Fear and social isolation as consequences of tuberculosis in VietNam: a gender analysis

Is convenience really king? Comparative evaluation of catastrophic costs due to tuberculosis in the public and private healthcare sectors of Viet Nam: a longitudinal patient cost study

BACKGROUND

In Viet Nam, tuberculosis (TB) represents a devastating life-event with an exorbitant price tag, partly due to lost income from daily directly observed therapy in public sector care. Thus, persons with TB may seek care in the private sector for its flexibility, convenience, and privacy. Our study aimed to measure income changes, costs and catastrophic cost incurrence among TB-affected households in the public and private sector.

METHODS

Between October 2020 and March 2022, we conducted 110 longitudinal patient cost interviews, among 50 patients privately treated for TB and 60 TB patients treated by the National TB Program (NTP) in Ha Noi, Hai Phong and Ho Chi Minh City, Viet Nam. Using a local adaptation of the WHO TB patient cost survey tool, participants were interviewed during the intensive phase, continuation phase and post-treatment. We compared income levels, direct and indirect treatment costs, catastrophic costs using Wilcoxon rank-sum and chi-squared tests and associated risk factors between the two cohorts using multivariate regression.

RESULTS

The pre-treatment median monthly household income was significantly higher in the private sector versus NTP cohort (USD 868 vs USD 578; P = 0.010). However, private sector treatment was also significantly costlier (USD 2075 vs USD 1313; P = 0.005), driven by direct medical costs which were 4.6 times higher than costs reported by NTP participants (USD 754 vs USD 164; P < 0.001). This resulted in no significant difference in catastrophic costs between the two cohorts (Private: 55% vs NTP: 52%; P = 0.675). Factors associated with catastrophic cost included being a single-person household [adjusted odds ratio (aOR = 13.71; 95% confidence interval (CI): 1.36-138.14; P = 0.026], unemployment during treatment (aOR = 10.86; 95% CI: 2.64-44.60; P < 0.001) and experiencing TB-related stigma (aOR = 37.90; 95% CI: 1.72-831.73; P = 0.021).

CONCLUSIONS

Persons with TB in Viet Nam face similarly high risk of catastrophic costs whether treated in the public or private sector. Patient costs could be reduced through expanded insurance reimbursement to minimize direct medical costs in the private sector, use of remote monitoring and multi-week/month dosing strategies to avert economic costs in the public sector and greater access to social protection mechanism in general.

A qualitative assessment on the acceptability of providing cash transfers and social health insurance for tuberculosis-affected families in Ho Chi Minh City, Vietnam

To achieve the Sustainable Development Goal's targets of universal health coverage (UHC) and poverty reduction, interventions are required that strengthen and harmonize both UHC and social protection. Vietnam is committed to achieving financial protection and over 90% of the general population has enrolled in its social health insurance (SHI) scheme. However, an estimated 63% of tuberculosis (TB)-affected households in Vietnam still face catastrophic costs and little is known about the optimal strategies to mitigate the costs of TB care for vulnerable families. This study assessed the acceptability of a social protection package containing cash transfers and SHI using individual interviews (n = 19) and focus group discussions (n = 3 groups). Interviews were analyzed through framework analysis. The study's main finding indicated that both conditional and unconditional cash transfers paired with SHI were acceptable, across six dimensions of acceptability. Cash transfers were considered beneficial for mitigating out-of-pocket expenditure, increasing TB treatment adherence, and improving mental health and general well-being, but the value provided was inadequate to fully alleviate the economic burden of the illness. The conditionality of the cash transfers was not viewed by participants as inappropriate, but it increased the workload of the TB program, which brought into question the feasibility of scale-up. SHI was viewed as a necessity by almost all participants, but people with TB questioned the quality of care received when utilizing it for auxiliary TB services. Access to multiple sources of social protection was deemed necessary to fully offset the costs of TB care. Additional research is needed to assess the impact of cash transfer interventions on health and economic outcomes in order to create an enabling policy environment for scale-up.

Moralization and Mismoralization in Public Health

Moralization is a social-psychological process through which morally neutral issues take on moral significance. Often linked to health and disease, moralization may sometimes lead to good outcomes; yet moralization is often detrimental to individuals and to society as a whole. It is therefore important to be able to identify when moralization is inappropriate. In this paper, we offer a systematic normative approach to the evaluation of moralization. We introduce and develop the concept of 'mismoralization', which is when moralization is metaethically unjustified. In order to identify mismoralization, we argue that one must engage in metaethical analysis of moralization processes while paying close attention to the relevant facts. We briefly discuss one historical example (tuberculosis) and two contemporary cases related to COVID-19 (infection and vaccination status) that we contend to have been mismoralized in public health. We propose a remedy of de-moralization that begins by identifying mismoralization and that proceeds by neutralizing inapt moral content. De-moralization calls for epistemic and moral humility. It should lead us to pull away from our tendency to moralize-as individuals and as social groups-whenever and wherever moralization is unjustified.

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.

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.

Self-reported gender differentials in the knowledge of tuberculosis transmission and curative possibility using national representative data in Ghana

Background

Health-seeking behaviour, stigma, and discrimination towards people affected by tuberculosis (TB) are influenced by awareness of the disease. Gender differentials in the diagnosis and treatment of TB have been reported in other settings of the world. However, little is known about the gender differences in the knowledge of TB transmission and curative possibility in Ghana.

Methods

The analysed data were a weighted sample of 9,396 women aged 15–49 years and 4,388 men aged 15–59 years, obtained from the 2014 Ghana Demographic and Health Survey. The dependent variable, correct knowledge regarding TB transmission and cure was derived from questions on the transmission of the disease and the possibility of a cure. A design-based multivariate logistic regression model in Stata 13.0/SE was used to identify the correlates of reporting correct knowledge.

Results

Overall, the mean knowledge score was 6.1±0.9 (maximum = 7). Of the 13,784 respondents, 45.7% (95% CI: 44.0–47.3) reported correct knowledge regarding TB transmission and cure. Men had significantly higher knowledge than women (50.9% versus 43.2%). Misconceptions, including TB transmitted through sharing utensils (13.3%), food (6.9%), touching a person with TB (4.5%), sexual contact (4.1%), and mosquito bites (0.4%) were noted. About 30% (33% women and 25% men) of the total sample would keep the information secret when a household member is affected with TB. In the adjusted analysis, age, gender, education, region, place of residence, wealth quintile, frequency of reading newspaper/magazine, listening to the radio, and watching television were significantly associated with reporting correct knowledge.

