Gender and tuberculosis control: perspectives on health seeking behaviour among men and women in Vietnam

The dynamics of tuberculosis transmission model with different genders

The dynamics of tuberculosis transmission model with different genders are to be established and studied. The basic regeneration numbers R 0 = R F + R M are to be defined, where R F and R M to be the basic reproduction number of tuberculosis transmission in female and male populations, respectively. The existence and global stability of the disease-free equilibrium was discussed when R 0 < 1 . The global dynamic behaviours of the corresponding limit system under some conditions are to be provided, including the existence, uniqueness, and global stability of the disease-free equilibrium and endemic equilibrium. The numerical simulation shows that the endemic equilibrium may be unique and stable when R 0 > 1 , and the system will undergo Hopf bifurcation based on some parameter values. Finally, we applied this model to analyse the transmission of tuberculosis in China, estimated the incidence of tuberculosis in China in 2035, and gave the conclusion that controlling the incidence of tuberculosis in male populations could better reduce the incidence of tuberculosis in China.

Individual journeys to tuberculosis care in Nigeria's private sector during the COVID-19 pandemic

BACKGROUND

Pre-COVID-19, individuals with tuberculosis (TB) in Nigeria were often underdiagnosed and untreated. TB services were mostly in the public sector with only 15% of new cases in 2019 reported from the private sector. Reports highlighted challenges in accessing care in the private sector, which accounted for 67% of all initial care-seeking. Our study examined patients' health seeking pathways for TB in Nigeria's private sector and explored any changes to care pathways during COVID-19.

METHODS

We conducted 180 cross-sectional surveys and 20 in-depth interviews with individuals having chest symptoms attending 18 high-volume private clinics and hospitals in Kano and Lagos States. Questions focused on sociodemographic characteristics, health-seeking behaviour, and pathways to care during the COVID-19 pandemic. All surveys and interviews were conducted in May 2021.

RESULTS

Most participants were male (111/180), with an average age of 37. Half (96/180) sought healthcare within a week of symptoms, while few (20/180) waited over 2 months. Individuals testing positive for TB had more health-seeking delays, and those testing negative for TB had more provider delays. On average, participants visited two providers in Kano and 1.69 in Lagos, with 61 of 180 in Kano and 48 of 180 in Lagos visiting other providers before the recruitment facility. Private providers were the initial encounters for most participants (60/180 in Kano, 83/180 in Lagos). Most respondents (164/180) experienced short-lived pandemic-related restrictions, affecting access to transportation, and closed facilities.

CONCLUSIONS

This study showed a few challenges in accessing TB care, necessitating continued investment in healthcare infrastructure and resources, particularly in the private sector. Understanding the different care pathways and delays in care provides opportunities for targeted interventions to improve deployment of services closer to where patients first seek care.

The more the better? How social support predicted perceived barriers to tuberculosis treatment across groups of different socioeconomic statuses

OBJECTIVE

Social support can lower perceived barriers to medical treatment, but this relationship may vary in groups of different socioeconomic statuses (SES). This study examined whether different types of social support predicted different types of perceived barriers to tuberculosis (TB) treatment and whether these relationships varied across different levels of SES.

METHOD

A paper-pencil survey covering 12 cities in Guangdong, China (N = 1386) was conducted in December 2020, which measured demographics, three types of perceived social support (informational, instrumental, and emotional) and barriers to TB treatment (cognitive, instrumental, and psychological).

RESULTS

Informational support and instrumental support were negatively related to cognitive barriers and instrumental barriers. These relationships were stronger among more educated individuals and urban residents. However, emotional support predicted psychological barrier positively, and this relationship was stronger among less educated individuals and rural residents.

CONCLUSION

High SES groups benefit more from individual-level support. Thus, there is a gap of social support, which reveals the power nature of social support exchanges.

PRACTICE IMPLICATIONS

TB campaigns need provide support for low SES groups to compensate for their insufficient support. Campaigns need provide information about disease management and the legal and financial support for TB patients, and change tuberculosis-related norms.

Characteristics of victim blaming related to COVID-19 in South Korea

This study aimed to determine the characteristics of the victim-blaming tendency of patients with coronavirus disease-2019 (COVID-19) and the worry of being blamed because of COVID-19 infection. This study utilized two methodologies based on the theory of defensive attribution and information processing. First, a media analysis was conducted to determine the characteristics of the two representative COVID-19 victim blaming cases (the Itaewon Club case and the Omicron-infected pastor case). The results show that from the viewpoint of defensive attribution theory, the victim blaming of patients infected with COVID-19 is related to social identity and moral violations committed by the patients. The Korean public emphasized their social identity and believed that the patients were different from them from an ego-defensive viewpoint. Second, we conducted three longitudinal online panel surveys (N1 = 1569; N2 = 1037; N3 = 833). The samples were selected by stratified random sampling based on sex, age, and 17 metropolitan regions in Korea. The results showed that as the number of COVID-19 cases increased, the respondents' level of risk perception decreased significantly. As the information processing theory explains, people who are familiar with the frequent risks of COVID-19 are less worried about being blamed by others. Meanwhile, the regression analysis found that victim blaming of the pastor was significantly related to the respondent's religion. We can conclude that the Korean people may blame the victims of COVID-19 because they believe that the victims are very different from an ego-defensive viewpoint. Furthermore, the trust variable appeared to be important: the more the respondents trusted the government, the more they blamed the victims of COVID-19. We term this phenomenon the "trust paradox."

Sex and Gender Differences in Bacterial Infections

There is a growing awareness of the importance of sex and gender in medicine and research. Women typically have stronger immune responses to self and foreign antigens than men, resulting in sex-based differences in autoimmunity and infectious diseases. In both animals and humans, males are generally more susceptible than females to bacterial infections. At the same time, gender differences in health-seeking behavior, quality of health care, and adherence to treatment recommendations have been reported. This review explores our current understanding of differences between males and females in bacterial diseases. We describe how genetic, immunological, hormonal, and anatomical factors interact to influence sex-based differences in pathophysiology, epidemiology, clinical presentation, disease severity, and prognosis, and how gender roles affect the behavior of patients and providers in the health care system.

Effect of treatment adherence on the association between sex and unfavourable treatment outcomes among tuberculosis patients in Puducherry, India: a mediation analysis

BACKGROUND

A better understanding of the complex interplay between risk factors of tuberculosis (TB) is essential. This study was part of the Regional Prospective Observational Research for Tuberculosis (RePORT) India consortium and includes newly diagnosed TB patients in Puducherry between 2014 and 2018. We employed mediation analysis to identify the effect of treatment adherence on association between sex and unfavourable TB treatment outcomes.

METHODS

Required demographic and treatment-related variables were extracted from the RePORT India consortium database and causal mediation analysis using parametric regression models was done.

RESULTS

Of the 712 TB patients, ~87 (12.2%) had unfavourable TB treatment outcomes. Total effect of male sex was significantly associated with the unfavourable TB treatment outcomes [adjusted odds ratio (aOR) = 2.48; 95% confidence interval (CI): 1.11-5.55]. However, the overall association between male sex and TB treatment outcomes was dominated by the indirect pathway, as the direct pathway does not show significant association (aOR = 1.67; 95% CI: 0.75-3.75), while the indirect pathway shows significantly higher odds of TB treatment outcomes (aOR = 1.48; 95% CI:1.27-1.73), indicating complete mediation by the treatment adherence.

CONCLUSIONS

The study has shown a complete mediation of sexes through TB treatment adherence for unfavourable treatment outcomes. Developing of treatment strategies require better understanding between the biological and social factors related to TB.

Gendered trajectories of depressive symptoms and social interactions among cancer patients

PURPOSE

This study examines whether and how depressive symptoms and social interactions change before and after cancer diagnosis, and whether this pattern varies by gender.

METHODS

This study used data about 722 middle- and older-aged adults from seven waves (3,963 person-observations) of the Korean Longitudinal Study of Ageing spanning 12 years between 2006 and 2018. Gender-stratified fixed effects regression models were used to investigate the effect of cancer diagnosis on changes in depressive symptoms and the frequency of social interactions (with friends, relatives, acquaintances, and neighbors) before and after cancer diagnosis.

