Assessing the consequences of stigma for tuberculosis patients in urban Zambia

Stigma in Tuberculosis: Time to Act on an Important and Largely Unaddressed Issue

Tuberculosis has afflicted mankind for centuries, serving as a prevalent cause of morbidity and mortality in high-burden countries. Despite ongoing efforts in tuberculosis control, critical issues, such as the psychological impact of the disease, often go unaddressed. This editorial sheds light on a crucial aspect of tuberculosis: the stigma associated with the infection and its profound impact. Additionally, it offers suggestions to overcome the shortcomings in the psychological management of patients.

Concurrent management of HIV and malaria: A comprehensive review of strategies to enhance quality of life

The co-occurrence of human immunodeficiency virus and malaria presents a complex medical scenario, significantly impacting the quality of life for affected individuals. This comprehensive review synthesizes current knowledge, challenges, and strategies concerning the concurrent management of these infections to improve overall well-being. Epidemiological insights reveal the prevalence and demographic trends, highlighting geographical areas of concern and socioeconomic factors contributing to the burden of co-infection. Pathophysiological interactions elucidate the compounding effects, altering disease progression and treatment outcomes. Healthcare challenges underscore the necessity for integrated care models, evaluating existing healthcare frameworks and their efficacy in addressing dual infections. In-depth analysis of interventions explores pharmacological, behavioral, and preventive measures, evaluating their efficacy and safety in co-infected individuals. Additionally, the review assesses psychosocial support mechanisms, emphasizing community-based interventions and peer networks in enhancing holistic care. Consideration is given to the role of antiretroviral therapy, malaria prevention strategies, and the evolving landscape of healthcare delivery in optimizing outcomes for this vulnerable population. The paper concludes by emphasizing the significance of multidisciplinary approaches and integrated care models, stressing the need for continued research and collaborative efforts to advance interventions and improve the quality of life for those navigating the complexities of human immunodeficiency virus and malaria co-infection.

Contact investigation in multidrug-resistant tuberculosis: ethical challenges

Contact investigation is an evidence-based intervention of multidrug-resistant tuberculosis (MDR-TB) to protect public health by interrupting the chain of transmission. In pursuit of contact investigation, patients' MDR-TB status has to be disclosed to third parties (to the minimum necessary) for tracing the contacts. Nevertheless, disclosure to third parties often unintentionally leads the MDR-TB patients suffered from social discrimination and stigma. For this reason, patients are less inclined to reveal their MDR-TB status and becomes a significant issue in contact investigation. This issue certainly turns into a negative impact on the public interest. Tension between keeping MDR-TB status confidential and safeguarding public health arises in relation to this issue. Regarding MDR-TB management, patient compliance with treatment and contact investigation are equally important. Patients might fail to comply with anti-TB therapy and be reluctant to seek healthcare due to disclosure concerns. In order to have treatment adherence, MDRTB patients should not live through social discrimination and stigma arising from disclosure and TB team has a duty to support them as a mean of reciprocity. However, implementation of contact investigation as a public health policy can still be challenging even with promising reciprocal support to the patients because MDR-TB patients are living in different contexts and situations. There can be no straight forward settlement but an appropriate justification for each distinct context is needed to strike a balance between individual confidentiality and public interest.

Stigma, depression, quality of life, and the need for psychosocial support among people with tuberculosis in Indonesia: A multi-site cross-sectional study

Stigma towards people with tuberculosis (TB-Stigma) is associated with other psychosocial consequences of TB including mental illness and reduced quality of life (QoL). We evaluated TB-Stigma, depression, QoL, and the need for psychosocial support among adults with TB in Indonesia, a high TB burden country. In this primary health facility-based survey in seven provinces of Indonesia, from February to November 2022, we interviewed adults receiving (a) intensive phase treatment for drug-susceptible (DS) TB at public facilities, (b) treatment at private facilities, (c) those lost to follow up (LTFU) to treatment, and (d) those receiving TB retreatment. We used our previously validated Indonesian TB-Stigma Scale, Patient Health Questionnaire-9, and EQ-5D-5L to measure TB-Stigma, depression, and QoL. Additional questions assessed what psychosocial support was received or needed by participants. We recruited and interviewed 612 people, of whom 60.6% (96%CI 59.6-64.5%) experienced moderate TB-Stigma. The average TB-Stigma scores were 19.0 (SD 6.9; min-max 0-50; Form A-Patient Perspective) and 23.4 (SD 8.4, min-max 0-50; Form B-Community Perspective). The scores were higher among people receiving treatment at private facilities (adjusted B [aB] 2.48; 0.94-4.03), those LTFU (aB 2.86; 0.85-4.87), males (aB 1.73; 0.59-2.87), those losing or changing job due to TB (aB 2.09; 0.31-3.88) and those living in a rural area (aB 1.41; 0.19-2.63). Depression was identified in 41.5% (95% CI 37.7-45.3%) of participants. Experiencing TB-Stigma was associated with moderately severe to severe depression (adjusted odds ratio [aOR] 1.23; 1.15-1.32) and both stigma and depression were associated with lower QoL (aB -0.013; [-0.016]-[-0.010]). Informational (20.8%), emotional (25.9%) and instrumental (10.6%) support received from peers or peer-groups was limited, and unmet need for such support was high. There is a sizeable and intersecting burden of TB-Stigma and depression among adults with TB in Indonesia, which is associated with lower QoL. Participants reported a substantial unmet need for psychosocial support including peer-led mutual support groups. A community-based peer-led psychosocial support intervention is critical to defray the psychosocial impact of TB in Indonesia.

Stigma and Associated Sex Disparities Among Patients with Tuberculosis in Uganda: A Cross-Sectional Study

Background

Tuberculosis (TB) is one of the leading causes of death from a single infectious agent globally. Stigma associated with TB encompassing self-, anticipated-, and public-stigma has significant negative effects on treatment adherence. In Uganda, limited data exist on the prevalence of stigma and its relationship with sex among patients with TB. We evaluate prevalence of three types of stigma and their relationship with the sex of patients undergoing TB treatment.

Methods

This cross-sectional study was conducted between July 2020 to March 2021 at selected TB clinics in Kampala, Uganda. Eligible participants were aged 18-65 with confirmed TB and starting their prescribed treatment. We collected data on socio-demographics and used 13 items to capture the self-, anticipated-, and public-stigma from which we composed the dependent variables. The primary independent variable was sex. We employed multivariable logistic regression analysis to evaluate the association between sex and the three stigma types. Additionally, we considered potential confounders such as age, HIV, and employment status. Statistical significance was defined as p<0.05.

Results

In this study we enrolled 144 participants with a mean age of 35.8 years (standard deviation = 12). Half of the participants (50%, n=72) were female, 44% had a secondary education, 37.5% were unemployed, and 32.6% were co-infected with HIV. The prevalence of self-stigma was 71.1%, anticipated stigma was 75.7%, and public stigma was 41.7%. Significant factors were associated with self-stigma were female sex (adjusted odds ratio (AOR): 2.35 95% CI: 1.02-5.74) and unemployment (AOR: 2.95 95% CI: 1.16-8.58). HIV-positive status was significantly associated with anticipated stigma (AOR: 3.58 95% CI: 1.38-11.23). However, none of the variables we evaluated showed a significant association with public stigma.

Conclusions

Our study showed a high prevalence of self, anticipated and public stigma among TB patients. Notably, females and unemployed individuals were at a higher risk of self-stigma, while those with HIV/AIDS and TB were more likely to report anticipated stigma. To combat stigma effectively, interventions should be tailored to cater to sex-specific needs and persons living with HIV. Future research should delve further in determinants of TB-related stigma in high-burden settings.

Prevalence of mental distress in adults with and without a history of tuberculosis in an urban Zambian community

People with tuberculosis (TB) are susceptible to mental distress. Mental distress can be driven by biological and socio-economic factors including poverty. These factors can persist beyond TB treatment completion yet there is minimal evidence about the mental health of TB survivors. A cross-sectional TB prevalence survey of adults was conducted in an urban community in Zambia. Survey participants were administered the five-item Self Reporting Questionnaire (SRQ-5) mental health screening tool to measure mental distress. Associations between primary exposure (history of TB) and other co-variates with mental distress were investigated using logistic regression. Of 3,393 study participants, 120 were TB survivors (3.5%). The overall prevalence of mental distress (SRQ-5 ≥ 4) in the whole study population was 16.9% (95% CI 15.6%-18.1%). Previous TB history was not associated with mental distress (OR 1.20, 95% CI 0.75-1.92, p-value 1.66). Mental distress was associated with being female (OR 1.23 95% CI 1.00-1.51), older age (OR 1.71 95% CI 1.09-2.68) and alcohol abuse (OR 1.81 95% CI 1.19-2.76). Our findings show no association between a previous TB history and mental distress. However, approximately one in six people in the study population screened positive for mental distress.