Conclusions

There was low knowledge regarding TB transmission and cure. Misconceptions regarding the transmission of TB prevailed among the participants. Gender differential in knowledge was observed. Comparatively, females were less likely to be aware of TB and report correct knowledge regarding TB transmission but were more likely to conceal information when a household member was affected by the disease.

Quantifying the global number of tuberculosis survivors: a modelling study

BACKGROUND

People who survive tuberculosis face clinical and societal consequences after recovery, including increased risks of recurrent tuberculosis, premature death, reduced lung function, and ongoing stigma. To describe the size of this issue, we aimed to estimate the number of individuals who developed first-episode tuberculosis between 1980 and 2019, the number who survived to 2020, and the number who have been treated within the past 5 years or 2 years.

METHODS

In this modelling study, we estimated the number of people who survived treated tuberculosis using country-level WHO data on tuberculosis case notifications, excluding those who died during treatment. We estimated the number of individuals surviving untreated tuberculosis using the difference between WHO country-level incidence estimates and notifications, applying published age-stratified and HIV-stratified case fatality ratios. To estimate survival with time, post-tuberculosis life tables were developed for each country-year by use of UN World Population Prospects 2019 mortality rates and published post-tuberculosis mortality hazard ratios.

FINDINGS

Between 1980 and 2019, we estimate that 363 million people (95% uncertainty interval [UI] 287 million-438 million) developed tuberculosis, of whom 172 million (169 million-174 million) were treated. Individuals who developed tuberculosis between 1980 and 2019 had lived 3480 million life-years (95% UI 3040 million-3920 million) after tuberculosis by 2020, with survivors younger than 15 years at the time of tuberculosis development contributing 12% (95% UI 7-17) of these life-years. We estimate that 155 million tuberculosis survivors (95% UI 138 million-171 million) were alive in 2020, the largest proportion (47% [37-57]) of whom were in the WHO South-East Asia region. Of the tuberculosis survivors who were alive in 2020, we estimate that 18% (95% UI 16-20) were treated in the past 5 years and 8% (7-9) were treated in the past 2 years.

INTERPRETATION

The number of tuberculosis survivors alive in 2020 is more than ten times the estimated annual tuberculosis incidence. Interventions to alleviate respiratory morbidity, screen for and prevent recurrent tuberculosis, and reduce stigma should be immediately prioritised for recently treated tuberculosis survivors.

FUNDING

UK Medical Research Council, the UK Department for International Development, the National Institute for Health Research, and the European and Developing Countries Clinical Trials Partnership.

Missing men with tuberculosis: the need to address structural influences and implement targeted and multidimensional interventions

Tuberculosis (TB) is treatable but is the leading infectious cause of death worldwide, with men over-represented in some key aspects of the disease burden. Men’s TB epidemiological scenario occurs within a wider public health and historical context, including their prior sidelining in health discussions. Differences are however noticeable in how some Western countries and high TB and HIV burden low and middle-income countries (LMIC) including in Africa have approached the subject(s) of men and health. The former have a comparatively long history of scholarship, and lately are implementing actions targeting men’s health and wellness, both increasingly addressing multilevel social and structural determinants. In contrast, in the latter men have received attention primarily for their sexual practices and role in HIV and AIDS and gender-based violence; moreover, interventions, guided by the public health approach, have stressed short-term, measurable and medical goals. Debates and the limited available empirical literature on men’s engagement with TB-related healthcare are nevertheless indicating need for a shift, within TB work with men in high burden LMICs towards, structural and multicomponent interventions.

Psychometric evaluation of a new drug-resistant tuberculosis stigma scale

OBJECTIVES

Stigma contributes to diagnostic delay, disease concealment, and reduced wellbeing for people with multidrug-resistant tuberculosis (MDR-TB) and their communities. Despite the negative effects of stigma, there are no scales to measure stigma in people with MDR-TB. This study aimed to develop and validate a scale to measure stigma in people affected by MDR-TB in Vietnam.

STUDY DESIGN AND SETTING

People with rifampicin-resistant (RR)-MDR-TB who had completed at least 3 months of treatment were invited to complete a survey containing 45 draft stigma items. Data analysis included exploratory factor analysis, internal consistency, content, criterion and construct validity, and test-retest reliability.

RESULTS

A total of 315 people with RR/MDR-TB completed the survey. Exploratory factor analysis revealed a 14 item RR/MDR-TB stigma scale with four subscales, including guilt, social exclusion, physical isolation, and blame. Internal consistency and test-retest reliability were good (Cronbach's Alpha = 0.76, ICC = 0.92). Construct validity was adequate with moderate correlations with related constructs.

CONCLUSION

Our RR/MDR-TB Scale demonstrated good psychometric properties in Vietnam. This scale will assist in the measurement of stigma in people with RR/MDR-TB. It will also aid in the evaluation of stigma reduction interventions in people with RR/MDR-TB.

Quality of life and associated factors among patients with tuberculosis at the University of Gondar comprehensive specialized hospital, Ethiopia

PURPOSE

Clinical outcomes have failed to capture the impact of tuberculosis (TB) on patients; consequently, a comprehensive measure is required. This study's objective was to determine the level of quality of life (QOL) and associated factors among patients with TB at the University of Gondar comprehensive specialized hospital, TB clinic.

METHODS

A cross-sectional study was conducted from April to June 2019. A total of 400 patients were selected. The world health organization quality-of-life (WHOQOL-Bref) questionnaire was used to measure QOL. Linear regression analysis was done to investigate potential predictors, and variables with a P value of <0.05 were considered statistically significant.

RESULTS

The participants had a mean age of 38.04 ± 13.53 years; the percentage of patients with pulmonary TB (PTB) was 52.71% and 57.36% were male. The QOL scores for physical, psychological, social and environmental domains were 43.54 ± 10.18, 46.67 ± 7.93, 39.79 ± 15.30 and 41.22 ± 12.90, respectively. PTB was associated with physical, psychological, social, and environmental domains (B = -3.99, P value <0.001), (B = -2.03, P value = 0.027), (B = -4.44, P value = 0.008), and (B = -2.83, P value = 0.029), individually; likewise, drug adherence was associated with physical (B = -10.36), psychological (B = -4.48), social (B = -14.46), and environmental (B = -8.44) domains at a P value <0.001. Education (B = 2.39, P value = 0.018), and co-morbidity (B = -4.28, P value = 0.023) were associated with the psychological domain. Finally, occupation was significantly associated with the environmental domain (B = -4.53, P value = 0.008).

