Factors affecting TB case detection and treatment in the Sissala East District, Ghana

doi:10.4236/jtr.2013.13006

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Vol.1, No.3, 29-36 (2013) Journal of Tubercul osis Resear ch

http://dx.doi.org/10.4236/jtr.2013.13006

Factors affecting TB case detection and treatment in

the Sissala East District, Ghana*

Collins K. Ahorlu1#, Frank Bonsu2

1Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana;

#Corresponding Author: [email protected]

2National TB Control Programme, Ghana Health Service, Accra, Ghana [email protected]

Received 16 July 2013; revised 24 August 2013; accepted 10 September 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Tuber culosis remains a major heal-

th problem affecting about a third of the world

population despite a number of preventive and

control measures taken in the past few decades.

Eighty-five percent of all tuberculosis cases are

concentrated in Asia and Africa due to lack of

education and health care infrastructure. Objec-

tive: To determine factors affecting low tuber-

culosis case detection in the Sissala East dis-

trict in the Upper West Region of Ghana. Meth-

ods: This was a descriptive study where semi-

structured questionnaire was administered to 61

respondents; six focus group discussions and

20 in-depth interviews were conducted to gen-

erate both qualitative and quantitative data for

analysis. Results: Tuberculosis, known locally

as Kesibine was identified as a major problem in

the district. The two most frequently reported TB

related distresses were coughing (96.7%) and

chest pains (95.0%). However, these distresses

were reported more after probing for them. The

most frequently spontaneously reported dis-

tress was reduced income (60.7%) for patients.

The most prominent cause reported was sexual

pollution (72.2%). Suspected tuberculosis pa-

tients are stigmatized and are denied sex by

their partners as shown in the following narra-

tive; I will not eat or have sex with her or eat any

leftover from her plate (male local h ealer, In-dep-

th interview). Case detection and treatment is

hampered by lack of communication between

sub-district facilities and the district hospital to

aid laboratory diagnosis. Conclusion: There is

therefore the need for vigorous health education

to inform the people about the biomedical

causes of TB and the availability of appropriate

treatment for the disease at health facilities.

However, the education should not aim at chang-

ing the “wrong beliefs” but focus on making

people aware of the biomedical causes and see

TB as treatable infection, which could be con-

trolled.

Keyw ords: TB; Treatment; Case Detection; Ghana

1. INTRODUCTION

Tuberculosis (TB) remains a major health problem af-

fecting about a third of the world population despite a

number of preventive and control measures taken in the

past few decades. It is responsible for an estimated 8.8

million cases and 1.4 million deaths globally [1,2].

Eighty-five percent of these TB cases are concentrated in

Asia and Africa where there is a lack of education, health

care infrastructure, poverty an d overcrowding [1 -5 ] .

It is estimated that Africa contributes about 29% and

34% of all TB related morbidity and mortality to the

global burden. In Ghana, TB remains a major cause of

preventable adult morbidity and mortality [6-11] and in

2007, WHO has estimated that 50,000 new TB cases

occurred in Ghana, making it the 19th most TB burden

country in Africa. However, TB has remained a fearful

disease among the Ghanaian population as demonstrated

by the local Akan name for it—“Nsamanwa”, which con-

notes both fear and death. The term “Nsamanwa” liter-

ally means “ghost cough”, which suggests that once you

get the disease, you have literally become a ghost or a

dead person [7-11]. The linguistic difference between the

Akan speaking and the Sissala speaking people notwith-

standing, TB patients are generally stigmatized across the

globe [10-12]. With this seriousness and fear associated

to TB, it is expected that suspected cases will seek for

*Competing Interest: We declare that we have no competing interest in

writing this paper.

C. K. Ahorlu, F. Bonsu / Journal of Tuberculosis Research 1 (2013) 29-36

treatment early at the health facility. But this was not the

case in the Sissala East District in the Upper West district

of Ghana where virtually no TB cases were being diag-

nosed. This could be due to massive stigma associated

with the disease among other things [6-16].

The main strategy for TB treatment globally is the di-

rectly observed treatment short course (DOTS) which

relies on case detection and treatment with multiple an-

timicrobial drugs for at least six months. It is anticipated

that this strategy will enhance treatment compliance and

thereby improve treatment outcome. Central to this stra-

tegy however is laboratory diagnosis to confirm clinical

cases before treatment is initiated [1,5,7,12]. This is

where the attitude of health workers toward patients in

terms of stigmatization could negatively influence the

health seeking behaviour among suspected patients [10,

11,17-20].

