Secondary analysis of tuberculosis stigma data from a cluster randomised trial in Zambia and South Africa (ZAMSTAR)

"As a patient I do not belong to the clinic, I belong to the community." Co-developing a multi-level, person-centred tuberculosis stigma intervention in Cape Town, South Africa

Background

Anticipated, internal, and enacted stigma are major barriers to TB care engagement, and directly impact patient well-being. Unfortunately, targeted stigma interventions are lacking. We aimed to co-develop a person-centred stigma intervention with TB-affected community members and health workers in South Africa.

Methods

Using a community-based participatory research approach, we conducted ten group discussions with people diagnosed with TB (past or present), caregivers, and health workers (total n=87) in Khayelitsha, Cape Town. Group discussions were facilitated by TB survivors. Discussion guides explored experiences and drivers of stigma and used human-centred design principles to co-develop solutions. Recordings were transcribed, coded, thematically analysed and then further interpreted using the socio-ecological model.

Results

Intervention components across socio-ecological levels shared common behaviour change strategies, namely education, empowerment, engagement, and innovation. At the individual level, participants recommended counselling to improve TB knowledge and provide ongoing support. TB survivors can guide messaging to nurture stigma resilience by highlighting that TB can affect anyone and is curable, and provide lived experiences of TB to decrease internal stigma. At the interpersonal level, support clubs and family-centred counselling were suggested to dispel TB-related myths and foster support. At the institutional level, health worker stigma reduction training informed by TB survivor perspectives was recommended. Consideration of how integration of TB/HIV care services may exacerbate TB/HIV intersectional stigma and ideas for restructured service delivery models were suggested to decrease anticipated and enacted stigma. At the community level, participants recommended awareness-raising events led by TB survivors, including TB information in school curricula. At the policy level, solutions focused on reducing the visibility generated by a TB diagnosis and resultant stigma in health facilities and shifting tasks to community health workers.

Conclusions

Decreasing TB stigma requires a multi-level approach. Co-developing a person-centred intervention with affected communities is feasible and generates stigma intervention components that are directed and implementable. Such community-informed intervention components should be prioritised by TB programs, including integrated TB/HIV care services.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Depressive symptoms and HIV risk behaviours among adolescents enrolled in the HPTN071 (PopART) trial in Zambia and South Africa

BACKGROUND

Mental health is a critical and neglected public health problem for adolescents in sub-Saharan Africa. In this paper we aim to determine the prevalence of depressive symptoms and the association with HIV risk behaviours in adolescents aged 15-19 years in Zambia and SA.

METHODS

We conducted a cross-sectional survey from August-November 2017 in seven control communities of HPTN 071 (PopART) trial (a community-randomised trial of universal HIV testing and treatment), enrolling approximately 1400 eligible adolescents. HIV-status was self-reported. Depressive symptoms were measured with the Short Mood and Feelings Questionnaire (SMFQ), with a positive screen if adolescents scored ≥12. We fitted a logistic regression model to identify correlates of depressive symptoms with subgroup analyses among those who self-reported ever having had sex, by gender and country.

RESULTS

Out of 6997 households approached, 6057 (86.6%) were enumerated. 2546 adolescents were enumerated of whom 2120 (83.3%) consented to participate and were administered the SMFQ. The prevalence of depressive symptoms was 584/2120 (27.6%) [95%CI: 25.7%-29.5%]. Adolescents in SA were less likely to experience depressive symptoms (Adjusted Odds Ratio [AOR] = 0.63 (95% CI: 0.50, 0.79), p-value<0.0001). Female adolescents (AOR = 1.46 (95% CI: 1.19, 1.81), p-value<0.0001); those who reported ever having sex and being forced into sex (AOR = 1.80 (95% CI: 1.45, 2.23), p-value<0.001) and AOR = 1.67 (95% CI: 0.99, 2.84); p-value = 0.057 respectively) were more likely to experience depressive symptoms. Among 850 (40.1%) adolescents who self-reported to ever having had sex; those who used alcohol/drugs during their last sexual encounter were more likely to experience depressive symptoms (AOR = 2.18 (95% CI: 1.37, 3.47); p-value = 0.001), whereas those who reported using a condom were less likely to experience depressive symptoms (AOR = 0.74 (95% CI: 0.55, 1.00); p-value = 0.053).