RESULTS

For both men and women, an increase in depressive symptoms was found in the first and second year after cancer diagnosis, though the increase in the second year was significantly greater for men than women. Only men continued to suffer higher depressive symptoms after the third year and subsequent years. This study also found a decrease in the frequency of social interactions only among men in the second year and subsequent years after cancer diagnosis.

CONCLUSION

Trajectories of psychosocial adjustment to cancer are gendered. The psychosocial consequences of cancer are greater and last longer for men than women.

Male Sex Is Associated With Worse Microbiological and Clinical Outcomes Following Tuberculosis Treatment: A Retrospective Cohort Study, a Systematic Review of the Literature, and Meta-analysis

BACKGROUND

Although the incidence of tuberculosis is higher in men than in women, the relationship of sex with tuberculosis treatment outcomes has not been adequately studied.

METHODS

We performed a retrospective cohort study and a systematic review and meta-analysis of observational studies during the last 10 years to assess sex differences in clinical and microbiological outcomes in tuberculosis.

RESULTS

In our cohort of 2894 Taiwanese patients with drug-susceptible pulmonary tuberculosis (1975 male and 919 female), male patients had higher adjusted hazards of 9-month mortality due to all causes (hazard ratio, 1.43 [95% confidence interval (CI), 1.03-1.98]) and infections (1.70 [1.09-2.64]) and higher adjusted odds of 2-month sputum culture positivity (odds ratio [OR], 1.56 [95% CI, 1.05-2.33]) compared with female patients. Smear positivity at 2 months did not differ significantly (OR, 1.27 [95% CI, .71-2.27]) between the sexes. Among 7896 articles retrieved, 398 were included in our systematic review describing a total of 3 957 216 patients. The odds of all-cause mortality were higher in men than in women in the pooled unadjusted (OR, 1.26 [95% CI, 1.19-1.34]) and adjusted (1.31 [1.18-1.45]) analyses. Men had higher pooled odds of sputum culture (OR, 1.44 [95% CI, 1.14-1.81]) and sputum smear (1.58 [1.41-1.77]) positivity, both at the end of the intensive phase and on completion of treatment.

CONCLUSIONS

Our retrospective cohort showed that male patients with tuberculosis have higher 9-month all-cause and infection-related mortality, with higher 2-month sputum culture positivity after adjustment for confounding factors. In our meta-analysis, male patients showed higher all-cause and tuberculosis-related mortality and higher sputum culture and smear positivity rates during and after tuberculosis treatment.

Factors associated with delay in diagnosis among tuberculosis patients in the north of Iran

BACKGROUND Recognizing factors that affect delay in diagnosis in patients with pulmonary tuberculosis (TB) is critical. This study aimed to identify such factors among TB patients in the north of Iran. METHODS In this retrospective cohort study, we reviewed patient’s medical records from the TB registration system of the Health Deputy of Mazandaran University of Medical Sciences, Sari, Iran that was responsible for the TB registry in the province from 2007 to 2017. All hospitals affiliated with the university, including private hospitals, reported TB cases directly to the health deputy. Patient’s gender, age, TB smear result, TB type, imprisonment, diabetes, nationality, residence area, and drug use were considered factors of delay in diagnosis, which was defined as a delay of >30 days between symptom onset and diagnosis. Data from 3,453 patients were analyzed using the chi-square test and logistic regression models. RESULTS The frequency of patients with delay in diagnosis was 67.7%. There was no association between delay in diagnosis and gender (p = 0.194), TB type (p = 0.140), and diabetes (p = 0.198). On the other hand, old age (≥60 years) was related to delay in diagnosis (OR = 1.37; 95% CI = 1.12–1.68; p = 0.002). The chance of delay in diagnosis in prisoners was lower than in non-prisoners (OR = 0.62; 95% CI = 0.46–0.82; p = 0.001). CONCLUSIONS Old age was a risk factor for delay in diagnosis, and interestingly, prisoners had been diagnosed significantly faster.

An Evaluation of Programmatic Community-Based Chest X-ray Screening for Tuberculosis in Ho Chi Minh City, Vietnam

Across Asia, a large proportion of people with tuberculosis (TB) do not report symptoms, have mild symptoms or only experience symptoms for a short duration. These individuals may not seek care at health facilities or may be missed by symptom screening, resulting in sustained TB transmission in the community. We evaluated the yields of TB from 114 days of community-based, mobile chest X-ray (CXR) screening. The yields at each step of the TB screening cascade were tabulated and we compared cohorts of participants who reported having a prolonged cough and those reporting no cough or one of short duration. We estimated the marginal yields of TB using different diagnostic algorithms and calculated the relative diagnostic costs and cost per case for each algorithm. A total of 34,529 participants were screened by CXR, detecting 256 people with Xpert-positive TB. Only 50% of those diagnosed with TB were detected among participants reporting a prolonged cough. The study’s screening algorithm detected almost 4 times as much TB as the National TB Program’s standard diagnostic algorithm. Community-based, mobile chest X-ray screening can be a high yielding strategy which is able to identify people with TB who would likely otherwise have been missed by existing health services.

Evaluating the yield of systematic screening for tuberculosis among three priority groups in Ho Chi Minh City, Viet Nam

BACKGROUND

In order to end tuberculosis (TB), it is necessary to expand coverage of TB care services, including systematic screening initiatives. However, more evidence is needed for groups among whom systematic screening is only conditionally recommended by the World Health Organization. This study evaluated concurrent screening in multiple target groups using community health workers (CHW).

METHODS

In our two-year intervention study lasting from October 2017 to September 2019, CHWs in six districts of Ho Chi Minh City, Viet Nam verbally screened three urban priority groups: (1) household TB contacts; (2) close TB contacts; and (3) residents of urban priority areas without clear documented exposure to TB including hotspots, boarding homes and urban slums. Eligible persons were referred for further screening with chest radiography and follow-on testing with the Xpert MTB/RIF assay. Symptomatic individuals with normal or without radiography results were tested on smear microscopy. We described the TB care cascade and characteristics for each priority group, and calculated yield and number needed to screen. Subsequently, we fitted a mixed-effect logistic regression to identify the association of these target groups and secondary patient covariates with TB treatment initiation.

RESULTS

We verbally screened 321 020 people including 24 232 household contacts, 3182 social and close contacts and 293 606 residents of urban priority areas. This resulted in 1138 persons treated for TB, of whom 85 were household contacts, 39 were close contacts and 1014 belonged to urban priority area residents. The yield of active TB in these groups was 351, 1226 and 345 per 100 000, respectively, corresponding to numbers needed to screen of 285, 82 and 290. The fitted model showed that close contacts [adjusted odds ratio (aOR) = 2.07; 95% CI: 1.38-3.11; P < 0.001] and urban priority area residents (aOR = 2.18; 95% CI: 1.69-2.79; P < 0.001) had a greater risk of active TB than household contacts.

CONCLUSIONS

The study detected a large number of unreached persons with TB, but most of them were not among persons in contact with an index patient. Therefore, while programs should continue to optimize screening in contacts, to close the detection gap in high TB burden settings such as Viet Nam, coverage must be expanded to persons without documented exposure such as residents in hotspots, boarding homes and urban slums.

Tuberculosis treatment outcomes: a fifteen-year retrospective study in Jos-North and Mangu, Plateau State, North - Central Nigeria

BACKGROUND

Globally, tuberculosis (TB) is the leading cause of death from a single infectious agent. Adherence to TB therapy is an important factor in treatment outcomes, which is a critical indicator for evaluating TB treatment programs. This study assessed TB treatment outcomes using a fifteen-year record of tuberculosis patients who received treatment in Jos-North and Mangu Local Government Areas of Plateau State, North-Central Nigeria.

METHODS

The retrospective facility based study was done in five TB treatment centers which account for more than half of data for tuberculosis patients in Plateau State. Data were collected from 10,156 TB patient's health records between 2001 and 2015. Treatment outcomes were categorized as successful (cured, treatment completed) or unsuccessful (non-adherent, treatment failure or death). A descriptive analysis was done to assess the factors associated with treatment outcomes. Relevant bivariate and multivariate logistic regression were done. All statistical analyses were performed on Stata version 11, College station, Texas, USA.