Acceptability and feasibility of tuberculosis-diabetes mellitus screening implementation in private primary care clinics in Yogyakarta, Indonesia: a qualitative study

BACKGROUND

The relationship between Tuberculosis (TB) and Diabetes Mellitus (DM) is intricate and intertwined, posing significant global health challenges. In addition, the increasing prevalence of DM worldwide raises concerns regarding the potential resurgence of tuberculosis. The implementation of tuberculosis prevention strategies is of the utmost importance, especially in countries like Indonesia that encounter a dual burden of TB and DM. The significance of TB screening in private primary care settings for patients with diabetes cannot be overstated. Implementing TB screening protocols in private primary care settings can assist in identifying diabetic patients with tuberculosis. Therefore, this study aims to explore the acceptability and feasibility of tuberculosis-diabetes mellitus screening implementation in private primary care clinics.

METHODS

We conducted implementation research with an exploratory qualitative design. Fifteen healthcare professionals from five private primary health care clinics in Yogyakarta, Indonesia, participated in five focus groups. The discussions were audio recorded, transcribed verbatim, and thematically analyzed. As part of the feasibility assessment, surveys were conducted in each clinic. We conducted a thematic analysis in accordance with the theoretical framework of acceptability and the feasibility assessment.

RESULTS

We identified that most private primary care clinics deemed the implementation of TB screening in DM patients acceptable and practicable. We revealed that the majority of diabetes patients enthusiastically accepted TB-DM screening services. In addition, we found that the healthcare professionals at the clinic are aware of the nature of the intervention and demonstrates a positive attitude despite a subtle burden. The stigma associated with COVID-19 has emerged as a new implementation barrier, joining TB stigma, lack of resources, and regulatory issues. We identify concealed and tiered screening as a potential method for enhancing the implementation of TB-DM screening.

CONCLUSIONS

The implementation of TB screening in DM patients in private primary care clinics had the potential to be acceptable and feasible. To achieve a successful implementation, consideration should be given to supporting factors, hindering factors, and strategies to improve TB screening in DM patients.

Adaptation and validation of a TB stigma scale for adolescents in Lima, Peru

BACKGROUND: TB-related stigma contributes to poor clinical outcomes and reduced wellbeing for affected individuals. Adolescents may be particularly susceptible to TB-related stigma due to their heightened sensitivity to peer acceptance, yet few studies have evaluated TB-related stigma in this group. Without a validated scale, it remains challenging to measure TB-related stigma in adolescents.METHODS: We adapted and validated the Van Rie TB Stigma Scale (VTSS) for adolescents on treatment for rifampicin-susceptible TB in Lima, Peru. The modified stigma scale was administered within a larger survey, which measured other psychosocial factors, including depression, adverse childhood experiences (ACEs), and social support. Data analysis included factor analysis, internal consistency, and convergent validity.RESULTS: From October 2020 to September 2021, 249 adolescents (individuals aged 10-19 years) completed the survey. Preliminary confirmatory factor analysis led to removal of two items. The final 10-item scale demonstrated good internal consistency (Cronbach's α = 0.82) and adequate model fit (χ²/df = 2.0; root mean square error of approximation: 0.06; comparative fit index: 0.94; Tucker-Lewis Index: 0.92: standardized root mean square residual: 0.05). Stigma was positively correlated with ACEs (γ = 0.13), depression (γ = 0.39), and suicidal ideation (γ = 0.27), and negatively correlated with social support (γ = -0.19).CONCLUSION: This adolescent TB stigma scale may serve as a practical tool to measure TB-related stigma and evaluate the impact of stigma-reduction interventions in adolescents.

The relationship between psychological resilience and depression among the diabetes patients under the background of "dynamic zero COVID-19": the mediating role of stigma and the moderating role of medication burden

Objective

Depression in diabetes patients is caused by their own disease or the surrounding social environment. How to cope with changes in mentality and adjust psychological stress responses, especially under China's dynamic zero COVID-19 policy, is worth further discussion. The researchers constructed a moderated mediation model to test the effect of psychological resilience during dynamic zero COVID-19 on depression in diabetes patients and the mediating role of stigma and the moderating effect of medication burden.

Method

From June to September, 2022, data were collected in Jinghu District, Wuhu City, Anhui Province, by multi-stage stratified sampling. Firstly, we selected a tertiary hospital randomly in Jinghu District. Secondly, departments are randomly chosen from the hospital. Finally, we set up survey points in each department and randomly select diabetes patients. In addition, we used the Connor-Davidson Elasticity Scale (CD-RISC) to measure psychological resilience of patients, and used the Stigma Scale for Chronic Illness (SSCI) to measure stigma, medication burden was measured by the Diabetes Treatment Burden Scale (DTBQ), and depression was assessed by the Patient Health Questionnaire-9 (PHQ-9). We used SPSS (version 23.0) and PROCESS (version 4.1) for data analysis.

Results

(1) Psychological resilience was negatively correlated with stigma, medication burden, and depression. Stigma was positively associated with medication burden and depression. Medication burden and depression are positively correlated, (2) The mediation analysis showed that psychological resilience had a direct predictive effect on depression, and stigma partially mediated the relationship, and (3) Medication burden moderates the direct pathway by which psychological resilience predicts depression; Medication burden moderates the first half of "psychological resilience → stigma → depression."

Conclusion

Under the mediating effect of stigma, psychological resilience can improve depression. Medication burden has a moderating effect on the relationship between psychological resilience and depression, and it also has a moderating effect on the relationship between psychological resilience and stigma. These results facilitate the understanding of the relationship mechanisms between psychological resilience and depression.

Surveillance of multidrug-resistant tuberculosis in sub-Saharan Africa through wastewater-based epidemiology

The spread of multidrug-resistant tuberculosis (MDR-TB) is a serious public health issue, particularly in developing nations. The current methods of monitoring drug-resistant TB (DR-TB) using clinical diagnoses and hospital records are insufficient due to limited healthcare access and underreporting. This study proposes using Wastewater-Based Epidemiology (WBE) to monitor DR-TB in six African countries (Ghana, Nigeria, Kenya, Uganda, Cameroon, and South Africa) and examines the impact of treated wastewater on the spread of TB drug-resistant genes in the environment. Using droplet-digital polymerase chain reaction (ddPCR), the study evaluated untreated and treated wastewater samples in selected African countries for TB surveillance. There was a statistically significant difference in concentrations of genes conferring resistance to TB drugs in wastewater samples from the selected countries (p-value<0.05); South African samples exhibited the highest concentrations of 4.3(±2,77), 4.8(±2.96), 4.4(±3,10) and 4.7(±3,39) log copies/ml for genes conferring resistance to first-line TB drugs (katG, rpoB, embB and pncA respectively) in untreated wastewater. This may be attributed to the higher prevalence of TB/MDR-TB in SA compared to other African countries. Interestingly, genes conferring resistance to second-line TB drugs such as delamanid (ddn gene) and bedaquiline (atpE gene) were detected in relatively high concentrations (4.8(±3,67 and 3.2(±2,31 log copies/ml for ddn and atpE respectively) in countries, such as Cameroon, where these drugs are not part of the MDR-TB treatment regimens, perhaps due to migration or the unapproved use of these drugs in the country. The gene encoding resistance to streptomycin (rrs gene) was abundant in all countries, perhaps due to the common use of this antibiotic for infections other than TB. These results highlight the need for additional surveillance and monitoring, such as WBE, to gather data at a community level. Combining WBE with the One Health strategy and current TB surveillance systems can help prevent the spread of DR-TB in populations.

Models of integration of TB and HIV services and factors associated with perceived quality of TB-HIV integrated service delivery in O. R Tambo District, South Africa

BACKGROUND

Tuberculosis is the leading infectious cause of death among people living with HIV. Reducing morbidity and mortality from HIV-associated TB requires strong collaboration between TB and HIV services at all levels with fully integrated, people-centered models of care.

METHODS

This is a qualitative study design using principles of ethnography and the application of aggregate complexity theory. A total of 54 individual interviews with healthcare workers and patients took place in five primary healthcare facilities in the O.R. Tambo district. The participants were purposively selected until the data reached saturation point, and all interviews were tape-recorded. Quantitative analysis of qualitative data was used after coding ethnographic data, looking for emerging patterns, and counting the number of times a qualitative code occurred. A Likert scale was used to assess the perceived quality of TB/HIV integration. Regression models and canonical discriminant analyses were used to explore the associations between the perceived quality of TB and HIV integrated service delivery and independent predictors of interest using SPSS® version 23.0 (Chicago, IL) considering a type I error of 0.05.

