Canada
| | | | | | - Michaile Anthony
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Hanlie Myburgh
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Nosivuyile Vanqa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Dillon T. Wademan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | | | | | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Ruvandhi R. Nathavitharana
- TB Proof, Cape Town, South Africa
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
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Nuttall C, Fuady A, Nuttall H, Dixit K, Mansyur M, Wingfield T. Interventions pathways to reduce tuberculosis-related stigma: a literature review and conceptual framework. Infect Dis Poverty 2022; 11:101. [PMID: 36138434 PMCID: PMC9502609 DOI: 10.1186/s40249-022-01021-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Prevention of tuberculosis (TB)-related stigma is vital to achieving the World Health Organisation's End TB Strategy target of eliminating TB. However, the process and impact evaluation of interventions to reduce TB-stigma are limited. This literature review aimed to examine the quality, design, implementation challenges, and successes of TB-stigma intervention studies and create a novel conceptual framework of pathways to TB-stigma reduction. METHOD We searched relevant articles recorded in four scientific databases from 1999 to 2022, using pre-defined inclusion and exclusion criteria, supplemented by the snowball method and complementary grey literature searches. We assessed the quality of studies using the Crowe Critical Appraisal Tool, then reviewed study characteristics, data on stigma measurement tools used, and interventions implemented, and designed a conceptual framework to illustrate the pathways to TB-stigma reduction in the interventions identified. RESULTS Of 14,259 articles identified, eleven met inclusion criteria, of which three were high quality. TB-stigma reduction interventions consisted mainly of education and psychosocial support targeted predominantly toward three key populations: people with TB, healthcare workers, and the public. No psychosocial interventions for people with TB set TB-stigma reduction as their primary or co-primary aim. Eight studies on healthcare workers and the public reported a decrease in TB-stigma attributed to the interventions. Despite the benefits, the interventions were limited by a dearth of validated stigma measurement tools. Three of eight studies with quantitative stigma measurement questionnaires had not been previously validated among people with TB. No qualitative studies used previously validated methods or tools to qualitatively evaluate stigma. On the basis of these findings, we generated a conceptual framework that mapped the population targeted, interventions delivered, and their potential effects on reducing TB-stigma towards and experienced by people with TB and healthcare workers involved in TB care. CONCLUSIONS Interpretation of the limited evidence on interventions to reduce TB-stigma is hampered by the heterogeneity of stigma measurement tools, intervention design, and outcome measures. Our novel conceptual framework will support mapping of the pathways to impacts of TB-stigma reduction interventions.
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Affiliation(s)
- Charlotte Nuttall
- grid.10025.360000 0004 1936 8470Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Ahmad Fuady
- grid.9581.50000000120191471Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, 10310 Jakarta, Indonesia
- grid.5645.2000000040459992XDepartment of Public Health, Erasmus MC University Medical Center Rotterdam, 3015GD Rotterdam, The Netherlands
- grid.9581.50000000120191471Primary Health Care Research and Innovation Center, Indonesian Medical Education and Research Institute, Faculty of Medicine Universitas Indonesia, 10430 Jakarta, Indonesia
| | - Holly Nuttall
- grid.10025.360000 0004 1936 8470Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Kritika Dixit
- grid.4714.60000 0004 1937 0626Social Medicine, Infectious Diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, 10653 Stockholm, Sweden
- Birat Nepal Medical Trust, Lazimpat Road, Lazimpat, Kathmandu, 44600 Nepal
| | - Muchtaruddin Mansyur
- grid.9581.50000000120191471Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, 10310 Jakarta, Indonesia
| | - Tom Wingfield
- grid.10025.360000 0004 1936 8470Department of Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
- grid.4714.60000 0004 1937 0626Social Medicine, Infectious Diseases, and Migration (SIM) Group, Department of Public Health Sciences, Karolinska Institute, 10653 Stockholm, Sweden
- grid.48004.380000 0004 1936 9764Departments of International Public Health and Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA UK
- grid.513149.bTropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L7 8XP UK
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Zimmer AJ, Heitkamp P, Malar J, Dantas C, O'Brien K, Pandita A, Waite RC. Facility-based directly observed therapy (DOT) for tuberculosis during COVID-19: A community perspective. J Clin Tuberc Other Mycobact Dis 2021; 24:100248. [PMID: 34189276 PMCID: PMC8225462 DOI: 10.1016/j.jctube.2021.100248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The COVID-19 pandemic has amplified the human rights issues of facility DOT. Transportation, stigma, fear of COVID, and restriction of liberties are barriers to facility DOT. Where possible, facility DOT should be replaced by vDOT and multi-month dispensing. Community-based DOT should be prioritized over facility-based DOT. People with TB must be empowered to participate in the TB response to enable a person-centred model of care.