RESULTS

During the study period, 58.1% (5904/10156) of the TB patients who received treatment were males. The Mean age ± SD was 35.5 ± 15.5 years. The overall treatment success rate was 67.4%; non-adherence/defaulting rate was 18.5%, with majority of patients defaulting at the end of intensive phase of treatment. The sputum conversion rate was 72.8% and mortality rate was 7.5%. A decrease in successful treatment outcomes rate from 83.8% in 2001 to 64.4% in 2015 was observed. The factors associated with treatment success were gender, age, year of enrollment, and HIV status. Extrapulmonary TB was less likely associated with treatment success (AOR:95% CI- 0.72:0.61-0.84, p < 0.001).

CONCLUSION

With the decrease in treatment success rates, underlying reasons for medication non-adherence and treatment failure should be resolved through adherence counseling involving the patient and treatment supporters, with education on voluntary counseling and testing for HIV among TB patients.

Health care seeking behavior among presumptive tuberculosis patients in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Health seeking behavior is one of the challenges affecting tuberculosis (TB) control program because of its high risk to prolonged diseases transmission and poor treatment outcome. Although there are few primary studies that reported diversified magnitudes of health seeking behavior among presumptive TB patients in Ethiopia, there is no review study that attempted to summarize the available evidence. Thus, this review was aimed to estimate the proportion of health care seeking behavior from health facility and to summarize the reasons why individuals with presumptive TB are not seeking health care in Ethiopia.

METHOD

A systematic review and meta-analysis study was conducted on primary studies that reported proportion of health seeking behavior among presumptive TB patients. Electronic databases: PubMed, Google Scholar and Science Direct were searched to retrieve studies published in English language from Ethiopia without restricting publication year. In addition, bibliographies of included studies were also screened to retrieve potential studies. The keywords "health seeking", "health seeking behavior", "TB suspects" and "presumptive TB" were used both in Medical Subject Heading (MeSH) and free text. Random effects meta-analysis model was used to estimate the pooled proportions of health care seeking and not seeking behaviors. Stata version 14 was used for data analysis.

RESULT

Five studies which involved 3230 patients with presumptive TB were included into this review. The pooled estimated proportion of health care seeking behavior among presumptive TB patients from health facilities was 65% (95% CI, 54-76%), while the pooled proportion of not seeking health care from any sources was 17% (95% CI;6-27%). In addition, 18% (95% CI; 5-30%) of presumptive TB patients were seeking health care from inappropriate sources. Being female, younger age, low income status, absence of previous TB treatment history, low education status were the risk factors that associated with low health care seeking behavior.

CONCLUSION

Considerable proportion of patients with presumptive TB were not seeking health care from health facilities or seeks care from inappropriate sources in Ethiopia. Implementing efforts that could improve health care seeking behavior is vital to prevent prolonged disease transmission through immediate treatment commencement.

Stigma matters in ending tuberculosis: Nationwide survey of stigma in Ethiopia

BACKGROUND

Tuberculosis (TB) affects, and claims the lives of, millions every year. Despite efforts to find and treat TB, about four million cases were missed globally in 2017. Barriers to accessing health care, inadequate health-seeking behavior of the community, poor socioeconomic conditions, and stigma are major determinants of this gap. Unfortunately, TB-related stigma remains unexplored in Ethiopia.

METHODS

This mixed methods survey was conducted using multistage cluster sampling to identify 32 districts and 8 sub-cities, from which 40 health centers were randomly selected. Twenty-one TB patients and 21 family members were enrolled from each health center, and 11 household members from each community in the catchment population.

RESULTS

A total of 3463 participants (844 TB patients, 836 from their families, and 1783 from the general population) were enrolled for the study. The mean age and standard deviation were 34.3 ± 12.9 years for both sexes (34.9 ± 13.2 for men and 33.8 ± 12.5 for women). Fifty percent of the study participants were women; 32.1% were illiterate; and 19.8% came from the lowest wealth quintile. The mean stigma score was 18.6 for the general population, 20.5 for families, and 21.3 for TB patients. The general population of Addis Ababa (AOR: 0.1 [95% CI: 0.06-0.17]), those educated above secondary school (AOR: 0.58 [95% CI: 0.39-0.87]), and those with a high score for knowledge about TB (AOR: 0.62 [95% CI: 0.49-0.78]) had low stigma scores. Families of TB patients who attended above secondary school (AOR: 0.37 [95% CI: 0.23-0.61]) had low stigma scores. TB patients educated above secondary school (AOR: 0.61 [95% CI: 0.38-0.97]) had lower stigma scores, while those in the first (AOR: 1.93: 95% CI 1.05-3.57) and third quintiles (AOR: 1.81: 95% CI: 1.08-3.05) had stigma scores twice as high as those in the highest quintile. Fear of job loss (32.5%), isolation (15.3%), and feeling avoided (9.3%) affected disclosure about TB.

CONCLUSIONS

More than a third of Ethiopians have high scores for TB-related stigma, which were associated with educational status, poverty, and lack of awareness about TB. Stigma matters in TB prevention, care, and treatment and warrants stigma reduction interventions.

Knowledge, attitudes, and practices related to TB among the general population of Ethiopia: Findings from a national cross-sectional survey

INTRODUCTION

Ethiopia is among the high-burden countries for tuberculosis (TB), TB/HIV, and drug-resistant TB. The aim of this nationwide study was to better understand TB-related knowledge, attitudes, and practices (KAPs) and generate evidence for policy and decision-making.

MATERIALS AND METHODS

We conducted a cross-sectional TB KAP survey in seven regions and two city administrations of Ethiopia. Eighty kebeles (wards) and 40 health centers were randomly selected for the study. Using systematic sampling, 22 households and 11 TB patients were enrolled from each selected village and health center, respectively. Variables with a value of p = < 0.25 were included in the model for logistic regression analysis.

RESULTS

Of 3,503 participants, 884 (24.4%), 836 (24.1%), and 1,783 (51.5%) were TB patients, families of TB patients, and the general population, respectively. The mean age was 34.3 years, and 50% were women. Forty-six percent were heads of households, 32.1% were illiterate, 20.3% were farmers, and 19.8% were from the lowest quintile. The majority (95.5%) had heard about TB, but only 25.8% knew that TB is caused by bacteria. Cough or sneezing was reported as the commonest means of TB transmission. The majority (85.3%) knew that TB could be cured. Men, better-educated people, and TB patients and their families have higher knowledge scores. Of 2,483 participants, 96% reported that they would go to public health facilities if they developed TB symptoms.

DISCUSSION

Most Ethiopians have a high level of awareness about TB and seek care in public health facilities, and communities are generally supportive. Inadequate knowledge about TB transmission, limited engagement of community health workers, and low preference for using community health workers were the key challenges.

CONCLUSIONS

Given misconceptions about TB's causes, low preference for use of community health workers, and inadequate engagement, targeted health education interventions are required to improve TB services.

Delays in diagnosis and treatment of pulmonary tuberculosis in patients seeking care at a regional referral hospital, Uganda: a cross sectional study

Objective

A cross-sectional survey involving 134 pulmonary TB patients started on TB treatment at the TB Treatment Unit of the regional referral hospital was conducted to ascertain the prevalence of individual and health facility delays and associated factors. Prolonged health facility delay was taken as delay of more than 1 week and prolonged patient delay as delay of more than 3 weeks. A logistic regression model was done using STATA version 12 to determine the delays.

Results

There was a median total delay of 13 weeks and 110 (82.1%) of the respondents had delay of more than 4 weeks. Patient delay was the most frequent and greatest contributor of total delay and exceeded 3 weeks in 95 (71.6%) respondents. At multivariate analysis, factors that influenced delay included poor patient knowledge on TB (adjOR 6.904, 95% CI 1.648–28.921; p = 0.04) and being unemployed (adjOR 3.947, 95% CI 1.382–11.274; p = 0.010) while being female was found protective of delay; adjOR 0.231, 95% CI 0.08–0.67; p = 0.007). Patient delay was the most significant, frequent and greatest contributor to total delay, and factors associated with delay included being unemployed, low knowledge on TB while being female was found protective of delay.

