| Abstract|| |
Context: Tuberculosis (TB) is primarily an airborne disease caused by the infection of a bacterium, Mycobacterium tuberculosis, which results in more than two million deaths per year worldwide. TB infection is spread when someone with active, infectious TB coughs, or sneezes. In Malaysia, TB is fast rising as a noncommunicable disease, with a death rate higher than death of human immunodeficiency virus (HIV)-AIDS. For instance, in 2015 health indicators, reported by the Ministry of Health, the mortality rate for TB was 5.33%, compared to HIV/AIDS at 1.91%. Aims: This study attempts to review the social determinants of TB transmission in Malaysia. Methods: This is a qualitative study and employs in-depth interview technique for data collection. A list of 36 informants was identified and approached; 22 of them agreed to be interviewed. The elites were chosen for their background, which related to public health and TB patient management. Each interview was recorded, transcribed, and analyzed using thematic analysis. Results: The study finds that the social determinants of TB transmission are related to the following factors: unhealthy lifestyle, inconvenient working environment, negative public perception and stigma, and financial concerns. Conclusions: The identification of as many TB contributing factors as possible is crucial in developing and implementing integrated programs and initiatives that involve all stakeholders in addressing and curbing the spread of the disease.
Keywords: In-depth interview, infection, Malaysia, social determinants, tuberculosis
|How to cite this article:|
Mokhtar KS, Abd Rahman NH. Social determinants of tuberculosis contagion in Malaysia. Ann Trop Med Public Health 2017;10:1215-20
| Introduction|| |
Tuberculosis (TB) is the oldest disease in human history; it has plagued mankind throughout its history and prehistory. According to Lamb-White  TB spreads through the air by germs released by coughing, sneezing, talking, or spitting. Although its spread pattern is similar to that of a cold or flu, TB is not as contagious; only people with active TB can spread the disease to others. To become infected, a person must spend prolonged periods in close contact with an infected person. Most healthy people with a fully functioning immune system are generally able to avoid the bacteria that cause TB. In some cases, the immune system walls off the TB bacteria but allows it to lay dormant in the body. This is called a “latent TB infection.” Those infected cannot spread the germs to other people. Mandell et al. noted that TB has been identified second after human immunodeficiency virus (HIV) as the most common killer infectious agent in adults worldwide. In 2013, about 80% of all reported TB cases occurred in just 22 countries. Nine million people fell ill with TB, and 1.5 million deaths from TB are reported annually worldwide; of these, 12% are associated with HIV/AIDS. The same trend has been seen in Malaysia, where, in 2015, a total of 1604 TB-infected patients died. The reported cases have increased by about 3.02%, compared to 2010, when 1557 patients died of TB. Although HIV/AIDS is not the sole cause for the rising trend, people who are infected with HIV/AIDS are at greater risk of becoming infected with and dying of TB, due to their weakened immune systems.
The social determinants of TB and barriers to receiving treatment are also important factors that have contributed to the rise of the disease and deaths. According to McKee et al., social determinants such as geographical, cultural, educational, and financial barriers are factors that may influence a patient's ability to seek and receive effective treatment for the disease. It is, therefore, necessary to understand the social determinants of TB that may act to prevent an infected person from accessing treatment and increase the time during which he or she can transmit the disease through contact and other social networks. Thus, this study attempts to review the social determinants of TB transmission in Malaysia. The identification of the possible determining factors is crucial for developing and implementing integrated programs and initiatives that involve all stakeholders in addressing and curbing the spread of the disease.
Social determinants of health are not a new anxiety in global health management strategy. It has been widely known since the mid-19th century that living conditions are crucial determinants of health. Health can easily be influenced through a variety of factors, including either positive or negative condition. Some of these factors are relatively fixed, such as genetics or biological features. However, social and economic status can heavily impact a person's health and social determinants, which are fluid, such as living and environmental surroundings, health and education availability, and social interactions. Each of these factors is capable of influencing humans' decision regarding their health and lifestyles. Raphael  suggested that a study on health social determinants should principally deal with the following fundamental issues: (a) what are the societal factors that shape health and help explain health inequalities? and (b) what are the societal forces that shape the quality of these societal factors? These two issues help identify factors that contribute to health social determinants and can serve as possible guidelines for formulating and implementing any related policies for managing health problems.
