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Tuberculosis in Migrant Populations. A Systematic Review of the Qualitative Literature

Bruno Abarca Tomás, Christopher Pell, Aurora Bueno Cavanillas, José Guillén Solvas, Robert Pool, María Roura

Bruno Abarca

on 5 February 2014

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Transcript of Tuberculosis in Migrant Populations. A Systematic Review of the Qualitative Literature

Tuberculosis in migrant populations
A systematic review of the qualitative literature
Bruno Abarca
February 2014

What is TB?
Importance and re-emergence
TB, poverty and migration
Control strategies
Aim and specific objectives
Systematic review
Search strategy
Inclusion criteria
Study selection
Categories of analysis
Knowledge of, attitudes towards and beliefs;
Seeking healthcare and TB diagnosis;
TB treatment and prophylaxis;
Social repercussions of TB.
Latent infection
BCG vaccine
Misha Friedman. Winner of the 2010 Images to Stop Tuberculosis Award. Donestk, Ucrania. WHO.
Ethnic minotiries, homeless, injecting drug users, prisoners,
Migrants' social, legal, and economic circumstances
Communication problems, loss of social
support, adapting to new surroundings, discrimination,
Fear of TB, stigma, changes in life-style related
to TB treatment

Early detection
mainly in most vulnerable groups
Treatment adherence
Latent infections
in certain circumstances, detection and
prophylactic treatment
To explore immigrants’ perceptions
of TB and TB control programmes
To examine their knowledge of, attitudes towards and beliefs about TB.
To analyze factors related to seeking TB care.
To analyze factors influencing treatment adherence.
To describe the social repercussions of a positive TB diagnosis
A Systematic review of qualitative studies
To identify, evaluate and synthesize the scientific evidence from primary studies in a specific research area
Necessary for the in-depth analysis of knowledge, attitudes and
experiences of migrants.
Studies identified from database searches
Selected studies
Duplicates (n=649)
Not relevant (n=2301)
Did not meet
inclusion criteria
Additional references
Qualitative studies.
Quantitave/qualitative with qualitative results.
In english, french and spanish.
There were no limits regarding place of study or publication date.
Study selection &
inclusion criteria
Research methods
of the studies
Individual interviews (23), focus groups (13), paricipant observation (3), case study (1)
of the studies
United States (14), Canada (2), United Kingdom (3), Sweden (1), Norway (1), Switzerland (1), Spain (1), China (2), Nepal (1), Oman (1), Kazakhstan (1), New Zealand (2)
of the studies
Men and women. Rural-to-urban migrants, or migrants coming from high TB incidence countries. Patients receiving treatment, healthy users, diagnosed with latent TB infection, patients not receiving treatment, health providers and key informants.
Categories of
TB treatment and prophylaxis
Social repercussions of TB
Seeking healthcare and TB diagnosis
1. Knowledge of, attitudes towards and beliefs around TB
2. Seeking healthcare and TB diagnosis
3. TB treatment and prophylaxis
4. Social repercussions of TB.
“These days, if you have TB, they say it’s AIDS. If you have pneumonia, they say it’s AIDS. If you have common fever, make sure you stay inside your house! Once you lose one kilogram, you’re finished. Some won’t even shake your hands or eat with you. The stigma is too much. So people prefer to die.”
Male Nigerian immigrant, ill with TB, in the UK.
Anticipated and enacted stigma.
(medical procedures)
and indirect
(losing a job, being evicted by a lanlord, or not being able to attend school)
Low level of knowledge and widespread misconceptions about TB and TB transmission.
"... [You can get TB] just being around someone who has it, or drinking out of their glass, or eating off of their plate, or by having relations with a woman who has TB"
Mexican migrant farmworker in the US.
Thought of as a severe disease that might be fatal. Even more severe in countries of origin.
"If you get TB, you die."
Male Mexican immigrant in the US,
with latent TB.
"...I don't think Somalis here, in America, have it. Maybe people in Africa..."
Male Somali immigrant in the US.
Main symptoms known, though sometimes not noticed or attributed to other conditions.
"People were mixing TB up with lung cancer, asthma, so the term, particularly the formal term of TB is not well understood. It's sort of lumped in with other lung conditions... There is a lot of miscommunication within the community. Not only some fears about this, but a whole lot of muddle around the condition."
Male Chinese immigrant in Canada.
Latent infection unknown and difficult to understand as a disease.
"When my son was diagnosed with latent TB infection, I thought he was going to die."
Male Mexican immigrant in the US.
The BCG vaccine, generally known. A false sense of over-protection. The distinction with the TB skin test not clear.
Many perceived that their situation as immigrants could increase their vulnerability to TB.
Weak social networks, illiteracy, adverse conditions during journeys, living in illegal refuges and detention centres, police extortion, labour conditions
TB-related stigmatization.
Some perceived that health staff treated immigrants differently.
Delays in diagnosis or seeking healthcare.
"At the beginning, I thought it might just be a cold, so after three or four days, I went twice to a pharmacy to buy some drugs. But I felt I was coughing more heavily after taking the medicine, so I decided to go to see a doctor in a private clinic."
Rural-born female Chinese migrant who suspected TB
Screening well received, seen as socially responsible. Comments on discrimination/distinction and privacy.
"Actually it is a good idea because if you do it (get screened for TB), you know you have it then you can cure it. If you don’t cure it you can carry on giving it to other people and then that is another problem to the country."