Seeking help when transgender: Exploring the difference in mental and physical health seeking behaviors between transgender and cisgender individuals in Ireland

Background: While there is growing awareness of the need to support the physical and mental wellbeing of transgender people, some may be reluctant to seek help from healthcare professionals. Little is understood about the mechanisms that influence help-seeking behavior in this group. Aims: This study aimed to compare transgender and cisgender participants in their likelihood to seek help for both physical and mental health conditions, and to explore whether this help-seeking behavior is predicted by a range of sociodemographic and psychological variables. Methods: 123 participants living in Ireland (cisgender= 67; transgender= 56) completed a questionnaire which included demographic questions, as well as measures of optimism (LOT-R), self-esteem (RSES), psychological distress (GHQ-12), attitudes towards seeking psychological help (ATSPPH-SF), and attitudes towards seeking help for a physical health problem (Attitudes Towards Seeking Medical Help Scale- Action/Intervention subscale). Associations between predictor variables and mental and physical health seeking were explored using correlation analysis and stepwise regressions. Results: Transgender participants were less likely to seek help for a physical health issue than cisgender participants, but did not differ in mental health help-seeking behaviors. Results suggest that this may be due to differences in optimism, self-esteem and psychological distress. Transgender participants had significantly lower optimism and self-esteem, which were two factors linked to poorer physical health seeking behaviors. Optimism also emerged as a significant predictor in mental health seeking behaviors. Discussion: The lack of a significant difference for mental health help-seeking between the transgender and cisgender participants is encouraging, as it suggests that there is less stigma surrounding mental illness than expected, however findings also contradict previous findings suggesting that physical health is less stigmatized. This could be due to stigma relating to gender-specific healthcare and suggests that healthcare professionals should acknowledge the specific healthcare needs and concerns among transgender individuals.

Explaining patient delay in healthcare seeking and loss to diagnostic follow-up among patients with presumptive tuberculosis in Tanzania: a mixed-methods study

BACKGROUND

Delay in healthcare seeking and loss to diagnostic follow-up (LDFU) contribute to substantial increase in tuberculosis (TB) morbidity and mortality. We examined factors, including perceived causes and prior help seeking, contributing to delay and LDFU during referral to a TB clinic among patients with presumptive TB initially seeking help at the pharmacies in Dar es Salaam Tanzania.

METHODS

In a TB clinic, a semi-structured interview based on the explanatory model interview catalogue (EMIC) framework for cultural epidemiology was administered to presumptive TB patients enrolled at pharmacies during an intervention study. We assessed delay in seeking care at any medical care provider for a period of ≥3 weeks after the onset of symptoms, LDFU during referral (not reaching the TB clinic), and LDFU for three required TB clinic visits among the presumptive and confirmed TB patients. Logistic regression models were used to assess factors associated with delay and LDFU.

RESULTS

Among 136 interviewed patients, 86 (63.2%) were LDFU from pharmacies and TB clinic while 50 (36.8%) were non-LDFU. Out of 136 patients 88 (64.7%) delayed seeking care, of whom 59 (67%) were females. Among the 86 (63.2%) patients in LDFU group, 62 (72.1%) delayed seeking care, while among the 50 (36.8%) non-LDFU, 26 (52.0%) had also delayed seeking care. Prior consultation with a traditional healer (aOR 2.84, 95% CI 1.08-7.40), perceived causes as ingestion (water and food) (aOR 0.38 CI 0.16-0.89), and substance use (smoking and alcohol) (aOR 1.45 CI 0.98-2.14) were all associated with patient delay. Female gender was associated with LDFU (aOR 3.80, 95% CI 1.62-8.87) but not with delay. Other conditions as prior illness and heredity were also associated with LDFU but not delay (aOR 1.48 CI 1.01-2.17).

CONCLUSION

Delay and LDFU after referral from the pharmacies were substantial. Notable effects of diagnosis and female gender indicate a need for more attention to women's health to promote timely and sustained TB treatment. Public awareness to counter misconceptions about the causes of TB is needed.

Such a long journey: What health seeking pathways of patients with drug resistant tuberculosis in Mumbai tell us

INTRODUCTION

The Indian Tuberculosis (TB) Programme currently faces the dual challenges of tackling increasing numbers of drug resistant (DR) TB cases and regulating practices of a pluralistic private sector catering to TB patients. A study of health seeking behaviour of DR-TB patients in such a situation, offers an opportunity to understand the problems patients face while interacting with health systems.

METHODOLOGY

Forty-six DR-TB patients drawn from 15 high TB burden wards in Mumbai were interviewed using an open ended interview tool. Interviews were audio recorded and transcribed. Pathway schematics developed from analysis of patient records, were linked to transcripts. Open coding was used to analyse these units and themes were derived after collating the codes.

RESULTS AND DISCUSSION

The paper presents themes interwoven with narratives in the discussions. These include awareness-action gap among patients, role of neighbourhood providers, responsiveness of health systems, the not-such a 'merry go round' that patients go/are made to go on while seeking care, costs of diagnostics and treatment, and how DR-TB is viewed as the 'big TB'.

CONCLUSION

The recommendations are based on a preventative ethos which is sustainable, compared to interventions with top-down approaches, which get piloted, but fail to sustain impact when scaled up.

A pilot project: 99DOTS information communication technology-based approach for tuberculosis treatment in Rajkot district

Background:

99DOTS (Directly Observed Treatment, Short course) is a low-cost, mobile phone-based technology that enables real-time remote monitoring of daily intake of treatment, first introduced by the Revised National Tuberculosis Programme under the national programme in 2015 in high-burden antiretroviral therapy (ART) centers. This project was launched for the first time in 2016 in Rajkot district, Gujarat, India, and hence this was an effort to evaluate 99DOTS.

Objectives:

The objective of this study was to evaluate treatment adherence rate and treatment outcome of 99DOTS-information communication technology (ICT)-based approach for tuberculosis (TB) management.

Materials and Methods:

Data from 99DOTS were obtained from February 2016 to September 2017 after obtaining approval from the Institutional Ethical Committee and permission from the head of the department of district TB center (DTC), Rajkot. Data were evaluated for sociodemographic pattern, adherence rate, and treatment outcome.

Results:

A total of total 347 registered patients, 197 (56.77%) patients diagnosed by private practitioners and 150 (43.22%) patients having HIV-TB from ART center were initiated TB treatment under 99DOTS project from nine different talukas of Rajkot district. Mean age of the registered TB patients was 36 ± 13.55 years with predominance of “new cases” (n = 275, 79.25%) and “male” gender (n = 257, 74.06%). The overall treatment adherence rate of 99DOTS was 96.03%, while adherence by “call” was 92.25% and adherence by “manual” was 32.12%. Cure rate was higher in patients with TB only (n = 113, 78.47%) as compared to patients with HIV-TB co-infection (n = 46, 67.64%). Defaulter rate (n = 19, 13.19%) was also higher in patients with TB only, while death rate (n = 14, 20.58%) was higher in patients of TB with HIV co-infection.

Conclusion:

99DOTS is an effective approach for improving TB medication adherence, thereby increasing the compliance to TB treatment. It will be helpful for easy access of treatment to patients from remote areas, improve notification of patients from private practitioners, and enable differentiated care.

Sex Differences in Quality of Life and Health Services Utilization among Elderly People in Rural Vietnam

As in much of the world, the elderly population in Vietnam is growing rapidly with two-thirds of them currently living in rural areas. Besides limited access to quality healthcare services, they also have unique health profiles and needs due to various factors, including the highly skewed sex ratio of more women residing in rural areas. However, the relationship between gender, health-seeking behaviors, and health outcomes in this under-served population has not been well characterized. This study sought to explore the associations of gender with health-related quality of life and health-seeking behavior among the elderly in Soc Son, a rural district of Hanoi, Vietnam. A cross-sectional design was used; elderly individuals were surveyed across the domains of socioeconomic information, health status, and healthcare service utilization. We found that overall, women had poorer health and quality of life even though gender difference did not appear to significantly influence their levels of health services utilization. A greater understanding of the systemic, sociocultural, and psychological factors underlying such differences may help better inform future healthcare service delivery strategies targeting this growing population in rural areas.

Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India

Background:

Stigma associated with tuberculosis (TB) is still common in many societies, contributing to delays in treatment seeking and treatment non-compliance. India has the highest burden of TB in the world with female TB patients bearing a considerable burden of TB-related stigma.

Objectives:

This study aimed to explore the manifestations and consequences of stigma experienced by female TB patients in an urban setting in India and their strategies to cope with the social stigma of TB.

Methods:

Twenty qualitative interviews were conducted with female TB patients who were either currently on treatment or had undergone treatment at a TB clinic in Kolkata, India. Data were coded and analyzed with the NVivo qualitative software using a thematic approach.

Results:

Our results indicated that TB stigma mainly manifested through social isolation and avoidance due to fear of contagion, gossip and verbal abuse, failed marriage prospects, and neglect from family. Consequences of stigma described by the women included non-disclosure, feelings of guilt, and mental health issues including suicidal ideation. Positive coping strategies used by women to cope with the experiences of stigma included positive reframing, prayer, talking to other patients, focusing on school work, and relaxation activities. Negative coping activities included self-imposed social isolation and anger. In some cases, non-disclosure due to stigma had an impact on TB transmission and control behaviors.

Conclusions:

Stigma-reduction strategies, such as community awareness programs and formation of social support groups to dispel the myths and misconceptions associated with TB, may improve TB treatment seeking and adherence.

Acknowledgement:

Our deepest thanks to the Reverend, St. James’ Church, Dr. Ali Akbar Chowdhury (Medical Officer), staff and participants at the Calcutta Diocesan Tuberculosis Relief Trust, without whom this study would not be possible. We also thank Sushmita Mukherjee for help with translations. Lastly, we thank the Sparkman Center for Global Health at the University of Alabama at Birmingham for providing travel funds for this study.

Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India

BACKGROUND

Stigma associated with tuberculosis (TB) is still common in many societies, contributing to delays in treatment seeking and treatment non-compliance. India has the highest burden of TB in the world with female TB patients bearing a considerable burden of TB-related stigma. Objectives: This study aimed to explore the manifestations and consequences of stigma experienced by female TB patients in an urban setting in India and their strategies to cope with the social stigma of TB.

METHODS

Twenty qualitative interviews were conducted with female TB patients who were either currently on treatment or had undergone treatment at a TB clinic in Kolkata, India. Data were coded and analyzed with the NVivo qualitative software using a thematic approach.

RESULTS

Our results indicated that TB stigma mainly manifested through social isolation and avoidance due to fear of contagion, gossip and verbal abuse, failed marriage prospects, and neglect from family. Consequences of stigma described by the women included non-disclosure, feelings of guilt, and mental health issues including suicidal ideation. Positive coping strategies used by women to cope with the experiences of stigma included positive reframing, prayer, talking to other patients, focusing on school work, and relaxation activities. Negative coping activities included self-imposed social isolation and anger. In some cases, non-disclosure due to stigma had an impact on TB transmission and control behaviors. Conclusions: Stigma-reduction strategies, such as community awareness programs and formation of social support groups to dispel the myths and misconceptions associated with TB, may improve TB treatment seeking and adherence.Acknowledgement: Our deepest thanks to the Reverend, St. James' Church, Dr. Ali Akbar Chowdhury (Medical Officer), staff and participants at the Calcutta Diocesan Tuberculosis Relief Trust, without whom this study would not be possible. We also thank Sushmita Mukherjee for help with translations. Lastly, we thank the Sparkman Center for Global Health at the University of Alabama at Birmingham for providing travel funds for this study.

A Bayesian Approach to Understanding Sex Differences in Tuberculosis Disease Burden

Globally, men have a higher epidemiologic burden of tuberculosis (incidence, prevalence, mortality) than women do, possibly due to differences in disease incidence, treatment initiation, self-cure, and/or untreated-tuberculosis mortality rates. Using a simple, sex-stratified compartmental model, we employed a Bayesian approach to explore which factors most likely explain men's higher burden. We applied the model to smear-positive pulmonary tuberculosis in Vietnam (2006-2007) and Malawi (2013-2014). Posterior estimates were consistent with sex-specific prevalence and notifications in both countries. Results supported higher incidence in men and showed that both sexes faced longer durations of untreated disease than estimated by self-reports. Prior untreated disease durations were revised upward 8- to 24-fold, to 2.2 (95% credible interval: 1.7, 2.9) years for men in Vietnam and 2.8 (1.8, 4.1) years for men in Malawi, approximately a year longer than for women in each country. Results imply that substantial sex differences in tuberculosis burden are almost solely attributable to men's disadvantages in disease incidence and untreated disease duration. The latter, for which self-reports provide a poor proxy, implies inadequate coverage of case-finding strategies. These results highlight an urgent need for better understanding of gender-related barriers faced by men and support the systematic targeting of men for screening.

Tuberculosis and the sexual and reproductive lives of women in Bangladesh

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

Stigmatising Attitudes Towards Co-workers with HIV in the Workplace of a Metropolitan State, Southwestern Nigeria

BACKGROUND

Despite demonstrating global concerns about infection in the workplace, very little research has explored how co-workers react to those living with HIV in the workplace in sub-Saharan Africa. This study aimed to assess the level of stigmatising attitude towards co-workers living with HIV in the workplace.

METHODS

The study was a descriptive cross-sectional survey involving 403 respondents. They were recruited from selected companies through a multistage sampling technique. Survey was carried out using pre-tested semi-structured questionnaires. Data were analyzed using the Statistical Package for the Social Sciences to generate frequencies, cross tabulations of variables at 5% level of significance. Logistic regression model was used to determine the predictors at 95% confidence intervals.

RESULTS

Mean age of respondents was 32.9 ± 9.4 years with 86.1% being females. Overall, slightly below two-third (63.0%) had good knowledge on transmission of HIV/AIDS while 218 (54.1%) respondents had a high stigmatising attitude towards co-workers with HIV in the workplace. More female respondents (69.6%) demonstrated high stigmatising attitudes towards co-workers with HIV in the workplace (p = 0.012). Female workers were twice more likely to have high stigmatising attitudes towards co-worker with HIV [OR 2.1 (95% CI: 1.13 - 3.83)].

CONCLUSION

Stigma towards people living with HIV/AIDs is still very persistent in different settings. Good knowledge amongst our participants about HIV/AIDs did not translate to low stigmatising attitudes among workers. Concerted efforts and trainings on the transmission of HIV/AIDs are essential to reduce stigma that is still very prevalent in workplace settings.

Survey on Tuberculosis Patients in Rural Areas in China: Tracing the Role of Stigma in Psychological Distress

Depressed patients had risks of non-adherence to medication, which brought a big challenge for the control of tuberculosis (TB). The stigma associated with TB may be the reason for distress. This study aimed to assess the psychological distress among TB patients living in rural areas in China and to further explore the relation of experienced stigma to distress. This study was a cross-sectional study with multi-stage randomized sampling for recruiting TB patients. Data was collected by the use of interviewer-led questionnaires. A total of 342 eligible and accessible TB patients being treated at home were included in the survey. Psychological distress was measured using the Kessler Psychological Distress Scale (K10). Experienced stigma was measured using a developed nine-item stigma questionnaire. Univariate analysis and multiple logistic regression were used to analyze the variables related to distress, respectively. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to present the strength of the associations. Finally, the prediction of logistic model was assessed in form of the Receiver Operating Characteristic (ROC) curve and the area under the ROC curve (AUC). According to the referred cut-off point from K10, this study revealed that 65.2% (223/342) of the participants were categorized as having psychological distress. Both the stigma questionnaire and the K10 were proven to be reliable and valid in measurement. Further analysis found that experienced stigma and illness severity were significant variables to psychological distress in the model of logistic regression. The model was assessed well in predicting distress by use of experienced stigma and illness severity in form of ROC and AUC. Rural TB patients had a high prevalence of psychological distress. Experience of stigma played a significant role in psychological distress. To move the barrier of stigma from the surroundings could be a good strategy in reducing distress for the patients and TB controlling for public health management.