Social determinants are defined by the World Health Organization  as the social conditions in which people live. They powerfully influence their chances of being healthy. There is also, however, interconnectivity with other factors, such as poverty, food insecurity, social exclusion and discrimination, poor housing, unhealthy early childhood conditions, and low occupational status. These are acknowledged as vital determinants of most diseases, deaths, and health inequalities globally. Meanwhile, Health Canada  has highlighted various health determinants that are also social determinants, such as income and social status, social support networks, education, employment and working conditions, physical and social environments, biology and genetic endowment, personal health practices, gender, and culture. The Centers for Disease Control and Prevention  outlined social determinants of health to include socioeconomic status, transportation, housing, access to services, discrimination by social grouping (e.g., race, gender, or class), and social and environmental stressors. Based on these descriptions of health social determinants, it is important to note that as follows:
- Social determinants contribute to health inequalities between social groups. This is because the effects of social determinants of health are not distributed equally or fairly across society
- Social determinants can influence health both directly and indirectly. For example, damp housing can directly contribute to respiratory disorders while educational disadvantage can limit access to employment, raising the risk of poverty and its adverse impact on health
- Social determinants of health are interconnected. For example, poverty is linked to poor housing, access to health services or diet, all of which are in turn linked to health
- Social determinants operate at different level. Structural issues, such as socioeconomic policies or income inequality, are often termed upstream factors. While downstream factors such as smoking or stress operate at individual level can be influenced by upstream factors.
The definitions of health social determinants are, in general, not much different from the social determinants for TB. Hargreaves et al. added that the key structure of TB epidemiology includes global socioeconomic inequalities, high level of population mobility, and rapid urbanization and population growth. These conditions influence the unequal allocation of key social determinants of TB and encompass food insecurity and malnutrition, substandard housing and environmental conditions, financial constraints, and geographic and cultural barriers to health care. Therefore, the population distribution of TB reflects the distribution of these social determinants.
| Methods|| |
This is a qualitative study that adopted in-depth interviews as the main methodology. The interviews were conducted with top-level personnel from seven selected states (Kuala Lumpur, Johor, Kelantan, Penang, Sabah, Sarawak, and Selangor) across Malaysia. A list of 36 informants was identified and approached, and 22 of them agreed to be interviewed. This group includes personnel from state health departments, health district offices, and hospitals. Most of them are experts in public health and involved directly in the implementation of the National TB Control Program. There were 22 interview sessions conducted. Each session was recorded and later transcribed and analyzed based on thematic analysis.
| Results and Discussion|| |
The findings of this study demonstrate the relationship between social determinants and TB transmission, which is vital to consider when formulating and implementing TB control programs and strategies. Based on the thematic analysis, this study found that there are four social determinants that challenge the efforts to control TB contagion in Malaysia. They are (i) unhealthy lifestyle, (ii) inconvenient working environment, (iii) negative public perception and stigma, and (iv) financial concerns. Each of these determinants is discussed below.
According to the study's informants, some TB patients are vagrants who are without family members, have been abandoned by family members, or do not want to live with their family members. Further, these vagrants have not received any social aid from society, which has kept them from getting additional aid and obscured them from society's view. The underlying reason for their TB infection can be traced to their lack of settled housing; they often shift among public places and places of worship. Then, when they are infected with TB, their habits of sleeping at various different locations poses a risk of spreading TB among those also living nearby. The lifestyle of this group of people is also marked by a neglect of general hygiene and health. They also often provide inaccurate contact information or incomplete home address. This means that efforts to monitor them cannot be executed well, and health authorities are unable to ensure that they follow prescribed treatments as scheduled.
The informants also cited the lifestyle of modern children as affecting patients' immune systems and heightening their possibility of becoming infected with TB. Children today tend to favor indoor activities over outdoor ones, which have led to low body immunity. Spending most of one's time indoors also exposes children to TB should there be any TB patient in the area.