RESULTS

Of the 54 participants, 39 (72.2%) reported that TB and HIV services were partially integrated while 15 (27.8%) participants reported that TB/HIV services were fully integrated. Using the Likert scale gradient, 23 (42.6%) participants perceived the quality of integrated TB/HIV services as poor while 13 (24.1%) and 18 (33.3%) perceived the quality of TB/HIV integrated services as moderate and excellent, respectively. Multiple linear regression analysis showed that access to healthcare services was significantly and independently associated with the perceived quality of integrated TB/HIV services following the equation: Y = 3.72-0.06X (adjusted R2 = 23%, p-value = 0.001). Canonical discriminant analysis (CDA) showed that in all 5 municipal facilities, long distances to healthcare facilities leading to reduced access to services were significantly more likely to be the most impeding factor, which is negatively influencing the perceived quality of integrated TB/HIV services, with functions' coefficients ranging from 9.175 in Mhlontlo to 16.514 in KSD (Wilk's Lambda = 0.750, p = 0.043).

CONCLUSION

HIV and TB integration is inadequate with limited access to healthcare services. Full integration (one-stop-shop services) is recommended.

Strategies to increase childhood tuberculosis case detection at the primary health care level: Lessons from an active case finding study in Zambia

INTRODUCTION

In high TB burden settings, it is estimated that 10-20% of total notifications should be children, however, currently only 6-8% of the total TB notifications in Zambia are children. We assessed whether the implementation of a multicomponent strategy, at primary healthcare facilities, that systematically targets barriers at each step of the childhood TB diagnostic cascade can increase childhood TB case detection.

METHODS

We conducted a controlled, interrupted time series analysis to compare childhood TB case notifications before (January 2018-December 2019), and during implementation (January 2020-September 2021) in two intervention and two control Level 1 hospitals in Lusaka, Zambia. At each of the intervention facilities, we implemented a multicomponent strategy constituting: (1) capacity development on childhood TB and interpretation of chest x-ray, (2) TB awareness-raising and demand creation activities, (3) setting up fast track TB services, (4) strengthening of household contact tracing, and (5) improving access to digital chest X-ray for TB screening and Xpert MTB/Rif Ultra for TB diagnosis, through strengthening sample collection in children.

FINDINGS

Among 5,150 children < 15 years screened at the two intervention facilities during the study period, 503 (9.8% yield) were diagnosed with TB. Of these, 433 (86.1%) were identified through facility-based activities (10.5% yield) and 70 (13.9%) were identified through household contact tracing (6.9% yield). Overall, 446 children (88.7%) children with TB were clinically diagnosed. Following implementation of the multicomponent strategy, the proportion children contributed to total TB notifications immediately changed by +1.5% (95%CI: -3.5, 6.6) and -4.4% (95%CI: -7.5, 1.4) at the intervention and control sites, respectively (difference 6.0% [95%CI: -0.7, 12.7]), p = 0.08); the proportion of childhood notifications increased 0.9% (95%CI: -0.7, 2.5%) each quarter at the intervention sites relative to pre-implementation trends, while declining 1.2% (-95%CI: -1.8, -0.6) at the control sites (difference 2.1% [95%CI: 0.1, 4.2] per quarter between, p = 0.046); this translated into 352 additional and 85 fewer childhood TB notifications at the intervention and control sites, respectively, compared to the pre-implementation period.

CONCLUSION

A standardized package of strategies to improve childhood TB detection at primary healthcare facilities was feasible to implement and was associated with a sustained improvement in childhood TB notifications.

A qualitative exploration into the presence of TB stigmatization across three districts in South Africa

BACKGROUND

Tuberculosis (TB) stigma is a barrier to active case finding and delivery of care in fighting the TB epidemic. As part of a project exploring different models for delivery of TB contact tracing, we conducted a qualitative analysis to explore the presence of TB stigma within communities across South Africa.

METHODS

We conducted 43 in-depth interviews with 31 people with TB and 12 household contacts as well as five focus group discussions with 40 ward-based team members and 11 community stakeholders across three South African districts.

RESULTS

TB stigma is driven and facilitated by fear of disease coupled with an understanding of TB/HIV duality and manifests as anticipated and internalized stigma. Individuals are marked with TB stigma verbally through gossip and visually through symptomatic identification or when accessing care in either TB-specific areas in health clinics or though ward-based outreach teams. Individuals' unique understanding of stigma influences how they seek care.

CONCLUSION

TB stigma contributes to suboptimal case finding and care at the community level in South Africa. Interventions to combat stigma, such as community and individual education campaigns on TB treatment and transmission as well as the training of health care workers on stigma and stigmatization are needed to prevent discrimination and protect patient confidentiality.

Prevalence of Hypercholesterolemia and Awareness of Risk Factors, Prevention and Management Among Adults Visiting Referral Hospital in Ethiopia

Background

Unhealthy lifestyles and physical inactivity are among the contributing factors of hypercholesterolemia. This study assessed the prevalence, awareness of risk factors, and prevention and treatment of hypercholesterolemia among adults who visited Woldia referral hospital, Northeast Ethiopia.

Methods

A cross-sectional survey was conducted among adults who visited Woldia referral hospital from May to August 2022. Data was collected using a structured questionnaire through a face-to-face interview and patient medical record review. Logistic regression analysis was employed to determine the association between hypercholesterolemia and other variables. A p-value at a 95% confidence level was statistically significant.

Results

A total of 1180 eligible adults were included in the study. The magnitude of hypercholesterolemia was 26.4%. The majority of the respondents were aware of some risk factors, such as higher fat intake (82.3%), obesity (67.2%), and lack of adequate exercise (56.1%). However, the majority of the respondents were not aware that smoking, alcohol consumption, and age (86.8% for all) had cardiovascular risk. The majority of the respondents were aware that eating a limited amount of saturated fat (56.5%), maintaining a healthy weight (67.2%), and taking prescribed medications properly (86.8%) can prevent the risk of hypercholesterolemia. However, a larger proportion of respondents were unaware that smoking cessation (86.8%), exercise (55.3%), alcohol restriction (86.8%), and stress avoidance (75.3%) can prevent cardiovascular risks. Age (p = 0.036), smoking (p = 0.007), alcohol use (p = 0.013), fruit consumption (p = 0.019), saturated oil use (p = 0.031), level of physical activity (p < 0.001), and body mass index (p = 0.03) were significantly associated with hypercholesterolemia.

Conclusion

This study concluded that more than one-fourth of adults had hypercholesterolemia. The majority of the respondents did not have an awareness of common cardiovascular risk factors and prevention and treatment techniques regarding unhealthy lifestyles and physical inactivity.

Patients' perceived quality of care and their satisfaction with care given for MDR-TB at referral hospitals in Ethiopia

BACKGROUND

There is presently dearth of evidence in Ethiopia on patients' perception on quality of care given for multi-drug resistant tuberculosis (MDR-TB) and their satisfaction with the care and services they receive for the disease. Moreover, there is no evidence on the experiences and practices of caregivers for MDR-TB regarding the functionality of the programmatic management of MDR-TB at referral hospitals in Ethiopia. Thus, this study was conducted to address these gaps. Evidence in these areas would help to institute interventions that could enhance patient satisfaction and their adherence to the treatment given for MDR-TB.

DESIGN AND METHODS

This study employed an inductive phenomenological approach to investigate patients' perception of the quality of care given for MDR-TB, level of their satisfaction with the care they received for MDR-TB and the experiences and practices of caregivers for MDR-TB on the functionality of the programmatic management of MDR-TB at referral hospitals in Ethiopia. The data were analysed manually, and that helped to get more control over the data.

RESULTS

The majority of the patients were satisfied with the compassionate communication and clinical care they received at hospitals. However, as no doctor was dedicated exclusively for the MDR-TB centre of the hospitals, patients could not get timely medical attention during emergent medical conditions. Patients were dissatisfied with the poor communication and uncaring practice of caregivers found at treatment follow-up centres (TFCs). Patients perceived that socio-economic difficulties are both the cause of MDR-TB and it has also challenged their ability to cope-up with the disease and its treatment. Patients were dissatisfied with the poor quality and inadequate quantity of the socio-economic support they got from the programme. Despite the high MDR-TB and HIV/AIDS co-infection, services for both diseases were not available under one roof.

CONCLUSIONS

Socio-economic challenges, inadequate socio-economic support, absence of integrated care for MDR-TB and HIV/AIDS, and the uncaring practice of caregivers at treatment follow-up centres are found to negatively affect patients' perceived quality of care and their satisfaction with the care given for MDR-TB. Addressing these challenges is recommended to assist patients' coping ability with MDR-TB and its treatment.

Social Support, Quality of Care, and Patient Adherence to Tuberculosis Treatment in Peru: The Mediating Role of Nurse Health Education

BACKGROUND

Peru is one of the countries with the highest burden of tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB) in the Latin American region and globally. Health education provided by nurses reinforces social support and the quality of patient care allows a greater impact on adherence to TB treatment.

PURPOSE

This study evaluated the mediating effect of treatment education between social support, quality of care, and treatment adherence in TB patients.

METHODS

A cross-sectional study was carried out considering 162 adult TB patients from four health centers of the public sector located in the center of the city of Lima, Peru. Data were collected on variables, such as social support, quality of care, health education, and adherence to TB treatment. SmartPLS was used for data analysis.