Facility-based directly observed therapy (DOT) has been the standard for treating people with TB since the early 1990s. As the commitment to promote a people-centred model of care for TB grows, the use of facility-based DOT has been questioned as issues of freedom, privacy, and human rights have been raised. The disruptions caused by the COVID-19 pandemic and ensuing lockdown measures have fast-tracked the need to find alternative methods to provide treatment to people with TB. In this study, we present quantitative and qualitative findings from a global community-based survey on the challenges of administering facility-based DOT during a pandemic as well as potential alternatives. Our results found that decreased access to transportation, the fear of COVID-19, stigmatization due to overlapping symptoms, and punitive measures against quarantine violations have made it difficult for persons with TB to receive treatment at facilities, particularly in low-resource settings. Potential replacements included greater focus on community-based DOT, home delivery of treatment, multi-month dispensing, and video DOT strategies. Our study highlights the need for TB programs to re-evaluate their approach to providing treatment to people with TB, and that these changes must be made in consultation with people affected by TB and TB survivors to provide a true people-centred model of care.
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Affiliation(s)
- Alexandra J. Zimmer
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
- Corresponding author at: 1001 rue Decarie, Montreal, Quebec H4A 3J1, Canada.
| | - Petra Heitkamp
- McGill International TB Centre, Montreal, Canada
- TB PPM Learning Network, Research Institute of the McGill University Health Centre, Canada
| | | | | | - Kate O'Brien
- We are TB/National TB Controllers Association, Smryna, USA
| | - Aakriti Pandita
- Division of Infectious Diseases, University of Colorado School of Medicine, Denver, USA
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Reid MJA, Arinaminpathy N, Bloom A, Bloom BR, Boehme C, Chaisson R, Chin DP, Churchyard G, Cox H, Ditiu L, Dybul M, Farrar J, Fauci AS, Fekadu E, Fujiwara PI, Hallett TB, Hanson CL, Harrington M, Herbert N, Hopewell PC, Ikeda C, Jamison DT, Khan AJ, Koek I, Krishnan N, Motsoaledi A, Pai M, Raviglione MC, Sharman A, Small PM, Swaminathan S, Temesgen Z, Vassall A, Venkatesan N, van Weezenbeek K, Yamey G, Agins BD, Alexandru S, Andrews JR, Beyeler N, Bivol S, Brigden G, Cattamanchi A, Cazabon D, Crudu V, Daftary A, Dewan P, Doepel LK, Eisinger RW, Fan V, Fewer S, Furin J, Goldhaber-Fiebert JD, Gomez GB, Graham SM, Gupta D, Kamene M, Khaparde S, Mailu EW, Masini EO, McHugh L, Mitchell E, Moon S, Osberg M, Pande T, Prince L, Rade K, Rao R, Remme M, Seddon JA, Selwyn C, Shete P, Sachdeva KS, Stallworthy G, Vesga JF, Vilc V, Goosby EP. Building a tuberculosis-free world: The Lancet Commission on tuberculosis. Lancet 2019; 393:1331-1384. [PMID: 30904263 DOI: 10.1016/s0140-6736(19)30024-8] [Citation(s) in RCA: 216] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 12/20/2018] [Accepted: 12/25/2018] [Indexed: 11/22/2022]
Affiliation(s)
- Michael J A Reid
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Nimalan Arinaminpathy
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | - Amy Bloom
- Tuberculosis Division, United States Agency for International Development, Washington, DC, USA
| | - Barry R Bloom
- Department of Global Health and Population, Harvard University, Cambridge, MA, USA
| | | | - Richard Chaisson
- Departments of Medicine, Epidemiology, and International Health, Johns Hopkins School of Medicine, Baltimore, MA, USA
| | | | | | - Helen Cox
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Mark Dybul
- Department of Medicine, Centre for Global Health and Quality, Georgetown University, Washington, DC, USA
| | | | - Anthony S Fauci
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | | | - Paula I Fujiwara
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Timothy B Hallett
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | | | | | - Nick Herbert
- Global TB Caucus, Houses of Parliament, London, UK
| | - Philip C Hopewell
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chieko Ikeda
- Department of GLobal Health, Ministry of Heath, Labor and Welfare, Tokyo, Japan
| | - Dean T Jamison
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Aamir J Khan
- Interactive Research & Development, Karachi, Pakistan
| | - Irene Koek
- Global Health Bureau, United States Agency for International Development, Washington, DC, USA
| | - Nalini Krishnan
- Resource Group for Education and Advocacy for Community Health, Chennai, India
| | - Aaron Motsoaledi
- South African National Department of Health, Pretoria, South Africa
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Mario C Raviglione
- University of Milan, Milan, Italy; Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Almaz Sharman
- Academy of Preventive Medicine of Kazakhstan, Almaty, Kazakhstan
| | - Peter M Small
- Global Health Institute, School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | | | - Zelalem Temesgen
- Department of Infectious Diseases, Mayo Clinic, Rochester, MI, USA
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK; Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands
| | | | | | - Gavin Yamey
- Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Bruce D Agins
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Sofia Alexandru
- Institutul de Ftiziopneumologie Chiril Draganiuc, Chisinau, Moldova
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Naomi Beyeler
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Stela Bivol
- Center for Health Policies and Studies, Chisinau, Moldova
| | - Grania Brigden
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Adithya Cattamanchi
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Danielle Cazabon
- McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Valeriu Crudu
- Center for Health Policies and Studies, Chisinau, Moldova
| | - Amrita Daftary
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Puneet Dewan
- Bill & Melinda Gates Foundation, New Delhi, India
| | - Laurie K Doepel
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | - Robert W Eisinger
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | - Victoria Fan
- T H Chan School of Public Health, Harvard University, Cambridge, MA, USA; Office of Public Health Studies, University of Hawaii, Mānoa, HI, USA
| | - Sara Fewer
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer Furin
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jeremy D Goldhaber-Fiebert
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | - Gabriela B Gomez
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen M Graham
