Treatment-Seeking for Tuberculosis-Suggestive Symptoms: A Reflection on the Role of Human Agency in the Context of Universal Health Coverage in Malawi
Tuberculosis (TB) is highly infectious and one of the leading killers globally. Several studies from sub-Saharan Africa highlight health systems challenges that affect ability to cope with existing disease burden, including TB, although most of these employ survey-type approaches. Consequently, few address community or patient perspectives and experiences. At the same time, understanding of the mechanisms by which the health systems challenges translate into seeking or avoidance of formal health care remains limited. This paper applies the notion of human agency to examine the ways people who have symptoms suggestive of TB respond to and deal with the symptoms vis-à-vis major challenges inherent within health delivery systems. Empirical data were drawn from a qualitative study exploring the ways in which notions of masculinity affect engagement with care, including men's well-documented tendency to delay in seeking care for TB symptoms. The study was carried out in three high-density locales of urban Blantyre, Malawi. Data were collected in March 2011 -March 2012 using focus group discussions, of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers; and in-depth interviews with 20 TB patients (female = 14) and 20 un-investigated chronic coughers (female = eight). The research process employed a modified version of grounded theory. Data were coded using a coding scheme that was initially generated from the study aims and subsequently progressively amended to incorporate concepts emerging during the analysis. Coded data were retrieved, re-read, and broken down and reconnected iteratively to generate themes. A myriad of problems were described for health systems at the primary health care level, centring largely on shortages of resources (human, equipment, and drugs) and unprofessional conduct by health care providers. Participants consistently pointed out how the problems could drive patients from promptly reporting symptoms at primary healthcare centres. The accounts suggest that in responding to illness symptoms including those suggestive of TB, patients navigate their options taking into cognisance past and current experiences with formal health systems. Understanding and factoring in the mediating role of such 'agency' is critical when implementing efforts to promote timely response to TB-suggestive symptoms.
Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi.|Helse Nord TB Initiative, College of Medicine, Blantyre, Malawi.
Moses
M
Kumwenda
Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi.|Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
Nicola
N
Desmond
School of Life & Medical Sciences, University College London, London, United Kingdom.
Graham
G
Hart
Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi.|London School of Hygiene and Tropical Medicine, London, United Kingdom.
Augustine
A
Choko
Helse Nord TB Initiative, College of Medicine, Blantyre, Malawi.
Geoffrey A
GA
Chipungu
Liverpool School of Tropical Medicine, Liverpool, United Kingdom.|School of Public Health and Family Medicine, College of Medicine, Blantyre, Malawi.
Deborah
D
Nyirenda
Institute for Global Health, University College London, London, United Kingdom.|School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
Tim
T
Shand
Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi.|London School of Hygiene and Tropical Medicine, London, United Kingdom.
Elizabeth L
EL
Corbett
HIV/ AIDS, Sexually Transmitted Infections & TB, Human Sciences Research Council, Durban, South Africa.
Jeremiah
J
Chikovore
D000962:Antimalarials / Q000627:therapeutic use; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins / Q000627:therapeutic use; D002908:Chronic Disease; D003153:Community Health Services / Q000592:standards / Q000706:statistics & numerical data; D003371:Cough / Q000175:diagnosis* / Q000188:drug therapy; D004338:Drug Combinations; D004983:Ethanolamines / Q000627:therapeutic use; D005260:Female; D005334:Fever / Q000188:drug therapy*; D005449:Fluorenes / Q000627:therapeutic use; D017144:Focus Groups / Q000379:methods*; D015438:Health Behavior; D006282:Health Personnel / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D008295:Malawi; D008297:Male; D057228:Masculinity; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D014376:Tuberculosis / Q000175:diagnosis* / Q000188:drug therapy
D000962:Antimalarials; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes