TB Stigma, Attitude and Practices among Urban Dwellers. A Descriptive Study on TB

TB Stigma, Attitude and Practices among Urban Dwellers. A Descriptive Study on TB

1. Aftab Ahmed 2. Abid Ghafoor Chaudhry 3. Haris Farooq

1. Anthropologist, Association for social Development Islamabad 2. Incharge Department of Sociology & Anthropology, PMAS-Arid Agriculture University Rawalpindi 3. Student (M.Sc Anthropology), PMAS-Arid Agriculture University Rawalpindi

ABSTRACT

Objective: objective of the study was to explore the Stigma, attitude and practices with special reference to TB in Urban areas.

Study Design: Descriptive study

Place and Duration of Study: This study was conducted in UC-49. Tehsil Malikwal District Mandi Bahawaldin from Jan-2013 to March-2013.   

Materials and Methods: To gather the data on set objective a structured questionnaire was implemented. To collect the data a sample of 70 was interviewed after verbal consent. Tool was refined as per the highlighted suggestions of pre-testing under similar environment. Data was entered in EpiData software and analyzed in SPSS.   

Results: Tables show the participation of both male and female as 70:30% respectively. In case of TB symptoms; Doctor or other medical worker was consulted for sharing by 91.4% respondents, 71.4% respondents would like to visit health facility (Government or Private), 14.3% visit the pharmacy for treatment, 30% were those who visit the health facility when they observed TB signs especially duration of cough, 65.7% urban residents visit the care center as soon they realize they had TB, 8.6% hate TB patients, 30% response friendly but avoid TB patients, 40% show sympathy toward TB patients, and 60% were said that the life of Tb patients were poor.  

Conclusion: In spite of health interventions aimed at awareness, treatment and rehabilitation of TB in Pakistan, the country still stands distinctively among the nations where TB is sky rising. The government and civil society need to move ahead from policy level to practical implementation of measures to prevent TB. At cultural perception level, there is a need to remove misconceptions about TB being the one that severely bars the social life mingling.

Key Words: TB, Stigma, Attitude and practices, Delay in treatment, Self treatment


 

INTRODUCTION

Tuberculosis (TB) is the world's a very old disease, is very common in developing countries. Once seemingly under control, it has now made a comeback never seen before with a retribution1. In the WHO Regional Office for the Eastern Mediterranean in 2004 gives an idea of such diseases prevalent in the eastern Mediterranean region, the number of , cases have been reported in the region (Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, Yemen and UNRWA) for 2005 were 321468 with Afghanistan contributing 25473 and Pakistan the leader at 163927 cases2.

Pakistan has been included in one of the high TB burden countries3. A person's perception about TB is pretended by his previous information of the disease. Tuberculosis’s better understandings depicted better health-seeking behavior. In Pakistan, 26 percent of TB patients have not heard about TB before diagnosis, surprisingly it is not worth noting that 10 percent of the total population have not heard about TB4. Researches from neighboring India, 56-99 percent of the population were well aware about the disease tuberculosis5-7. Also previous studies depicts that lack of knowledge is believed to be as one of the reason in Pakistan to increase TB burden8.

Earlier studies evidences show that geographical factor of stigmatization among TB infected peoples, predominantly those living in urban communities. The results of existing studies showed that people in urban areas feel hindered and ashamed, if they find themselves suffering from tuberculosis. Tuberculosis has long been associated with similar feelings9-12.

Fear of transmitting infection and to avoid potential inequity from the society is the result of individual stigma. Findings of the existing literature show that regardless of residential areas either rural or urban it was observed that communities normally reject TB patients. Graph of TB stigmatization among masses raises due to perceived threat of infection and supposed link between TB and low caste, poverty, infamous behavior and divine punishment13.

Self treatment14, stigma, perception and beliefs about TB (TB treatment, diagnosis, TB is curable, causes by evil spirits etc) were identified as risk factors15. It was observed that many TB patients were very reluctant to attend NTP health facility because it means that they have to disclose TB in public. In many countries, TB is so closely associated with HIV that is why patients fear and think that they reveal their HIV status to their neighbors16.