RESULTS

The results showed that social support and quality of care significantly influence health education. Likewise, health education mediates social support and quality of care for better adherence to treatment.

CONCLUSION

It is recommended that hospitals take initiatives to provide better health education on TB treatment to ensure better adherence to treatment.

Factors Associated with Medication Adherence in Elderly Individuals with Tuberculosis: A Qualitative Study

Methods

This qualitative study was conducted in two phases, using an integrative literature review and individual interviews. Studies were gathered without time restriction from MEDLINE databases, Institute for Scientific Information (ISI), Google Scholar, Scopus, and EMBASE, as well as national databases, including Scientific Information Database and Magiran. The findings of 38 studies that met the inclusion criteria were analyzed through the conventional content analysis method based on the ecological approach. After reviewing and forming the data matrix, purposive sampling was performed among healthcare professionals, elderly tuberculosis patients aged 60 and over, and family caregivers of elderly patients to conduct individual interviews. Data obtained from 20 interviews were analyzed using the directed content analysis method. After coding, the data from individual interviews were entered based on similarity and difference in the categories of data matrix obtained from the literature review.

Results

In general, the aforementioned codes were placed in four main categories, including individual factors (i.e., biological factors, affective-emotional factors, behavioral factors, cognitive factors, tuberculosis-related factors, and economic factors), interpersonal factors (i.e., patient's relationship with treatment team and family-related factors), factors related to healthcare service provider centers (i.e., medical centers' facilities and capacity building in healthcare service provider), and extraorganizational factors (i.e., social factors and health policymaking).

Conclusion

The results of this study showed that medication adherence in elderly patients with tuberculosis was a complex and multidimensional phenomenon. Therefore, society, policymakers, and healthcare providers should scrutinize the factors affecting medication adherence in this group of patients to plan and implement more effective interventions.

A study on tuberculosis disease disclosure patterns and its associated factors: Findings from a prospective observational study in Chennai

BACKGROUND

Disclosure of tuberculosis (TB) status by patients is a critical step in their treatment cascade of care. There is a lack of systematic assessment of TB disclosure patterns and its positive outcomes which happens dynamically over the disease period of individual patients with their family and wider social network relations.

METHODS

This prospective observational study was conducted in Chennai Corporation treatment units during 2019-2021. TB patients were recruited and followed-up from treatment initiation to completion. Information on disease disclosures made to different social members at different time points, and outcomes were collected and compared. Bivariate and multi variate analysis were used to identify the patients and contact characteristics predictive of TB disclosure status.

RESULTS

A total of 466 TB patients were followed-up, who listed a total of 4039 family, extra familial and social network contacts of them. Maximum disclosures were made with family members (93%) and half of the relatives, occupational contacts and friendship contacts (44-58%) were disclosed within 15 days of treatment initiation. Incremental disclosures made during the 150-180 days of treatment were highest among neighbourhood contacts (12%), and was significantly different between treatment initiation and completion period. Middle aged TB patients (31 years and 46-55 years) were found less likely to disclose (AOR 0.56 and 0.46 respectively; p<0.05) and illiterates were found more likely to disclose their TB status (AOR 3.91; p<0.05). Post the disclosure, family contacts have mostly provided resource support (44.90%) and two third of all disclosed contacts have provided emotional support for TB patients (>71%).

CONCLUSION

Findings explain that family level disclosures were predominant and disclosures made to extra familial network contacts significantly increased during the latter part of treatment. Emotional support was predominantly received by TB patients from all their contacts post disclosure. Findings could inform in developing interventions to facilitate disclosure of disease status in a beneficial way for TB patients.

Characterising and Addressing the Psychosocial Impact of Tuberculosis in Indonesia (CAPITA): A study protocol

Background: Tuberculosis (TB)-related stigma remains a key barrier for people with TB to access and engage with TB services and can contribute to the development of mental illnesses. This study aims to characterise stigmatisation towards people with TB and its psychosocial impact in Indonesia. Methods: This study will apply a sequential mixed method in two main settings: TB services-based population (setting 1) and workplace-based population (setting 2). In setting 1, we will interview 770 adults with TB who undergo sensitive-drug TB treatment in seven provinces of Indonesia. The interview will use the validated TB Stigma Scale questionnaire, Patient Health Questionnaire-9, and EQ-5D-5L to assess stigma, mental illness, and quality of life. In Setting 2, we will deploy an online questionnaire to 640 adult employees in 12 public and private companies. The quantitative data will be followed by in-depth interview to TB-related stakeholders. Results: CAPITA will not only characterise the enacted stigma which are directly experienced by people with TB, but also self-stigma felt by people with TB, secondary stigma faced by their family members, and structural stigma related to the law and policy. The qualitative analyses will strengthen the quantitative findings to formulate the potential policy direction for zero TB stigma in health service facilities and workplaces. Involving all stakeholders, i.e., people with TB, healthcare workers, National Tuberculosis Program officers, The Ministry of Health Workforce, company managers, and employees, will enhance the policy formulation. The validated tool to measure TB-related stigma will also be promoted for scaling up to be implemented at the national level. Conclusions: To improve patient-centered TB control strategy policy, it is essential to characterise and address TB-related stigma and mental illness and explore the needs for psychosocial support for an effective intervention to mitigate the psychosocial impact of TB.

eHealth in TB clinical management

BACKGROUND: The constant expansion of internet and mobile technologies has created new opportunities in the field of eHealth, or the digital delivery of healthcare services. This TB meta-analysis aims to examine eHealth and its impact on TB clinical management in order to formulate recommendations for further development.METHODS: A systematic search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework in PubMed and Embase of articles published up to April 2021. Screening, extraction and quality assessment were performed by two independent researchers. Studies evaluating an internet and/or mobile-based eHealth intervention with an impact on TB clinical management were included. Outcomes were organised following the five domains described in the WHO "Recommendations on Digital Interventions for Health System Strengthening" guideline.RESULTS: Search strategy yielded 3,873 studies, and 89 full texts were finally included. eHealth tended to enhance screening, diagnosis and treatment indicators, while being cost-effective and acceptable to users. The main challenges concern hardware malfunction and software misuse.CONCLUSION: This study offers a broad overview of the innovative field of eHealth applications in TB. Different studies implementing eHealth solutions consistently reported on benefits, but also on specific challenges. eHealth is a promising field of research and could enhance clinical management of TB.

The socioeconomic impact of tuberculosis on children and adolescents: a scoping review and conceptual framework

BACKGROUND

Tuberculosis (TB) has been repeatedly shown to have socioeconomic impacts in both individual-level and ecological studies; however, much less is known about this effect among children and adolescents and the extent to which being affected by TB during childhood and adolescence can have life-course implications. This paper describes the results of the development of a conceptual framework and scoping review to review the evidence on the short- and long-term socioeconomic impact of tuberculosis on children and adolescents.

OBJECTIVES

To increase knowledge of the socioeconomic impact of TB on children and adolescents.

METHODS

We developed a conceptual framework of the socioeconomic impact of TB on children and adolescents, and used scoping review methods to search for evidence supporting or disproving it. We searched four academic databases from 1 January 1990 to 6 April 2021 and conducted targeted searches of grey literature. We extracted data using a standard form and analysed data thematically.

RESULTS

Thirty-six studies (29 qualitative, five quantitative and two mixed methods studies) were included in the review. Overall, the evidence supported the conceptual framework, suggesting a severe socioeconomic impact of TB on children and adolescents through all the postulated pathways. Effects ranged from impoverishment, stigma, and family separation, to effects on nutrition and missed education opportunities. TB did not seem to exert a different socioeconomic impact when directly or indirectly affecting children/adolescents, suggesting that TB can affect this group even when they are not affected by the disease. No study provided sufficient follow-up to observe the long-term socioeconomic effect of TB in this age group.

CONCLUSION

The evidence gathered in this review reinforces our understanding of the impact of TB on children and adolescents and highlights the importance of considering effects during the entire life course. Both ad-hoc and sustainable social protection measures and strategies are essential to mitigate the socioeconomic consequences of TB among children and adolescents.

Tuberculosis and Sexual and Reproductive Health of Women in Four African Countries

Tuberculosis (TB) is a major reason of maternal mortality in low-income countries, and it increases the probability of adverse sexual and reproductive health (SRH) outcomes, including ectopic pregnancy and perinatal mortality. The data presented here is from the TB Sequel observational cohort conducted in four African countries. For this sub-study, we selected only female participants, who were diagnosed with drug susceptible TB and followed-up until the end of anti-TB treatment. The data collection included questionnaires, clinical examination and laboratory tests at TB diagnosis, day 14, month 2, 4 and 6. A total of 486 women, with 88.3% being 18-49 years old, were included in the analysis. Around 54.7% were HIV positive. Most of the participants (416/486; 85.6%) in our cohort were considered cured at month 6. Only 40.4% of non-pregnant women of reproductive age used contraception at TB diagnosis. A total of 31 out of 486 women experienced pregnancy during TB treatment. Pregnancy outcomes varied between live birth (16/31; 51.6%), induced abortion (6/31; 19.4%), miscarriage (4/31; 12.9%) and stillbirth (3/31; 9.6%). Integration and linking of SRH services with TB programmes are vital to increase contraception use and protect women from obstetric risks associated with pregnancy during TB treatment.