Social factors that are known to be driving the global

increase in TB cases include; overcrowding, especially in

urban centres, late reporting and diagnosis, non-compli-

ance to treatment schedule, lack of commitment on the

part of national control programme in developing coun-

tries, lack of education, health care infrastructure and

poverty [2,3,6].

Despite increased efforts at prevention and the wide-

spread availability of effective short-course anti-tuber-

culosis chemotherapy in the past few decades, the inci-

dence of tuberculosis is on the increase both in devel-

oped and developing countries. The emergence of ex-

tremely drug resistant tuberculosis (XDR-TB) from

South Africa is going to be a major threat to TB control

in Africa (http://allafrica.com/stories/200610180119.html).

This is because, in sub-Saharan Africa, case detection

rates are still low and the period from first symptom to

diagnosis and treatment could be quite long [21].

This study was designed to determine factors affecting

low TB case detection in the Sissala East District in the

Upper West Region of Ghana. This operational study

became necessary to generate information for the Ghana

national TB control programme for appropriate remedial

actions to be taken to forestall any catastrophe that may

result from untreated TB cases in the study area.

2. MATERIALS AND METHODS

2.1. Study Area

The study was conducted in the Sissala East, a rural

district located in the north-eastern part of the Upper

West Region of Gh ana with Tumu as its capital. The dis-

trict shares about 300 kilometer border with Burkina

Faso. According to the 2010 population and housing

census, there are 56,528 people living in the district [22].

The district is predominantly rural where over 75% of

the people are engaged in subsistence agriculture

(DHMT annual report, 2010). The formal health system

in the district con sists of 1 district hospital, 5 health cen-

ters (HC). However, low health service utilization was

reported in the district (DHMT, annual report, 2010). The

national TB control program initiated this research to

ascertain why very little or no TB cases were being re-

corded in the district in recent years.

2.2. Data Collection Techniques

This was a descriptive study employing both qualita-

tive and quantitative techniques for data collection.

EMIC (insider perspective) interviews were conducted

with 61 persons to generate quantitative data. EMIC in-

terviews are instruments used for assessing representa-

tions of illness or specified health problems from the

perspective of affected persons, their family or commu-

nity members. The instrument blends qualitative and

quantitative approaches to study illness-related experi-

ences, meanings and behaviours [23]. The EMIC tool

was designed to generate relevant representations and

categories of distress, perceived causes, help-seeking

behaviours and perceived or experienced TB related

sti gma. Respondents were enrolled into the stu dy th rou gh

purposive sampling, using the snowball technique, where

each person identified also brought at least one other

person with similar condition. An initial screening was

done on each person brought to be sure that they meet

the inclusion criterion, which is coughing continuously

for 14 days or more before they were enrolled into the

study after receiving their consent to participate. This

technique was adopted we could not generate a list of

suspected TB cases and the district hospital has no recent

patients list to select the sample from. However, commu-

nity leaders were able to refer some suspected cases to

the researchers who were then asked to refer at least one

person with similar condition (coughing for 14 or more

days).

To allow for group interactions and to generate diver-

gent locally valid TB representations and categories, Six

FGDs (three for each sex) were conducted with selected

adults aged 18 years and above. Also, 20 in-depth inter-

views were conducted (three chiefs, three queen mothers

or women representatives, six health workers and eight

traditional healers). These qualitative techn iques allowed

us to determine the ethnographic features of TB in the

district.

2.3. Analysis

Qualitative data were analysed using Maxqda software

after the data were entered into Microsoft word in a for-

mat that allows importation to Maxqda in a preformatted

C. K. Ahorlu, F. Bonsu / Journal of Tuberculosis Research 1 (2013) 29-36

coded form. Content analysis was then performed on

relevant segments to generate representative narratives

for presentation to complement and clarify quantitative

findings. The quantitative data was entered into EpiInfo

version 3.3.2, which was also used to perform descriptive

analysis for presentation.

2.4. Ethical Considerations

The study was reviewed by the Institutional Review

Board of the Noguchi Memorial Institute for Medical

Research, University of Ghana. Each participant was

informed of the objectives, methods, anticipated benefits

and potential hazards of the study. Participants were as-

sured that all information collected for the study would

be kept confidential, and that in an y resulting publication

it would not be possible to link the data to individuals

and families in the study. Written inform consent was

obtained from all participants and none have declined

participation in the stud y. Participants signed/thump print

the consent form together with a witness to accept par-

ticipation in the study.

