The relationship between (stigmatizing) views and lay public preferences regarding tuberculosis treatment in the Eastern Cape, South Africa

Social Isolation, Social Exclusion and Access to Resources: Mapping the Gendered Impact of TB-related Stigma Among TB Patients in Eastern Cape Province, South Africa

Background Stigma and isolation among people living with tuberculosis (PLWTB) is well documented. Poorly understood are the gendered pathways by which TB-related stigma results in isolation or impacts access to resources during one's illness-to-health journey. Methods We interviewed PLWTB receiving treatment at government clinics in Buffalo City Metro, South Africa. Semi-structured guides explored: TB symptom experiences; access-to-care; treatment motivation; key supporters; and access to mental and tangible resources (MTRs) during illness. Open coding was done inductively, with MTR domains informed by the Network-Individual-Resource Model. Findings were analyzed through a cyclic iterative and deductive process using social isolation and exclusion as interpretive lenses. Memos and pathway mapping examined gendered differences in stigma, isolation, and access to networked MTRs. Results One-hundred forty-two PLWTB (Men = 93; Women = 61) were interviewed. PLWTB described pervasive TB stigma and isolation. Women described self-isolating in response to enacted and anticipated stigma. Men described active exclusion by friends and family. Women's maintenance of familial ties facilitated access to MTRs while ill. Men's systematic exclusion reduced their agency to access resources. Men and women described regaining of physical strength and recovery of social networks, but also the sustained post-treatment stigma impact. Conclusions We identified gendered pathways through which TB stigma and isolation affect access to MTRs. For women, stigma led to social isolation, but familial networks maintained access to MTRs, fostering resilience. Men experienced social exclusion, reduced agency to access MTRs, and increased vulnerability during illness. Findings can guide gender-responsive interventions to reduce the impact of TB stigma on health outcomes.

Quantification and correlates of tuberculosis stigma along the tuberculosis testing and treatment cascades in South Africa: a cross-sectional study

Background

South Africa has one of the world’s worst tuberculosis (TB) (520 per 100 000 population) and TB-human immunodeficiency virus (HIV) epidemics (~ 56% TB/HIV co-infected). While individual- and system-level factors influencing progression along the TB cascade have been identified, the impact of stigma is underexplored and underappreciated. We conducted an exploratory study to 1) describe differences in perceived community-level TB stigma among community members, TB presumptives, and TB patients, and 2) identify factors associated with TB stigma levels among these groups.

Methods

A cross sectional study was conducted in November 2017 at public health care facilities in Buffalo City Metro (BCM) and Zululand health districts, South Africa. Community members, TB presumptives, and TB patients were recruited. Data were collected on sociodemographic characteristics, TB knowledge, health and clinical history, social support, and both HIV and TB stigma. A validated scale assessing perceived community TB stigma was used. Univariate and multivariate linear regression models were used to describe differences in perceived community TB stigma by participant type and to identify factors associated with TB stigma.

Results

We enrolled 397 participants. On a scale of zero to 24, the mean stigma score for TB presumptives (14.7 ± 4.4) was statistically higher than community members (13.6 ± 4.8) and TB patients (13.3 ± 5.1). Community members from Zululand (β = 5.73; 95% CI 2.19, 9.72) had higher TB stigma compared to those from BCM. Previously having TB (β = − 2.19; 95% CI − 4.37, 0.0064) was associated with reduced TB stigma among community members. Understanding the relationship between HIV and TB disease (β = 2.48; 95% CI 0.020, 4.94), and having low social support (β = − 0.077; 95% CI − 0.14, 0.010) were associated with increased TB stigma among TB presumptives. Among TB Patients, identifying as Black African (β = − 2.90; 95% CI − 4.74, − 1.04) and knowing the correct causes of TB (β = − 2.93; 95% CI − 4.92, − 0.94) were associated with decreased TB stigma, while understanding the relationship between HIV and TB disease (β = 2.48; 95% CI 1.05, 3.90) and higher HIV stigma (β = 0.32; 95% CI 0.21, 0.42) were associated with increased TB stigma.

Conclusions

TB stigma interventions should be developed for TB presumptives, as stigma may increase initial-loss-to-follow up. Given that stigma may be driven by numerous factors throughout the TB cascade, adaptive stigma reduction interventions may be required.

Tuberculosis-related stigma among adults presenting for HIV testing in KwaZulu-Natal, South Africa

BACKGROUND

Tuberculosis (TB)-related stigma presents a major barrier to care of persons with TB through its impact on treatment initiation and retention in care. This is particularly challenging in settings with high prevalence of both TB and HIV where fear of HIV/AIDS can amplify stigma surrounding TB. The purpose of this study was to validate a TB stigma scale for use among persons presenting for outpatient HIV screening in the Umlazi township of South Africa and evaluate factors associated with TB-related stigma in this high HIV burden setting.

METHODS

In this cross-sectional study, we measured TB-related stigma in adults prior to HIV testing using a 12-item scale designed to assess experienced and felt TB-related stigma.