Why wait? The social determinants underlying tuberculosis diagnostic delay

BACKGROUND

Early detection and diagnosis of tuberculosis remain major global priorities for tuberculosis control. Few studies have used a qualitative approach to investigate the social determinants contributing to diagnostic delay and none have compared data collected from individual, community, and health-system levels. We aimed to characterize the social determinants that contribute to diagnostic delay among persons diagnosed with tuberculosis living in resource-constrained settings.

METHODS/PRINCIPLE FINDINGS

Data were collected in public health facilities with high tuberculosis incidence in 19 districts of Lima, Peru. Semi-structured interviews with persons diagnosed with tuberculosis (n = 105) and their family members (n = 63) explored health-seeking behaviours, community perceptions of tuberculosis and socio-demographic circumstances. Focus groups (n = 6) were conducted with health personnel (n = 35) working in the National Tuberculosis Program. All interview data were transcribed and analysed using a grounded theory approach. The median delay between symptom onset and the public health facility visit that led to the first positive diagnostic sample was 57 days (interquartile range 28-126). The great majority of persons diagnosed with tuberculosis distrusted the public health system and sought care at public health facilities only after exhausting other options. It was universally agreed that persons diagnosed with tuberculosis faced discrimination by public and health personnel. Self-medication with medicines bought at local pharmacies was reported as the most common initial health-seeking behaviour due to the speed and low-cost of treatment in pharmacies. Most persons diagnosed with tuberculosis initially perceived their illness as a simple virus.

CONCLUSIONS

Diagnostic delay was common and prolonged. When individuals reached a threshold of symptom severity, they addressed their health with the least time-consuming, most economically feasible, and well-known healthcare option available to them. In high-burden settings, more human and material resources are required to promote tuberculosis case-finding initiatives, reduce tuberculosis associated stigma and address the social determinants underlying diagnostic delay.

Delays and Pathways to Final Tuberculosis Diagnosis in Patients from a Referral Hospital in Urban China

AbstractChina is among the countries with the largest epidemic of drug susceptible and resistant tuberculosis globally. We investigated the locations tuberculosis patients visited before being diagnosed, total diagnostic delay, and risk factors associated with total delay from a large tuberculosis referral hospital in Nanjing, China. We conducted a retrospective cohort study among tuberculosis patients who initiated anti-tuberculosis treatment within 3 months prior to the study date. Patient information regarding time and locations visited while seeking care for tuberculosis-related symptoms was collected through face-to-face interviews. Crude and adjusted Cox proportional hazard ratios of factors associated with time to diagnosis were calculated. Of 179 bacteriologically confirmed patients, 37% were women and median age was 41 (interquartile range [IQR], 26-62). Public hospitals were the most commonly visited health-care institution and repeated visits to them were common. The mean days to tuberculosis diagnosis were 50.3. Female patients (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.04-1.48) or patients who contacted a health-care provider 2 weeks after becoming symptomatic (HR, 1.59; 95% CI, 1.43-1.70) were significantly less likely to have a timely diagnosis. In a referral hospital in urban China, we found that female tuberculosis patients took significantly more time to reach diagnosis than males and patients often cycled in public hospitals for multiple visits before reaching final diagnosis. Health professionals at public hospitals in Nanjing should be encouraged to refer potential tuberculosis patients as soon as possible to avoid nosocomial transmission.

Diagnostic delay and associated factors among patients with pulmonary tuberculosis in Kerala

Introduction

Delay in the diagnosis of tuberculosis (TB) can lead to an increased infectivity period, delayed treatment, and increased severity of the disease. The objective of this study was to estimate the diagnostic delay and factors associated with the delay in diagnosis among the newly diagnosed smear-positive pulmonary TB patients in Kerala, India.

Materials and Methods

A cross-sectional study was conducted among TB patients who were in the intensive phase of directly observed treatment short-course treatment in four randomly selected TB units in a district in Kerala during the years 2012-2013. Diagnostic delay was defined as the delay between the onset of symptoms and diagnosis. Data collection using a modified World Health Organization questionnaire was done by interviewing 302 participants.

Results

Mean age of the participants was 48.6 ± 14.5 years. Males constituted 76.5% of the study population. The mean diagnostic delay was 43.5 ± 29.1 days (median: 37 days). The median patient and health system delays were 16 days and 15 days, respectively. Patient delay (55.6%) contributed more than health system delay (44.4%). Poor knowledge about TB, first consulting a private physician, and increased number of consultations were found to be significantly associated with diagnostic delay.

Conclusion

The diagnostic delay in tuberculosis reported in this study was lower than other studies in India but it needs further reduction. Both patients and health providers play a role in a delay in diagnosis, and poor knowledge about the disease among the patients was one of the main risk factors. Interventions to improve knowledge and awareness of the disease and to increase the suspicion of chest symptomatic by health-care providers in the private sector are vital to reduce diagnostic delay.

The tale of seeking treatment: A qualitative study of pulmonary tuberculosis patients

Aim

The aims of the study were unravelling patients’ health-seeking behaviour pathways to seek medication in healthcare facilities and key factors that determined patients’ immediacy in seeking medical treatment.

Method

By involving 5 pulmonary TB patients who were undertaking treatment at Pegirian Primary Health Centre, Surabaya, Indonesia, the research was carried out using an explorative qualitative research design, and the chosen data collection technique was semi-structured interview.

Results

The research findings demonstrated that all participants showed five rather similar health-seeking behaviour sequences, such as: (a) defining symptoms; (b) asking laypeople opinions on symptoms; (c) undertaking non-medical treatment to reduce the symptoms; (d) taking laypeople’s suggestions to visit healthcare facilities into consideration; (e) deciding to undergo treatment process. Several barriers that caused treatment delay were inaccurate symptom definition and poor health-related risk perception. Meanwhile, reinforcing factors were relatives’ appeal to seek treatment, the existence of comorbid/previous diseases, access to healthcare facilities, and increasing perceived severity of the symptoms.

Conclusion

Research findings showed that participants performed similar health-seeking pathways. Hindering factors that caused treatment delay were mostly related to cultural-based illness definition and knowledge. Research findings would be potentially beneficial to local primary healthcare for designing interventions that encourage patients to seek professional help and reduce treatment delay.

Individual, household and community level factors associated with keeping tuberculosis status secret in Ghana

Background

In tuberculosis (TB) control, early disclosure is recommended for the purposes of treatment as well as a means of reducing or preventing person-to-person transmission of the bacteria. However, disclosure maybe avoided as a means of escaping stigma, and possible discrimination. This study aimed at providing insights into factors associated with intentions of Ghanaians to keep positive TB diagnosis in their families’ a secret.

Methods

The paper was based on data from the 2014 Ghana Demographic and Health Survey. Descriptive statistics of proportions with Chi-square test and binary logistic regression were used to identify individual, household and community level factors that predicted the outcome variable (keeping TB secret).

Results

Women were more inclined (33%) than men (25%) to keep TB in the family a secret. Views about keeping TB secret declined with age for both sexes. For women, higher education had a positive association with whether TB in the family would be kept a secret or not but the same was not observed for men. In a multivariable regression model, the strongest predictor of keeping TB secret was whether the respondent would keep HIV secret, and this was uniform among women (OR = 6.992, p < 0.001) and men (OR = 9.870, p < 0.001).

Conclusion

Unwillingness towards disclosing TB status in Ghana is associated with varied socioeconomic and demographic characteristics, which may be driven by fears of stigma and discrimination. Addressing TB-related stigma and discrimination can enhance positive attitudes towards TB disclosure. For an infectious disease such as TB, openness towards status disclosure is important for public health.

Health Seeking Behaviour among Individuals with Presumptive Tuberculosis in Zambia

Background

Tuberculosis (TB) prevalence surveys offer a unique opportunity to study health seeking behaviour at the population level because they identify individuals with symptoms that should ideally prompt a health consultation.

Objective

To assess the health-seeking behaviour among individuals who were presumptive TB cases in a national population based TB prevalence survey.