According to other information provided by the informants, HIV patients comprise a great proportion of all TB patients. HIV patients who are drug addicts have very low body immunity, which renders them more likely to be infected with TB. Their lifestyle, marked by shared drug taking, living in nonhygienic places, and not taking care of their own hygiene, leads to higher rates of TB infection among them. The increasing number of HIV carriers and drug addicts has indirectly contributed to the increasing number of TB patients in the country. Many previous studies have also confirmed the close association between HIV and TB, which has resulted in the increasing TB incidence rate.,, Furthermore, this coinfection of disease poses a serious threat to TB eradication worldwide, particularly in the developing world.
Inconvenient working environments
According to the study's informants, individuals who work in institutions where their workplace is a closed area, such as police lockups, jails, psychiatric hospitals, nursing homes, rehabilitation centers, army camps, and factories, are exposed to a higher risk of TB infection. For instance, one TB patient was detained in a police lock-up, or jail, for a period, but he was not aware of his sickness. He then might have spread the TB bacteria to the person on duty and the other detainees. There are a few studies reporting on TB infections among detainees or inmates.,, This group, however, faces a higher probability of becoming infected because of the prison environment and its infrastructure, which provides them with only a small amount of space to use and share among them. Thus, the overcrowding, poor ventilation and nutrition, limited health services, and constant exchange of inmates coming in and out of prison contribute to on-going disease transmission. In addition, staff who work in psychiatric hospitals and perform treatments on psychiatric patients who are TB-infected without being aware of their status are at risk. In short, health-care workers are a very high-risk group.
According to the informants' information, the University of Malaya conducted a study of infectious TB disease within the staff and residents at the Kajang Jail. They found that 80% of the staff and jail residents were infected with TB. In fact, the informants note that two medical staff members at Permai Hospital, Johor, contracted the disease while treating psychiatric patients at the hospital. These two statements show that the risk of being infected by TB is high for those who work in covered and closed areas. This is also due to many of the detainees in police lockup, rehabilitation centers and being treated in hospitals' HIV-positive status; they may also be carriers of TB. Infection risks are higher for those staff members who work in these closed-area facilities. Apart from prisoners and patients under treatment, infection with TB from colleagues who are carrying the bacteria also contributes to the spread of the disease. The working environment in factories, for example, is often marked by low air ventilation and a high density of workers; these can contribute to the spread of TB if anyone is carrying the TB bacteria.
We must also consider the risk of health-care workers becoming TB patients after frequent contact with TB patients. The previous studies have shown a 2–50 times greater risk of contracting TB in a hospital setting, compared to community settings; this makes health-care workers likely potential patients. Health-care workers are categorized as a group at high risk of TB infection since they are the frontline team who deal with TB patients almost every day. Some claim that the risk of TB transmission from patients to healthcare workers is a neglected problem in many countries, especially low- and middle-income ones. Most of these countries cannot protect workers adequately, as they lack the financial and human resources needed to prevent TB transmission effectively. The workplace is seen as a medium for TB transmission, and this becomes worse if there are many people in the same place since large numbers of people can lead to greater infections among them.
Negative public perception and stigma
According to the informants, some TB patients receive treatment late and, in worse cases, patients pass away due to a lack of medical treatment. Some patients believe that the signs of TB, such as a persistent cough, are an artificial problem or black magic. These patients opt to seek treatment using talismans and traditional medical practitioners (traditional healers) because they think that modern medicine will not heal them since their symptoms are artificial or black magic. Other studies have found that TB patients who initially visit traditional healers for treatment do so because of empathy, the pill burden, or because they have a desire to identify a deeper, or perhaps hidden, meaning or narrative for the sickness.
In addition to the above, there are some patients who choose to get treatment from complimentary traditional medication without consulting a medication specialist first. By doing this, the treatment might not be effective and could make the TB infection even more serious. Certain other patients only seek treatment from a specialist after their condition has become chronic or alternative treatments have shown no improvement and changes.
