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Abstract

Global tuberculosis incidence has declined marginally over the past decade, and tuberculosis remains out of control in several parts of the world including Africa and Asia. Although tuberculosis control has been effective in some regions of the world, these gains are threatened by the increasing burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. XDR tuberculosis has evolved in several tuberculosis-endemic countries to drug-incurable or programmatically incurable tuberculosis (totally drug-resistant tuberculosis). This poses several challenges similar to those encountered in the pre-chemotherapy era, including the inability to cure tuberculosis, high mortality, and the need for alternative methods to prevent disease transmission. This phenomenon mirrors the worldwide increase in antimicrobial resistance and the emergence of other MDR pathogens, such as malaria, HIV, and Gram-negative bacteria. MDR and XDR tuberculosis are associated with high morbidity and substantial mortality, are a threat to health-care workers, prohibitively expensive to treat, and are therefore a serious public health problem. In this Commission, we examine several aspects of drug-resistant tuberculosis. The traditional view that acquired resistance to antituberculous drugs is driven by poor compliance and programmatic failure is now being questioned, and several lines of evidence suggest that alternative mechanisms-including pharmacokinetic variability, induction of efflux pumps that transport the drug out of cells, and suboptimal drug penetration into tuberculosis lesions-are likely crucial to the pathogenesis of drug-resistant tuberculosis. These factors have implications for the design of new interventions, drug delivery and dosing mechanisms, and public health policy. We discuss epidemiology and transmission dynamics, including new insights into the fundamental biology of transmission, and we review the utility of newer diagnostic tools, including molecular tests and next-generation whole-genome sequencing, and their potential for clinical effectiveness. Relevant research priorities are highlighted, including optimal medical and surgical management, the role of newer and repurposed drugs (including bedaquiline, delamanid, and linezolid), pharmacokinetic and pharmacodynamic considerations, preventive strategies (such as prophylaxis in MDR and XDR contacts), palliative and patient-orientated care aspects, and medicolegal and ethical issues. [post_title] => The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => the-epidemiology-pathogenesis-transmission-diagnosis-and-management-of-multidrug-resistant-extensively-drug-resistant-and-incurable-tuberculosis [to_ping] => [pinged] => [post_modified] => 2021-04-07 11:27:43 [post_modified_gmt] => 2021-04-07 15:27:43 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1486 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [1] => WP_Post Object ( [ID] => 1480 [post_author] => 4 [post_date] => 2021-04-07 10:25:55 [post_date_gmt] => 2021-04-07 14:25:55 [post_content] =>

Abstract

Stigma associated with tuberculosis (TB) is often regarded as a barrier to health seeking and a cause of social suffering. Stigma studies are typically patient-centred, and less is known about the views of communities where patients reside. This study examined community perceptions of TB-related stigma. A total of 160 respondents (80 men and 80 women) without TB in the general population of Western Maharashtra, India, were interviewed using Explanatory Model Interview Catalogue interviews with same-sex and cross-sex vignettes depicting a person with typical features of TB. The study clarified features of TB-related stigma. Concealment of disease was explained as fear of losing social status, marital problems and hurtful behaviour by the community. For the female vignette, heredity was perceived as a cause for stigmatising behaviour. Marital problems were anticipated more for the male vignette. Anticipation of spouse support, however, was more definite for men and conditional for women, indicating the vulnerability of women. Community views acknowledged that both men and women with TB share a psychological burden of unfulfilled social responsibilities. The distinction between public health risks of infection and unjustified social isolation (stigma) was ambiguous. Such a distinction is important for effective community-based interventions for early diagnosis of TB and successful treatment. [post_title] => Gender and community views of stigma and tuberculosis in rural Maharashtra, India [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => gender-and-community-views-of-stigma-and-tuberculosis-in-rural-maharashtra-india [to_ping] => [pinged] => [post_modified] => 2021-04-07 10:25:55 [post_modified_gmt] => 2021-04-07 14:25:55 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1480 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [2] => WP_Post Object ( [ID] => 1478 [post_author] => 4 [post_date] => 2021-04-07 10:22:29 [post_date_gmt] => 2021-04-07 14:22:29 [post_content] =>