3. RESULTS

3.1. Socio-Demographic Characteristics of

Survey Respondents

EMIC interview participants were made up of 30

males and 31 females with the mean (±Std) age of 39.6

years. Majority of the survey respondents were Muslim

(73.8%) and most of them were married (67.2%). Major-

ity (67.2%) of them had no education and were mainly

farmers (70.5%) and petty traders (16.4%).

3.2. Common Illnesses

Malaria/fever (98.4%) was the most common illness

mentioned by respondents. The rest were coughing

(62.3%), stomach pains (54.1%), diarrhoea (26.2%) and

chest pains (21.3%). However, among all these health

problems the two most troubling reported were ma-

laria/fever (45.9%) and coughing (22.9%). Almost all

(95.1%) survey respondents said persistent cough or sus-

pected TB was a problem in the district. The most pro-

minent local name/term for TB reported was Kesibine

(85.2%). Kesibine was also mentioned as the local name

for TB during in-depth interview with traditional healers

and community leaders as well as during focus group

discussion (FGD) with the general adult population. All

related names/terms for TB have meanings attached to

them, for example, the term Kesibine or kesibelle was

explained to mean “black cough or prolong cough with

blood in the sputum”, the term Boye was explained to

mean “coughing with blood” and Kukuezine means

“coughing till blood comes out”.

3.3. Distresses Suffered by Suspected TB

Patients

Various distresses associated with TB were reported

by suspected TB patients, prominent distress reported

spontaneously was reduced income (60.7%) while the

two most frequently reported distresses after probing

were coughing (96.7%) and chest pains (95.0%) (Table 1)

Table 1. Distresses reported either spontaneously or probed*.

Spontaneous Responses Probed Responses Total

Constraining Factors (Variables)** Frequency (%) Frequency (%) %

Blood in sputum

Breathlessness

Chest pains

Concern about cours e of illness

Coughing

Difficulty finding partner

Fever

Headache

Loss of appetite

Loss of job/wage

Marital Problems

Reduced income

Reduced social status

Sadness, anxiety or worry

Side effect of dr ugs

Social isolation

Weakness

Weight loss

10 (16.4)

18 (29.5)

7 (11.4)

25 (41.0)

7 (11.5)

14 (23.0)

16 (26.2)

23 (37.7)

13 (21.3)

19 (31.1)

11 (18.0)

37 (60.7)

15 (24.6)

35 (57.4)

18 (29.5)

24 (39.3)

17 (27.9)

22 (36.1)

30 (49.2)

51 (83.6)

7 (11.5)

52 (85.2)

11 (18.0)

25 (41.0)

27 (44.3)

18 (29.5)

1 (1.6)

13 (21.3)

3 (4.9)

14 (23.0)

1 (1.6)

11 (18.0)

27 (44.3)

31 (50.8)

52.5

78.7

95.0

52.5

96.7

41.0

67.2

82.0

50.8

32.7

39.3

65.6

47.6

80.4

31.1

47.5

83.6

78.7

Multiple choices allowed; **Sorted alphabetically in column 1.

C. K. Ahorlu, F. Bonsu / Journal of Tuberculosis Research 1 (2013) 29-36

The following representative narratives confirmed the

importance of the distresses reported:

TB may lead to reduction in the income of the patient

and this in itself can lead to death. …affects both the

economic and physical live of the patients which make

them feel miserable (Male traditional healer, IDI).

…TB in the family can disturb other family members

as they waste a lot of money and time on the patient. In

this community TB patients are not allowed to have sex

with their husbands and this make life difficult for the

family and in some cases the man will go and marry an-

other wife while keeping the original wife in isolation

(female traditional healer, IDI).

Majority of the survey respondents (80.3%) main-

tained that women who h ave TB suffer from it more than

men in the district for various reasons, some of which

were represented in the following narratives:

There are some differences…the truth is that women

with suspected TB find it more difficult to live with the

disease. …a woman with TB will never get a partner to

marry in this community, but a man with TB can easily

get a partner to marry (Female, FGD).