CONCLUSION

This study revealed that the QOL of patients was relatively low compared to that of other studies. Notably, social domains were affected more than other domains. Non-adherence and PTB were negatively associated with all domains. Therefore, health professionals should emphasize patients' drug adherence.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

Introduction:

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

Methods:

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

Result:

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

Conclusion:

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

Quality of life, tuberculosis and treatment outcome; a case-control and nested cohort study

BACKGROUND

Global tuberculosis policy increasingly emphasises broad tuberculosis impacts and highlights the lack of evidence concerning tuberculosis-related quality of life (QOL).

METHODS

Participants were recruited in 32 Peruvian communities between July 13, 2016 and February 24, 2018 and followed-up until November 8, 2019. Inclusion criteria were age ≥15 years for "patients" (n=1545) starting treatment for tuberculosis disease in health centres; "contacts" (n=3180) who shared a patient's household for ≥6 h·week^-1; and randomly selected "controls" (n=277). The EUROHIS-QOL questionnaire quantified satisfaction with QOL, health, energy, activities of daily living (ADL), self, relationships, money and living place.

FINDINGS

Newly diagnosed tuberculosis was most strongly associated with lower QOL scores (p<0.001). Patients initially had lower QOL than controls for all EUROHIS-QOL questions (p≤0.01), especially concerning health, ADL and self. Lower initial QOL in patients predicted adverse treatment outcomes and scores <13 points had 4.2-fold (95% CI 2.3-7.6) increased risk of death versus those with higher QOL scores (both p<0.001). Patient QOL was re-assessed 6 months later, and for patients with successful treatment QOL became similar to participants who had never had tuberculosis, whereas patients who did not complete treatment continued to have low QOL (p<0.001). Multidrug-resistant tuberculosis was associated with lower QOL before and during treatment (both p<0.001). Contacts had lower QOL if they lived with a patient who had low QOL score (p<0.0001) or were a caregiver for the patient (p<0.001).

CONCLUSIONS

Tuberculosis was associated with impaired psychosocioeconomic QOL which recovered with successful treatment. Low QOL scores predicted adverse treatment outcome. This brief EUROHIS-QOL eight-item questionnaire quantified the holistic needs of tuberculosis-affected people, potentially guiding patient-centred care.

Characteristics Indicative of Tuberculosis/HIV Coinfection in a High-Burden Setting: Lessons from 13,802 Incident Tuberculosis Cases in Harare, Zimbabwe

Country-specific interventions targeting high-risk groups are necessary for a global reduction in Tuberculosis (TB)/HIV burden. We analyzed the data of 13,802 TB cases diagnosed in Harare, Zimbabwe, during 2013-2017. Pearson's chi-square tests and multivariate logistic regression models were used to identify patient characteristics significantly associated with TB/HIV coinfection. Of the 13,802 TB cases analyzed, 9,725 (70.5%) were HIV positive. A significantly higher odds of having TB/HIV coinfection diagnosis was found among females, patients aged 25-64 years, previously treated cases, and acid-fast bacillus sputum smear-negative cases. Compared with nondisseminated pulmonary TB, miliary TB (adjusted odds ratio [aOR]: 1.469, 95% CI: 1.071, 2.015) and TB meningitis (aOR: 1.715, 95% CI: 1.074, 2.736) both had a significantly higher odds for TB/HIV coinfection, whereas pleural TB (aOR 0.420, 95% CI: 0.354, 0.497) and all other extrapulmonary TB (EPTB) (aOR: 0.606, 95% CI: 0.516 0.712) were significantly less likely to have TB/HIV coinfection. The risk for TB/HIV coinfection varied significantly by patients' sociodemographic and clinical characteristics in Harare. Our finding that different forms of EPTB have different relationships with HIV coinfection has extended the knowledge base about clinical markers for TB/HIV coinfection which can lead to a greater public health impact on eliminating TB/HIV infection.

Health-Related Quality of Life (HRQoL) scores vary with treatment and may identify potential defaulters during treatment of tuberculosis

Introduction

Nigeria ranks third among the 22 high-burden TB countries in the world. With the availability of effective treatment strategies, and more patients surviving the disease, assessment of Patient Reported Outcomes (PROs) has become imperative to assist with patient evaluation of measured outcomes and thus improve morbidity. Literature is scarce on assessment and impact of chemotherapy on Health-Related Quality of Life (HRQoL) for patients with tuberculosis.

Aim

This study evaluates the variation in Health-Related Quality of Life (HRQoL) in pulmonary TB patients during the intensive phase of treatment.

Methods

We recruited patients with pulmonary TB (PTB), from 3 different TB clinics across Ife Ijesha Zone, Osun State, Nigeria. Consenting patients were administered Short Form-36 HRQoL questionnaire at recruitment and at the end of intensive phase of treatment. HRQoL scores were compared at these two-time points, the degrees of changes were calculated and relationships with some. Directly Observed Therapy-Short (DOTS) course outcome measures were obtained. Logistic regression was used to identify factors associated with greatest change in HRQoL scores.

Results

Of the 130 recruited patients, we analysed data for 126 patients who met the inclusion criteria. Mean age was 36.7(SD15.5). The overall mean HRQoL score obtained at enrolment was 43.18 (SD 17.2) and 60.22 (SD19.83) at end of 2 months; mean change =17.04 p<0.001). The least change was on the emotional well-being domain (mean change = 4.24, p=0.05). Predictor of significant change in HRQoL scores were previous history of TB, HIV status and TB severity, p<0.05 each. High physical functioning score was a strong predictor of defaulters (OR = 5.3; 95%CI: 2.11–9.05, p = 0.01).

Conclusion

Emotional domain is least affected by PTB while younger patients with no physical impairment are more likely to default treatment. Various aspects of HRQoL can be a useful tool for patient's evaluation and outcome prediction.

Care and social support from family and community in patients with pulmonary tuberculosis in Pakistan

Objectives

This study aimed to validate the Medical Outcome Study-Social Support Survey (MOS-SSS) instrument in Pakistan and to quantify the nature of care and social support currently extended to patients with pulmonary tuberculosis (TB) in Pakistan.