Abstract

Multidrug-resistant tuberculosis (MDR-TB) has emerged as a possible threat to global tuberculosis control efforts in recent years. It is a challenge not only from a public health point of view but also in the context of global economy, especially in the absence of treatment for MDR-TB at national-level programs in developing countries. Biological accounts are insufficient to understand the emergence and dynamics of drug resistance. This article focuses essentially on the need for a holistic perspective, linking biosocial determinants that would probably lead to better insights into MDR-TB control strategies. [post_title] => Multidrug-resistant tuberculosis (MDR-TB) in India: an attempt to link biosocial determinants [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => multidrug-resistant-tuberculosis-mdr-tb-in-india-an-attempt-to-link-biosocial-determinants [to_ping] => [pinged] => [post_modified] => 2021-04-07 10:22:29 [post_modified_gmt] => 2021-04-07 14:22:29 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1478 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [3] => WP_Post Object ( [ID] => 1477 [post_author] => 4 [post_date] => 2021-04-07 10:20:00 [post_date_gmt] => 2021-04-07 14:20:00 [post_content] =>

Abstract

Gender-specific patterns of experience, meaning, and behaviour for tuberculosis (TB) require consideration to guide control programmes. To clarify concepts of gender, culture, and TB in a rural endemic population of Maharashtra, India, this study of 80 men and 80 women employed qualitative and quantitative methods of cultural epidemiology, using a locally adapted semi-structured Explanatory Model Interview Catalogue (EMIC) interviews are instruments for cultural epidemiological study of the distribution of illness-related experiences, meanings, and behaviours. This interview queried respondents without active disease about vignettes depicting a man and woman with typical features of TB. Emotional and social symptoms were frequently reported for both vignettes, but more often considered most distressing for the female vignette; specified problems included arranging marriages, social isolation, and inability to care for children and family. Job loss and reduced income were regarded most troubling for the male vignette. Men and women typically identified sexual experience as the cause of TB for opposite-sex vignettes. With wider access to information about TB, male respondents more frequently recommended allopathic doctors and specialty services. Discussion considers the practical significance of gender-specific cultural concepts of TB. [post_title] => Cultural concepts of tuberculosis and gender among the general population without tuberculosis in rural Maharashtra, India [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => cultural-concepts-of-tuberculosis-and-gender-among-the-general-population-without-tuberculosis-in-rural-maharashtra-india [to_ping] => [pinged] => [post_modified] => 2021-04-07 10:20:01 [post_modified_gmt] => 2021-04-07 14:20:01 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1477 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [4] => WP_Post Object ( [ID] => 1468 [post_author] => 4 [post_date] => 2021-04-06 11:48:26 [post_date_gmt] => 2021-04-06 15:48:26 [post_content] =>

Abstract

Objectives This study explored the acceptability of cough etiquette, wearing masks and separation by tuberculosis (TB) suspects and TB patients in two districts in Uganda. Design The study was conducted in Mukono and Wakiso districts in central Uganda. Eighteen in-depth interviews with patients and eight focus group discussions with health workers were conducted. Patients were asked for their opinions on cough etiquette, patient separation and wearing of masks. Results Patients and health workers felt that physical separation was ideal, yet separation and masking were regarded as embarrassing to patients, emphasizing their potential infectiousness. Patients reported greater willingness to cover their mouth with a handkerchief than to wear a mask. Good counseling and health education were suggested to improve patients’ adoption of separation and masking. However patients expressed concerns about equity, coercive and stigmatizing approaches. Universal precautions were more acceptable than targeted ones, with the exception of separating TB patients. Lack of community awareness about airborne transmission of TB was identified as a barrier to accepting and adopting TB infection control measures. Conclusion Scaling up effective TB infection control norms and behaviors requires a patient-centered, rights-based, and evidence-based approach. Socially acceptable measures like covering the mouth and nose with a handkerchief should be promoted. We recommend that further studies are needed to explore how community advocacy impacts on acceptability of masking. Furthermore, the efficacy of covering the mouth using a handkerchief or piece of cloth compared to wearing a mask in TB prevention needs to be evaluated. [post_title] => Acceptability of masking and patient separation to control nosocomial Tuberculosis in Uganda: A qualitative study [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => acceptability-of-masking-and-patient-separation-to-control-nosocomial-tuberculosis-in-uganda-a-qualitative-study [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:48:26 [post_modified_gmt] => 2021-04-06 15:48:26 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1468 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [5] => WP_Post Object ( [ID] => 1467 [post_author] => 4 [post_date] => 2021-04-06 11:45:01 [post_date_gmt] => 2021-04-06 15:45:01 [post_content] =>

Abstract

Background

Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions.

Methods

We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations.

Results

Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes.