...people relate to male and female patients differ-

ently…a man with suspected TB is never suspected of

having AIDS but every woman with suspected TB is taken

to be AIDS patient and this makes life very difficult we

the women (Female suspected patient, EMIC interview).

3.4. Causes of TB

Varied causes of TB were reported and the most

prominent cause reported was sexual pollution (72.2%).

Thus, spontaneously (45.9%) and after probing (26.3%)

(Table 2). The following representative narratives ex-

plained some of the causes in detailed:

Kessibine (TB) is transmitted through sexual inter-

course with an infected person. …drinking fresh milk

from infected animals could also cause it (male opinion

leader, IDI).

The disease is transmitted through exchange of saliva

with an infected person. …when shared a handkerchief

with infected persons and through sexual intercourse,

especially when the woman coughs during sex (female,

FGD).

When you sleep with a woman and she carelessly

cough on you, you could develop TB. You can also get TB

from eating cat meat or other infected animas. It is in the

air but it can also be caused when one partner during

sexual intercourse cough very deeply. It can also be

caused by over working and drinking of bad water (Male

traditional Healer , IDI).

Table 2. Perceived causes reported either spontaneously or after probing*.

Spontaneous Responses Probed Responses

Perceived Causes (Variables)** Frequency Percentage Frequency Percentage

Total %

Drugs abused

Air borne/exposure

Alcohol

Blood-related problems

Constitutional weakness

Contact with Affected Person

Evil spirits/gods

Fate (star)

Food

Germs/infections

Hereditary

Injury/accident/surgery

Insect bite

Lack of personal hygiene

Lack of sanitation

Mental/emotional stress

Neglected previous illness

Physical exertion/hard work

Pregnancy/child bir th

Prescribed medicines

Previous illness

Sexual pollution

Smoking

Water

6 (9.8)

16 (26.2)

12 (19.7)

18 (29.5)

13 (21.3)

14 (23.0)

15 (24.6)

14 (23.0)

8 (13.1)

7 (11.5)

17 (27.9)

6 (9.8)

10 (16.4)

11 (18.0)

12 (19.7)

8 (13.1)

17 (27.9)

8 (13.1)

16 (26.2)

28 (45.9)

14 (23.0)

6 (9.8)

12 (19.7)

23 (36.1)

16 (26.2)

13 (21.3)

4 (6.6)

11 (18.0)

6 (9.8)

4 (6.6)

17 (27.9)

11 (18.0)

12 (19.7)

2 (3.3)

16 (26.2)

5 (8.2)

9 (14.8)

6 (9.8)

3 (4.9)

21 (34.4)

10 (16.4)

4 (6.6)

16 (26.3)

22 (36.1)

18 (29.5)

29.5

62.3

45.9

50.8

27.9

41.0

34.4

39.6

41.0

29.5

31.2

36.0

24.6

32.8

27.8

24.6

47.5

27.9

29.5

32.8

72.2

59.1

39.3

*Multiple choices allowed; **Sorted alphabetically in column 6.

C. K. Ahorlu, F. Bonsu / Journal of Tuberculosis Research 1 (2013) 29-36 33

3.5. Traditional Healers and TB Treatment

Five out of the six traditional healers interviewed said

that they are able to treat and cure TB completely. They

however admitted that, just like biomedicine, some sus-

pected TB patients who came to them did not receive

complete cure. They were of the view that some of the

patients require being on treatment for very long time in

order to get cured, which was not affordable to the pa-

tients both in terms of time and money. The following

narratives vividly captured these po sitions:

In some TB cases, our herbal medications are more

effective and better than biomedicines. …they are some-

times treated badly at the hospital…th ey prefer coming to

us ...so instead of condemning us, we should be sup-

ported to help treat TB p atients (Male Traditional healer,

IDI).

3.6. Health Seeking for Suspected TB

Most of the survey respondents (85.2%) sought help

when they suspected that they have TB and they report-

edly went to the Government hospital/clinics (84.6%).

However, they maintained that no sputum sample was

taken from them for laboratory analysis, even though

they had reported that they were coughing for more than

two weeks. Also, all survey respondents admitted that

they had consulted traditional healers at one time or the

other for their prolong coughing. The following narra-

tives vividly echoed that position:

I went to the clinic at the beginning of my problem, but

I must say that the way suspected TB patients are treated

in this community makes it difficult for me to keep going

to the clinic to avoid being labelled as an IDS patient

(Middle aged lady, FGD).