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France; Department of Paediatrics, Center for International Child Health, University of Melbourne, Melbourne, VIC, Australia; Burnet Institute, Melbourne, VIC, Australia
| | - Devesh Gupta
- Revised National TB Control Program, New Delhi, India
| | - Maureen Kamene
- National Tuberculosis, Leprosy and Lung Disease Program, Ministry of Health, Nairobi, Kenya
| | | | - Eunice W Mailu
- National Tuberculosis, Leprosy and Lung Disease Program, Ministry of Health, Nairobi, Kenya
| | | | - Lorrie McHugh
- Office of the Secretary-General's Special Envoy on Tuberculosis, United Nations, Geneva, Switzerland
| | - Ellen Mitchell
- International Institute of Social Studies, Erasmus University Rotterdam, The Hague, Netherland
| | - Suerie Moon
- Department of Global Health and Population, Harvard University, Cambridge, MA, USA; Global Health Centre, The Graduate Institute Geneva, Geneva, Switzerland
| | | | - Tripti Pande
- McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Lea Prince
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | | | - Raghuram Rao
- Ministry of Health and Family Welfare, New Delhi, India
| | - Michelle Remme
- International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
| | - James A Seddon
- Department of Medicine, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK; Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Casey Selwyn
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Priya Shete
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Juan F Vesga
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | | | - Eric P Goosby
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
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Wu S, Li R, Su W, Ruan Y, Chen M, Khan MS. Is knowledge retained by healthcare providers after training? A pragmatic evaluation of drug-resistant tuberculosis management in China. BMJ Open 2019; 9:e024196. [PMID: 30904847 PMCID: PMC6475142 DOI: 10.1136/bmjopen-2018-024196] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 12/11/2018] [Accepted: 01/21/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Considering the urgent need of training to improve standardised management of drug-resistant infectious disease and the lack of evidence on the impact of training, this study evaluates whether training participants' knowledge on multidrug-resistant tuberculosis (MDR-TB) is improved immediately and a year after training. SETTING AND PARTICIPANTS The study involved 91 MDR-TB healthcare providers (HCPs), including clinical doctors, nurses and CDC staff, who attended a new MDR-TB HCP training programme in Liaoning and Jiangxi provinces, China. MAIN OUTCOME MEASURES A phone-based assessment of participants' long-term retention of knowledge about MDR-TB management was conducted in July 2017, approximately 1 year after training. The proportion of correct responses in the long-term knowledge assessment was compared with a pretraining test and an immediate post-training test using a χ2 test. Factors influencing participants' performance in the long-term knowledge assessment were analysed using linear regression. RESULTS Across both provinces, knowledge of definitions of drug-resistant TB, standardised MDR-TB case detection protocols and laboratory diagnosis was improved 1 year after the training by 14.5% (p=0.037), 32.4% (p<0.001) and 31% (p<0.001) relative to pretraining. However, compared with immediately after training, the knowledge of the three topics declined by 26.5% (p=0.003), 19.8% (p=0.018) and 52.7% (p<0.001) respectively in Jiangxi, while no significant decline was observed in Liaoning. Additionally, we found that obtaining a higher score in the long-term knowledge assessment was associated with longer years of clinical experience (coefficient=0.51; 95 CI% 0.02 to 0.99; p=0.041) and attending training in Liaoning (coefficient=0.50; 95% CI 0.14 to 0.85; p=0.007). CONCLUSION Our study, the first to assess knowledge retention of MDR-TB HCPs 1 year after training, showed an overall positive long-term impact of lecture-style group training on participants' knowledge. Knowledge decline 1 year after training was observed in one province, Jiangxi, and this may be partly addressed by targeted support to HCPs with fewer years of clinical experience.
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Affiliation(s)
- Shishi Wu
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Renzhong Li
- National Center for Tuberculosis Control and Prevention, China CDC, Beijing, China
| | - Wei Su
- National Center for Tuberculosis Control and Prevention, China CDC, Beijing, China
| | - Yunzhou Ruan
- National Center for Tuberculosis Control and Prevention, China CDC, Beijing, China
| | - Mingting Chen
- National Center for Tuberculosis Control and Prevention, China CDC, Beijing, China
| | - Mishal S Khan
- Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, London, UK
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Ngamvithayapong-Yanai J, Luangjina S, Thawthong S, Bupachat S, Imsangaun W. Stigma against tuberculosis may hinder non-household contact investigation: a qualitative study in Thailand. Public Health Action 2019; 9:15-23. [PMID: 30963038 DOI: 10.5588/pha.18.0055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 12/09/2018] [Indexed: 11/10/2022] Open
Abstract
Setting A northern province in Thailand. Objectives To explore experiences and perspectives on tuberculosis (TB) contact investigations in non-household contacts. Design Focus group discussions and in-depth interviews with eight groups: three groups of former TB patients (teachers, students and hospital staff) and five groups of representatives from congregate settings such as schools and workplaces. Data were analysed using the modified grounded theory. Result Annual health check-ups at the workplace contributed to the early detection of active TB in teachers. Former TB patients were highly exposed to non-household contacts, but contact investigations were limited to household contacts only. Barriers and facilitators for non-household contact investigations are associated with five factors, including information, awareness and knowledge about TB; stigma; empathy; health system response and informing non-household contacts about TB exposure. Stigma may be the main barrier to investigations among non-household contacts because TB patients tend to withhold information about their diagnosis from colleagues. Lack of knowledge and misperceptions regarding TB transmission contributed to stigma. Empathy with other people encouraged TB patients to inform non-household contacts. Conclusion Non-household contact investigations are not performed despite the risk of TB transmission. To promote contact investigations in congregate settings, interventions to overcome TB stigma and improve public knowledge about TB transmission are required.