CONCLUSION

The prevalence of depressive symptoms among adolescents ranged from 25-30% and was associated with increased HIV-risk behaviour.

Interventions pathways to reduce tuberculosis-related stigma: a literature review and conceptual framework

BACKGROUND

Prevention of tuberculosis (TB)-related stigma is vital to achieving the World Health Organisation's End TB Strategy target of eliminating TB. However, the process and impact evaluation of interventions to reduce TB-stigma are limited. This literature review aimed to examine the quality, design, implementation challenges, and successes of TB-stigma intervention studies and create a novel conceptual framework of pathways to TB-stigma reduction.

METHOD

We searched relevant articles recorded in four scientific databases from 1999 to 2022, using pre-defined inclusion and exclusion criteria, supplemented by the snowball method and complementary grey literature searches. We assessed the quality of studies using the Crowe Critical Appraisal Tool, then reviewed study characteristics, data on stigma measurement tools used, and interventions implemented, and designed a conceptual framework to illustrate the pathways to TB-stigma reduction in the interventions identified.

RESULTS

Of 14,259 articles identified, eleven met inclusion criteria, of which three were high quality. TB-stigma reduction interventions consisted mainly of education and psychosocial support targeted predominantly toward three key populations: people with TB, healthcare workers, and the public. No psychosocial interventions for people with TB set TB-stigma reduction as their primary or co-primary aim. Eight studies on healthcare workers and the public reported a decrease in TB-stigma attributed to the interventions. Despite the benefits, the interventions were limited by a dearth of validated stigma measurement tools. Three of eight studies with quantitative stigma measurement questionnaires had not been previously validated among people with TB. No qualitative studies used previously validated methods or tools to qualitatively evaluate stigma. On the basis of these findings, we generated a conceptual framework that mapped the population targeted, interventions delivered, and their potential effects on reducing TB-stigma towards and experienced by people with TB and healthcare workers involved in TB care.

CONCLUSIONS

Interpretation of the limited evidence on interventions to reduce TB-stigma is hampered by the heterogeneity of stigma measurement tools, intervention design, and outcome measures. Our novel conceptual framework will support mapping of the pathways to impacts of TB-stigma reduction interventions.

Conceptualization, detection, and management of psychological distress and mental health conditions among people with tuberculosis in Zambia: a qualitative study with stakeholders' and TB health workers

BACKGROUND

In recent years, there has been increased recognition of the need to integrate mental health services into routine tuberculosis (TB) care. For successful integration, policymakers need to first understand the practices of TB health workers in the management of mental health conditions, including depression, anxiety, and psychological distress, and use this to decide how best mental health services could be delivered in tandem with TB services. In this qualitative study we aimed to understand how TB health workers and other stakeholders viewed mental health conditions linked to TB and how they screened and treated these in their patients.

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), conducted in eight urban communities in Zambia. Data were collected through 17 focus group discussions with local health committee members (n = 96) and TB stakeholders (n = 57) present in the communities. Further in-depth interviews were held with key TB health workers (n = 9). Thematic analysis was conducted.

RESULTS

TB stakeholders and health workers had an inadequate understanding of mental health and commonly described mental health conditions among TB patients by using stigmatizing terminology and overtones, for example "madness", which often implied a characterological flaw rather an actual illness. Psychological distress was also described as "overthinking", which participants attributed to psychosocial stressors, and was not perceived as a condition that would benefit from mental health intervention. There were no standard screening and treatment options for mental health conditions in TB patients and most TB health workers had no mental health training. TB Stakeholders and health workers understood the negative implications of mental health conditions on TB treatment adherence and overall wellbeing for TB patients.