Methods

A cross sectional survey was conducted between 2013 and 2014 among 66 survey clusters in Zambia. Clusters were census supervisory areas (CSAs). Participants (presumptive TB cases) were individuals aged 15 years and above; having either cough, fever or chest pain for 2 weeks or more; and/or having an abnormal or inconclusive chest x-ray image. All survey participants were interviewed about symptoms and had a chest X-ray taken. An in-depth interview was conducted to collect information on health seeking behaviour and previous TB treatment.

Results

Of the 6,708 participants, the majority reported at least a history of chest pain (3,426; 51.1%) followed by cough (2,405; 35.9%), and fever (1,030; 15.4%) for two weeks or more. Only 34.9% (2,340) had sought care for their symptoms, mainly (92%) at government health facilities. Of those who sought care, 13.9% (326) and 12.1% (283) had chest x-ray and sputum examinations, respectively. Those ever treated for TB were 9.6% (644); while 1.7% (114) was currently on treatment. The average time (in weeks) from onset of symptoms to first care-seeking was 3 for the presumptive TB cases. Males, urban dwellers and individuals in the highest wealth quintile were less likely to seek care for their symptoms. The likelihood of having ever been treated for TB was highest among males, urban dwellers; respondents aged 35–64 years, individuals in the highest wealth quintile, or HIV positive.

Conclusion

Some presumptive TB patients delay care-seeking for their symptoms. The health system misses opportunities to diagnose TB among those who seek care. Improving health-seeking behaviour among males, urban dwellers and those with a higher social economic status; and addressing health care lapses in TB case detection is required if TB is to be effectively controlled in Zambia.

Patients infected by tuberculosis and human immunodeficiency virus facing their disease, their reactions to disease diagnosis and its implication about their families and communities, in Burkina Faso: a mixed focus group and cross sectional study

Background

Patients facing tuberculosis (TB) and human immunodeficiency virus (HIV) infection receive particular care. Despite efforts in the care, misconceptions about TB and HIV still heavily impact patients, their families and communities. This situation severely limits achievement of TB and HIV programs goals. This study reports current situation of TB patients and patients living with HIV/AIDS (PLWHA) facing their disease and its implications, by comparing results from both qualitative and quantitative study design.

Methods

Cross sectional study using mixed methods was used and excluded patients co-infected by TB and HIV. Focus group included 96 patients (6 patients per group) stratified by setting, disease profile and gender; from rural (Orodara Health District) and urban (Bobo Dioulasso) areas, all from Hauts-Bassins region in Burkina Faso. Quantitative study included 862 patients (309 TB patients and 553 PLWHA) attending TB and HIV care facilities in two main regions (Hauts-Bassins and Centre) of Burkina Faso.

Results

A content analysis of reports found TB patients and PLWHA felt discriminated and stigmatized because of misconceptions with its aftermaths (rejection, emotional and financial problems), mainly among PLWHA and women patients. PLWHA go to healers when facing limited solutions in health system. There are fewer associations for TB patients, and less education and sensitization sessions to give them opportunity for sharing disease status and learning from other TB patients. TB patients and PLWHA still need to better understand their disease and its implication. Access to care (diagnosis and treatment) remains one of the key issues in health system, especially for PLWHA. Individual counseling is centered among PLWHA but not for TB patients. With research progress and experiences sharing, TB patients and PLWHA have some hope to implement their life project, and to receive psychosocial and nutritional support.

Conclusion

Despite international aid, TB patients and PLWHA are facing misconceptions effects. There is a need to reinforce health education towards patients and healers, inside community, health centers and associations, and for specific settings. International aid must be adapted to specific targets and strategies implementing programs. Maintaining psychosocial and nutritional support is crucial for better outcomes of medication adherence. Individual counseling has to be centered among TB patients and PLWHA.

mHealth for Tuberculosis Treatment Adherence: A Framework to Guide Ethical Planning, Implementation, and Evaluation

Promising mHealth approaches for TB treatment adherence include:

Video observation

Patient- or device-facilitated indirect monitoring

Direct monitoring through embedded sensors or metabolite testing

To mitigate ethical concerns, our framework considers accuracy of monitoring technologies, stigmatization and intrusiveness of the technologies, use of incentives, and the balance of individual and public good.

Vietnam during Economic Transition: A Tracer Study of Health Service Access and Affordability

For many decades, Vietnam had a well-structured public health service with extensive population coverage, with free care at government health facilities until 1989. Since then the country has been going through economic transition, including major changes to the health system. These include the reduction of financial support to public facilities and the introduction of user charges. Concern has been growing about the effect of these changes on access and affordability of health care, particularly for poor families. Using data from the Vietnam National Health Survey conducted in 2001–2002, the authors conducted a tracer study of people with diarrheal illness to examine equity in access to and use of health care and the financial burdens placed on patients in seeking care. The study found that children, the elderly, and the poorly educated were more likely to suffer from diarrhea; poor people often did not seek any care regardless of severity of illness, largely because they could not afford it. The opportunity cost due to lost income was also much greater for poor families. Several new policies have been developed in Vietnam to improve access to basic health care for the poor. However, the effects of such policies require close monitoring and remain to be evaluated.

Stigma against Tuberculosis Patients in Addis Ababa, Ethiopia

Background

Stigma attached to tuberculosis contributes to the limited effectiveness of current TB control approaches. However, there is a dearth of studies that explore the causes of stigma attached to tuberculosis and its effects on patients and tuberculosiscontrol programs in Ethiopia.

Methods

An institution-based qualitative study was conducted at St. Peter Tuberculosis Specialized Hospital in Addis Ababa, Ethiopia from July to August, 2015. Ten in-depth interviews and 6 key-informant interviews were carried out among tuberculosis patients and healthcare workers, respectively.The Open Code computer software package was used to analyze the data thematically.

Results

The study revealed that fear of infection and inappropriate health education messages by media were the main causes of tuberculosis stigma. The patients experienced isolation within their family and community, separation, and financial crisis. The stigma attached to tuberculosis may contribute to delayed healthcare seeking, poor treatment adherence, and poor prognosis.

Conclusion

Interventions thatreduce the stigma attached to tuberculosis should target on areas, such as creating community awareness, patient counseling on problem-solving and emotional skills, preparing culturally sensitive and scientifically sound media messages, providing financial support for the patients, and enhancing the qualities of the healthcare workers, such as empathy, concern, respect for the patient and cultural sensitivity.

Durations and Delays in Care Seeking, Diagnosis and Treatment Initiation in Uncomplicated Pulmonary Tuberculosis Patients in Mumbai, India

Background

Timely diagnosis and treatment initiation are critical to reduce the chain of transmission of Tuberculosis (TB) in places like Mumbai, where almost 60% of the inhabitants reside in overcrowded slums. This study documents the pathway from the onset of symptoms suggestive of TB to initiation of TB treatment and examines factors responsible for delay among uncomplicated pulmonary TB patients in Mumbai.

Methods

A population-based retrospective survey was conducted in the slums of 15 high TB burden administrative wards to identify 153 self-reported TB patients. Subsequently in-depth interviews of 76 consenting patients that fit the inclusion criteria were undertaken using an open-ended interview schedule. Mean total, first care seeking, diagnosis and treatment initiation duration and delays were computed for new and retreatment patients. Patients showing defined delays were divided into outliers and non-outliers for all three delays using the median values.

Results

The mean duration for the total pathway was 65 days with 29% of patients being outliers. Importantly the mean duration of first care seeking was similar in new (24 days) and retreatment patients (25 days). Diagnostic duration contributed to 55% of the total pathway largely in new patients. Treatment initiation was noted to be the least among the three durations with mean duration in retreatment patients twice that of new patients. Significantly more female patients experienced diagnostic delay. Major shift of patients from the private to public sector and non-allopaths to allopaths was observed, particularly for treatment initiation.

Conclusion

Achieving positive behavioural changes in providers (especially non-allopaths) and patients needs to be considered in TB control strategies. Specific attention is required in counselling of TB patients so that timely care seeking is effected at the time of relapse. Prioritizing improvement of environmental health in vulnerable locations and provision of point of care diagnostics would be singularly effective in curbing pathway delays.