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Affiliation(s)
| | - S Luangjina
- TB/HIV Research Foundation, Chiang Rai, Thailand
| | - S Thawthong
- TB/HIV Research Foundation, Chiang Rai, Thailand
| | - S Bupachat
- TB/HIV Research Foundation, Chiang Rai, Thailand
| | - W Imsangaun
- Department of Internal Medicine, Chiangrai Prachanukroh Hospital, Chiang Rai, Thailand
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Probandari A, Sanjoto H, Mahanani MR, Azizatunnisa L, Widayati S. Being safe, feeling safe, and stigmatizing attitude among primary health care staff in providing multidrug-resistant tuberculosis care in Bantul District, Yogyakarta Province, Indonesia. HUMAN RESOURCES FOR HEALTH 2019; 17:16. [PMID: 30832666 PMCID: PMC6398218 DOI: 10.1186/s12960-019-0354-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/15/2019] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Patient-centered care approach in multidrug-resistant tuberculosis care requires health worker safety that covers both being safe and feeling safe to conduct the services. Stigma has been argued as a barrier to patient-centered care. However, there has been relatively little research addressing the issues of safety and stigma among health staff. This paper explored the issue of being safe, feeling safe, and stigmatizing attitude among health staff working with multidrug-resistant tuberculosis cases in primary health care facilities in Indonesia. METHODS Using a mixed methods research design, data was collected with structured questionnaires among 123 staff, observations of infection control in 17 primary health care facilities, and in-depth interviews among 22 staff. RESULTS The findings showed suboptimal infection control infrastructures for the primary health care facilities. The knowledge and motivation to follow multidrug-resistant tuberculosis care protocols are suboptimal. Feeling unsafe is related to stigmatizing attitude in providing multidrug-resistant tuberculosis care. CONCLUSION Being safe, feeling unsafe, and stigmatizing attitude are challenges in providing patient-centered multidrug-resistant tuberculosis care in primary health care facilities in Indonesia. Serious efforts are needed on all levels to ensure safety and prevent irrational stigma.
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Affiliation(s)
- Ari Probandari
- Department of Public Health, Faculty of Medicine, Universitas Sebelas Maret, Jalan Ir. Sutami 36A, Surakarta, 57126 Indonesia
- Disease Control Research Group, Faculty of Medicine, Universitas Sebelas Maret, Jalan Ir. Sutami 36A, Surakarta, 57126 Indonesia
| | - Hary Sanjoto
- Disease Control Research Group, Faculty of Medicine, Universitas Sebelas Maret, Jalan Ir. Sutami 36A, Surakarta, 57126 Indonesia
| | - Melani Ratih Mahanani
- Disease Control Research Group, Faculty of Medicine, Universitas Sebelas Maret, Jalan Ir. Sutami 36A, Surakarta, 57126 Indonesia
| | - Luthfi Azizatunnisa
- Disease Control Research Group, Faculty of Medicine, Universitas Sebelas Maret, Jalan Ir. Sutami 36A, Surakarta, 57126 Indonesia
| | - Sampir Widayati
- Bantul District Health Office, Komplek II Kantor Pemerintah Kabupaten Bantul Jalan Lingkar Timur, Manding, Trirenggo, Bantul, Yogyakarta Province 55714 Indonesia
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Sima BT, Belachew T, Abebe F. Health care providers' knowledge, attitude and perceived stigma regarding tuberculosis in a pastoralist community in Ethiopia: a cross-sectional study. BMC Health Serv Res 2019; 19:19. [PMID: 30621678 PMCID: PMC6325851 DOI: 10.1186/s12913-018-3815-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 12/13/2018] [Indexed: 11/10/2022] Open
Abstract
Background Tuberculosis (TB) remains the prime killer disease among infectious diseases. TB control depends on early case detection and treatment in a directly observed treatment short course (DOTS) programme. The success of DOTS depends on the ability of the health care system to identify and properly manage TB cases. The present study aims to assess healthcare provider (HCP) knowledge, attitude and perceived stigma regarding TB and perception about traditional healers. Methods A descriptive cross sectional study was conducted among 108 HCPs using a semi-structured, self-administered questionnaire from September 2014 to January 2015. The study district has a high TB burden area with one district hospital, 4 health centres, and 18 health posts. All health facilities and HCPs available during the study period in the district were included in the study. Statistical software for social science (SPSS) version 22 and STATA version 14 were used to enter and analyse data, respectively. Results The majority (64%) of the HCPs had poor overall knowledge regarding TB, and 67.6 and 57.6% had poor knowledge regarding TB diagnosis and nature of the