Perceptions, Attitudes, Experiences and Opinions of Tuberculosis Associated Stigma: A Qualitative Study of the Perspectives among the Bolgatanga Municipality People of Ghana

Tuberculosis (TB) is the tenth leading cause of death worldwide. About 1.3 million people die from TB each year, and most of them are in developing countries. The stigma associated with TB is a barrier to seeking treatment and adequate care. It causes a delay in treatment-seeking and diagnosis and thus decreases the likelihood of being cured and ultimately leads to death. The objective of this study was to explore the perceptions, attitudes, experiences, and opinions about stigma related to TB among adults infected with TB and adults who were not infected with TB. Our study was qualitative in nature. The study was conducted in the community of Bolgatanga municipality of the upper-east region of Ghana. Three focus group discussions (FGDs) were conducted; one with six TB-infected females, one with seven TB-infected males, and one with six non-TB-infected participants. Data were analyzed using qualitative content analysis and presented in pre-defined and/or emerging themes: perception about signs and symptoms observed by TB infected person, attitudes towards TB patients before and after diagnosis, reasons for stigmatization, perception about diagnostic testing, and taking the drugs. Transcripts of the discussions were read, and a list of meanings for units, codes, and themes was generated on the research question. We identified the existence of stigma associated with TB. TB-infected male patients had more autonomy in decision-making about receiving treatment and other family matters compared to female TB patients. TB-infected women suffered more economic vulnerability due to the loss of their work, and the stigma was worsened due to delayed diagnosis and treatment, and they were regarded as liabilities rather than assets. TB-infected patients became stigmatized because non-TB-infected community participants did not want to come into close contact with them. Our findings suggest heightening of advocacy, communication, social mobilization, and health education on TB in the community of Bolgatanga municipality is needed to allay TB-related stigma, especially for women.

'People listen more to what actors say': A qualitative study of tuberculosis-related knowledge, behaviours, stigma, and potential interventions in Puducherry, India

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.

Perceived risk of COVID-19 diagnosis and stigma among Nigerians

The World Health Organization (WHO) classified Nigeria as one of the 13 African countries with a higher risk of spreading COVID-19. Although the Nigerian government and its health agencies set directives in place to help curb the spread of COVID-19, there are instances of unconcerned attitudes and adherence to false and superstitious beliefs surrounding COVID-19 among Nigerians. The current study examined the general perception of COVID-19 risk among Nigerians. Additionally, it examined the fear of possible stigmatization if an individual is diagnosed with COVID-19. A cross-section of 332 Nigerian men and women responded to measures on perceived vulnerability to diseases, perception of risk of being infected with COVID-19, COVID-19 stigma, and social and demographic characteristics. The findings show that respondents with a higher perception of vulnerability to diseases reported higher COVID-19 risk and perception of COVID-19-related stigma. Further, we found that gender, age, and education impacted COVID-19 risk and perception of COVID-19-related stigma. Our findings suggest that risk perceptions and attitudes towards COVID-19 can impact the level of preparedness against a pandemic. Also, the findings could inform strategies for the proper implementation of health protective measures at national, state, and local government levels during a viral outbreak.

Pre-Diagnosis Health Seeking Behaviors and Experiences Post-Diagnosis, among Men Diagnosed with Tuberculosis in a District of Gauteng Metropolitan City, South Africa: In-Depth Interviews

BACKGROUND

Tuberculosis remains the number one killer among infectious diseases in South Africa. The TB disease burden is said to be higher among males, 1.6 times more than females in 2018. Moreover, men are reported to have poor healthcare-seeking behaviors. Loss in social and physical functioning, including reduced sexual desires and changes in family life, have been reported following a TB diagnosis. This study explored the meaning that male TB patients attach to their TB diagnosis and impact of TB infection in their lives and those of the people living with them.

METHODS

This exploratory qualitative study was conducted among 25 participants recruited among male patients seeking TB care from two clinics in informal settlements of the city of Johannesburg. In-depth interviews with open-ended questions were conducted using an audio recorder for the collection of data. Data analysis was conducted on the NVivo version 12 software following an inductive thematic approach.

RESULTS

The ages of the participants ranged between 18 and 61 years. Most were unemployed, and only a few were married or in steady relationships. From the two emerging themes, pre-TB diagnosis health-seeking behaviors and post TB-diagnosis experiences, several subthemes were identified. For the former theme, the subthemes include, seeking help from community-based healers and self-medicating, waiting for some period to see if the alternative medicine or treatment worked, taking time to visit a healthcare facility, triggers to seek healthcare, and symptoms reported on presentation to the healthcare facility. The post-TB diagnosis subthemes include making sense of the TB diagnosis, context of disclosing the TB status, fear of social exclusion and experiences of stigma, support received during illness, life changes after TB infection and diagnosis, and lessons learned from the TB experience and future healthcare-seeking behavior.

CONCLUSION

Secrecy about the TB diagnosis indicates fear of social exclusion, and this could be due to the highly stigmatized nature of TB. Waiting to see if alternative medication worked, delayed the TB diagnosis, with consequent late initiation of the anti-TB treatment. The life changes experienced post-TB diagnosis affect the quality of life of the participants and their families. The study recommends that these issues be addressed as a priority.

Analysing interventions designed to reduce tuberculosis-related stigma: A scoping review

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.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

Supplementary Information

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

Making cough count in tuberculosis care

Cough assessment is central to the clinical management of respiratory diseases, including tuberculosis (TB), but strategies to objectively and unobtrusively measure cough are lacking. Acoustic epidemiology is an emerging field that uses technology to detect cough sounds and analyze cough patterns to improve health outcomes among people with respiratory conditions linked to cough. This field is increasingly exploring the potential of artificial intelligence (AI) for more advanced applications, such as analyzing cough sounds as a biomarker for disease screening. While much of the data are preliminary, objective cough assessment could potentially transform disease control programs, including TB, and support individual patient management. Here, we present an overview of recent advances in this field and describe how cough assessment, if validated, could support public health programs at various stages of the TB care cascade.

Zimmer et al. discuss the importance of cough assessment in clinical management of tuberculosis (TB). They describe how acoustic epidemiology, which uses recording devices and artificial intelligence to detect, record and analyze cough, can be used in TB control and individual patient management.

Patients' perceptions and experiences of directly observed therapy for TB

AIM

To understand patients' perceptions and experiences of directly observed therapy (DOT) for tuberculosis treatment in the UK.

METHOD

Patients receiving DOT as part of their TB treatment participated in semi-structured and audio-recorded interviews. Data were analysed using a framework approach.

RESULTS

Non-adherence was driven by socio-cultural, mental health, employment and discrimination factors. Patients valued DOT for its support and social connection but those in employment feared it could lead to disclosure and social discredit.

CONCLUSION

TB patients experience social isolation and fear discrimination. DOT offers a degree of social connection and support for marginalised patients but fails to tackle fundamental barriers to adherence such as mental health issues, addictions, housing and discrimination. Practice implications: Flexible patient-centred methods of DOT should be offered throughout patients' treatment. Research into multi-agency responsibility for promoting adherence needs to be commissioned, implemented and evaluated. Telemedicine and nurse-led clinics may improve access to care and improve patient experience.

'You say you are a TB doctor, but actually, you do not have any power': health worker (de)motivation in the context of integrated, hospital-based tuberculosis care in eastern China

BACKGROUND

In China, tuberculosis (TB) care, traditionally provided through the Centre for Disease Control (CDC), has been integrated into 'designated' public hospitals at County level, with hospital staff taking on delivery of TB services supported by CDC staff. Little is known about the impact of this initiative on the hospital-based health workers who were delegated to manage TB. Drawing on a case study of two TB 'designated' hospitals in Zhejiang province, we explored factors influencing hospital-based health workers' motivation in the context of integrated TB service delivery.

METHODS

We conducted 47 in-depth interviews with health officials, TB/hospital managers, clinicians, radiologists, laboratory staff and nurses involved in the integrated model of hospital-based TB care. Thematic analysis was used to develop and refine themes, code the data and assist in interpretation.

RESULTS

Health workers tasked with TB care in 'designated' hospitals perceived their professional status to be low, related to their assessment of TB treatment as lacking need for professional skills, their limited opportunities for professional development, and the social stigma surrounding TB. In both sites, the integrated TB clinics were under-staffed: health workers providing TB care reported heavy workloads, and expressed dissatisfaction with a perceived gap in their salaries compared with other clinical staff. In both sites, health workers were concerned about poor infection control and weak risk management assessment systems.

