van der Westhuizen Helene-Mari, Ehrlich Rodney, Somdyala Ncumisa, Greenhalgh Trisha, Tonkin-Crine Sarah, Butler Chris C
Division of Occupational Medicine, School of Public Health, University of Cape Town, Cape Town, South Africa.
Zithulele Research Unit, Mqanduli, South Africa.
BMC Glob Public Health. 2024 Oct 3;2(1):66. doi: 10.1186/s44263-024-00097-8.
Tuberculosis (TB) is a stigmatised disease with intersectional associations with poverty, HIV, transmission risk and mortality. The use of visible TB infection prevention and control (IPC) measures, such as masks or isolation, can contribute to stigma.
To explore stigma in this condition, we conducted in-depth individual interviews with 18 health workers and 15 patients in the rural Eastern Cape of South Africa using a semi-structured interview guide and narrative approach. We used reflexive thematic analysis guided by line-by-line coding. We then interpreted these key findings using Link and Phelan's theoretical model of stigma, related this to stigma mitigation recommendations from participants and identified levels of intervention with the Health Stigma and Discrimination Framework.
Participants shared narratives of how TB IPC measures can contribute to stigma, with some describing feeling 'less than human'. We found TB IPC measures sometimes exacerbated stigma, for example through introducing physical isolation that became prolonged or through a mask marking the person out as being ill with TB. In this context, stigma emerged from the narrow definition of what mask-wearing symbolises, in contrast with broader uses of masks as a preventative measure. Patient and health workers had contrasting perspectives on the implications of TB IPC-related stigma, with patients focussing on communal benefit, while health workers focussed on the negative impact on the health worker-patient relationship. Participant recommendations to mitigate TB IPC-related stigma included comprehensive information on TB IPC measures, respectful communication between health workers and patients, shifting the focus of TB IPC messages to communal safety (which could draw on ubuntu, a humanist framework) and using universal IPC precautions instead of measures targeted at someone with infectious TB.
Health facilities may unwittingly perpetuate stigma through TB IPC implementation, but they also have the potential to reduce it. Evoking 'ubuntu' as an African humanist conceptual framework could provide a novel perspective to guide future TB IPC stigma mitigation interventions, including policy changes to universal IPC precautions.
结核病是一种带有污名化的疾病，与贫困、艾滋病毒、传播风险和死亡率存在交叉关联。使用口罩或隔离等可见的结核病感染预防与控制（IPC）措施可能会加重污名化。
为探究这种情况下的污名化问题，我们在南非东开普省农村地区，采用半结构化访谈指南和叙事方法，对18名卫生工作者和15名患者进行了深入的个人访谈。我们采用逐行编码指导下的反思性主题分析。然后，我们运用林克和费伦的污名理论模型来解读这些关键发现，将其与参与者提出的减轻污名化建议相关联，并通过健康污名与歧视框架确定干预层面。
参与者分享了结核病IPC措施如何导致污名化的经历，有些人形容感觉自己“低人一等”。我们发现结核病IPC措施有时会加剧污名化，例如通过实施长期的身体隔离，或者通过口罩将患者标记为患有结核病。在这种情况下，污名源于对戴口罩所象征意义的狭隘定义，这与将口罩作为预防措施的更广泛用途形成对比。患者和卫生工作者对结核病IPC相关污名化的影响有不同看法，患者关注社区利益，而卫生工作者关注对医患关系的负面影响。参与者提出的减轻结核病IPC相关污名化的建议包括提供有关结核病IPC措施的全面信息、卫生工作者与患者之间进行尊重性沟通、将结核病IPC信息的重点转向社区安全（这可以借鉴人文主义框架“乌班图”）以及使用通用的IPC预防措施，而不是针对传染性结核病患者采取的措施。
医疗机构可能会在实施结核病IPC过程中不知不觉地延续污名化，但它们也有减轻污名化的潜力。将“乌班图”作为一种非洲人文主义概念框架来唤起，可以为指导未来减轻结核病IPC污名化的干预措施提供一个新的视角，包括对通用IPC预防措施进行政策调整。