Design

This is a cross-sectional study design conducted within a period of 3 months from 1 November 2016 to 31 January 2017.

Participants

A total of 269 patients, registered at 11 TB centres and private clinics, were interviewed through an interviewer-administered questionnaire.

Main outcome measures

Cronbach's alpha was used to measure the internal consistency and reliability of the MOS-SSS survey instrument. Univariate and multivariable logistic regressions have been used to explore the association between care and social support, and socioeconomic factors.

Result

This study validated the use of the MOS-SSS among patients with TB in Pakistan. Findings of the study revealed significant differences among the socioeconomic groups of patients in each subscale of social support. Additionally, results of logistic regressions showed that patients who were older (adjusted OR=6.17, 95% CI 1.55 to 24.59, p≤0.01), male (adjusted OR=2.73, 95% CI 1.49 to 4.98, p≤0.01), widow (adjusted OR=0.17, 95% CI 0.04 to 0.80, p≤0.05), and had a larger household size (adjusted OR=5.69, 95% CI 1.32 to 24.65, p≤0.05), higher monthly income (adjusted OR=2.00, 95% CI 1.11 to 3.60, p≤0.05) and house ownership (adjusted OR=1.99, 95% CI 1.10 to 3.60, p≤0.05) were significant factors associated with the extent of care and social support that the participants received.

Conclusion

To cure TB, this study suggests a coordinated approach that includes not only clinical services to address this issue but also a strong social support system based on family and community necessary throughout the treatment process.

Community-wide Screening for Tuberculosis in a High-Prevalence Setting

BACKGROUND

The World Health Organization has set ambitious targets for the global elimination of tuberculosis. However, these targets will not be achieved at the current rate of progress.

METHODS

We performed a cluster-randomized, controlled trial in Ca Mau Province, Vietnam, to evaluate the effectiveness of active community-wide screening, as compared with standard passive case detection alone, for reducing the prevalence of tuberculosis. Persons 15 years of age or older who resided in 60 intervention clusters (subcommunes) were screened for pulmonary tuberculosis, regardless of symptoms, annually for 3 years, beginning in 2014, by means of rapid nucleic acid amplification testing of spontaneously expectorated sputum samples. Active screening was not performed in the 60 control clusters in the first 3 years. The primary outcome, measured in the fourth year, was the prevalence of microbiologically confirmed pulmonary tuberculosis among persons 15 years of age or older. The secondary outcome was the prevalence of tuberculosis infection, as assessed by an interferon gamma release assay in the fourth year, among children born in 2012.

RESULTS

In the fourth-year prevalence survey, we tested 42,150 participants in the intervention group and 41,680 participants in the control group. A total of 53 participants in the intervention group (126 per 100,000 population) and 94 participants in the control group (226 per 100,000) had pulmonary tuberculosis, as confirmed by a positive nucleic acid amplification test for Mycobacterium tuberculosis (prevalence ratio, 0.56; 95% confidence interval [CI], 0.40 to 0.78; P<0.001). The prevalence of tuberculosis infection in children born in 2012 was 3.3% in the intervention group and 2.6% in the control group (prevalence ratio, 1.29; 95% CI, 0.70 to 2.36; P = 0.42).

CONCLUSIONS

Three years of community-wide screening in persons 15 years of age or older who resided in Ca Mau Province, Vietnam, resulted in a lower prevalence of pulmonary tuberculosis in the fourth year than standard passive case detection alone. (Funded by the Australian National Health and Medical Research Council; ACT3 Australian New Zealand Clinical Trials Registry number, ACTRN12614000372684.).

Quality of life with tuberculosis

Tuberculosis diagnosis and treatment currently revolves around clinical features and microbiology. The disease however adversely affects patients’ psychological, economic, and social well-being as well, and therefore our focus also additionally needs to shift towards quality of life (QOL). The disease influences all QOL domains and substantially adds to patient morbidity, and these complex and multidimensional interactions pose challenges in accurately quantifying impairment in QOL. For this review, PubMed database was queried using keywords like quality of life, health status and tuberculosis, and additional publications identified by a bibliographic review of shortlisted articles. Both generic and specific QOL scales show a wide variety of derangements in scores, and results vary across countries and patient groups. In particular, diminished capacity to work, social stigmatization, and psychological issues worsen QOL in patients with tuberculosis. Although QOL has been consistently shown to improve during standard anti-tubercular therapy, many patients continue to show residual impairment. It is also not clear if specific situations like presence of comorbid illnesses, drug resistance, or co-infection with human immunodeficiency virus additionally worsen QOL in these patients. There is a definite need to incorporate QOL assessment as adjunct outcome measures in tuberculosis control programs. Governments and program managers need to step up socio-cultural reforms and health education, and provide additional incentives to patients, to counter impairment in QOL.

Treatment outcomes among children, adolescents, and adults on treatment for tuberculosis in two metropolitan municipalities in Gauteng Province, South Africa

Background

Gauteng Province has the second lowest tuberculosis (TB) incidence rate in South Africa but the greatest proportion of TB/HIV co-infection, with 68% of TB patients estimated to have HIV. TB treatment outcomes are well documented at the national and provincial level; however, knowledge gaps remain on how outcomes differ across detailed age groups.

Methods

Using data from South Africa’s National Electronic TB Register (ETR), we assessed all-cause mortality and loss to follow-up (LTFU) among patients initiating treatment for TB between 01/2010 and 12/2015 in the metropolitan municipalities of Ekurhuleni Metropolitan Municipality and the City of Johannesburg in Gauteng Province. We excluded patients who were missing age, had known drug-resistance, or transferred into TB care from sites outside the two metropolitan municipalities. Among patients assigned a treatment outcome, we investigated the association between age group at treatment initiation and mortality or LTFU (treatment interruption of ≥2 months) within 10 months after treatment initiation using Cox proportional hazard models and present hazard ratios and Kaplan-Meier survival curves.

Results

We identified 182,890 children (<10 years), young adolescent (10–14), older adolescent (15–19), young adult (20–24), adult (25–49), and older adult (≥50) TB cases without known drug-resistance. ART coverage among HIV co-infected patients was highest for young adolescents (64.3%) and lowest for young adults (54.0%) compared to other age groups (all over 60%). Treatment success exceeded 80% in all age groups (n = 170,017). All-cause mortality increased with age. Compared to adults, young adults had an increased hazard of LTFU (20–24 vs 25–49 years; aHR 1.43 95% CI: 1.33, 1.54) while children, young adolescents, and older adults had lower hazard of LTFU. Patients with HIV on ART had a lower risk of LTFU, but greater risk of death when compared to patients without HIV.