CONCLUSIONS

Inadequate attention to workforce issues for TB control in China, specifically the professional status, welfare, and development as well as incentivization of infectious disease control workers has contributed to dissatisfaction and consequently poor motivation to serve TB patients within the integrated model of TB care. It is important to address the failure to motivate health workers and maximize public good-oriented TB service provision through improved government funding and attention to the professional welfare of health workers providing TB care in hospitals.

COVID-19—What Price Do Children Pay? An Analysis of Economic and Social Policy Factors

Numerous studies have addressed the indirect consequences of the COVID-19 pandemic for children such as social isolation or increases in reported child maltreatment. Research on the economic and sociopolitical consequences is scarce as they can only be evaluated with a time lag. To improve our understanding of future, long-term developments in the context of the COVID-19 pandemic, we gathered findings from the still unexploited empirical literature on the aftermath of earlier pandemics, epidemics, and other infectious disease outbreaks. On top of this, we scrutinized research on past economic crises to interpret the link between changes in the economy and the health of children. Many of the side effects of battling the spread of the current pandemic, such as school closures, the stigma of infection, or conflicts about vaccines, are not novel and have already been documented in connection with previous infectious disease outbreaks. Results highlight that changes in the financial situation of families and socio-political challenges affect the situation and daily routine of children and youth in the long term. In consequence, the already pronounced socioeconomic inequalities will likely further increase. On top of this, due to reduced revenues, child protective services are likely to face challenges in the availability of human and financial resources.

Characterising and Addressing the Psychosocial Impact of Tuberculosis in Indonesia (CAPITA): A study protocol

Background: Tuberculosis (TB)-related stigma remains a key barrier for people with TB to access and engage with TB services and can contribute to the development of mental illnesses. This study aims to characterise stigmatisation towards people with TB and its psychosocial impact in Indonesia. Methods: This study will apply a sequential mixed method in two main settings: TB services-based population (setting 1) and workplace-based population (setting 2). In setting 1, we will interview 770 adults with TB who undergo sensitive-drug TB treatment in seven provinces of Indonesia. The interview will use the validated TB Stigma Scale questionnaire, Patient Health Questionnaire-9, and EQ-5D-5L to assess stigma, mental illness, and quality of life. In Setting 2, we will deploy an online questionnaire to 640 adult employees in 12 public and private companies. The quantitative data will be followed by in-depth interview to TB-related stakeholders. Results: CAPITA will not only characterise the enacted stigma which are directly experienced by people with TB, but also self-stigma felt by people with TB, secondary stigma faced by their family members, and structural stigma related to the law and policy. The qualitative analyses will strengthen the quantitative findings to formulate the potential policy direction for zero TB stigma in health service facilities and workplaces. Involving all stakeholders, i.e., people with TB, healthcare workers, National Tuberculosis Program officers, The Ministry of Health Workforce, company managers, and employees, will enhance the policy formulation. The validated tool to measure TB-related stigma will also be promoted for scaling up to be implemented at the national level. Conclusions: To improve patient-centered TB control strategy policy, it is essential to characterise and address TB-related stigma and mental illness and explore the needs for psychosocial support for an effective intervention to mitigate the psychosocial impact of TB.

Tackling the global impact of substandard and falsified and unregistered/unlicensed anti-tuberculosis medicines

Substandard and falsified (SF) medicines are a global health challenge with the World Health Organization (WHO) estimating that 1 in 10 of medicines in low- and middle-income countries (LMICs) are SF. Antimicrobials (i.e. antimalarials, antibiotics) are the most commonly reported SF medicines. SF medicines contribute significantly to the global burden of infectious diseases and antimicrobial resistance (AMR). This article discusses the challenges associated with the global impact of SF and unregistered/unlicensed antimicrobials with a focus on anti-TB medicines. Tuberculosis (TB) is the 13th leading cause of death worldwide, and is currently the second leading cause of death from a single infectious agent, ranking after COVID-19 and above HIV/AIDS. Specifically in the case of TB, poor quality of anti-TB medicines is among the drivers of the emergence of drug-resistant TB pathogens. In this article, we highlight and discuss challenges including the emergence of SF associated AMR, patient mistrust and lack of relevant data. We also present study reports to inform meaningful change. Recommended solutions involve the adaptation of interventions from high-income countries (HICs) to LMICS, the need for improvement in the uptake of medication authentication tools in LMICs, increased stewardship, and the need for global and regional multidisciplinary legal and policy cooperation, resulting in improved legal sanctions.

Good citizens, perfect patients, and family reputation: Stigma and prolonged isolation in people with drug-resistant tuberculosis in Vietnam

Stigma and isolation are common in people with tuberculosis (TB). Social isolation contributes to reduced health outcomes and TB treatment adherence. Stigma and the drivers of isolation in people with Drug-Resistant (DR)-TB may include modifiable advice and practices of family and Health Care Workers (HCW). This study aimed to understand the drivers of isolation and stigma from the perspective of people with DR-TB in Vietnam. A greater understanding of stigma and isolation is important to identify and balance patients' needs and disease transmission risk. In-depth interviews were conducted with 12 people with DR-TB and seven HCWs who care for people with DR-TB in two provinces in Vietnam. Interviews were audio-recorded, transcribed verbatim and translated to English. Data collection and analysis were conducted simultaneously. The data were then analysed using a thematic framework approach. Stigma and extended isolation were common experiences among people with DR-TB. To mitigate stigma, people with DR-TB used the local term 'lao lực' to describe their condition to others which is believed to be a less infectious and less stigmatising type of TB. This study identified that although HCW informed people with DR-TB of when they were no longer infectious and isolation was no longer required, their infection control advice was not always consistent. Despite knowing they were no longer infectious, most people with DR-TB continued to self-isolate to minimise the perceived repercussions of societal stigma, to protect their 'thể diện' (honour, prestige, reputation), and eliminate all risk of transmitting DR-TB to their family. This study identified three interconnected drivers of self-isolation in Vietnam, including fear of infecting others, fear of stigmatization, and to protect family reputation. TB control programmes need to better understand the social aspects of DR-TB to enable them to better support patients. Educating HCW to provide evidence-based infection control advice is vital.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sociological variety and the transmission efficiency of Mycobacterium tuberculosis: a secondary analysis of qualitative and quantitative data from 15 communities in Zambia

OBJECTIVES

Selected Zambian communities formed part of a cluster randomised trial: the Zambia and South Africa TB and AIDS Reduction study (ZAMSTAR). There was wide variability in the prevalence of Mycobacterium tuberculosis infection and tuberculosis (TB) disease across these communities. We sought to clarify whether specific communities could have been more/less vulnerable to M. tuberculosis transmission as a result of sociological variety relevant to transmission efficiency.

DESIGN

We conducted a mixed methods secondary analysis using existing data sets. First, we analysed qualitative data to categorise and synthesise patterns of socio-spatial engagement across communities. Second, we compared emergent sociological variables with a measure of transmission efficiency: the ratio of the annual risk of infection to TB prevalence.

SETTING

ZAMSTAR communities in urban and peri-urban Zambia, spanning five provinces.

PARTICIPANTS

Fifteen communities, each served by a health facility offering TB treatment to a population of at least 25 000. TB notification rates were at least 400 per 100 000 per annum and HIV seroprevalence was estimated to be high.

RESULTS

Crowding, movement, livelihoods and participation in recreational activity differed across communities. Based on 12 socio-spatial indicators, communities were qualitatively classified as more/less spatially crowded and as more/less socially 'open' to contact with others, with implications for the presumptive risk of M. tuberculosis transmission. For example, watching video shows in poorly ventilated structures posed a presumptive risk in more socially open communities, while outdoor farming and/or fishing were particularly widespread in communities with lower transmission measures.

CONCLUSIONS

A dual dynamic of 'social permeability' and crowding appeared relevant to disparities in M. tuberculosis transmission efficiency. To reduce transmission, certain socio-spatial aspects could be adjusted (eg, increasing ventilation on transport), while more structural aspects are less malleable (eg, reliance on public transport). We recommend integrating community level typologies with genome sequencing techniques to further explore the significance of 'social permeability'.

TRIAL REGISTRATION NUMBER

ISRCTN36729271.

The Impact of Tuberculosis on the Well-Being of Adolescents and Young Adults

The health needs of adolescents and young adults (AYAs) have been neglected in tuberculosis (TB) care, control, and research. AYAs, who are distinct from younger children and older adults, undergo dynamic physical, psychological, emotional, cognitive, and social development. Five domains of adolescent well-being are crucial to a successful transition between childhood and adulthood: (1) Good health; (2) connectedness and contribution to society; (3) safety and a supportive environment; (4) learning, competence, education, skills, and employability; and (5) agency and resilience. This review summarizes the evidence of the impact of TB disease and treatment on these five domains of AYA well-being.