Conclusions

Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs. [post_title] => A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => a-scoping-review-of-health-related-stigma-outcomes-for-high-burden-diseases-in-low-and-middle-income-countries [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:45:01 [post_modified_gmt] => 2021-04-06 15:45:01 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1467 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [6] => WP_Post Object ( [ID] => 1466 [post_author] => 4 [post_date] => 2021-04-06 11:42:30 [post_date_gmt] => 2021-04-06 15:42:30 [post_content] =>

Abstract

Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health. This correspondence article seeks to assess how developments over the past 5 years have contributed to the state of programmatic knowledge—both approaches and methods—regarding interventions to reduce stigma in health facilities, and explores the potential to concurrently address multiple health condition stigmas. It is supported by findings from a systematic review of published articles indexed in PubMed, Psychinfo and Web of Science, and in the United States Agency for International Development’s Development Experience Clearinghouse, which was conducted in February 2018 and restricted to the past 5 years. Forty-two studies met inclusion criteria and provided insight on interventions to reduce HIV, mental illness, or substance abuse stigma. Multiple common approaches to address stigma in health facilities emerged, which were implemented in a variety of ways. The literature search identified key gaps including a dearth of stigma reduction interventions in health facilities that focus on tuberculosis, diabetes, leprosy, or cancer; target multiple cadres of staff or multiple ecological levels; leverage interactive technology; or address stigma experienced by health workers. Preliminary results from ongoing innovative responses to these gaps are also described. The current evidence base of stigma reduction in health facilities provides a solid foundation to develop and implement interventions. However, gaps exist and merit further work. Future investment in health facility stigma reduction should prioritize the involvement of clients living with the stigmatized condition or behavior and health workers living with stigmatized conditions and should address both individual and structural level stigma. [post_title] => Stigma in health facilities: why it matters and how we can change it [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => stigma-in-health-facilities-why-it-matters-and-how-we-can-change-it [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:42:30 [post_modified_gmt] => 2021-04-06 15:42:30 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1466 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [7] => WP_Post Object ( [ID] => 1465 [post_author] => 4 [post_date] => 2021-04-06 11:33:55 [post_date_gmt] => 2021-04-06 15:33:55 [post_content] =>

Abstract

Community-led tuberculosis (TB) active case finding is widely promoted, heavily funded, but many efforts fail to meet expectations. The underlying reasons why TB symptom screening programs underperform are poorly understood. This study examines Nigerian stakeholders’ insights to characterize the mechanisms, enabling structures and influences that lead programs to succeed or fail.

Eight focus group discussions were held with Community Health Workers (CWs) from four models of community-based TB screening and referral. In-depth interviews were conducted with 2 State TB program managers, 8 Community based organizations (CBOs), and 6 state TB and Leprosy Local Government supervisors. Transcripts were coded using Framework Analysis to assess how divergent understandings of CWs’ roles, expectations, as well as design, political and structural factors contributed to the observed underperformance.

Altruism, religious faith, passion, and commitment to the health and well-being of their communities were reasons CWs gave for starting TB symptom screening and referral. Yet politicized or donor-driven CWs' selection processes at times yielded implementers without a firm grounding in TB or the social, cultural, and physical terrain. CWs encountered suspicion, stigma, and hostility in both health facilities and communities. As the interface between the TB program and communities, CWs often bore the brunt of frustrations with inadequate TB services and CBO/iNGO collaboration. Some CWs expended their own social and financial capital to cover gaps in the active case finding (ACF) programs and public health services or curtailed their screening activities.

Effective community-led TB active case finding is challenging to design, implement and sustain. Contrary to conventional wisdom, CWs did not experience it as inherently empowering. Sustainable, supportive models that combine meaningful engagement for communities with effective program stewardship and governance are needed. Crucially effective and successful implementation of community-based TB screening and referral requires a functional public health system to which to refer.

[post_title] => Community health care workers in pursuit of TB: Discourses and dilemmas [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => community-health-care-workers-in-pursuit-of-tb-discourses-and-dilemmas [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:33:55 [post_modified_gmt] => 2021-04-06 15:33:55 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1465 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [8] => WP_Post Object ( [ID] => 1464 [post_author] => 4 [post_date] => 2021-04-06 11:29:29 [post_date_gmt] => 2021-04-06 15:29:29 [post_content] =>