Health workers interviewed were of the view that TB

patients have lukewarm attitude towards treatment as

indicated in the following representative narratives:

During intensive treatment period, they (patients) usu-

ally complain about the injections or drugs as being too

much (A Nurse at the District Hospital).

Patients that were diagnosed in the past did not come

to the clinic regularly to collect or take their medications

and this affected the progress of the programme (District

TB focal person).

Majority of respondents (91.8%) said th ey will sup port

the idea of community DOT provided the “providers” are

trained community members who they can trust. They

maintained that they will readily utilise the services of

the community DOT providers but will be happy if they

would come to their homes with the medicines.

3.7. Stigma

Majority (63.9%) of the survey respondents said they

have never tried to prevent other people from knowing

about their persistent cough (suspected TB). However,

29.5% of them said they have tried to hide their condi-

tion from other people. Also, majority (75.4%) of them

have discussed their condition with persons they consid-

ered intimate. For those who discussed their problem

with close relatives, most of them talked to either their

spouse (47.8%) or parents (37.0%). The following narra-

tives explained why some respondents will not want to

talk about their condition to others:

...TB is viewed in this community as a bad and dan-

gerous disease, so if you have it, people will not want to

associate with you, they will not wan t to eat with you and

this makes you feel uncomfortable (lady FGD).

Those with TB will not declare it publicly because

people in this commu nity see TB patients as co rps (living

but dead, they are not even allowed to have sex with their

partners (male FGD).

The following narratives revealed how community

members will relate to their spouses when they are diag-

nosed with TB;

I will not eat with her or eat any leftover from her

plate (male local healer, IDI).

…not have sex with h er and I will not sh are a drinking

cup with her, though I will support her to attend clinic

for treatment (male FGD).

…will relate nicely to him but I will not eat with him

because it is not good to get too closer to him (female

FGD).

About halve of the survey respondents (50.8%) said

they think less of themselves because of their persistent

coughing. Also, majority (52.5%) said they were some-

times made to feel shame because of their condition.

Moreover, 54.1% of them said they were less respected

in the district because of their condition. The following

narratives explained these positions;

In this community, once people know that you have TB,

they will not want to have anything to do with you. They

will start to look at you as a good for nothing person

who is awaiting death; they will be careful not to con-

tract the disease (lady suspected TB patient, EMIC).

Some people will be sympathetic with you and try to

help you but others will think less of you because they

will continue to think that you got the disease through

sexual pollution (lady suspected TB patient, EMIC).

About halve (49.2%) of the survey respondents said

that they never suspected that people were trying to

avoid them. However, 26.2% reported that people have

tried to avoid them because of their conditions while

21.3% were not sure. On the other hand, health workers

interviewed reported that patients who came to them in

the past were worried that others would get to know

about their TB status. These patients were then assured

of confidentiality of their clinical records. Health work-

ers also maintain that the fear of stigmatisation may be

C. K. Ahorlu, F. Bonsu / Journal of Tuberculosis Research 1 (2013) 29-36

the cause of low TB case reporting to the health facility

for diagnosis and treatment. These positions were aptly

explained in the following narrative:

People always think that if you have TB it means that

you have carelessly coughed during sexual intercourse

and therefore shun your company and this have nega-

tively affected the confidence of suspected TB patients to

come to the clinic for fear that they will be exposed to

public ridicule (Nurse, ID I) .

3.8. Defaulter Rate

Treatment default rate was reportedly high as captured

in the following narratives:

Some people do stop going for their medications be-

cause they do not want others to find out that they have

TB …some do not start at all…in my case, I am planning

to go but I am yet to discuss it with my husband (Female

suspected patient, EMIC).

We have seen only a few cases here and once they are

getting better or saw some improvement in their health,

they stop coming for medications (Nurse, IDI).

People stop coming for TB medication because of their

preference for traditional healers and self medications as

a way of keeping other people away from knowing about

their TB status. Some people do complain about the side

effects of the medication and I think that may be one of

the reasons why they default on treatment (District TB

focal person, IDI).

...Dropping out of treatment do not happened only

with the orthodox medication but also with our herbal

medication too. ...the reason is that when the patients are

treated for some time, their condition imp roves then they

think that they a re cured. ...some people natura lly do not

like taking medicine and have to be forced to take it. For

such people, once their condition gets better they will

definitely stop coming for the medication (Male Tradi-

tional Healer, IDI).