"Their place is beyond the town's border": A qualitative exploration of stigma associated with tuberculosis in rural and urban areas of Lagos, Nigeria

Tuberculosis (TB) remains a major public health challenge in Nigeria with a minimum yield of various TB control efforts due to sociocultural determinants of health including TB-associated stigma. Therefore, to achieve the Sustainable Development Goal targets for TB control, an understanding and reduction in TB-associated stigma is necessary. The study aims to explore the perspective of community members and investigate the possible ways of mitigating TB-associated stigma in rural and urban areas in Lagos State, Nigeria. Eight focus group discussions (FGD) were conducted among eight homogenous groups of participants living in the community in rural and urban areas of Lagos state who were stratified by gender, between July and November 2017. Analysis of data was done using the modified grounded theory. A total of 86 participants took part in the FGDs. There were various stigmatising behaviours towards people infected with TB in rural and urban communities studied. This includes: Not willing to eat with people suffering from TB, withdrawal from TB patients in social gatherings, verbal abuse of TB patients and refusing to visit their houses because of their illness. There were also misconceptions about the cause of TB in our study which includes spiritual attack, ingestion of cat hair and inhalation of dust. However, participants in the study believed that mitigating the effect of TB-associated stigma will require adequate community education on TB, provision of financial and emotional support to the patients, as well as the involvement of community leaders in TB control activities and stigma reduction interventions. TB-associated stigma exists in rural and urban communities, with a lack of appropriate knowledge of TB and fear of infection as a major determinant in rural and urban areas respectively. Health education and sensitisation about TB, with community leaders as champions could help to mitigate the effect of TB-associated stigma.

Barriers and facilitators to accessing tuberculosis care in Nepal: a qualitative study to inform the design of a socioeconomic support intervention

OBJECTIVE

Psychosocial and economic (socioeconomic) barriers, including poverty, stigma and catastrophic costs, impede access to tuberculosis (TB) services in low-income countries. We aimed to characterise the socioeconomic barriers and facilitators of accessing TB services in Nepal to inform the design of a locally appropriate socioeconomic support intervention for TB-affected households.

DESIGN

From August 2018 to July 2019, we conducted an exploratory qualitative study consisting of semistructured focus group discussions (FGDs) with purposively selected multisectoral stakeholders. The data were managed in NVivo V.12, coded by consensus and analysed thematically.

SETTING

The study was conducted in four districts, Makwanpur, Chitwan, Dhanusha and Mahottari, which have a high prevalence of poverty and TB.

PARTICIPANTS

Seven FGDs were conducted with 54 in-country stakeholders, grouped by stakeholders, including people with TB (n=21), community stakeholders (n=13) and multidisciplinary TB healthcare professionals (n=20) from the National TB Programme.

RESULTS

The perceived socioeconomic barriers to accessing TB services were: inadequate TB knowledge and advocacy; high food and transportation costs; income loss and stigma. The perceived facilitators to accessing TB care and services were: enhanced championing and awareness-raising about TB and TB services; social protection including health insurance; cash, vouchers and/or nutritional allowance to cover food and travel costs; and psychosocial support and counselling integrated with existing adherence counselling from the National TB Programme.

CONCLUSION

These results suggest that support interventions that integrate TB education, psychosocial counselling and expand on existing cash transfer schemes would be locally appropriate and could address the socioeconomic barriers to accessing and engaging with TB services faced by TB-affected households in Nepal. The findings have been used to inform the design of a socioeconomic support intervention for TB-affected households. The acceptability, feasibility and impact of this intervention on TB-related costs, stigma and TB treatment outcomes, is now being evaluated in a pilot implementation study in Nepal.

Tuberculosis stigma: Assessing tuberculosis knowledge, attitude and preventive practices in surulere, Lagos, Nigeria

Context

Tuberculosis (TB), though preventable and curable, remains a global health problem, ranked one of the top causes of death worldwide, despite the World Health Organization's strategies. This may be due to the stigma surrounding the disease.

Aim

This study assesses TB stigma in light of knowledge, attitudes, and preventive practices among individuals in an urban community.

Settings and Design

This was a descriptive, cross-sectional study among 317 residents of Surulere, Lagos, Nigeria, selected by multi-stage sampling.

Subjects and Methods

Data were collected using a pretested, semi-structured, interviewer-administered questionnaire and analyzed using Epi InfoTM version 7.2.2.6 2018 (Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA).

Statistical Analysis Used

Descriptive variables were summarized as frequencies, and the Chi-square test was used to test the associations. The level of significance was predetermined at P ≤0.05.

Results

Most participants were between the age group of 21 and 40 years. Approximately 9 out of every 10 respondents (91.8%) were aware of TB. Overall, only 2.4% of respondents had good knowledge of TB, more than half (59.1%) had positive attitudes toward TB, about one-third (37.1%) had good preventive practices and 22.7% of respondents expressed TB stigma, 63.6% would show no compassion or desire to help people with TB while 64.3% would rather people with TB were never employed. However, good knowledge translated into less stigma (P <0.001).

Conclusions

Most participants were aware of TB, although knowledge, attitude, and practice levels were poor. Knowledge was found to reduce TB stigma, reinforcing the need for improved community literacy regrading TB. This has the potential to influence health-seeking behavior and promote better TB prevention, detection, and treatment outcomes.

Tuberculosis in times of COVID-19

The COVID-19 pandemic has caused widespread disruptions to tuberculosis (TB) care and service delivery in 2020, setting back progress in the fight against TB by several years. As newer COVID-19 variants continue to devastate many low and middle-income countries in 2021, the extent of this setback is likely to increase. Despite these challenges, the TB community can draw on the comprehensive approaches used to manage COVID-19 to help restore progress and mitigate the impact of COVID-19 on TB. Our team developed the ‘Swiss Cheese Model for Ending TB’ to illustrate that it is only through multisectoral collaborations that address the personal, societal and health system layers of care that we will end TB. In this paper, we examine how COVID-19 has impacted the different layers of TB care presented in the model and explore how we can leverage some of the lessons and outcomes of the COVID-19 pandemic to strengthen the global TB response.

TB stigma and its correlates among HIV-positive people who inject drugs in Ukraine

BACKGROUND: TB is commonly stigmatized. Correlates of perceived TB stigma have not been assessed specifically among HIV-positive people who inject drugs (PWIDs). It is also unclear how perceived TB stigma intersects with other forms of stigma affecting this population. We aimed to evaluate perceived TB stigma, its correlates and its intersection with HIV and substance use stigma among HIV-positive PWIDs in Ukraine.METHODS: Among 191 participants at three sites across Ukraine, we assessed stigma scores, socio-demographic, behavioral and health-related variables by TB status (history of active TB infection, history of treatment for latent TB infection LTBI, no history of TB infection). We used self-reported history of LTBI treatment as a proxy for LTBI status. We used ordinary least squares to estimate factors associated with perceived TB stigma.RESULTS: Lower perceived TB stigma scores were associated with LTBI status (adjusted beta (aβ) -0.2, 95% CI -0.3 to 0.0; P = 0.032). Higher perceived TB stigma scores were associated with higher substance use stigma scores (aβ 0.1, 95% CI 0.0 to 0.2; P = 0.004). Depressive symptoms were common in this sample, although not significantly associated with TB status.CONCLUSION: History of LTBI treatment appears to impact beliefs about perceived TB stigma. Individuals who endorse higher substance use stigma are more likely to hold stigmatizing perceptions about people with TB. HIV-positive PWIDs with history of active TB infection or LTBI treatment commonly experience mental health distress. This stigma intersection needs further exploration in this population, including of its relation with mental health, to provide further insights for targeted interventions.

Pathways to care and preferences for improving tuberculosis services among tuberculosis patients in Zambia: A discrete choice experiment

BACKGROUND

Delays in the diagnosis of tuberculosis (TB) contribute to a substantial proportion of TB-related mortality, especially among people living with HIV (PLHIV). We sought to characterize the diagnostic journey for HIV-positive and HIV-negative patients with a new TB diagnosis in Zambia, to understand drivers of delay, and characterize their preferences for service characteristics to inform improvements in TB services.

METHODS

We assessed consecutive adults with newly microbiologically-confirmed TB at two public health treatment facilities in Lusaka, Zambia. We administered a survey to document critical intervals in the TB care pathway (time to initial care-seeking, diagnosis and treatment initiation), identify bottlenecks and their reasons. We quantified patient preferences for a range of characteristics of health services using a discrete choice experiment (DCE) that assessed 7 attributes (distance, wait times, hours of operation, confidentiality, sex of provider, testing incentive, TB test speed and notification method).

RESULTS

Among 401 patients enrolled (median age of 34 years, 68.7% male, 46.6% HIV-positive), 60.9% and 39.1% were from a first-level and tertiary hospital, respectively. The median time from symptom onset to receipt of TB treatment was 5.0 weeks (IQR: 3.6-8.0) and was longer among HIV-positive patients seeking care at a tertiary hospital than HIV-negative patients (6.4 vs. 4.9 weeks, p = 0.002). The time from symptom onset to initial presentation for evaluation accounted for the majority of time until treatment initiation (median 3.0 weeks, IQR: 1.0-5.0)-an important minority of 11.0% of patients delayed care-seeking ≥8 weeks. The DCE found that patients strongly preferred same-day TB test results (relative importance, 37.2%), facilities close to home (18.0%), and facilities with short wait times (16.9%). Patients were willing to travel to a facility up to 7.6 kilometers further away in order to access same-day TB test results. Preferences for improving current TB services did not differ according to HIV status.