disease, respectively. Moreover, most 66.7 and 55.6% of the HCPs had an unfavourable attitude towards TB and TB control systems, respectively. Slightly under half (49.1%) of the HCPs had a favourable attitude towards TB patients, and the majority (88.9%) had low perceived stigma. The majority (87.0%) of the HCPs indicated the importance of community involvement in TB control activity. Moreover, most (60.2%) of the HCPs showed willingness to collaborate with traditional healers (THs) on TB control activity. Conclusions Healthcare workers’ knowledge gap and unfavourable attitude towards TB control systems reported in this study may cause poor TB care delivery. HCPs’ perception of the importance of community involvement in TB control and willingness to collaborate with THs on TB management could be an opportunity to strengthen the World Health Organization’s (WHO’s) component of End TB strategy through community engagement. Training and workshops could be used to address the knowledge gap and the unfavourable attitude regarding TB among HCPs. Electronic supplementary material The online version of this article (10.1186/s12913-018-3815-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bezawit Temesgen Sima
- Department of Health Education and Behavioral Science, Institute of Health, Jimma University, P.O. Box 378, Jimma, Ethiopia. .,Department of Community Medicine and Global Health, Institute for Health and Society, Faculty of Medicine, University of Oslo, P.O. Box 1130, Blindern, 0318, Oslo, Norway.
| | - Tefera Belachew
- Department of Population and Family Health, Institute of Health Science, Jimma University, P.O. Box 378, Jimma, Ethiopia
| | - Fekadu Abebe
- Department of Community Medicine and Global Health, Institute for Health and Society, Faculty of Medicine, University of Oslo, P.O. Box 1130, Blindern, 0318, Oslo, Norway
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Wu S, Roychowdhury I, Khan M. Evaluations of training programs to improve human resource capacity for HIV, malaria, and TB control: a systematic scoping review of methods applied and outcomes assessed. Trop Med Health 2017; 45:16. [PMID: 28680324 PMCID: PMC5493875 DOI: 10.1186/s41182-017-0056-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/16/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Owing to the global health workforce crisis, more funding has been invested in strengthening human resources for health, particularly for HIV, tuberculosis, and malaria control; however, little is known about how these investments in training are evaluated. This paper examines how frequently HIV, malaria, and TB healthcare provider training programs have been scientifically evaluated, synthesizes information on the methods and outcome indicators used, and identifies evidence gaps for future evaluations to address. METHODS We conducted a systematic scoping review of publications evaluating postgraduate training programs, including in-service training programs, for HIV, tuberculosis, and malaria healthcare providers between 2000 and 2016. Using broad inclusion criteria, we searched three electronic databases and additional gray literature sources. After independent screening by two authors, data about the year, location, methodology, and outcomes assessed was extracted from eligible training program evaluation studies. Training outcomes evaluated were categorized into four levels (reaction, learning, behavior, and results) based on the Kirkpatrick model. FINDINGS Of 1473 unique publications identified, 87 were eligible for inclusion in the analysis. The number of published articles increased after 2006, with most (n = 57, 66%) conducted in African countries. The majority of training evaluations (n = 44, 51%) were based on HIV with fewer studies focused on malaria (n = 28, 32%) and TB (n = 23, 26%) related training. We found that quantitative survey of trainees was the most commonly used evaluation method (n = 29, 33%) and the most commonly assessed outcomes were knowledge acquisition (learning) of trainees (n = 44, 51%) and organizational impacts of the training programs (38, 44%). Behavior change and trainees' reaction to the training were evaluated less frequently and using less robust methods; costs of training were also rarely assessed. CONCLUSIONS Our study found that a limited number of robust evaluations had been conducted since 2000, even though the number of training programs has increased over this period to address the human resource shortage for HIV, malaria, and TB control. Specifically, we identified a lack evaluation studies on TB- and malaria-related healthcare provider training and very few studies assessing behavior change of trainees or costs of training. Developing frameworks and standardized evaluation methods may facilitate strengthening of the evidence base to inform policies on and investments in training programs.