CONCLUSIONS

TB stakeholders and health workers in Zambia have a complex conceptualisation of mental health and illness, that does not support the mental health needs of TB patients. The integration of mental health training in TB services could be beneficial and shift negative attitudes about mental health. Further, TB patients should be screened for mental health conditions and offered treatment. Trial registration number NCT03739736-Registered on the 14th of November 2018- Retrospectively registered- https://clinicaltrials.gov/ct2/results?cond=&term=NCT03739736&cntry=&state=&city=&dist.

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

Stigma is a critical barrier for TB care delivery; yet data on stigma reduction interventions is limited. This review maps the available literature on TB stigma reduction interventions, using the Health Stigma and Discrimination framework and an implementation analysis to identify research gaps and inform intervention design. Using search terms for TB and stigma, we systematically searched PubMed, EMBASE and Web of Science. Two independent reviewers screened all abstracts, full-texts, extracted data, conducted a quality assessment, and assessed implementation. Results were categorized by socio-ecological level, then sub-categorized by the stigma driver or manifestation targeted. After screening 1865 articles, we extracted data from nine. Three studies were implemented at the individual and interpersonal level using a combination of TB clubs and interpersonal support to target internal and anticipated stigma among persons with TB. Two studies were implemented at the interpersonal level using counselling or a video based informational tool delivered to households to reduce stigma drivers and manifestations. Three studies were implemented at the organizational level, targeting drivers of stigma among healthcare workers (HW) and enacted stigma among HWs. One study was implemented at the community level using an educational campaign for community members. Stakeholder consultation emphasized the importance of policy level interventions and education on the universality of risk to destigmatize TB. Review findings suggest that internal and anticipated TB stigma may be addressed effectively with interventions targeted towards individuals using counselling or support groups. In contrast, enacted TB stigma may be better addressed with information-based interventions implemented at the organizational or community level. Policy level interventions were absent but identified as critical by stakeholders. Implementation barriers included the lack of high-quality training and integration with mental health services. Three key gaps must be addressed in future research: consistent stigma definitions, standardized stigma measurement, and measurement of implementation outcomes.

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.

Reframing Intersectional Stigma for a South African Context Integrating Tuberculosis, HIV and Poverty Stigmas

ABSTRACT

Intersectionality is closely intertwined with Black feminism within the context of the United States. As a result, intersectionality is often overlooked in non-Western contexts where racial homogeneity may reduce some of the impact of race on marginalization. This article will look at intersectional stigma from the South African context using the tuberculosis/HIV (TB/HIV) treatment environment in South Africa to exemplify intersectionality's versatility as an analytic method outside of the United States. We will use colonial history and contemporary research to reframe intersectionality considering a new set of stigmatized identities, including HIV stigma, TB stigma, and poverty stigma, to create a situation-specific framework adapted from a model by Bulent Turan and colleagues.

Severely stigmatised skin neglected tropical diseases: a protocol for social science engagement

More than one billion people are affected by neglected tropical diseases (NTDs) and many of these diseases are preventable. While the grouping of these conditions as NTDs has generated vast mapping, mass drug administration and surveillance programmes, there is growing evidence of gaps and weaknesses in purely biomedical approaches, and the need for responses that also recognise the social determinants of health. In order to unpack the social and political determinants of NTDs, it is important to view the problem from a social science perspective. Given this background, the Social Sciences for Severe Stigmatizing Skin Diseases (5S) Foundation has recently been established by the Centre for Global Health Research at Brighton and Sussex Medical School. The broad aim of the 5S Foundation is to incorporate social science perspectives in understanding and addressing the problems around three NTDs, namely, podoconiosis, mycetoma and scabies. This protocol paper sets out the aims and approaches of the 5S Foundation while activities such as research, public engagement, training and capacity building get underway.