In Pakistani communities TB has long been associated as a disease that every one infected or supposed to be infected by TB virus wants to hide it from others people including their family, friends and neighbors in recent past. Situation regarding the awareness about TB signs and symptoms, diagnosis, treatment and treatment duration and beliefs of communities is getting improved after the interventions of NTP and other private line departments like NGOs with particular focus to cure TB from Pakistan. Still stigma, self treatment and to avoid sharing T status with other and delay in getting treatment from specialized TB health facility is grounded. This research was focused to explore stigmatization, attitude and practices of people urban areas regarding TB.

MATERIALS AND METHODS

To collect the data on study objective a structured questionnaire was implemented after improvement activity as suggestions were highlighted during pre-testing of the tool. Data was gathered form a sample of 70 people including 49 male and 21 female of UC-49 of Tehsil Malikwal, District Mandi Bahawaldin. Data was collected after the verbal consent of the participants and ethical consideration of research. With the help of experienced researchers the data was collected, verified and entered in EpiData. SPSS was used to do analysis and further analytical requirements.

RESULTS

Below chart shows the 58.6% participation from the age group of 20-30 years. 17.1% of the participants were in the category of 31-40 years of age, 14.3% belongs to 41-50 years of age and 10% were those enjoying 51 and above year of age.

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Bar Chart No. 1: Age of Participants

Pie chart explains the gender distribution of the participants of study. Percentile shows 70% involvement from male side and 30% from female side to collect the opinion of both sides of gender.

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Pie-chart No. 1: Gender Distribution of Participants

Table No. 1: If you had TB Symptoms whom you shared with first?

Category

Frequency

Percent

Doctor or other medical worker

64

91.4

Other family member

4

5.7

Close friend

2

2.9

Total

70

100

Table 1 shows that 91.4% participants want to visit doctor to share TB if he had. In 5.7% cases they were likely to expose TB with their family members and 2.9% were those respondents who would like to share with their close friends if they had TB.

Table No. 2: If You Had Symptoms of TB Then Where You Go first?

Category

Frequency

Percent

Go to health facility

50

71.4

Go to pharmacy

10

14.3

Go to traditional healer

1

1.4

Pursue self-treatment?

7

10

Other treatment options

2

2.9

Total

70

100

Table No. 3: If You Had Symptoms of TB, When Would You Go to The Health Facility?

Category

Frequency

Percent

When treatment on my own does not work

3

4.3

When symptoms that look like TB signs especially duration of cough

21

30

As soon as I realize that my symptoms might be related to TB

46

65.7

Total

70

100

Table 2 explains the responses of study participants about where they want to go if they had symptoms of TB. 71.4% of the respondents would like to visit health facility, 14.3% were in favor to visit pharmacy only, 1.4% were those who inclined toward the services of traditional healer and 10% were those who would like to pursue self treatment if they had TB symptoms.

Table 3 shows that if someone had symptoms of TB then when would he visit health facility for specialized treatment of TB. Percentile shows that 4.3% of the respondents visit the health facility when their self medication does not work, 30% respondents were of the view that they would like to visit health facility when TB symptoms especially cough prolonged up-to 3 weeks because 3 weeks cough is main symptom of TB and 65.7% were those participants who said that as early they realize that they had TB symptoms they would like to visit health facility for treatment.

Table No. 4: What is the Response of Community toward TB patient?

Category

Frequency

Percent

Most people reject him or her

6

8.6

Most people are friendly, but they avoid TB patients

21

30

The community mostly supports and helps

43

61.4

Total

70

100

Table 4 explains that if a person had TB then what would be the expected response of the community toward that respective patient. In 8.6% cases respondents were of the view that community rejects TB patients, 30% were those who said that mostly community attitude toward TB patients were observed friendly and 61.4% respondents were of the view that community normally provide support and help to the patient and motivate them for the treatment.

Table No. 5: Your Feeling toward People who Have TB?

Category

Frequency

Percent

Sympathy

28

40

Hate

2

2.9

Friendly but I will try to avoid him or her

8

11.4

I will support and help him or her

31

44.3

Others

1

1.4

Total

70

100

Table 5 focused particularly about the feelings of respondents toward a TB patient. Percentile explains that 40% respondents were behave in sympathetic form toward TB patient, 2.9% said that they feel hate for TB patients, 11.4% were those respondents who used to behave in friendly way but also try to avoid them, predominantly 44.3% respondents inclined to support and help TB patients.