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Affiliation(s)
- Shishi Wu
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
| | - Imara Roychowdhury
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
| | - Mishal Khan
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore.,Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT United Kingdom
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Pardeshi GS, Kadam D, Chandanwale A, Bollinger R, Deluca A. Resident doctors' attitudes toward tuberculosis patients. Indian J Tuberc 2016; 64:89-92. [PMID: 28410704 DOI: 10.1016/j.ijtb.2016.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 09/16/2016] [Accepted: 11/01/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The attitude of the resident doctors toward tuberculosis (TB) patients can affect their treatment seeking behavior, compliance to treatment as well as reinforce the stigma attached to the disease by the society at large. AIMS To assess the attitudes of resident medical doctors toward TB patients. MATERIAL AND METHODS A cross-sectional study was conducted among postgraduate resident medical doctors at B.J. Government Medical College and Sassoon General Hospital, Pune in September 2014. The background characteristics and attitudes were assessed using a semi-structured questionnaire. The responses were analyzed using Chi-square/Fishers exact test and calculating odds ratio (OR). RESULTS Of the 212 resident doctors who responded to the question on attitudes, 132 (62%) see TB patients on a daily basis, 40 (19%) of the resident doctors had attended a training program on TB, and 99 (47%) respondents knew of a colleague with TB. Only 104 (49%) of the residents reported feeling compassion for and the desire to help TB patients. The residents who had attended a training program in TB were three times more likely to report compassion and a desire to help TB patients than those who had not undergone such training [28/40 vs 76/172; p=0.005; OR=2.95, 95% CI (1.33-6.61)]. Compared to residents who did not know of a colleague with TB, residents who knew of a colleague with TB were nearly three times more likely to avoid managing TB patients or fear them and think they may cause infection [33/99 vs 17/113; p=0.002; OR=2.82, 95% CI (1.39-5.76)]. CONCLUSION The feeling of fear, lack of compassion, and tendency to avoid TB patients reported by 51% of the patients is a cause of concern. Addressing the knowledge gaps through training programs and ensuring safe working environment will make residents more supportive and compassionate toward TB patients which will contribute to TB control.
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Affiliation(s)
- Geeta S Pardeshi
- Department of Community Medicine, Mahavir Medical College and Safdarjung Hospital, New Delhi, India.
| | - Dileep Kadam
- Department of Medicine, Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune, Maharashtra, India
| | - Ajay Chandanwale
- Byramjee Jeejeebhoy Government Medical College/Sassoon General Hospital, Pune, Maharashtra, India
| | - Robert Bollinger
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, MD, USA
| | - Andrea Deluca
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Evaluating the impact of healthcare provider training to improve tuberculosis management: a systematic review of methods and outcome indicators used. Int J Infect Dis 2016; 56:105-110. [PMID: 27979785 DOI: 10.1016/j.ijid.2016.11.421] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/26/2016] [Accepted: 11/29/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Developing human resources capacity is vital for tuberculosis (TB) control in low- and middle-income countries. Although investments in TB healthcare provider (HCP) training programmes have increased, it is unclear whether these are robustly evaluated. The objective of this systematic review was to synthesize the methods and outcome indicators used to assess TB HCP training programmes. METHODS A systematic scoping review of publications reporting on evaluations of training programmes for TB HCPs - including doctors, nurses, paramedics, and lay health workers - was conducted through a search in three electronic databases, Google Scholar, and five websites of non-profit organizations. Data on the study location, population trained, outcomes assessed, and evaluation approach were extracted. RESULTS After screening 499 unique publications, 21 were eligible for inclusion in the analysis. The majority of evaluations were conducted in Africa. The most common evaluation methods were a review of patient records (n=8, 38%) and post-training interview with trainees (n=7, 33%). In terms of outcomes, more than half of the studies (n=12, 57%) evaluated knowledge acquisition of trainees, with only six (29%) assessing on-the-job behaviour change. CONCLUSIONS Even though more funds have been invested in TB HCP training, publications from robust evaluations assessing the impact on quality of care and behaviour change are limited.
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Chizimba R, Christofides N, Chirwa T, Singini I, Ozumba C, Sikwese S, Banda HT, Banda R, Chimbali H, Ngwira B, Munthali A, Nyasulu P. The association between multiple sources of information and risk perceptions of tuberculosis, Ntcheu district, Malawi. PLoS One 2015; 10:e0122998. [PMID: 25885532 PMCID: PMC4401750 DOI: 10.1371/journal.pone.0122998] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 02/26/2015] [Indexed: 11/30/2022] Open
Abstract
Background Tuberculosis (TB) is one of the main causes of death in developing countries. Awareness and perception of risk of TB could influence early detection, diagnosis and care seeking at treatment centers. However, perceptions about TB are influenced by sources of information. Aim This study aimed to determine the association between multiple sources of information, and perceptions of risk of TB among adults aged 18–49 years. Methods A cross-sectional study was conducted in Ntcheu district in Malawi. A total of 121 adults were sampled in a three-stage simple random sampling technique. Data were collected using a structured questionnaire. Perceptions of risk were measured using specific statements that reflected common myths and misconceptions. Low risk perception implied a person having strong belief in myths and misconceptions about TB and high risk perception meant a person having no belief in myths or misconceptions and demonstrated understanding of the disease. Results Females were more likely to have low risk perceptions about TB compared to males (67.7% vs. 32.5%, p = 0.01). The higher the household asset index the more likely an individual had higher risk perceptions about TB (p = 0.006). The perception of risk of TB was associated with sources of information (p = 0.03). Use of both interpersonal communication and mass media was 2.8 times more likely to be associated with increased perception of risk of TB (Odds Ratio [OR] = 2.8; 95% Confidence interva1[CI]: 3.1–15. 6; p = 0.01). After adjusting for sex and asset ownership, use of interpersonal communication and mass media were more likely to be associated with higher perception of risk of TB (OR, 2.0; 95% CI: 1.65–10.72; p = 0.003) compared with interpersonal communication only (OR 1.6, 95%; CI: 1.13–8.98, p = 0.027). Conclusion The study found that there was association between multiple sources of information, and higher perceptions of risk of TB among adults aged 18–49 years.
