Gender matters : Understanding of access barriers to community-based tuberculosis care in Bangladesh

University dissertation from Stockholm : Karolinska Institutet, Department of Public Health Sciences

Abstract: Background: Females lesser use of TB control services is a grave concern worldwide, entailing more gender research in quest of practical remedies. Objective: To understand the gender differences in various clinical steps for TB care, explore gender-specific access barriers to TB control; and measure smear-positive PTB prevalence in different population groups of rural Bangladesh. Methods: The studies were implemented in 12 subdistricts under the BRAC community-based DOTS programme, representing 10 subdistricts for Studies I-IV and 2 for Study V. Studies I, II and V embraced the cross-sectional design, and III and IV the cultural epidemiological descriptive qualitative design. Using the programme registry cases data of 3,600 systematically selected patients from outpatient clinic, laboratory and TB treatment registers (1,200 from each), the Study I examined female-male differences at various clinical steps for TB treatment. Study II surveyed 1,000 conveniently chosen newly diagnosed PTB patients (500 females and 500 males), and assessed sex differences in different delays in help seeking for TB treatment. Study V, a population-based survey measured the smear-positive PTB prevalence in different population groups, and assessed socio-economic-demographic profiles of the sputum-positive PTB incident cases, and non-cases. Employing the 30 cluster survey methods, the study visited 44,455 households spread over 60 clusters (30 each in Monohardi and Shibpur subdistricts), identified persons with prolonged cough for at least three weeks, collected two sputum specimens (morning and spot) from each reported person, and these were tested in field laboratories for AFB. Socio-economic-demographic data were collected from the smear-positive PTB incident households and also from 239 non-TB incident households. A patient with at least one sputum-positive slide was defined as a smear-positive PTB case. Descriptive and inferential statistical analyses compared the outcomes of these studies between females and males, and different socio-economic groups. Data for Studies III and IV were collected from 102 purposively selected patients (50 women and 52 men) undergoing TB treatment. Locally adapted semi-structured EMIC (Explanatory Model Interview Catalogue) interviews inquired about the TB-related patterns of distress (PD), perceived causes (PC) and help seeking behaviour (HS), and TB associated stigma. Prominence of reported categories was evaluated by frequency of respondents reporting the category, and comparing between women and men. Qualitative meaning of gender-specific features of PD, PC and HS, and stigma was clarified from patients narratives. TB-related stigma was assessed individually, and in a validated index by sex, and related illness narratives elaborated the identified quantitative relationships. Chi-squared test for trend assessed female-male differences in PD, PC and HS. Salient results: Female-to-male ratios (FMR) were consistently less than 1 at different clinical steps for TB treatment, but positive treatment outcome revealed no sex disparity (female 93% vs. male 89%). Female sex was associated with longer total delay , total diagnostic delay and patient s delay. Both women and men patients frequently reported diverse features of stigma, but these adversely affected more women than men. Gender differences in the patterns of distress, perceived causes, and help seeking behaviours were substantial. Women patients reported more diverse somatic distress, whilst men reported more about TB-related financial distress. As perceived cause of TB, men emphasised on smoking and women on food shortage stemming from their limited access to economic resources. Most women initially relied predominantly on informal home remedies for the cure. The estimated true smear-positive PTB period prevalence was 122.2/100,000, more common in males than females. The prevalence rate was almost identical across different wealth quintiles, indicating that all social groups are at risk of TB. Rise in the age of TB patients, and smoking habit substantially increased probability for remaining undetected. Conclusion: Sex differences existed at different clinical steps for TB control. Women compared with men, encountered longer delays at various clinical stages for TB treatment. The adverse effects of stigma both reflected and worsened gender inequalities. Gender disparities were evident in the patterns of distress, perceived causes, and help seeking behaviours, affecting more women, whilst TB-related financial distress affected more men. The estimated true period prevalence of smear-positive PTB was high in the community, and almost all socio-economic groups were at risk of TB.

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