"She only say me I have to take my blood pressure and my urine from me, she haven’t mentioned the tuberculosis test but when I came and she saw perhaps I am a black person, or something like that, I am not saying she is racist or something like that, I don’t say that, but I think it is because I am African."
Male African immigrant with suspected TB in the UK.
Contact tracing difficult.
"Once Smittskydds people put you in their books (records), they follow not only the patient but the whole family and this puts fear and suspicion in peoples’ minds. . . so people see themselves as “marked” and not see the advantage of controlling infection. Nevertheless, they feel pursued by authority."
Male Somali immigrant, ill with TB in Sweden.
Barriers to accessing healthcare:
Not knowing it is free.
Not speaking the local language.
Fear of a painful test or the stigma.
Having to miss work to attend an appointment.
Transport difficulties.
Queues and waiting lists.
Not having health insurance. Costs of medical consultations..
Irregular residence status.
Feeling “singled out”.
The stigma associated with being seen enter a TB clinic.
"Clinics for immigrants" in dangerous neighbourhoods.
Cultural differences with “Western” medical services.
"I started coughing in November and it wasn’t until mid-January that I was referred to hospital for chest X-ray."
Male Nigerian immigrant receiving TB treatment in the UK.
Fear of being infected, shame or a negative reaction and attempts to safeguard personal and family dignity led individuals to hide the diagnosis.

Eventually, they might even be rejected.
Factors facilitating adherence to treatment.
"The free treatment policy means I need to pay all the medical costs first. It does little to release my current financial burden in treating TB."
Male Chinese rural-to-urban migrant, diagnosed with TB.
Adverse effects of TB medication.
“It will kill the germs... stop the virus from continuing... the infection will disappear... I will feel better, not to be contagious especially for my children...”
Latin American immigrant, ill with TB in the US.
A variety of expectations about therapy for latent TB. In some communities, it was well understood.
Barriers to periodic visits.
Strange language, impersonal information, rigid opening hours, loss of privacy with interpreters
‘‘(Treat with) not generic medicine, good medicine… Generic’s no good medicine.’’

Somali immigrant in the US.
Family support, receiving personal advice, personal relationships on the same cultural terms. Positive relationships with health providers, perceived a crucial element.
Overall costs (liver medication, repeated X-rays).
Lenght of TB treatment, abscence of symptoms false impression of adherence.
US. Coaxing patients ("certificate for jobs and schooling after completing treatment").
Use of traditional medicines to counter adverse effects of "strong" antibiotics.