Interpretation of serial interferon-gamma test results to measure new tuberculosis infection among household contacts in Zambia and South Africa

BACKGROUND

A more stringent QuantiFERON-TB Gold In-Tube (QFT) conversion (from negative to positive) definition has been proposed to allow more definite detection of recent tuberculosis (TB) infection. We explored alternative conversion definitions to assist the interpretation of serial QFT results and estimate incidence of TB infection in a large cohort study.

METHODS

We used QFT serial results from TB household contacts aged ≥15 years, collected at baseline and during two follow-up visits (2006-2011) as part of a cohort study in 24 communities in Zambia and South Africa (SA). Conversion rates using the manufacturers' definition (interferon-gamma (IFN-g) < 0.35 to ≥0.35, 'def1') were compared with stricter definitions (IFN-g < 0.2 to ≥0.7 IU/ml, 'def2'; IFN-g < 0.2 to ≥1.05 IU/ml, 'def3'; IFN-g < 0.2 to ≥1.4 IU/ml, 'def4'). Poisson regression was used for analysis.

RESULTS

One thousand three hundred sixty-five individuals in Zambia and 822 in SA had QFT results available. Among HIV-negative individuals, the QFT conversion rate was 27.4 per 100 person-years (CI:22.9-32.6) using def1, 19.0 using def2 (CI:15.2-23.7), 14.7 using def3 (CI:11.5-18.8), and 12.0 using def4 (CI:9.2-15.7). Relative differences across def1-def4 were similar in Zambia and SA. Using def1, conversion was less likely if HIV positive not on antiretroviral treatment compared to HIV negative (aRR = 0.7, 95%CI = 0.4-0.9), in analysis including both countries. The same direction of associations were found using def 2-4.

CONCLUSION

High conversion rates were found even with the strictest definition, indicating high incidence of TB infection among household contacts of TB patients in these communities. The trade-off between sensitivity and specificity using different thresholds of QFT conversion remains unknown due to the absence of a reference standard. However, we identified boundaries within which an appropriate definition might fall, and our strictest definition plausibly has high specificity.

Social trust and health seeking behaviours: A longitudinal study of a community-based active tuberculosis case finding program in the Philippines

Introduction

Social trust is an important driver of health seeking behaviours and plays a particularly important role for diseases that have a high degree of stigma associated with them, such as tuberculosis (TB). Individuals experiencing poverty also face additional social and financial barriers in accessing care for TB. We examined an active case finding (ACF) initiative embedded in a program targeting those living in poverty (Transform) implemented by International Care Ministries (ICM), a Philippine-based non-governmental organization (NGO), and analyzed how different forms of social trust may affect the initial uptake of ACF.

Methods

Program monitoring data and a cross-sectional survey conducted at the beginning of Transform included six dimensions of social trust: satisfaction with family life, satisfaction with friendships, and level of trust in relatives, neighbours, pastor or religious leader, and local government officials. Amongst individuals suspected of having TB who received referrals post-screening, multilevel modelling examined the effects of social trust on rural health unit (RHU) attendance.

Results

Among the subset of 3350 individuals who received TB screening in 51 communities, 889 (26.5%) were symptom positive and required referral to the RHU, but only 24.1% of those who received referrals successfully attended the RHU. Multilevel regression analysis showed that for each unit increase on the Likert scale in baseline level of family satisfaction and level of trust in relatives, the odds of attending an RHU was 1.03 times (95% CI: 0.99, 1.07) and 1.06 times greater (95% CI: 1.00, 1.11), respectively, independent of other factors.

Conclusion

These results suggest that social trust in family members could play a valuable role in addressing stigma and rejection, both cited as barriers to higher screening rates. It is recommended that ACF programs that target TB, or other diseases that are stigmatized, prioritize trust-building as an important component of their intervention.

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Role of social trust on health clinic attendance among extreme poor examined.

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Effect of five relationship types in supporting tuberculosis testing explored.

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Trust in family relationships predicted greater health clinic testing.

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Health interventions for stigmatized diseases should prioritize trust-building.