 

 

Table No. 6: Quality of Life of a Person with TB

Category

Frequency

Percent

Normal

11

15.7

Poor

42

60

Very Poor

16

22.9

Good

1

1.4

Total

70

100

Table 6 shows the perception of study participants about the quality of life of TB patients. In 15.7% cases respondents were of the view that Tb patients living their normal life, 60% of the participants were of the view that TB patients living poor lives, 22.9% were in favor of very poor life style of TB patients and only 1.4% respondents said that TB infected patients living good lives in routine.

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Pie-Chart No. 2: Source of Information

Source is information is always very crucial to create awareness among masses. There are many way and techniques to spread information among communities about any particular topic. In this focused TB research 64% of the study respondents were mentioned TB as a source of information, still radio is in use as reported 4% times in current study, 6% respondents take information from newspapers and magazines, LHW as a source of information reported 4% and 22% of the respondents said that their friends, family members, neighbors and colleagues were the main source of information regarding TB.

DISCUSSION

Stigma, self treatment and delay in getting treatment are very obvious and life threatening factors associated with attitude and practices of general public regarding TB in Pakistan. Data of current study shows that situation is not as worse as depicted in earlier studies and literature existed on similar factors. In Pakistan, TB DOTS program almost working on 100% Government health facilities throughout rural and urban areas. Efforts of DOTS program along with the active participation and interventions of private sector including basic education project on TB disease with an appreciated effort to spread information about signs & symptoms, diagnosis & treatment and to avoid every expected delay for treatment including stigma, self treatment and to utilize private health practitioners like spiritual healers, untrained medical staff, traditional and homeopathic consultants but still there is a need of improvement especially regarding attitude of health staff and to enhance the quality of services17,18.   

In previous studies degree of kinship was reciprocally coupled with stigmatization. Moral support provided by family members often plays an important role in early diagnosis and treatment compliance19, 20. Growing TB education among masses can help to reduce inequity and stigma as deficiency of primary information about the disease is played an important stigmatization contributing factor in TB21

Several existing studies depicted self-treatment as major contributing problem in treatment delay15. A study conducted earlier in Pakistan with the results that 50% of patients practiced self-treatment and 42% would like to visit pharmacy as first after getting TB symptoms14, but the opinion of respondents in current study is different with the results to practices self-treatment as reported 10% and to visit pharmacy at first was reported 14%.  

Previous studies show that in spite of having high class knowledge about TB more than half of patients did not practiced appropriate health seeking behavior in term of timely visit to suitable health facility for specialized care, which reflects the high level of stigma associated with the disease. Some other studies also reported that information alone is not the only factor to measure health seeking behavior of TB patients or their devotion to timely treatment, but importantly the patient’s attitudes and practices22-24

Multiple factors affect natural attitudes and practices of human beings such as socio-cultural belief system, stigma, socio-economic status, access to health facilities and availability of quality care. A very intensive community-based media campaign is highly recommended to reduce the stigma associated with TB. Educational activities, such as increasing awareness in the community should be started instead of being limited to the target behavior modification25.

CONCLUSION

Unfortunately, Pakistan is among the nations of the world that witness highest rates of case identification regarding TB. On the other hand, TB is more than a disease in cultural level. The TB is seen as a physical problem that not only damages the health of patient but also excludes him or her from the social relations, stops the patients from appearing in the social circles and meeting with family, relatives, friends, colleagues, co-workers and neighborhood. Though it can be said that few interventions regarding war against TB are already underway but there is a need for serious thinking, planning and adopting practical measures for TB control. The patients need proper screening, treatments and opportunities for physical rehabilitation. In addition, there is a need that the government may take one step ahead in order to work on the social stigma related to TB prevailing among the general masses of the country. People need to understand via social and attitudinal engineering that TB is curable as well as it does not restricts the patients to perform normal life routines and chores.

REFERENCES

1.       Aliyu MH, Salihu HM. Tuberculosis and HIV disease: two decades of a dual epidemic. Wien Klin Wochenschr 2003;115(19–20):685-97.

2.       WHO EMRO report 2005. Available from: http://www.emro.who.int/stb/

3.       World Health Organization. Global TB Database; 2010. (Online) (Cited 2011, Sept 4). Available from URL: www.who.int/tb/data

4.       Khan JA, Irfan M, Zaki A, Beg M, Hussain SF, Rizvi N. Knowledge, attitude and misconceptions regarding tuberculosis in Pakistani patients. J Pak Med Assoc 2006; 56: 211-4.