Doctors’ explanations about side effects and their symptoms, could be incongruent with the immigrants’ explanatory model of disease.

Immigration made the illness experience worse. Besides, infectiousness of TB reinforced feelings of being "out of place".
“...don’t splash all over the mainstream media that immigrants have TB
it will just make the discrimination that might exist, even higher.”
Immigrant and interview facilitator in Canada.
“I do not want community doctors to visit me regularly. Others will know that I am sick and have TB. My landlord will expel me if he knows (I have TB).”
Chinese rural to urban immigrant, ill with TB.
Association with HIV/AIDS and drug use.
“I remember in our family, one of our relatives had TB, and we isolated him. It used to scare the heck out of me. We would talk to him from a distance.”
Philippine immigrant in the US.
Past TB-related experiences of family members and in the country of origin influence
Immigrants’ knowledge of and attitudes towards TB are largely built on their
previous experiences
Even though the immigrant populations were heterogeneous, there were
common challenges amongst groups
, such as the perception of TB as being highly
contagious and severe
, frequent
lack of treatment adherence
, obstacles to effective
with health providers and/or anticipated and enacted
that hindered treatment and isolated the patient.
However, these similarities should not obscure the
needs of specific groups
Immigrants require appropriate information on TB aetiology and transmission tailored to different
language abilities
levels of knowledge and beliefs systems
, in addition to screening strategies and health care provision that are adapted to their particular
traditions, values and social relationships
, in order to guarantee information, screening, diagnosis and adherence to treatment.
Beyond escalating current interventions and increasing monitoring of TB incidence and prevalence in immigrant populations
it is crucial to understand immigrants’ perceptions of TB and the specific obstacles that they face
when accessing the health system, seeking a diagnosis and adhering to a treatment programme.
The association of the disease with
inappropriate behaviour and the severity attributed to TB
sometimes resulted in an escalation of fear and stigmatization.
Contradictions in the information in home (common disease, BCG accepted, loss of immunity unknown) and host countries.
The previous model has to be revised and compared
with the new explanation.
Delayed TB diagnosis
is frequent. Fear of immigration authorities may even complicate tracing contacts and screening.
Screening with
coercion or linked to legalizing residence
has a questionable public health impact.
False feeling of protection
amongst both immigrants and health professionals.
Cultural understanding, personal
and immigrants' trust in health professionals, key factor for adherence and diagnosis.
"Traditional remedies"...
Threat or help to deal with common adverse effects?
Bilateral relationship between
TB-related stigma and TB screening/treatment.
Social and economic
consequences of TB beyond perceptions of stigma
Why are immigrants more vulnerable? Circumstances at country of origin (reactivation of imported infections) vs.
journey and living conditions at host countries
(social exclusion and poverty).
Diversity of contexts, respondents and approaches
Lack of easily-comparable information on relevant issues
Knowledge of, attitudes towards and beliefs around TB
Factors encouraging to seek healthcare:
The desire to receive a negative result to avoid stigma.
The right to stay legally until completing treatment.
Wanting to find out about ones’ health status.
To protect family members from infection.
In some cases, the norm was to pass through many health centres prior to receiving a TB test.
"We do know that tuberculosis is not difficult to treat. The problem is that health care services have to give the medication but they have no control if people will take it. How do we deal with this problem? You must have a strategic plan. First, the education is too mechanical... you need the personal touch."
Male Vietnamese community leader and immigrant in the US.
Ambivalence in the perception of Modern vs. Traditional medicine. Generic drugs perceived as poor quality.
Factors hampering adherence to treatment.
Oman. Deportation policies after successful treatment.
Feeling of stigma preventing immigrants from prevention, diagnosis, treatment, and sharing information with their doctors.

TB as shameful, dirty and sinful. Reported attempts at hiding a TB diagnosis.
A bad use of
may lead to false image of success
Abarca Tomás B, Pell C, Bueno Cavanillas A, Guillén Solvas J, Pool R, Roura M.
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