Patient predictors of health-seeking behaviour for persons coughing for more than two weeks in high-burden tuberculosis communities: the case of the Western Cape, South Africa

Background

This study aimed to analyse the patient predictors of health-seeking behaviour for persons coughing for more than 2 weeks to better understand this vulnerable and important population.

Methods

The study analysed data from a cohort study (SOCS - Secondary Outcome Cohort Study) embedded in a community randomised trial ZAMSTAR (Zambia and South Africa TB and AIDS Reduction Study) in eight high-burden TB communities in the Western Cape, South Africa. These datasets are unique as they contain TB-related data as well as data on health, health-seeking behaviour, lifestyle choices, employment, socio-economic status, education and stigma. We use uni- and multivariate logistic regressions to estimate the odds ratios of consulting for a cough (of more than 2 weeks duration) for a range of relevant patient predictors.

Results

Three hundred and forty persons consulted someone about their cough and this represents 37% of the 922 participants who reported coughing for more than 2 weeks. In the multivariate analysis, respondents of black ethnic origin (OR 1.99, 95% CI 1.28–3.12, P < 0.01), those with higher levels of education (OR 1.05 per year of education, 95% CI 1.00–1.10, P = 0.05), and older respondents (OR 1.02 per year, 95% CI 1.01–1.04, P < 0.01) had a higher likelihood of consulting for their chronic cough. Individuals who smoked (OR 0.63, 95% CI 0.45–0.88, P < 0.01) and those with higher levels of socio-economic status (OR 0.81, 95% CI 0.71–0.92, P < 0.01) were less likely to consult. We find no evidence of stigma playing a role in health-seeking decisions, but caution that this may be due to the difficulty of accurately and reliably capturing stigma due to, amongst other factors, social desirability bias.

Conclusions

The low levels of consultation for a cough of more than 2 weeks suggest that there are opportunities to improve case-finding. These findings on health-seeking behaviour can assist policymakers in designing TB screening and active case-finding interventions that are targeted to the characteristics of those with a chronic cough who do not seek care.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3992-6) contains supplementary material, which is available to authorized users.

Addressing knowledge gaps and prevention for tuberculosis-infected Indian adults: a vital part of elimination

BACKGROUND

India plans to eliminate tuberculosis (TB) by 2025, and has identified screening and prevention as key activities. Household contacts (HHCs) of index TB cases are a high-risk population that would benefit from rapid implementation of these strategies. However, best practices for TB prevention and knowledge gaps among HHCs have not been studied. We evaluated TB knowledge and understanding of prevention among tuberculin skin-test (TST) positive HHCs. While extensive information is available in other high-burden settings regarding TB knowledge gaps, identifying how Indian adult contacts view their transmission risk and prevention options may inform novel screening algorithms and education efforts that will be part of the new elimination plan.

METHODS

We approached adult HHC to administer a questionnaire on TB knowledge and understanding of infection. Over 1 year, 100 HHC were enrolled at a tertiary hospital in Pune, India.

RESULTS

The study population was 61% (n = 61) female, with a mean age of 36.6 years (range 18-67, SD = 12). Education levels were high, with 78 (78%) having at least a high school education, and 23 (24%) had at least some college education. Four (4%) of our participants were HIV-infected. General TB knowledge among HHC was low, with a majority of participants believing that you can get TB from sharing dishes (70%) or touching something that has been coughed on (52%). Understanding of infection was also low, with 42% believing that being skin-test positive means you have disease. To assess readiness for preventive therapy, we asked participants whether they are at a higher risk of progressing to active disease because of their LTBI status. Fifty-four (55%) felt that they are at higher risk. Only 8% had heard of preventive therapy.

CONCLUSION

Our TB knowledge survey among HHCs with evidence of recent exposure found that knowledge is poor and families are confused about transmission in the household. It is imperative that the Indian program develop tools and incentives that can be used to educate TB cases and their families on what infected HHCs can do to prevent disease, including preventive therapy.