Conclusions

Young adults in urban areas of Gauteng Province experience a disproportionate burden of LTFU and low coverage of ART among co-infected patients. This group should be targeted for interventions aimed at improving clinical outcomes and retention in both TB and HIV care.

"Who Will Marry a Diseased Girl?" Marriage, Gender, and Tuberculosis Stigma in Asia

In a qualitative study on the stigma associated with tuberculosis (TB), involving 73 interviews and eight focus groups conducted in five sites across three countries (Bangladesh, Nepal, and Pakistan), participants spoke of TB's negative impact on the marriage prospects of women in particular. Combining the approach to discovering grounded theory with a conceptualization of causality based on a realist ontology, we developed a theory to explain the relationships between TB, gender, and marriage. The mechanism at the heart of the theory is TB's disruptiveness to the gendered roles of wife (or daughter-in-law) and mother. It is this disruptiveness that gives legitimacy to the rejection of marriage to a woman with TB. Whether or not this mechanism results in a negative impact of TB on marriage prospects depends on a range of contextual factors, providing opportunities for interventions and policies.

Cross-cultural adaptation of the instrument "tool to estimate patient's costs" in priority municipalities of Brazil in tuberculosis control

Abstract Introduction: Tuberculosis is historically associated with poverty, generating costs that can influence treatment. Considering the impact of the costs of illness, the importance of adapting the instrument is highlighted. Objective: To adapt transculturally to Brazilian Portuguese the instrument Tool to Estimate Patient's Costs. Methods: Study of the type transcultural adaptation of instrument. The translation followed the criteria described by Herdman, 1998, in order to preserve functional equivalence as much as possible. The questionnaire with cross-cultural adaptation was applied to 77 patients, with at least one full month of treatment for the disease. Results: Instrument was shown with Cronbach Alpha above 0.71 constituting a good tool for measuring the costs of the disease, being necessary modifications. Conclusions: This study suggests the creation of an instrument adapted for the treatment of TB in Brazil, for the evaluation of costs with the illness by tuberculosis.

Two Years of Retrospective Study on the Incidence of Tuberculosis in Dir Lower Valley, Khyber Pakhtunkhwa, Pakistan

Background: Pakistan has high tuberculosis (TB) burden with alarming mortality and morbidity, and its rate increases day by day, especially in remote areas where access of quality health is not available. Objective: The objective of the study was to determine the incidence rate of pulmonary TB in the Dir valley among the suspected patients according to age-, gender-, and location-wise prevalence of the disease. Methods: A retrospective descriptive study was designed from January 2015 to December 2016. All the 556 people registered are suspected patients of pulmonary tuberculosis sputum smear (PTB-SS) positive, whereas the remaining cases were diagnosed with extra-pulmonary TB and hence excluded from the study. Results: The ratio of PTB-SS-positive cases was higher in females (50.5%, n = 281) compared with males (49.5%, n = 275). Furthermore, in the age group 1 to 20 years, the percentage of PTB-SS-positive cases was 28.1% (n = 156), in 21 to 40 years 40.3% (n = 224), in 41 to 60 years 18.7% (n = 104), in 61 to 80 years 11.2% (n = 62), and at age group >81 years, it was 1.8% (n = 10). No difference was found in the years 2015 and 2016 regarding PTB-SS-positive cases registration. Age and health care facilities (P < .000) and treatment outcome (P < .000) have a strong relationship. No significant relation was found with other demographics variables (P > 0.05). Conclusion: It was concluded from our finding that TB was considerably increased in the general population of District Dir (Lower), and proper supervision, diagnosis, treatment, and awareness of rapid prophylactic measures are needed to eradicate the issue.

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.

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.

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.

Health-Related Quality of Life, Depression and Anxiety in Hospitalized Patients with Tuberculosis

Background

Much of the attention of tuberculosis (TB) programs is focused on outcomes of microbiological cure and mortality, and health related quality of life (HRQL) is undervalued. Also, TB patients have a significantly higher risk of developing depression and anxiety compared with those in the general population. We intend to evaluate the HRQL and the prevalence of symptoms of depression and anxiety in hospitalized patients with TB.

Methods

Cross-sectional study in a tertiary care hospital in Brazil. Adult patients with pulmonary TB that were hospitalized during the study period were identified and invited to participate. HRQL was measured using the Medical Outcomes Study Short Form-36 (SF-36) version 2. Hospital Anxiety and Depression Scale (HADS) was used to record symptoms of anxiety and depression.

Results

Eighty-six patients were included in the analysis. The mean age of all patients was 44.6±15.4 years, 69.8% were male, and 53.5% were white. Thirty-two patients (37.2%) were human immunodeficiency virus positive. Twenty-seven patients (31.4%) met study criteria for depression (HADS depression score ≥11) and 33 (38.4%) had anxiety (HADS anxiety score ≥11). Scores on all domains of SF-36 were significantly lower than the Brazilian norm scores (p<0.001).

Conclusion

The present study shows that TB patients may have a poor HRQL. Additionally, we found a possible high prevalence of depression and anxiety in this population. Health care workers should be aware of these psychological disorders to enable a better management of these patients. The treatment of these comorbidities may be associated with better TB outcomes.

The experiences of high school students with pulmonary tuberculosis in China: a qualitative study

Background

Clustered tuberculosis (TB) still occurred nationally in Chinese schools every year, where high school students patients accounts for the highest proportion. These young TB patients are in a critical period of physical and psychological growth. Research on their illness experience and analysis of underlying causes remains blank. The purpose of this study is to explore the overall illness experience of Chinese high school TB patients and to investigate the individual and social causes of such experience.

Methods

Twenty-two high school TB patients in a certain county of Shaanxi province were interviewed in-depth twice when initial diagnosed and during intermediate treatment periods. Interview data were analyzed by framework approach.

Results

The high school TB patients worried about interruption of studies rather than the disease. They generally showed a lack of awareness of tuberculosis, were highly dependent on parents, and received assistance from teachers and students during the treatment. Most of them did not show obvious stigma.