3.9. Reasons for Not Attending

clinic/Hospital with TB

Formal health workers interviewed reported that sus-

pected TB cases were going to traditional healers instead

of the clinic/hospital because of the persistent belief that

TB is caused by witches. This was represented in the

following narrative:

Our culture made people to think that TB is caused by

witchcraft or other malevolent spirits; hence their pref-

erence for traditional healing practices (Hospital Labo-

ratory Tech nician, IDI).

I think that religious believes are also affecting the

rate at which suspected TB patients come to the clinic

because they sometimes believe that TB can be cured

through prayers from Muslim healers (Malam s) (Com-

munity health nurse, IDI).

3.10. Case Detection and Treatment

Case detection and treatment is hampered by the fact

that there is no facility at the sub-district levels for test-

ing suspected patients. Also, drugs are received from the

district level only when a case has been confirmed at the

District hospital. Staff at the sub-district level have la-

mented that most specimen sent to the district hospital

for testing either have no results send to them or takes so

long before the result are sent to them and this was put-

ting probable patients way from reporting at their fa-

cilities. They maintained that, it was making things dif-

ficult for them, especially when they do not know what

to do for the patients without the test result. The follow-

ing narratives captured in detail the difficulty that pe-

riphery facilities go through to diagnose and treat TB.

In fact there are many problems with the way we treat

suspected TB cases here. In the first place the people are

unwilling to come because of stigmatisation but the few

that come to us also have to wait for a long time before

getting into treatment because we have to wait for the

test result from Tumu. You see this young girl (pointing to

the girl); it took more than one year to get her into

treatment because we did not get the laboratory result

from Tumu. ...the patient kept coming to me ...I sent an-

other sample and this time, nothing was heard from

Tumu about it. ...about three month ago I sent a third

sample ...I followed it up on every market day until about

two weeks ago when I received the test result and it was

positive. ...she is now on drug and looking a bit better

now. How can you explain this situation to suspected TB

patients? (A nurse: in charge of a sub-district facility,

IDI).

3.11. Financial and Social Support

Majority (70.5%) of the survey respondents said they

were being supported by their spouse and other family

members in various ways, especially financial and social

supports (Table 3). The three most important decision

makers during illness in the Sissala East Districts were

parents (54.1%), the sick person himself (27.9%) and

spouse (21.3%).

4. DISCUSSION

The results show that people with suspected cough and

other community members as well as traditional healers

were awa re that TB cou ld be treated at biomedical health

facilities. However, people who have coughed for more

than 14 days (suspected TB cases) were not going to the

health facilities for diagnosis and treatment ([6,7,10],

gmj 2008, phm 2009). Various reasons could be assigned

to this behaviour; however from our results three main

C. K. Ahorlu, F. Bonsu / Journal of Tuberculosis Research 1 (2013) 29-36 35

Table 3. Sources of financial support available to suspected TB

patients*.

Variable

(Sources of Financial Support) Frequency** Percentage

Parents 41 67.2

Self 24 39.3

Spouse 15 24.6

Adult children 14 23.0

Extended family members 12 19.7

Friends 4 6.6

Religious affiliations 1 1.6

*Multiple choices allowed; **Sorted in descending order in column 2.

reasons clearly stood out. The first one was the fear of

stigmatization both by community members and health

care providers. Community members presumed every

suspected TB patient to be suffering from HIV/AIDS, a

condition that is even more stigmatized than TB in the

study area ([16], Weiss 2006) and similar findings were

reported from elsewhere [12,13] It is good for health care

providers to protect themselves against infections but

when this is done in ways that cause some discomfort to

patients then it may serve as a disincentive for seeking

health at health facilities ([13-15], g mj 2008, phm 2009).

Secondly, the lack of effective communication be-

tween the peripheral facilities and the laboratory at the

district hospital, where the results for samples from the

periphery facilities are not communicated on time and in

some cases not communicated at all, could also be af-

fecting the confidence of suspected patients in the health

care facilities since the laboratory results are needed for

the initiation of treatment or otherwise. This may also

affect health care providers at the periphery facilities as

they may not be encourag ed to send more samples to the

district laboratory.

Thirdly, the availability of traditional healers to man-

age suspected TB cases either rightly or wrongly may be

keeping suspected patients away from the health care

facilities because they share a common worldview and

local beliefs with suspected patients, which makes them

more attractive ([6,10], Dodo r 2008).