Are current case-finding methods under-diagnosing tuberculosis among women in Myanmar? An analysis of operational data from Yangon and the nationwide prevalence survey

Background

Although there is a large increase in investment for tuberculosis control in Myanmar, there are few operational analyses to inform policies. Only 34 % of nationally reported cases are from women. In this study, we investigate sex differences in tuberculosis diagnoses in Myanmar in order to identify potential health systems barriers that may be driving lower tuberculosis case finding among women.

Methods

From October 2014 to March 2015, we systematically collected data on all new adult smear positive tuberculosis cases in ten township health centres across Yangon, the largest city in Myanmar, to produce an electronic tuberculosis database. We conducted a descriptive cross-sectional analysis of sex differences in tuberculosis diagnoses at the township health centres. We also analysed national prevalence survey data to calculate additional case finding in men and women by using sputum culture when smear microscopy was negative, and estimated the sex-specific impact of using a more sensitive diagnostic tool at township health centres.

Results

Overall, only 514 (30 %) out of 1371 new smear positive tuberculosis patients diagnosed at the township health centres were female. The proportion of female patients varied by township (from 21 % to 37 %, p = 0.0172), month of diagnosis (37 % in February 2015 and 23 % in March 2015 p = 0.0004) and age group (26 % in 25–64 years and 49 % in 18–25 years, p < 0.0001). Smear microscopy grading of sputum specimens was not substantially different between sexes. The prevalence survey analysis indicated that the use of a more sensitive diagnostic tool could result in the proportion of females diagnosed at township health centres increasing to 36 % from 30 %.

Conclusions

Our study, which is the first to systematically compile and analyse routine operational data from tuberculosis diagnostic centres in Myanmar, found that substantially fewer women than men were diagnosed in all study townships. The sex ratio of newly diagnosed cases varied by age group, month of diagnosis and township of diagnosis. Low sensitivity of tuberculosis diagnosis may lead to a potential under-diagnosis of tuberculosis among women.

Dynamics of a Mathematical Model for Tuberculosis with Variability in Susceptibility and Disease Progressions Due to Difference in Awareness Level

This work extends a mathematical model for the transmission dynamics of tuberculosis that examined the impact of certain factors on tuberculosis case detection (Okuonghae and Omosigho, 2011). The extended model now classifies the latently infected individuals by their level of tuberculosis awareness (as was done for the susceptible sub-population) and further expands the number of key factors that can positively affect the tuberculosis case detection rate. The effect of these identified factors on the associated reproduction number of the model is considered. It is shown that the system can undergo the phenomenon of backward bifurcation when the associated reproduction number of the model is less than unity; in a special case, the effect of exogenous re-infection on the backward bifurcation phenomenon is significantly dictated by the level of awareness of the latently infected individuals. Qualitative and quantitative analysis of the model showed the effect of key identified factors on the dynamics of tuberculosis while suggesting a serious concentration on tuberculosis awareness programmes, active case finding strategies and use of active cough identification for identifying likely TB cases and sustaining awareness campaigns over a long period of time.

Close to community health providers post 2015: Realising their role in responsive health systems and addressing gendered social determinants of health

Universal health coverage is gaining momentum and is likely to form a core part of the post Millennium Development Goal (MDG) agenda and be linked to social determinants of health, including gender; Close to community health providers are arguably key players in meeting the goal of universal health coverage through extending and delivering health services to poor and marginalised groups; Close to community health providers are embedded in communities and may therefore be strategically placed to understand intra household gender and power dynamics and how social determinants shape health and well-being. However, the opportunities to develop critical awareness and to translate this knowledge into health system and multi-sectoral action are poorly understood; Enabling close to community health providers to realise their potential requires health systems support and human resource management at multiple levels.

Evolutionary concept analysis of health seeking behavior in nursing: a systematic review

BACKGROUND

Although the research in health seeking behavior has been evolving, its concept remains ambiguous. Concept clarification, as a central basis of developing knowledge, plays an undeniable role in the formation of nursing sciences. As the initial step toward the development of theories and theoretical models, concept analysis is broadly used through which the goals can be used and tested. The aim of this study was to report an analysis of the concept of "health seeking behavior".

METHOD

Employing a rigorous evolutionary concept analysis approach, the concept of health seeking behavior was examined for its implications, use, and significance in the discipline of nursing between 2000 and 2012. After applying inclusion and exclusion criteria, a total of 40 articles and 3 books were selected for the final analysis.

RESULTS

The definition of attributes, antecedents, and consequences of health seeking behavior was performed through concept analysis. Core attributes (interactional, processing, intellectual, active, decision making based and measurable) were studied. The antecedents of concept were categorized as social, cultural, economic, disease pattern and issues related to health services. Health-seeking behavior resulted in health promotion and disease risk reduction. In addition, it led to predicting the future probable burden of the diseases, facilitation of the health status, early diagnosis, complete and effective treatment, and complication control.

CONCLUSION

Health-seeking behavior, as a multi-dimensional concept, relies on time and context. An awareness of health-seeking behavior attributes antecedents and consequences results in promoting the status, importance and application of this concept in the nursing profession.

SOCIAL, HISTORICAL AND CULTURAL DIMENSIONS OF TUBERCULOSIS

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

'For a mere cough, men must just chew Conjex, gain strength, and continue working': the provider construction and tuberculosis care-seeking implications in Blantyre, Malawi

BACKGROUND

Delay by men in seeking healthcare results in their higher mortality while on HIV or tuberculosis (TB) treatment and contributes to ongoing community-level disease transmission before going on treatment.

OBJECTIVE

To understand masculinity's role in delay in healthcare seeking for men, with a focus on TB-suggestive symptoms.

DESIGN

Data were collected between March 2011 and March 2012 in low-income suburbs in urban Blantyre using focus group discussions with community members (n=8) and health workers (n=2), in-depth interviews with 20 TB patients (female=14) and 20 uninvestigated chronic coughers (female=8), and a 3-day participatory workshop with 27 health stakeholder representatives. The research process drew to a large extent on grounded theory principles in the manner of Strauss and Corbin (1998) and also Charmaz (1995).

RESULTS

Role descriptions by both men and women in the study universally assigned men as primary material providers for their immediate family, that is, the ones earning and bringing livelihood and additional material needs. In a context where collectivism was valued, men were also expected to lead the provision of support to wider kin. Successful role enactment was considered key to achieving recognition as an adequate man; at the same time, job scarcity and insecurity, and low earnings gravely impeded men. Pressures to generate continuing income then meant constantly looking for jobs, or working continuously to retain insecure jobs or to raise money through self-employment. All this led men to relegate their health considerations.

CONCLUSIONS

Early engagement with formal healthcare is critical to dealing with TB and HIV. However, role constructions as portrayed for men in this study, along with the opportunity costs of acknowledging illness seem, in conditions of vulnerability, important barriers to care-seeking. There is a need to address hidden care-seeking costs and to consider more complex interventions, including reducing precarity, in efforts to improve men's engagement with their health.

Gender Differences in the Interpretation of Experiences of Patients with Tuberculosis in Medellín, Colombia

OBJECTIVE

This study sought to determine gender differences in the interpretation of tuberculosis (TB) in a group of patients from the city of Medellín.

METHODOLOGY

This was a qualitative study, with the grounded theory method. Twelve semistructured interviews were applied to patients from both genders who were cured of TB. The sample was selected through convenience and for analysis the information was categorized through the Atlas Ti tool.

RESULTS

Regarding the symptoms, the most reported is cough, but men manifest expectoration more frequently. Men overstated the symptoms, while women tend to minimize them. Women report mental impairment and emotional-type manifestations produced by the disease. Men and women expressed ignorance about the disease upon diagnosis. Both manifested fear of infection, work incapacity, loss of employment, rejection by others, and death. Also highlighted is the importance of family support and of the healthcare personnel. Women expressed shame in that others knew of their disease and mentioned greater intolerance with taking the medications.

CONCLUSION

The gender role constructed culturally constitutes the central axis that explains how men and women interpret TB and can be modified by educational and accompaniment processes. Family support plays an important role in the healing process. Although common aspects exist, delving into the gender differences against the interpretation of TB may permit a different approach of the disease and better control of it.