Conclusion

The unique education system and sociocultural factors in China are the root of special illness experience of high school TB patients. Huge pressure in college entrance examination leads sick students to worry about interruption of studies more than the disease itself. Their serious lack of awareness of TB, caused by the ignorance of school, parents and the students, becomes the biggest obstacle to timely diagnosis and treatment. Whether high dependence on parents is conducive to disease recovery varies with each individual. Meanwhile, patients’ weak stigma could play a positive role in disease recovery. Educational and medical institutions should develop more effective TB control strategies based on these factors.

A cross-sectional study to assess the stigma associated with tuberculosis among tuberculosis patients in Udupi district, Karnataka

BACKGROUND

For decades, tuberculosis and other communicable diseases like human immunodeficiency virus/acquired immune deficiency syndrome, leprosy, etc., have been associated with stigma and discrimination by the society; this can interfere with the lifestyle and disease management among these patients.

OBJECTIVE

To assess the stigma experienced by tuberculosis patients and to find the factors associated with stigma.

METHODS

A cross-sectional study was conducted among 209 sputum-positive and sputum-negative tuberculosis patients. Convenient sampling was used to identify the patients. A predesigned, pretested proforma from Explanatory Model Interview Catalogue developed by World Health Organization was used for data collection.

RESULTS

The study revealed that out of 209 respondents, 51.2% of the respondents experienced some form of stigma. Majority of the patients have received only primary education and 71.3% of the respondents were males. Most of the patients were under category 1 of Directly Observed Treatment Short course. Age, education, and smear status of the patient were found to be associated with stigmatization (P<0.05), whereas factors like gender, income, occupation, family history, and marital status were found to be not significantly associated with stigmatization.

CONCLUSION

Effective counseling measures are recommended for tuberculosis patients with advancing age and education which can help reduce stigmatization and thereby improve quality of life.

[Social stigma and the families of patients with tuberculosis: a study based on cluster and multiple correspondence analysis]

The social stigma associated with TB is a challenge facing management of the area of public health care. The aim of this study was to investigate the social stigma in families of patients with TB and identify the profile of those who are affected by the event in relation to socioeconomic and demographic conditions. It is a cross-sectional study that was conducted in 2011 in the city of Ribeirão Preto, state of São Paulo, Brazil, with a sample of 110 individuals. The data were analyzed using the univariate descriptive technique and cluster and multiple correspondence assessment. The stigmatized groups tend to have lower scholarity, incipient access to the media and little understanding about TB, as opposed to those that have higher educational levels, continuous access to the media, consider themselves well informed and show proactive attitudes to deal with the disease. The identification of varied profiles highlights the need to develop health interventions to cater to the singularities of families with respect to the social stigma of the disease.

Psychosocial wellbeing of patients with multidrug resistant tuberculosis voluntarily confined to long-term hospitalisation in Nigeria

Background and objective

Patient isolation, which is a widely successful treatment strategy for tuberculosis (TB), has been suspected to have effects on patient psychosocial wellbeing. We assessed the psychosocial wellbeing of multidrug resistant TB (MDR-TB) patients in voluntary and isolated long-term hospitalisation in Nigeria.

Methods

98 accessible and consenting patients in four drug-resistant treatment centres (University College Hospital and Government Chest Hospital, Ibadan; Mainland Hospital, Lagos, and Lawrence Henshaw Memorial Hospital, Calabar) were enrolled in this study. Data were collected using an 18-item psychosocial wellbeing questionnaire including sociodemographic characteristics. We used descriptive statistics to present demographic characteristics; the χ² test was used to assess associations between psychosocial wellbeing and independent variables and the relationship was modelled using logistic regression.

Results

The mean age of respondents was 36.1±11.9 years and 63% were males. Respondents had been in hospital an average of 4.5±1.9 months. Females had more psychosocial concerns compared with males. The most common concerns recorded among respondents were concern that people will get to know that the respondent had a bad type of TB (70%), discontent with being separated from and longing for the company of their marital partner (72%), concerns that they may have taken too many drugs (73%), and displeasure with being unable to continue to engage in their usual social and economic activities (75%). Respondents who were employed had eight times the odds of having more psychosocial concerns than the median number among respondents. Respondents who were supported by their own families during hospitalisation experienced a lower burden of psychosocial concerns compared with those who were supported by third parties.

Conclusions

Prolonged hospitalisation resulted in significant psychosocial burden for the MDR-TB patients in our study centres. There is a need to consider alternative approaches that place less psychosocial burden on patients without compromising quality of care.

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.

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

Background

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

Methods

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

Results

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

Conclusion

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

Treatment-Seeking for Tuberculosis-Suggestive Symptoms: A Reflection on the Role of Human Agency in the Context of Universal Health Coverage in Malawi

Tuberculosis (TB) is highly infectious and one of the leading killers globally. Several studies from sub-Saharan Africa highlight health systems challenges that affect ability to cope with existing disease burden, including TB, although most of these employ survey-type approaches. Consequently, few address community or patient perspectives and experiences. At the same time, understanding of the mechanisms by which the health systems challenges translate into seeking or avoidance of formal health care remains limited. This paper applies the notion of human agency to examine the ways people who have symptoms suggestive of TB respond to and deal with the symptoms vis-à-vis major challenges inherent within health delivery systems. Empirical data were drawn from a qualitative study exploring the ways in which notions of masculinity affect engagement with care, including men's well-documented tendency to delay in seeking care for TB symptoms. The study was carried out in three high-density locales of urban Blantyre, Malawi. Data were collected in March 2011 -March 2012 using focus group discussions, of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers; and in-depth interviews with 20 TB patients (female = 14) and 20 un-investigated chronic coughers (female = eight). The research process employed a modified version of grounded theory. Data were coded using a coding scheme that was initially generated from the study aims and subsequently progressively amended to incorporate concepts emerging during the analysis. Coded data were retrieved, re-read, and broken down and reconnected iteratively to generate themes. A myriad of problems were described for health systems at the primary health care level, centring largely on shortages of resources (human, equipment, and drugs) and unprofessional conduct by health care providers. Participants consistently pointed out how the problems could drive patients from promptly reporting symptoms at primary healthcare centres. The accounts suggest that in responding to illness symptoms including those suggestive of TB, patients navigate their options taking into cognisance past and current experiences with formal health systems. Understanding and factoring in the mediating role of such 'agency' is critical when implementing efforts to promote timely response to TB-suggestive symptoms.