While the men reported that there was no gender dif-

ferences in the distresses suffered by TB patients; most

of the ladies, especially during FGD sessions, said there

were some gender differences in TB-related distresses in

the community. These differences must therefore be

taken seriously and dealt with when working on TB

stigma reduction in the district. This findings show how

quantitative data alone could not clearly bring out the

features of stigma and other distresses associated with

TB, especially among women in a male dominated envi-

ronments.

Both health care providers and healers complained of

high treatment dropout among TB patients. This must be

addressed through patients’ education and support system.

The need and importance of completing treatment to

reduce the risk of the emergence of drug resistance must

be emphasized ([6,10], Dodor, 2008, gmj 2008, phm

2009). The dangers and benefits associated with treat-

ment dropout must be drummed home in ant TB-related

health education programme in the study area.

The introduction of community-based DOT for TB

treatment was endorsed by respondents. However, this

must be implemented by training volunteers sufficiently

enough not only to deliver and supervise medication but

also to identify suspected cases and support them to re-

port at designated health care facilities. This may b e use-

ful considering the distance some patients have to cover

to access health services as this will reduce the travel

cost to the patients and family caretakers and thereby

improve treatment adherence [1].

TB patients, apart from the stigma also suffer from

lack of income due to reduce capacity to work. TB also

damage intimate relationships since women with sus-

pected TB were not allowed to have sex with their hus-

bands and this could lead to divorce and neglect which

will further exacerbate the suffering of the patient [6,10].

5. CONCLUSIONS

The understanding of TB as a deadly disease should

serve as an entry point to encourage appropriate health

seeking behaviour for suspected TB patients. To be suc-

cessful, however there is the need to emphasise the point

that TB could become deadly only if it is not treated at

the clinic/hospital appropriately early. Also, the avail-

ability of effective treatment at health facilities must be

promoted. The need to ex pand laboratory facilities to the

periphery facilities could not be overemphasized as this

greatly affects the time of first health seeking for sus-

pected TB and the start of the actual treatment. The

situations where laboratory results take months to be

made available to the periphery facilities cannot be al-

lowed to persist if the current control measures are to

make headway as expected.

Although this study did not verify the claim by tradi-

tional healers that they could cure TB, the control pro-

gramme should find a co llaborative wa y to use healers to

gain access to suspected TB patients. This is because the

people will continue to visit traditional healers as the

local perception of TB naturally favours the use of the

services of traditional healers. There is ther efo re th e n eed

for vigorous health education to inform the people about

the biomedical causes of TB and the availability of ap-

propriate treatment for the disease at health facilities.

However, the education should not aim at changing the

C. K. Ahorlu, F. Bonsu / Journal of Tuberculosis Research 1 (2013) 29-36

[10] Dodor, E.A. (2008) Health professionals expose TB pa-

tients to stigmatization in society: Insights from commu-

nities in an urban District in Ghana. Ghana Medical Jour-

nal, 42, 144-148.

“wrong beliefs” but focus on making people aware of the

biomedical causes and see TB as treatable infection,

which could be controlled.

[11] Doror, E.A., Kelly, S. and Neal, K. (2009) Health profes-

sionals as stigmatizers of tuberculosis: Insights from

community members and patients with TB in an urban

district in Ghana. Psychology, Health & Medicine, 14,

301-310. http://dx.doi.org/10.1080/13548500902730127

6. ACKNOWLEDGEMENTS

We are grateful to the Sissala East District Health Ad ministration for

collaborating with us on this study. We sincerely thank the community

assistants and the two research assistants who conducted the interviews

and performed translation during qualitative data collection for their

assistance on the field. Thanks to professor Koram for his support and

Cynthia Ahorlu for data entry and secretarial support. Many thanks to

the chiefs and people of the study area especially the respondents.

Financial support was provided by the Ghana National TB Control

Programme, Ghana Health Service, Accra.

[12] Data, K., Bhatnagar, T. and Murhekar, M. (2010) Private

practitioners’ knowledge, attitude and practices about TB,

Hooghly district, India. Indian Journal of Tuberculosis,

57, 199-206.

[13] Goffman, E. (1963) Stigma: Notes on the management of

spoiled identity. Prentice Hall, Englewood Cliffs.