Book Content Overview

Chapter 1 introduces readers to stigma theory and some basic definitions of types of stigma. Chapter 2 (methodology) offers an overview of the scientific and operational considerations for matching your stigma measurement method to your question. Chapter 3 teaches formative qualitative research techniques to and out why the TB stigma takes a particular form, where the stigma comes from, and how stigma operates in your setting. Chapter 4 focuses on the measurement of TB stigma at the community level. This chapter details special considerations for embedding TB stigma measures in household surveys (e.g., scale length), and in settings with concentrated vs. generalized HIV epidemics. Chapter 5 focuses on measurement of TB discriminatory attitudes and behaviors in institutions such as prisons, schools, and health facilities, and has a special focus on measuring enacted TB stigma (discriminatory behaviors) through observational methods. The TB stigma literature has focused more on discrimination and disparagement of individual TB patients and less on the structural forms of discrimination. Chapter 6 covers the measurement of structural stigma. Chapter 7 teaches the basic principles of TB stigma measurement among TB patients. This is a relatively well-developed field with validated TB stigma scales robust in a variety of settings. Nevertheless, there are statistical and sampling challenges that require special consideration. Techniques for measuring secondary stigma are introduced in Chapter 8. This chapter describes the best practices for measuring stigma among healthcare workers (HCW), family members, and those in TB-affected industries. HCW stigma measurement is a high priority because HCW are often stigmatized for their vital TB care work, and yet may simultaneously mistreat TB patients. Chapter 9 explores how to measure TB stigma among socially networked populations who are already marginalized and socially excluded for other reasons. It outlines the efforts required to obtain reliable and unbiased estimates. State-of-the-art methods for capturing self-stigma, resilience, and self-efficacy are covered in Chapter 10. It is vital to measure the strengths and forms of 8resistance of people affected by TB. Documenting how some groups successfully detect stigma can inform interventions. Chapter 11 teaches how to deconstruct the language of TB programs to identify stigmatizing rhetoric and discourse. This chapter explores methods for policy analysis to pinpoint stigma embedded in norms and guidelines. Chapter 12 describes how to engage civil society and TB patients meaningfully in TB stigma measurement efforts. This text provides useful tips on participatory strategies that prevent further stigmatization and ensure dignity. Chapter 13 lays out the methodological foundations for incorporating the costs of TB stigma and social disadvantage into a cost-effectiveness analysis. Policy and strategy debates in TB control may have unintended consequences that should be anticipated. Chapter 14 involves intersectional and compound stigmas, such as the double stigma of TB/HIV. It is widely understood that TB stigma can be enmeshed with other kinds of social exclusions and marginalities. This creates analytical challenges that must be managed carefully to prevent bias and confusion. Chapter 15 describes how to study the impact of TB on complex behaviors, such as health-seeking, adherence, and mortality. This is a field of particular interest to TB programs seeking to understand the impact of TB stigma on their program. Chapter 16 gives concrete advice for those who want to develop and validate their own TB stigma scales. Chapter 17 gives step-by-step instructions for analyzing qualitative data from formative stigma research.

[post_title] => TB StigmaMeasurement Guidance [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => tb-stigmameasurement-guidance [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:29:29 [post_modified_gmt] => 2021-04-06 15:29:29 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1464 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) [9] => WP_Post Object ( [ID] => 1463 [post_author] => 4 [post_date] => 2021-04-06 11:23:52 [post_date_gmt] => 2021-04-06 15:23:52 [post_content] =>

Abstract

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. [post_title] => Psychometric evaluation of a new drug-resistant tuberculosis stigma scale [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => psychometric-evaluation-of-a-new-drug-resistant-tuberculosis-stigma-scale [to_ping] => [pinged] => [post_modified] => 2021-04-06 11:23:52 [post_modified_gmt] => 2021-04-06 15:23:52 [post_content_filtered] => [post_parent] => 0 [guid] => https://sshiftb.org/?post_type=resources&p=1463 [menu_order] => 0 [post_type] => resources [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 10 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 1486 [post_author] => 4 [post_date] => 2021-04-07 11:27:43 [post_date_gmt] => 2021-04-07 15:27:43 [post_content] =>

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Here are some resources relevant to social science work in TB, many of which involve contributors of SSHIFTB. Please contact us if you would like to submit a new resource.

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The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis

Gender and community views of stigma and tuberculosis in rural Maharashtra, India

Multidrug-resistant tuberculosis (MDR-TB) in India: an attempt to link biosocial determinants

Cultural concepts of tuberculosis and gender among the general population without tuberculosis in rural Maharashtra, India

Acceptability of masking and patient separation to control nosocomial Tuberculosis in Uganda: A qualitative study

A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries

Stigma in health facilities: why it matters and how we can change it

Community health care workers in pursuit of TB: Discourses and dilemmas

TB StigmaMeasurement Guidance

Psychometric evaluation of a new drug-resistant tuberculosis stigma scale

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