RESULTS

Among 848 adults, mean age was 32 years, 54% were male, and the median TB stigma score was 19 of 36 (interquartile range 15-23). We identified two factors in the stigma scale which had excellent reliability (Cronbach's alpha 0.85, 0.89). Persons with high TB stigma were more likely to be male (adjusted relative risk ratio [aRRR] 1.56, 95% confidence interval [CI] 1.11-2.28) and have accurate knowledge of TB transmission (aRRR 1.90, 95% CI 1.16-3.10) as compared to those with low stigma. Variables not significantly associated with stigma in the multivariate model included education, income, prior TB or HIV diagnoses, and depression.

CONCLUSIONS

Male sex and TB knowledge were associated with higher TB stigma in an outpatient HIV clinic in a South African township. Identifying risk factors associated with stigma will be important to guide stigma reduction interventions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Three Case Studies in Making Fair Choices on the Path to Universal Health Coverage

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity, and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for those who are worse off in a number of dimensions (including health, access to health services, and social and economic status), and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting.

Needs assessment for adapting TB directly observed treatment intervention programme in Limpopo Province, South Africa: A community-based participatory research approach

Background

Limpopo Province is one of the hardest hit by tuberculosis and human immune virus infections in the country. The province has been implementing a directly observed treatment strategy since 1996. However, the cure rate was 64% in 2015 and remains far from the set target by the World Health Organization of 85%. Poor health-care seeking and adherence behaviours were identified as major risk behaviours.

Aim

To apply a Community-Based Participatory Research (CBPR) approach in identifying barriers and facilitators to health-care seeking and adherence to treatment, and to determine strategies and messages in order to inform the design of an adapted intervention programme.

Setting

This study was conducted in three districts in the Limpopo Province, Capricorn, Mopani and Sekhukhune districts.

Methods

The community participatory research approach was applied. Purposive sampling was used to sample participants. Focus group discussions were used to collect data. Participatory analysis was used comparing findings within and across all the participants.

Results

A total of 161 participated in the study. Participants included coordinators, professional nurses, supporters and patients. Major modifiable behavioural-related barriers were lack of knowledge about tuberculosis, misinformation and misperceptions cultural beliefs, stigma and refusal of treatment support. Environment-related barriers were attitudes of health workers, lack of support by family and community, lack of food and use of alcohol and drugs. Strategies and messages included persuasive and motivational messages to promote healthy behaviour.

Conclusion

Joint programmatic collaboration between the community and academic researchers is really needed for interventions to address the needs of the community.

The influence of social capital and socio-economic conditions on self-rated health among residents of an economically and health-deprived South African township

BACKGROUND

Surprisingly few studies have investigated the interplay of multiple factors affecting self-rated health outcomes and the role of social capital on health in developing countries, a prerequisite to strengthening our understanding of the influence of social and economic conditions on health and the most effective aid. Our study aimed to identify social and economic conditions for health among residents of an economically and health-deprived community.

METHODS

Data were gathered through a survey administered to respondents from 1,020 households in Grahamstown a suburb in the Eastern Cape, South Africa (response rate 97.9%). We investigated the influence of social and economic conditions (education, employment, income, social capital, housing quality and neighborhood quality) on self-rated health. We used ordinal logistic regression analyses to identify the relationship of these conditions and self-rated health.

RESULTS

Our study found that education and social capital positively correlated with health; unemployment, poor educational level and advanced age negatively correlated. We found no significant correlations between self-rated health and housing quality, neighbourhood quality, income, gender, or marital status.

CONCLUSION

We highlight the possible impacts of social capital, employment, and education on health, and suggest that health outcomes may be improved through interventions beyond the health system: creating job opportunities, strengthening social capital, bettering educational systems, and promoting educational access. Policymakers should consider the benefits of such programmes when addressing health outcomes in financially distressed districts.

Socio-economic status and self-reported tuberculosis: a multilevel analysis in a low-income township in the Eastern Cape, South Africa

Few studies have investigated the interplay of multiple factors affecting the prevalence of tuberculosis in developing countries. The compositional and contextual factors that affect health and disease patterns must be fully understood to successfully control tuberculosis. Experience with tuberculosis in South Africa was examined at the household level (overcrowding, a leaky roof, social capital, unemployment, income) and at the neighbourhood level (Gini coefficient of inequality, unemployment rate, headcount poverty rate). A hierarchical random-effects model was used to assess household-level and neighbourhood-level effects on self-reported tuberculosis experience. Every tenth household in each of the 20 Rhini neighbourhoods was selected for inclusion in the sample. Eligible respondents were at least 18 years of age and had been residents of Rhini for at least six months of the previous year. A Kish grid was used to select one respondent from each targeted household, to ensure that all eligible persons in the household stood an equal chance of being included in the survey. We included 1,020 households within 20 neighbourhoods of Rhini, a suburb of Grahamstown in the Eastern Cape, South Africa. About one-third of respondents (n=329; 32%) reported that there had been a tuberculosis case within the household. Analyses revealed that overcrowding (P≤0.05) and roof leakage (P≤0.05) contributed significantly to the probability of a household tuberculosis experience experience, whereas higher social capital (P≤0.01) significantly reduced this probability. Overcrowding, roof leakage and the social environment affected tuberculosis prevalence in this economically disadvantaged community. Policy makers should consider the possible benefits of programs that deal with housing and social environments when addressing the spread of tuberculosis in economically poor districts.