5.       Sharma N, Malhotra R, Taneja DK, Saha R, Ingle GK. Awareness and perception about tuberculosis in the general population of Delhi. Asia Pac J Public Health 2007; 19: 10-5.

6.       Kar M, Logaraj M. Awareness, attitude and treatment seeking behavior regarding tuberculosis in a rural area of Tamil Nadu. Ind J Tuberc 2010; 57:226-9.

7.       Malhotra R, Taneja DK, Dhingra VK, Rajpal S, Mehra M. Awareness regarding Tuburculosis in a rural population of Delhi. Ind J Comm Med 2002; 27: 62-8

8.       Ali SS, Rabbani F, Siddiqui UN, Zaidi AH, Sophie A, Virani SJ, et al. Tuberculosis: do we know enough? A study of patients and their families in an outpatient hospital setting in Karachi, Pakistan. Int J Tuberc Lung Dis 2003; 7: 1052-8.

9.       Armijos RX, Weigel MM, Qincha M, Ulloa B. The meaning and consequences of tuberculosis for an at-risk urban group in Ecuador. Rev Panam Salud Publ 2008, 23(3):188-97.

10.    Kelly P: Isolation and stigma. the experience of patients with active tuberculosis. J Comm Health Nurs 1999, 16(4):233-41.

11.    Macq J, Solis A, Martinez G. Assessing the stigma of tuberculosis. Psychol Health Med 2006, 11(3): 346-52.

12.    Jaramillo E. Tuberculosis and stigma: predictors of prejudice against people with tuberculosis. J Health Psych 1999, 4(1):71-9.

13.    Baral SC, Karki DK, Newell JN. Causes of stigma and discrimination associated with tuberculosis in Nepal: a qualitative study. BMC Public Health 2007;7:211.

14.    WHO: Diagnostic and treatment delay in tuberculosis. Geneva, World Health Organisation; 2006.

15.    Yimer S, Bjune G, Alene G. Diagnostic and treatment delay among pulmonary tuberculosis patients in Ethiopia: a cross sectional study. BMC Infect Dis 2005;5:112.

16.    Xu B, Jiang QW, Xiu Y, Diwan VK. Diagnostic delays in access to tuberculosis care in counties with or without the National Tuberculosis Control Programme in rural China. Int J Tuberc Lung Dis 2005;9(7):784-790.

17.    Croft RP, Croft RA. Knowledge, attitude and practice regarding leprosy and tuberculosis in Bangladesh. Lepr Rev 1999;70:34-42.

18.    Murty KJ, Frieden TR, Yazdani A, Hreshikesh P. Publicprivate partnership in tuberculosis: experience in Hyderabad, India. Int J Tuberc Lung Dis 2001;5(4):354–9.

19.    Liefooghe R, Baliddawa JB, Kipruto EM, Vermeire C, De Munynck AO. From their own Perspective. A Kenyan Community's Perception of Tuberculosis. Trop Med Int Health 1997;2:809-21.

20.    Liefooghe R, Michiels N, Habib S, Moran MB, De Muynck A. Perception and social consequences of tuberculosis: a focus group study of tuberculosis patients in Sialkot, Pakistan. Soc Sci Med 1995; 41:1685-1692.

21.    Eastwood SV, Hill PC. A gender-focused qualitative study of barriers to accessing tuberculosis treatment in the Gambia, West Africa. Int J Tuberc Lung Dis 2004;8(1):70-5.

22.    Yamada S, et al. Attitudes regarding tuberculosis in immigrants from the Philippines to the United States. Family Med 1999;31(7):477–82.

23.    Johansson E, et al. Attitudes to compliance with tuberculosis treatment among women and men in Vietnam. IntJ Tuberculosis and Lung Dis 1999; 3(10):862–8.

24.    Jackson L, Yuan L. Family physicians managing tuberculosis. Qualitative study of overcoming barriers. Canadian Family Phys 1997;43:649–55.

25.    Hashim DS, Al Kubaisy W, Al Dulayme A. Knowledge, attitudes and practices survey among health care workers and tuberculosis patients in Iraq. La Revue de Santé de la Méditerranée orientale 2003;9(4):2003.

 

 

Address for Corresponding Author:

Aftab Ahmed C/O Dr. Abid Chaudhry

Department of Sociology & Anthropology

PMAS-Arid Agriculture University, Rawalpindi

Cell No.: +92-345-974-0985

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.