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.

Psycho-Socio-Economic Issues Challenging Multidrug Resistant Tuberculosis Patients: A Systematic Review

Background

Limited treatment options, long duration of treatment and associated toxicity adversely impact the physical and mental well-being of multidrug-resistant tuberculosis (MDR-TB) patients. Despite research advances in the microbiological and clinical aspects of MDR-TB, research on the psychosocial context of MDR-TB is limited and less understood.

Methodology

We searched the databases of PubMed, MEDLINE, Embase and Google Scholar to retrieve all published articles. The final manuscripts included in the review were those with a primary focus on psychosocial issues of MDR-TB patients. These were assessed and the information was thematically extracted on the study objective, methodology used, key findings, and their implications. Intervention studies were evaluated using components of the methodological and quality rating scale. Due to the limited number of studies and the multiple methodologies employed in the observational studies, we summarized these studies using a narrative approach, rather than conducting a formal meta-analysis. We used ‘thematic synthesis’ method for extracting qualitative evidences and systematically organised to broader descriptive themes.

Results

A total of 282 published articles were retrieved, of which 15 articles were chosen for full text review based on the inclusion criteria. Six were qualitative studies; one was a mixed methods study; and eight were quantitative studies. The included studies were divided into the following issues affecting MDR-TB patients: a) psychological issues b) social issues and economic issues c) psychosocial interventions. It was found that all studies have documented range of psychosocial and economic challenges experienced by MDR-TB patients. Depression, stigma, discrimination, side effects of the drugs causing psychological distress, and the financial constraints due to MDR-TB were some of the common issues reported in the studies. There were few intervention studies which addressed these psychosocial issues most of which were small pilot studies. There is dearth of large scale randomized psychosocial intervention studies that can be scaled up to strengthen management of MDR-TB patients which is crucial for the TB control programme.

Conclusion

This review has captured the psychosocial and economic issues challenging MDR patients. However there is urgent need for feasible, innovative psychosocial and economic intervention studies that help to equip MDR-TB patients cope with their illness, improve treatment adherence, treatment outcomes and the overall quality of life of MDR-TB patients.

Social support received by multidrug-resistant tuberculosis patients and related factors: a cross-sectional study in Zhejiang Province, People's Republic of China

OBJECTIVES

The objective of this study is to assess the social support received by patients diagnosed with multidrug-resistant tuberculosis (MDR-TB) in Zhejiang Province, People's Republic of China and the factors that may have influenced it.

METHODS

A total of 220 MDR-TB patients participated in the questionnaire-based survey, and the data from 212 valid questionnaires were analyzed. The respondents reported their sociodemographic status, disease features, and attitudes toward the disease. The social support rating scale was used to measure the patients' social support scores. An Independent Samples t-test, one-way analysis of variance, and a multiple linear regression model were used to analyze the related factors for the social support scores.

RESULT

The average social support score of each MDR-TB patient was 32.56±7.86. Participants who were single, widowed or divorced, retired, and had fewer family members and lower family income were found to have lower social support scores. Participants unwilling to disclose their disease tended to have less social support (31.59<34.23, P=0.010). Participants who perceived great help from health care workers reported higher social support rating scale scores than those who perceived no help (35.36.29.89, P=0.014).

CONCLUSION

MDR-TB patients in Zhejiang Province were shown to have a low level of social support. Patients who were not married, had smaller families, and lower family income received less social support, suggesting that family harmony could be an important source of social support. Patients' self-isolation may contribute to a decrease in the amount of support they receive from their surroundings. Health care organizations need to offer more social support to MDR-TB patients.

Improving access to effective care for people with chronic respiratory symptoms in low and middle income countries

Chronic respiratory symptoms are amongst the most common complaints among low and middle-income country (LMICs) populations and they are expected to remain common over the 10 to 20 year horizon. The underlying diseases (predominantly chronic obstructive pulmonary disease, asthma and tuberculosis) cause, and threaten to increasingly cause, substantial morbidity and mortality. Effective treatment is available for these conditions but LMICs health systems are not well set up to provide accessible clinical diagnostic pathways that lead to sustainable and affordable management plans especially for the chronic non communicable respiratory diseases. There is a need for clinical and academic capacity building together with well-conducted health systems research to underpin health service strengthening, policy and decision-making. There is an opportunity to integrate solutions for improving access to effective care for people with chronic respiratory symptoms with approaches to tackle other major population health issues that depend on well-functioning health services such as chronic communicable (e.g. HIV) and non-communicable (e.g. cardiovascular and metabolic) diseases.

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

SETTING

Ribeirão Preto, São Paulo, Brazil.

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

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.

Lifestyle, attitudes and needs of uncured XDR-TB patients living in the communities of South Africa: a qualitative study

OBJECTIVE

Patient-level data are required to inform strategies interrupting transmission and default in patients with extensively drug-resistant TB (XDR-TB) to improve models of care and identify potential routes of transmission. We therefore explored the experiences, lifestyle, attitudes and needs of patients with uncured XDR-TB, who failed or interrupted therapy, living without treatment in the community.

METHODS

We conducted in-depth interviews with 12 community-based patients from South Africa. Family members were interviewed when patients were unavailable. Interviews were analysed using inductive thematic analysis.

RESULTS

The thematic experiences identified from the interviews were as follows: (i) living with but not being cured of XDR-TB, (ii) altered lifestyle in the community, (iii) experiences with community health care, (iv) local community members, and (v) wants and needs. Patients identified mistrust in health care, futility of treatment regimens, a need for a purpose in life and subsistence as major concerns. Restriction of living in the community for patients whose treatment had failed resulted in self-imposed isolation. Defaulters focused more on the never-ending drug regimen and bad experiences with health care contributing to non-adherence. Family members emphasised an under-recognised experience of unforeseen burden, obligation, worry and discomfort. Lack of knowledge and lack of concern about transmission was evident.

CONCLUSION

Current models of care are not adequately meeting the needs of patients with uncured XDR-TB and relatives. These data inform the need for community-based palliative care, vocational facilities to improve economic opportunities, home-based infection control and improved psychosocial support to increase patient adherence, reduce transmission, provide income and relieve the burden on family members.