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Affiliation(s)
- Robert Chizimba
- Health Department, Save the Children International, Lilongwe, Malawi
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicola Christofides
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tobias Chirwa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Isaac Singini
- Johns Hopkins Research Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Chineme Ozumba
- Department of Public Health, School of Health Sciences, Monash, South Africa
| | - Simon Sikwese
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Pakachere Institute of Health and Development Communication, Blantyre, Malawi
| | - Hastings T. Banda
- Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Rhoda Banda
- National Tuberculosis Control Program, Community Health Sciences Unit, Ministry of Health, Lilongwe, Malawi
| | - Henry Chimbali
- Health Promotion Services, Ministry of Health, Lilongwe, Malawi
| | - Bagrey Ngwira
- Department of Community Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Peter Nyasulu
- Department of Public Health, School of Health Sciences, Monash, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
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Balogun M, Sekoni A, Meloni ST, Odukoya O, Onajole A, Longe-Peters O, Ogunsola F, Kanki PJ. Trained community volunteers improve tuberculosis knowledge and attitudes among adults in a periurban community in southwest Nigeria. Am J Trop Med Hyg 2014; 92:625-32. [PMID: 25510722 DOI: 10.4269/ajtmh.14-0527] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Nigeria has the world's 10th largest tuberculosis (TB) burden. Targeted community-based interventions can potentially help reduce TB incidence. We designed an intervention in a periurban community where 10 community volunteers were trained to provide community TB education and also detect and refer TB suspects to a nearby clinic. To determine the effect of the intervention on knowledge, attitude, and preventive practices of TB, we compared results from a pre-intervention survey with those of a post-intervention survey. Pre-intervention, respondents had a mean knowledge score of 10.6 ± 7.0 of a possible 34, a mean attitude score of 5.8 ± 3.3 of a possible 10, and a mean practice score of 5.3 ± 1.4 of a possible 7. The intervention significantly increased the mean knowledge score to 16 ± 5.4 (P < 0.001) and mean attitude score to 7.0 ± 1.8 (P < 0.001); however, there was no statistically significant difference in the mean practice score. Eight TB suspects were referred to the clinic, and one suspect was subsequently diagnosed with TB. The use of trained community volunteers to share information on TB improved the overall knowledge and attitudes of respondents. Continued empowerment of the community should be encouraged to promote TB prevention and care.
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Affiliation(s)
- Mobolanle Balogun
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts; Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria; Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Adekemi Sekoni
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts; Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria; Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Seema Thakore Meloni
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts; Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria; Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Oluwakemi Odukoya
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts; Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria; Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Adebayo Onajole
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts; Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria; Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Olukemi Longe-Peters
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts; Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria; Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Folasade Ogunsola
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts; Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria; Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Phyllis J Kanki
- Department of Community Health and Primary Care, College of Medicine of the University of Lagos, Lagos, Nigeria; Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, Massachusetts; Department of Community Health, Lagos University Teaching Hospital, Lagos, Nigeria; Department of Medical Microbiology and Parasitology, College of Medicine of the University of Lagos, Lagos, Nigeria
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Ibrahim LM, Hadejia IS, Nguku P, Dankoli R, Waziri NE, Akhimien MO, Ogiri S, Oyemakinde A, Dalhatu I, Nwanyanwu O, Nsubuga P. Factors associated with interruption of treatment among Pulmonary Tuberculosis patients in Plateau State, Nigeria. 2011. Pan Afr Med J 2014; 17:78. [PMID: 24711884 PMCID: PMC3972906 DOI: 10.11604/pamj.2014.17.78.3464] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 12/13/2013] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Nigeria has one of the highest tuberculosis (TB) burdens in the world with estimated incidence of 133 per 100,000 populations. Multi-drug resistant TB (MDR-TB) is an emerging threat of the TB control in Nigeria caused mainly by incomplete treatment. This study explored factors that affect adherence to treatment among patients undergoing direct observation of TB treatment in Plateau state, Nigeria. METHODS Between June and July 2011, we reviewed medical records and interviewed randomly selected pulmonary TB patients in their eighth month of treatment. Information on patients? clinical, socio-demographic and behavioral characteristics was collected using checklist and structured questionnaire for knowledge of treatment duration and reasons for interruption of treatment. We conducted focus group discussions with patients about barriers to treatment adherence. Data were analyzed with Epi Info software. RESULTS Of 378 records reviewed, 229 (61%) patients were male; mean age 37.6±13.5 years and 71 (19%) interrupted their treatment. Interruption of treatment was associated with living >5 km from TB treatment site (AOR: 11.3; CI 95%: 5.7-22.2), lack of knowledge of duration of treatment (AOR: 6.1; CI 95%: 2.8-13.2) and cigarette smoking (AOR: 3.4; CI 95%: 1.5- 8.0). Major reasons for the interruption were lack of transport fare (40%) and feeling well (25%). Focused group discussions revealed unfriendly attitudes of health care workers as barriers to adherence to treatment. CONCLUSION This study revealed knowledge of the patients on the duration of treatment, distance and health workers attitude as the major determinants of adherent to TB treatment. Training for health care workers on patient education was conducted during routine supportive supervision.
