Knowledge, attitudes, beliefs, and stigma related to latent tuberculosis infection: a qualitative study among Eritreans in the Netherlands

Abstract

Background Tailored and culturally appropriate latent tuberculosis (TB) infection screening and treatment programs, including interventions against TB stigma, are needed to reduce TB incidence in low TB incidence countries. However, we lack insights in stigma related to latent TB infection (LTBI) among target groups, such as asylum seekers and refugees. We therefore studied knowledge, attitudes, beliefs and stigma associated with LTBI among Eritrean asylum seekers and refugees in the Netherlands.Methods We interviewed adult Eritrean asylum seekers and refugees: 26 semi-structured group interviews following TB and LTBI related health education and LTBI screening, and 31 semi-structured individual interviews with Eritreans during or after completion of LTBI treatment. We used a thematic analysis to identify, analyse and report patterns in the data. ResultsDespite TB/LTBI education, misconceptions embedded in cultural beliefs about TB transmission and prevention persisted. Fear of getting infected with TB was the cause of reported enacted (isolation and gossip) and anticipated (concealment of treatment and self-isolation) stigma by participants on LTBI treatment. Conclusion The inability to differentiate LTBI from TB disease and consequent fear of getting infected by persons with LTBI led to enacted and anticipated stigma comparable to stigma related to TB disease among Eritreans. Additional to continuous culturally sensitive education activities, TB prevention programs should implement evidence-based interventions reducing stigma at all phases in the LTBI screening and treatment cascade.Consequently, patients conceal their disease, do not comply with treatment and isolate themselves.We lack insights in the burden of LTBI related stigma among target groups for TB prevention activities in low TB incidence countries. (7,8) Scambler (2009) defined stigma as "a social process, experienced or anticipated, characterized by exclusion, rejection, blame or devaluation that results from experience, perception or reasonable anticipation of an adverse social judgement about a person or a group."(9) Stigma can be classified in three categories (7, 10): (1) enacted stigma, in which a person experiences exclusion and/or discrimination. For example, TB patients are regularly rejected by family, friends or communities, resulting from fear of TB.(11); (2) felt stigma, in which a person has feelings of shame, fear, and guilt regarding their (potentially) stigmatized disease. For example, labelling immigrants as high-TB-risk groups can induce feelings of discrimination.(11) (3) anticipated stigma, in which a person perceives, fears and/or expects stigmatization because of their disease. For example, Chinese immigrants in Canada believed that society would exclude those with an LTBI diagnosis.(8) Out of fear of exclusion, they would conceal their LTBI diagnosis and treatment to people in their social network. Besides suffering of the individual, stigma can also negatively affect public health: fear of TB and related stigma can cause ...