'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 disparities in retreatment patients of tuberculosis: A north Indian study

Background:

‘Retreatment’ for tuberculosis (TB) has long been a neglected area in global TB control India. However India disproportionately accounts for nearly half of retreatment TB cases notified globally. Sex differences vary in different age groups and in different parts of the world. The present study focuses on whether gender-based differences are present in notification rates, clinical presentation, and treatment outcomes of different subcategories of patients registered under category II of Revised National TB Control Programme (RNTCP) Chandigarh.

Materials and Methods:

A longitudinal study was designed and the patients registered under RNTCP category II from June 2010 to December 2011. Out of total 607 patients registered during this period under category II of RNTCP in Chandigarh, 545 consented to participate in the study. These were followed-up to September 2012 till the completion of treatment. All 545 recruited cases were stratified into males and females and the results analyzed. The Z test for proportion (for comparing differences in proportions) and Student's t-test (for comparing mean) were performed for statistical analysis.

Results:

From the cohort of 545 patients, 348 (63.9%) were males and 197 (36.1%) were female patients with overall male to female ratio 1.8:1. The proportion of male patients notified was significantly higher than females (Z = 5.93, P < 0.001). The proportion of extrapulmonary cases was higher in the females (28.4%) as compared with males (17%) (P < 0.001). Males outnumbered females in all the unfavorable outcomes death, default, and failure. The default in males was significant as compared to the females (Z = 5.21, P < 0.001).

Conclusions:

The findings of this study suggest a sex difference in the notification rate of retreatment cases of TB. Reasons for a better outcome and low notification rate for TB in females are more due to epidemiological factors than a differential access of the health care. Integrated research is required to outline the relative roles played by epidemiology.

Assessing the consequences of stigma for tuberculosis patients in urban Zambia

BACKGROUND

Stigma is one of the many factors hindering tuberculosis (TB) control by negatively affecting hospital delay and treatment compliance. In Zambia, the morbidity and mortality due to TB remains high, despite extended public health attempts to control the epidemic and to diminish stigma.

STUDY AIM

To enhance understanding of TB-related stigmatizing perceptions and to describe TB patients' experiences of stigma in order to point out recommendations to improve TB policy.

METHODS

We conducted a mixed method study at Kanyama clinic and surrounding areas, in Lusaka, Zambia; structured interviews with 300 TB patients, multiple in-depth interviews with 30 TB patients and 10 biomedical health workers, 3 focus group discussions with TB patients and treatment supporters, complemented by participant observation and policy analysis of the TB control program. Predictors of stigma were identified by use of multivariate regression analyses; qualitative analysis of the in-depth interviews, focus group discussions and participant observation was used for triangulation of the study findings.

RESULTS

We focused on the 138/300 patients that described TB-related perceptions and attitudes, of whom 113 (82%) reported stigma. Stigma provoking TB conceptions were associated with human immunodeficiency virus (HIV)-infection, alleged immoral behaviour, (perceived) incurability, and (traditional) myths about TB aetiology. Consequences of stigma prevailed both among children and adults and included low self-esteem, insults, ridicule, discrimination, social exclusion, and isolation leading to a decreased quality of life and social status, non-disclosure, and/or difficulties with treatment compliance and adherence. Women had significantly more stigma-related problems than men.

CONCLUSIONS

The findings illustrate that many TB patients faced stigma-related issues, often hindering effective TB control and suggesting that current efforts to reduce stigma are not yet optimal. The content and implementation of sensitization programs should be improved and more emphasis needs to be placed on women and children.

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.

Control, struggle, and emergent masculinities: a qualitative study of men's care-seeking determinants for chronic cough and tuberculosis symptoms in Blantyre, Malawi

Background

Men’s healthcare-seeking delay results in higher mortality while on HIV or tuberculosis (TB) treatment, and implies contribution to ongoing community-level TB transmission before initiating treatment. We investigated masculinity’s role in healthcare-seeking delay for men with TB-suggestive symptoms, with a view to developing potential interventions for men.

Methods

Data were collected during March 2011- March 2012 in three high-density suburbs in urban Blantyre. Ten focus group discussions were carried out of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers. Individual interviews were done with 20 TB patients (female =14) and 20 un-investigated chronic coughers (female = eight), and a three-day workshop was held with 27 health stakeholder representatives.

Results

An expectation to provide for and lead their families, and to control various aspects of their lives while facing limited employment opportunities and small incomes leaves men feeling inadequate, devoid of control, and anxious about being marginalised as men. Men were fearful about being looked at as less than men, and about their wives engaging in extramarital sex without ability to detect or monitor them. Control was a key defining feature of adequate manhood, and efforts to achieve it also led men into side-lining their health. Articulate and consistent concepts of men’s bodily strength or appropriate illness responses were absent from the accounts.

Conclusions

Facilitating men to seek care early is an urgent public health imperative, given the contexts of high HIV/AIDS prevalence but increasingly available treatment, and the role of care-seeking delay in TB transmission. Men’s struggles trying to achieve ideal images seem to influence their engagement with their health. Ambiguous views regarding some key masculinity representations and the embrace of less harmful masculinities raise questions about some common assumptions that guide work with men. Apparent ‘emergent masculinities’ might be a useful platform from which to support the transformation of harmful masculinity. Finally, the complex manifestations of masculinity indicate the need for interventions targeting men in health and TB control to assume supportive, multidimensional and long-term outlooks.

Is there a need to mitigate the social and financial consequences of tuberculosis at the individual and household level?

This paper reviews evidence on social and economic costs of tuberculosis. Key socio-economic consequences include stigma, social isolation, increased out-of-pocket expenditures for medical and non-medical costs and reduced income. Many of the financing methods that households use have long-term negative impacts and the poor are most vulnerable to these costs. Together, these negative consequences adversely affect TB control, in terms of delayed diagnosis, delayed initiation of treatment, suboptimal adherence and failure to complete treatment, as well as the coping and well being of the individual and household. There are two ways to reduce treatment costs for the patient; one can either reduce the direct and indirect costs of seeking a diagnosis and obtaining treatment and/or provide income transfers to offset some of those costs incurred. Social transfers in the form of food, cash or vouchers can mitigate the negative effects by enabling the individual to seek a diagnosis, protecting minimum food expenditures, reducing the need to accumulate debt and reduce productive assets and reducing the negative impacts on other household members, particularly young children and school-age children.

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

Objectives and Background

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

Methodology

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

Results

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