CONCLUSIONS

Prolonged intervals from TB symptom onset to treatment initiation were common, especially among PLHIV, and were driven by delayed health-seeking. Addressing known barriers to timely diagnosis and incorporating patients' preferences into TB services, including same-day TB test results, may facilitate earlier TB care engagement in high burden settings.

'TB is a disease which hides in the body': Qualitative data on conceptualisations of tuberculosis recurrence among patients in Zambia and South Africa

The WHO estimates 58 million people experienced one or more TB disease episodes between 2000 and 2018. These 'former TB patients' are at greater risk of future TB infection and death than TB naïve people. Additionally, former TB patients experience social, psychological, and physiological difficulties after microbiological cure. Drawing on semi-structured interviews collected with 28 people from communities in Zambia (n = 8) and South Africa (n = 2) between October 2018 and March 2019, we describe their perceptions of having two or more TB episodes. Utilising a discursive analytic approach, we interrogated how participants conceptualise their risk of disease recurrence. Despite being surprised by subsequent TB episodes, participants utilised their bodily experiences of TB signs and symptoms alongside their experiential knowledge of health systems processes to procure timely diagnosis and care. Yet, many participants were unable to resume social and economic participation. Experiences of multiple TB episodes and correlating social, economic, and physiological vulnerabilities, challenged participants biomedical understanding of TBs curability. Through notions of dirt and 'staining', participants conceptualise TB as a sinister, malicious presence they are bound to encounter time and again. Health providers should discuss the risk of TB recurrence with patients and promote prevention, early detection, and diagnosis of TB disease.

Persistent Discrimination of TB in Southeastern China: Results from Four Repeated Population-Based Surveys During the Period of 2006-2018

Objective

To analyze the changes in discriminatory attitudes and isolated behaviors of the public toward tuberculosis (TB) in the Zhejiang Province and to determine the associated factors with TB discrimination.

Methods

Data were obtained from four cross-sectional population-based investigations from 2006 to 2018. A total of 26,246 respondents were interviewed using unified questionnaires that measured knowledge, attitudes, and behaviors regarding TB. The changes in public attitudes and behaviors towards TB over time were analyzed. The effect of socio-demographic factors and the level of TB awareness on TB discriminatory attitudes and isolated behaviors were evaluated.

Results

The results of these four cross-sectional studies found that TB discrimination had not changed much over the decade. Overall, discriminatory attitudes were present in 63.5% of the respondents who knew about TB (81.2%). Nearly 31.2% of those who reported being surrounded by people with TB (5.8%) showed isolated behaviors. Older respondents, those with a low education level, and farmers were prone to having discriminatory attitudes or behaviors. Those aware of the infectiousness and transmission routes of TB, and those who felt that TB was serious were more likely to discriminate against TB (P < 0.001). Those aware that TB can be cured were non-discriminatory (aOR = 0.77, 95% CI: 0.72–0.82).

Conclusion

Discriminatory attitudes and isolated behaviors toward TB have not changed significantly in southeastern China over the survey years, and persistent discrimination against TB still exists among the public. The multiple causes of discrimination cannot be addressed through basic health education. Tailor-made strategies, relevant policy measures, and an enabling social environment for TB are urgently required.

Gender inequality and the double burden of disease in low-income and middle-income countries: an ecological study

INTRODUCTION

Many low-income and middle-income countries (LMIC) suffer from a double burden of infectious diseases (ID) and non-communicable diseases (NCD). Previous research suggests that a high rate of gender inequality is associated with a higher ID and NCD burden in LMIC, but it is unknown whether gender inequality is also associated with a double burden of disease. In this ecological study, we explored the association between gender inequality and the double burden of disease in LMIC.

METHODS

For 108 LMIC, we retrieved the Gender Inequality Index (GII, scale 0-1) and calculated the double burden of disease, based on disability-adjusted life-years for a selection of relevant ID and NCD, using WHO data. We performed logistic regression analysis to study the association between gender inequality and the double burden of disease for the total population, and stratified for men and women. We adjusted for income, political stability, type of labour, urbanisation, government health expenditure, health infrastructure and unemployment. Additionally, we conducted linear regression models for the ID and NCD separately.

RESULTS

The GII ranged from 0.13 to 0.83. A total of 37 LMIC had a double burden of disease. Overall, the adjusted OR for double burden of disease was 1.05 per 0.01 increase of GII (95% CI 0.99 to 1.10, p=0.10). For women, there was a borderline significant positive association between gender inequality and double burden of disease (OR 1.05, 95% CI 1.00 to 1.11, p=0.06), while there was no association in men (OR 0.99, 95% CI 0.95 to 1.04, p=0.75).

CONCLUSION

We found patterns directing towards a positive association between gender inequality and double burden of disease, overall and in women. This finding suggests the need for more attention for structural factors underlying gender inequality to potentially reduce the double burden of disease.

Towards TB elimination: how are macro-level factors perceived and addressed in policy initiatives in a high burden country?

BACKGROUND

Notwithstanding extensive general discussion of the effects of upstream forces on health, there has been limited empirical examination, let alone systematic evidence documenting policy responses to such pathways in the area of tuberculosis (TB) management and control. Our study aimed to gain insight into how macro level drivers of TB are perceived by key stakeholders involved in TB management and control in a high-endemic country, and to assess how such concerns are being addressed in policy initiatives in this setting. South Africa was chosen for this case study due to our team's long-standing collaborations there, its very high burden of TB, and its introduction of a strategic plan to combat this disease.

METHOD

Semi-structured interviews were conducted with 20 key informants who were purposively selected for their knowledge and expertise of TB in South Africa. South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022 was then reviewed to examine how identified themes from the interviews were reflected in this policy document.

RESULTS

A history of colonization, the migrant labour system, economic inequality, poor shelter, health system challenges including TB governance, the HIV epidemic, and pertinent socio-cultural factors were all perceived to be major drivers of the epidemic. Although South Africa's current National Strategic Plan makes a firm discursive commitment to addressing the structural or macro-level drivers of TB, our analysis revealed that this commitment was not clearly reflected in projected budgetary allocations.

CONCLUSION

As in many other high burden settings, macro-level drivers of TB are widely recognized. Nonetheless, while micro-level (biomedical and clinical) measures, such as improving diagnostic procedures and investment in more efficacious drugs, are being (and well should be) implemented, our findings showed that macro-level drivers of TB are underrepresented in budgeting allocations for initiatives to combat this disease. Although it could be argued that structural drivers that undermine health-promoting actions are beyond the purview of the health sector itself, we argue that strategic plans to combat TB in high burden settings need more attention to directly considering such drivers to prompt the necessary changes and reduce the burden of this and other such diseases.

Tuberculosis-related stigma and its determinants in Dalian, Northeast China: a cross-sectional study

Background

The stigma of tuberculosis (TB) poses a significant challenge to TB control because it leads to delayed diagnosis and non-adherence. However, few studies on TB-related stigma have been completed in China. The aim of the current study was to explore the status of TB-related stigma and its associated predictive factors among TB patients in Dalian, Northeast China.

Methods

An institution-based, cross-sectional survey was conducted among outpatients at Dalian Tuberculosis Hospital in Liaoning Province, Northeast China. Data were collected by using a questionnaire that measured TB-related stigma, treatment status, anxiety, social support, doctor-patient communication and so on. A multiple linear regression model was used to determine the predictors of TB-related stigma.

Results

A total of 601 eligible participants were recruited. The mean score for TB-related stigma was 9.07, and the median score was 10. The average scores for anxiety, social support and doctor-patient communication were 4.03, 25.41 and 17.17, respectively. Multiple linear regression analysis revealed that patients who were female (β = 1.19, 95% CI: 0.38–2.01, P < 0.05), had self-assessed moderate or severe disease (β = 1.08, 95% CI: 0.12–2.03 and β = 1.36, 95% CI: 0.03–2.70, respectively, P < 0.05), and had anxiety (β = 0.38, 95% CI: 0.30–0.46, P < 0.001) were more likely to have a greater level of TB-related stigma than their counterparts. However, a significantly lower level of TB-related stigma was observed in patients with good social support (β = − 0.25, 95% CI: − 0.33--0.17, P < 0.001) and doctor-patient communication (β = − 0.14, 95% CI: − 0.29--0.00, P < 0.05).

Conclusions

This study showed that stigma among TB patients was high. Targeted attention should be paid to female patients and patients with moderate or severe disease in TB stigma-related interventions. Moreover, the important role of social support and doctor-patient communication in reducing TB-related stigma should also be emphasized.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10055-2.