Society's perceptions of TB patients have also led to patients' ignorance about seeking treatment. Although a patient might be aware that he needs TB treatment, he may also worry that he will be abandoned by society, given people's fears of TB. People may shun interactions and communication with the patient. A TB diagnosis can indirectly affect the social life of a patient and pose a high risk of unemployment, as the treatment period is long and employers normally do not want to take the risk of hiring a worker with TB, for fear of losing customers and affecting other employees. Finally, community members often display a negative attitude toward TB patients, because of the fear of contagion through casual transmission.
Poverty is another factor identified as contributing to the increase of people suffering from TB, according to the study's informants. Poverty has resulted in groups of people who do not have proper and hygienic living conditions. Unhealthy living environments, coupled with insufficient exposure to sunlight and good air ventilation, are common among poor people who face a high risk of contracting TB.,
For patients currently undergoing treatment for TB, the first obstacle that the informants identified was that they could not follow the TB treatment schedule, due to transportation costs. Many patients live far from hospitals and treatment centers, which means they face high expenses to travel for care. This results in a financial burden on the patient, given that treatment is a daily necessity for a very long period. For patients who have their own transportation, it might still be difficult for them to afford the fuel needed to take them to the hospital or treatment center daily.
The second obstacle patients' face is not being able to spare the time for treatment. The journey to the hospital or treatment center and time spent waiting for treatment is burdensome. Patients must also take medical leave from their jobs, and those who are poor might not have enough income to cover their family's living expenses if they are not working. This, then, forces them to opt to work and to give up the consistency required to adhere to the treatment schedules provided by hospitals and treatment centers.
Poverty also means that poor people do not have sufficient meals and proper nutrition for their family members, especially children. This has resulted in low immunity in them to protect against TB. Further, there are some people who work part-time to earn extra income to support their families. This indirectly forces them to forgo caring for their own health, especially in terms of putting more efforts toward earning an income, compared to getting TB treatment.
The informants confirmed that, somehow, there is aid allocated to reduce the financial burden of those suffering from TB. Subsidized treatment is available at some hospitals and treatment centers; however, the informants have found this aid to be insufficient, given the recent and dramatic increases in public transportation and fuel costs. Moreover, the informants expressed concerns that the aid might not reach the intended recipients' hands, those suffering from TB and who are receiving treatment. With this in mind, the informants suggest that the distribution of aid, and the amount of aid provided, need to be studied and revised, as doing so could really help to support patients' transportation costs. This could also help reduce the attrition rate for receiving TB treatment among the poor since the long duration and high expenses related to transportation could be addressed. This could also alleviate lost sources of income since patients might not be able to work during their treatment period.
| Conclusions|| |
This study shows that unhealthy lifestyles, inconvenient working environments, social stigma, and financial concerns are the factors that have led to the rise of TB infection in Malaysia. Therefore, the government should implement an ambitious and inclusive program to reduce the spread of TB. The program should address the patients' and public's social and economic factors. For instance, the occupational health and safety management system should be strengthened in all relevant and high-risk facilities and institutions, to promote a safe and healthy working environment. In addition, a program to educate and encourage people to talk about TB should be implemented aggressively. This could help to increase public awareness and knowledge of TB. Finally, to address financial concerns among TB patients, a rigorous study should be conducted to better understand the issue and to recommend proper solutions that both patients and the government (especially the health department) can see as a win-win situation. Patients would be able to complete their full course of treatment, and the health department would be able to manage and control TB infections more effectively.
Financial support and sponsorship
The study was supported by the Ministry of Higher Education, Malaysia, under Long-term Research Grant Scheme entitled Enhancement of Relevant National Policies for Effective TB Management: Lesson Drawing and Control (account number 203.PJJAUH.67212003).
Conflicts of interest
There are no conflicts of interest.
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Khairiah Salwa Mokhtar
Political Science Department, School of Distance Education, Universiti Sains Malaysia, 11800 USM, Penang
Source of Support: None, Conflict of Interest: None