[14] Weiss, M.G., Ramakrishna, J. and Somma, D. (2006)

Health-related stigma: Rethinking concepts and interven-

tions. Psychology, Health & Medicine , 11, 277-287.

http://dx.doi.org/10.1080/13548500600595053

REFERENCES

[1] World Health Organization (2011) ChouWHO report.

Global TB control. WHO/ HTM/TB/2011.16. WHO, Ge-

neva, Switzerland.

[15] Lawn, S.D., Afful, B. and Acheampong, J.W. (1998) Pul-

monary tuberculosis: Diagnostic delay in Gha nai an a dult s.

International Journal of Tuberculosis and Lung Disease,

2, 635-640.

[2] Hargreaves, J.R., Boccia, D., Evans, C.A., Adato, M.,

Petticrew, M. and Porter, D.H. (2010) The social deter-

minants of Tuberculosis: From evidence to action. Amer-

ican Journal of Public Health, 101, 654-662.

http://dx.doi.org/10.2105/AJPH.2010.199505

[16] Hancock, C. and Oulton, J.A. (2003) Nurses: Fighting

AIDS stigma, caring for all. International Council of

Nurses, Geneva.

[17] Liefooghe, R., Michiels, N., Habib, S., Moran, M.B. and

De Muynck, A. (1995) Perception and social conse-

quences of tuberculosis: A focus group study of tubercu-

losis patients in Sialkot, Pakistan. Social Science & Med-

icine, 41, 1685-1692.

http://dx.doi.org/10.1016/0277-9536(95)00129-U

[3] World Health Organization (2010) WHO report 2010.

Global TB control. WHO/HTM/TB/2010.7. WHO, Ge-

neva.

[4] Balasubramanian, V.N., Oommen, K. and Samuel, R.

(2000) Dot or not? Direct observation of anti tuberculosis

treatment and patient outcomes, Kerala State, India. The

International Journal of Tuberculosis and Lung Disease,

4, 409-413.

[18] Macq, J., Solis, A., Martinez, G., Martinez, P. and Dujar-

din, B. (2005) An exploration of the social stigma of tu-

berculosis in five “municipios” of Nicaragua to reflect on

local interventions. Health Policy, 74, 205-217.

http://dx.doi.org/10.1016/j.healthpol.2005.01.003

[5] Gilani, S.I. and Khurram, M. (2012) Perception of tuber-

culosis in Pakistan: Findings of a nation-wide survey.

Japan Pharmaceutical Manufacturers Association, 62,

116-120. [19] Volinn, I.J. (1983) Health Professionals as stigmatizers

and destigmatizers of diseases: Alcoholism and leprosy as

examples. Social Science & Medicine, 17, 385-393.

http://dx.doi.org/10.1016/0277-9536(83)90341-6

[6] Lawn, S.D. and Achempong, J.V.V. (1999) Pulmonary

tuberculosis in adults: Factors associated with mortality at

a Ghanaian teaching hospital. West African Journal of

Medicine, 18, 270-274. [20] Rafferty, J. (2005) Curing the stigma of leprosy. Leprosy

Review, 76, 119-126.

[7] (2006) Technical policy and guidelines for TB/HIV col-

laboration in Ghana. Ghana Health Service, Accra. [21] Yeboah-Manu, D., Asante-Poku, A., Ampah, K.A., Kpeli,

G., Danso, E., et al. (2012) Drug susceptibility pattern of

mycobacterium tuberculosis isolates from Ghana; corre-

lation with clinical response. Mycobacterial Disease, 2,

107. http://dx.doi.org/10.4172/2161-1068.1000107

[8] Dodor, E.A. and Afenyadu, G.Y. (2005) Factors associ-

ated with tuberculosis treatment default and completion at

the Effia-Nkwanta Regional Hospital in Ghana. Transac-

tions of the Royal Society of Tropical Medicine and Hy-

giene, 99, 827-832.

http://dx.doi.org/10.1016/j.trstmh.2005.06.011

[22] Weiss, M.G. (2001) Cultural epidemiology: An introduc-

tion and overview. Anthropology & Medicine, 8, 5-29.

http://dx.doi.org/10.1080/13648470120070980

[9] Lawn, S.D. (2000) Tuberculosis in Ghana: Social stigma

and compliance with treatment. International Journal of

Tuberculosis and Lung Disease, 4, 1190-1191.

[23] (2012) Population and Housing census. Summary of final

results. Ghana Statistical Service, Accra.

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