Ideas, attitudes and TB treatmentseeking behavior among AIDS and TB patients in Phnom Penh, Cambodia

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Ideas, attitudes and TB treatment-seeking
behavior among AIDS and TB patients in Phnom
Penh, Cambodia
Jan de Lind van Wijngaarden and Gill Fletcher,
FHI/Cambodia June 2001
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Results of qualitative research conducted by
FHI/IMPACT and Action/IEC as part of the
FHI/Gorgas TB/ERA Project
Introduction

• This research was carried out to meet two of the
  TB/ERA project objectives Assessment of TB
  burden in vulnerable populations and the design
  and production of IEC materials
• This presentation will focus on
• TB and AIDS patients
• Misconceptions about TB/AIDS, treatment-seeking
  behavior, stigma and discrimination
• Recommendations arising from the research

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Research informants

• Patients who receive drugs from the DOTS Home
  Delivery Program in Phnom Penh (N8)
• Patients who attend Cenat to receive drugs as
  DOTS out-patients (N7)
• Patients under the Home Care Network (HCN) in
  Phnom Penh (N16)

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Methodology

• Individual interviews and observations
• Random selection of participants using NTP and
  Home Care Network patient lists
• Cambodian researchers
• Tape recorders used

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Possible pitfalls

• Interviews were carried out in homes and Cenat
  hospital confidentiality could not be
  guaranteed
• Researchers were new to the subject of TB not
  always sufficient probing
• Data analysis conducted in English some info
  may have been lost
• Sometimes HCN or Cenat staff were present
  during the interview

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Main misconceptions

• TB can be transmitted by eating together/sharing
  plates or other objects
• TB can be transmitted by sleeping
  together/having sex
• TB is a hereditary disease
• TB can be transmitted by sharing a TB patients
  bathroom
• TB is transmitted through dust

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Consequences

• Self-isolation of patients
• Increased risk of stigma and discrimination from
  the community
• Increased confusion between HIV/TB symptoms,
  transmission modes, treatment and cure

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Determinants for seeking treatment

• Symptoms cough and fever
• Important function of pharmacists (drug sellers)
• Smaller role for traditional healers
• Public/private hospitals
• Only 2 out of 15 patients on TB treatment
  started their treatment at the NTP

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• Most patients knew TB is treatable and curable
  and that AIDS is not
• Stigma and discrimination (felt rather than
  enacted) seems an important obstacle
• DOTS patients main motivation to continue
  treatment was that they noticed improvement in
  their health since enrolling

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Consequences

• Most patients have had untreated or
  inappropriately treated TB for a long time before
  enrolling in DOTS
• Potential risk of increased drug resistance
• Potential risk for increased transmission due to
  inappropriate treatment and advice
• Discouragement of treatment-seeking in general
  population

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Stigma and discrimination

• So far TB seems less stigmatizing than HIV
• An increase in TB cases among AIDS patients may
  change this
• Felt stigma found frequently, enacted stigma
  less frequently
• Spontaneous community support mechanisms exist

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Consequences

• Negative factor in treatment-seeking behavior
• Context of AIDS may worsen this (see Jintana
  et al., 2000, in Thailand)
• Self-isolation due to felt stigma decreases
  quality of life of TB patients and family members

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Recommendations

• IEC materials explaining what TB is, the fact
  that it is curable, where to go to seek treatment
  and how to prevent transmission are urgently
  needed
• IEC materials need to be backed by more behavior
  change communication training for Home Care
  Network teams and DOTS home delivery program staff

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• Strategies to diminish discrimination and
  stigmatization of both TB and AIDS patients must
  be explored
• More research is needed into treatment-seeking
  behavior of patients with TB in high-prevalence
  AIDS areas, to monitor the mechanism found in
  Chiang Rai by Jintana et al. (2000)

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• As only a small minority of TB patients started
  their treatment career at NTP, a stronger
  marketing and publicity strategy is needed for
  the NTP, in order to position it as a more
  desirable treatment option for patients with
  chronic cough
• Relationships between the government and
  organizations working in TB and AIDS care must be
  strengthened further

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Thank you
for your attention
And thanks to NTP, NCHADS, KHANA, Servants, JICA,
and MSF-Ffor their inputs and support