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Affiliation(s)
| | | | - Patrick Nguku
- Nigeria Field Epidemiology and Laboratory Training Program, Nigeria
| | - Raymond Dankoli
- Nigeria Field Epidemiology and Laboratory Training Program, Nigeria
| | | | | | | | - Akin Oyemakinde
- Nigeria Field Epidemiology and Laboratory Training Program, Nigeria
| | - Ibrahim Dalhatu
- Centers for Disease Control and Prevention, Nigeria Country Office, Abuja Nigeria
| | - Okey Nwanyanwu
- Centers for Disease Control and Prevention, Nigeria Country Office, Abuja Nigeria
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Uchenna Onyeonoro U, Ngozi Chukwu J, C. Nwafor C, O. Meka A, C. Oshi D. Effect of TB behaviour change communication (BCC) intervention in Enugu state, southeast Nigeria. HEALTH EDUCATION 2013. [DOI: 10.1108/he-10-2012-0050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– In 2007, Nigeria commenced a nationwide behavioural change communication (BCC) intervention to increase uptake of tuberculosis (TB) care services. The purpose of this paper is to evaluate the effect of TB BCC intervention on knowledge and perception of TB in Enugu state, southeast Nigeria.
Design/methodology/approach
– This is a cross-sectional study carried out in December 2009 in which a total of 1,200 respondents (620 males and 580 females) from six local government areas (three urban and three rural), selected by multi-stage sampling technique were interviewed using a semi-structured questionnaire.
Findings
– The survey showed that most of the respondents had access to radio and about half to television. Access to media was significantly higher in urban areas than rural areas. Radio and community were the commonest sources of information of TB. The majority of the respondents were aware of that there was a message, however, ability to recall the content of the message varied. Significant association was observed between knowledge of the health education message and knowledge of TB transmission, that TB is curable and of appropriate care-seeking behaviour. Access to this media health education intervention was determined by age, gender, educational status, literacy, religion and access to media.
Practical implications
– The study showed that TB BCC is associated with high-level awareness of TB disease and appropriate care-seeking behaviour. Socio-demographic characteristics and locality were found to influence access to mass media communication. Therefore, consideration should be given to the appropriateness of medium of communication in the design of TB BCC. However, there is need to combine it with other strategies to reach the disadvantaged population.
Originality/value
– This study is the first population-based survey to ascertain access to TB-related BCC intervention and its effect on knowledge and care-seeking behaviour of this study population.
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Bati J, Legesse M, Medhin G. Community's knowledge, attitudes and practices about tuberculosis in Itang Special District, Gambella Region, South Western Ethiopia. BMC Public Health 2013; 13:734. [PMID: 23924362 PMCID: PMC3750843 DOI: 10.1186/1471-2458-13-734] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 07/30/2013] [Indexed: 11/10/2022] Open
Abstract
Background Tuberculosis (TB) is one of the primary public health problems in developing countries. HIV/AIDS, poverty, undernutrition, over-crowded living conditions and lack of knowledge about the disease have been known to increase the risk of spreading the bacteria and the risk of developing the disease. The objective of this study was to assess the level of TB knowledge, attitudes and practices of rural communities of Itang Special District of the Gambella Regional State of Ethiopia. Methods Between November 2011 and January 2012, a community-based cross sectional study was carried out in a randomly selected rural kebeles (i.e. the smallest administrative units) of Itang communities. The study participants were interviewed using pre-tested questionnaire. The overall knowledge, attitudes and practices of the study participants were assessed using the mean score of each outcome as a cut-off value. Having a score above the mean on each of the three target outcomes was equated with having a good level of knowledge, or having favorable attitude and good practices towards TB. Results Out of 422 study participants (58.5% males and 41.5% females) only 3.3% mentioned bacteria/germ as a cause of pulmonary TB (PTB) and 9.9% mentioned cough for at least two weeks as the sign of TB. Taking the mean knowledge score as the cut-off value, 57.6% (95% CI: 52.7% to 62.3%) of the study participants had good level of knowledge about TB, 40.8% (95% CI: 36.0% to 45.6%) had favorable attitude towards TB and 45.9% (95% CI: 41.1% to 50.9%) had good practices. Female participants were less likely to have good level of knowledge [adjusted odds ratio (AOR) = 0.33, 95% CI, 0.21 to 0.51, p < 0.001], less likely to have favorable attitude (AOR = 0.23, 95% CI, 0.14 to 0.37) and less likely to have good practices (AOR = 0.37, 95% CI, 0.24 to 0.57, p < 0.001) compared to male participants. Conclusion Majority of the study participants had no correct information about the causative agent of TB and the main symptom of PTB. Moreover, low level of overall knowledge, attitudes and practices about TB was associated with female participants. Hence, TB control strategy in the present study area should include community awareness raising component.
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Affiliation(s)
- Jango Bati
- Gambella Teachers Education and Health Science College, Gambella, Ethiopia
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