Study characteristics
The characteristics of the 10 studies synthesized are presented in Table 1.
A variety of methods were used in data collection including in-depth interviews, focus group discussions (FGDs), semi-structured interviews and key informant interviews. Sample size ranged from 24 to 221.
The ten studies differed in focus even though all directly or indirectly explored factors influencing diagnosis and treatment to care- including barriers to direct observable treatment short course (DOTS), the WHO endorsed system of TB care [27-30]; the role of family members [27, 31-33], patent medicine vendors (PMVs) [34] and treatment supporters [30]; particular focus on gender-based factors [33], care pathways [27], challenges of drug-resistant TB care [32] and TB/HIV co-infection [31]; as well as community-level interventions waith some particular reference to TB [35].
The quality assessment for the selected studies are shown in Table 2.
Synthesis of results
The thematic synthesis yielded several inter-related codes, subthemes and themes (Figure 2) [36].
The barrier and facilitator descriptive subthemes were mirrors of each other under the ‘Individual factors’ and the ‘Health system factors’ analytical themes. More barriers were reported than facilitators and articles had varying contributions to the themes.
Each of the three analytical themes of individual factors; interpersonal influences; and health system factors are presented in more detail below.
Individual factors
This analytical theme reflects the individual-level factors that determine the use of healthcare. It emanated from three descriptive subthemes of financial capacity, education and knowledge, attitudes and beliefs. These subthemes emerged from factors reflected in the following selected quotes:
“It is only a prophet who can destroy the powers of the witch. So, such persons who have TB can only be cured through prayers by powerful prophets” (41 years old female, uneducated farmer) [37].
‘It took some time before I went to get drugs for this illness... I went to two prayer houses yet I did not get better ...so I started taking herbal treatment’ (FGD, 42-year-old male) [29].
“Health seeking depends on the level of education. The illiterate would delay going to hospital. They first use local herbs.” “Patients first move to chemists and herbalists and finally hospital if they cannot get cure from these sources. Where they go first depends on whether they believe TB is man-made, natural, or caused by witchcraft.” [27].
Some of these factors were inter-related, for example illiterate patients were more likely to delay treatment in favor of prayer houses and traditional healers.
Interpersonal influences
This theme refers to the effect of the family and community on the decision-making processes of people in need of care, ranging from codes on stigma and discrimination to community awareness campaigns. It is also reflected in the extent of deference women are expected to have towards their husbands when it comes to health seeking decisions. It emerged from 5 descriptive subthemes – family influence (relative’s recommendation); community involvement; community attitudes and beliefs; gender barriers; and alternative care options. Some of the originating quotes are shown below.
“Women should be submissive to their husbands. A woman who knows more than her husband portends danger to the community. If a man says the medicine is good, then it is good. If he says the medicine is not good, who is the wife to disagree.” (MUA, elderly, female, non-literate, farmer) [37].
“… The ability of a woman to pay for hospital treatment does not mean that she can just get up and go to the hospital without her husband’s permission.” [37].
“The community leader… argued that traditionally, infection with TB is not grounds for divorce, but spouses often cloak the real reason for seeking separation. . .” [27].
“…For the transport workers, for instance, no passenger will join your transport service if they consider you infected” (FGD, young men) [27].
Factors like stigma and discrimination affected women differently from men, as several participants were quoted saying a female TB patient would be a pariah and would be unlikely to get suitors or could possibly be divorced as a result of her illness. Also, a husband who attribute TB to other causes or who have negative perceptions about its management could potentially prevent his wife from accessing care.
On the other hand, family and community support was a facilitator to initiating and adhering to treatment.
“For me it was very traumatic to start taking drugs I have not been used to... but I got so many encouragements, people around me, .... And probably to be frank, if not for their own encouragement and everything, I would have stopped; because this is my last month, I wouldn’t have taken it this far, I would have stopped, but they encouraged me that I had to complete the period of medication” Female TB Patient, Asokoro [30].
Patent medicine vendors are readily available in the communities and see a lot of clients with coughs. However, many PMVs were not trained on TB control nor were aware of TB DOTS centers but were overwhelmingly eager to be part of the TB control effort [34].
“We are in the local communities, a very interior part of the community, and we deal with people of the local communities; hence, such people come to the patent medicine shop to re- quest, “sir, do you have something like this” (PMV practitioner) [34]
“They (PMVs) should be informed, involved, educated, and trained.... You will know what you have learnt, and if anything comes up, you will tell the person” (PMV leader) [34].
Health system factors
Health system barriers were a recurring theme in all the studies. They emerged from codes around poor coverage of services, weak referral system, low numbers and poor skills in health workers, poor attitude of staff and quality of care, corrupt staff demanding illegal charges from patients and the relatively high cost of patient cards. These codes were grouped into 3 descriptive subthemes- coverage of services, human resource, and cost of service. Some quotes shown below reflect these.
“If they [hospitals] want to help us they should make their opening hours flexible so that we [women] can also go there in the evening hours, after the days’ work. That will be more convenient for women.” [37].
“There is no general hospital around. The nearest one … is far from here. Many people don’t want to go there because of cost of the transportation and services. People treat themselves at home or go to herbalists. Only very few people go to private hospitals as they are very expensive [35].
“Efficacy and cost of treatment are topmost. Also, the attitude of health staff is a major issue. Although treatment is said to be free, health workers extort money from patients” (Utu women, far from clinic) [27].
“Both health workers and herbalists have the same attitude. In the hospital you pay for cards, the herbalist demand money for entering the bush. However, in the hospital the much-trumpeted free treatment is not true because health workers demand money. Sometimes the drugs” [27] .
““Even some nurses and medical workers treated us like we are not fit to live again. They keep a distance when they want to communicate with us. If you come closer, they will shout go! go!! go!!! ........ The feeling of stigma is very difficult. I felt like the worst person on earth having MDR-TB” (IDI, 29, Male[32].
“All the health programmes in this community are designed for women and children. Is there nothing that can be done for adult males and females? If we are sick and not treated, we will transfer the sickness to the children[35].
Other factors that were mentioned include poor referral systems between levels of healthcare, absence of doctors at community levels and illegal charges demanded from patients.
Key facilitators included the financial support provided to the patient by the program.
“I thank you for providing us this money...most times when I want to come to the hospital I borrow money for transportation then when I collect the money I will go and pay back” (IDI, 45-year-old female) [29].