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Metrics details. The setting for this study was the Pacific island nation of Vanuatu, an archipelago of 82 islands, located in the South Pacific Ocean. Our objective was to assess the knowledge, attitudes and practices of tuberculosis TB patients towards TB. This was a descriptive study using qualitative and quantitative methods. Qualitative analysis was based on open questions permitting fuller explanations. We used thematic analysis and developed a posteriori inductive to draw conclusions.

Patients cited cost, distance and beliefs about TB causation as reasons for first consulting a traditional healer or going to the hospital. Of the TB patients who consulted a traditional healer first, The dating guy sex in Talana was an average of two weeks delay before they consulted the health service. In some cases, however, the delay was up to six years. The majority of the TB patients interviewed did not attribute TB to a bacterial cause. Consulting a traditional healer for health care, including while seeking a diagnosis for TB symptoms, was common and may have delayed diagnosis.

People require better information about TB to correct commonly held misperceptions about the disease. Traditional healers could also be engaged with the national TB programme, in order to refer people with s and symptoms of TB to the nearest health service. Peer Review reports. Tuberculosis TB is strongly linked to poverty, and a range of other social, environmental and biological determinants [ 1 ].

In the Pacific Islands region, TB remains a public health problem [ 2 ] and rates have not decreased ificantly over the last ten years despite increased funding, better public health evidence about how to manage the disease and targeted public heath interventions deed to decrease the burden of TB [ 2 ].

This is especially true in the lower income countries in the Pacific and in sub-populations that are socioeconomically disadvantaged.

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In these populations, TB rates are stagnating [ 23 ]. The Pacific Islands region comprises 22 Pacific Island countries and territories with varying levels of income and development, and with different health systems.

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In many of these communities, a generalised TB epidemic is taking place. In the Pacific communities affected by TB, knowledge, attitudes and behaviours about TB can determine health-seeking behaviour, adherence to TB treatment, TB treatment outcomes and ongoing transmission of TB.

Most available data comes from high burden countries, particularly in Africa, but also India and Asia [ 4 — 8 ]. One study from the Pacific explored the reasons for late presentation to hospital following onset of TB symptoms [ 9 ]. However, there is little other research The dating guy sex in Talana TB knowledge, attitudes, and behaviours in particular health-seeking practices in the Pacific, apart from information in some Demographic and Health Surveys DHSsthat include a component on TB.

In studies conducted in Africa, TB patients believed that TB is caused by supernatural and physical causes [ 41011 ]. In rural Malawi TB was believed to be sexually transmitted [ 12 ] and in Kenya, TB patients attributed it to smoking, alcohol, hard work, exposure to the cold, hereditary factors, and exposure to other TB patients [ 10 ]. In rural Uganda, TB patients, traditional healers and community leaders attributed TB to shared use of cooking and eating utensils, heavy labour, smoking, bewitchment and hereditary factors [ 4 ].

In rural South Africa, TB patients and the community attributed TB to breaking cultural rules that demand abstinence from sex, environmental pollution, smoking and alcohol [ 11 ], while in Mwanza, Tanzania, TB patients attributed TB to similar factors; smoking, alcohol, bewitchment, and hereditary factors [ 13 ]. In a study of Filipino immigrants in the United States, causal beliefs included exposure to bacteria and viruses, smoking, alcohol, overwork, poor nutrition, colds, cough and fever, and contact with a person with TB [ 14 ].

Most studies and surveys are predicated on the medical explanation of TB. For example, in the DHSs The dating guy sex in Talana the Pacific Islands region, respondents are often asked: whether they have heard of TB, whether it is spread through the air, if it can be cured, and if they would keep a TB diagnosis secret. Worldwide, many people with symptoms of TB consult traditional healers, often before seeking western medical care [ 51819 ]. The proportion of people who would first consult a traditional healer depends on the setting, and on contextual factors, including cost, ease of access and local beliefs about TB causation [ 19 — 22 ].

Aetiological beliefs strongly influence choice of care, and if witchcraft is considered the cause, a traditional healer will likely be sought first [ 4911 ]. Some patients consult traditional healers western medical services concurrently [ 419 ]. TB patients may also opt to self-treat with home remedies or over-the-counter medications [ 2627 ]. Knowledge, attitudes and behaviour of TB patients have not been reported for the Pacific in the peer-reviewed scientific literature. Indigenous staff working for NTPs in Pacific Islands, particularly in Melanesia, report that: a consultation with a traditional healer as part of TB health-seeking behaviour is common; b both western medicine and traditional medicine are often taken concurrently by people with TB; c consultation with traditional healers may delay TB diagnosis; and d collaboration between the Ministry of Health and traditional healers may be possible but requires further research.

In Vanuatu — a Melanesian country in the Pacific Ocean — the NTP staff noted that many of their TB patients reported accessing traditional healers before attending the outpatient clinic. Further, they reported that many ni-Vanuatu TB patients have advanced disease at hospital presentation, perhaps caused by of a delay in TB diagnosis involving traditional medicine and care.

Therefore, we decided to assess the knowledge, attitudes and self-reported behaviours of TB patients in Vanuatu. Our specific objectives were to: a describe the characteristics of a group of TB patients from four sites in Vanuatu; b describe knowledge about TB among these patients; and c describe their health-seeking practices and behaviour. This study used a combination of qualitative and quantitative methods. We used ethnographic methods, recruiting indigenous researchers to conduct individual interviews that documented the knowledge, attitudes and behaviours of TB patients.

Semi-structured questionnaires containing both closed and open-ended questions were used to determine knowledge, attitudes and practices regarding the cause, diagnosis, health-seeking behaviour and treatment of TB. Our analysis used a grounded-theory approach, where interview data were organised thematically, creating various uniquewhich in turn were used to explain and create a theoretical perspective [ 28 ].

Our study adhered to the RATS guidelines for qualitative research i. Relevance, Appropriateness, Transparency and Soundness of interpretive approach [ 29 ]. The study was conducted in the Republic of Vanuatu. Vanuatu is an island nation in the South Pacific, located approximately 1, kilometres east of northern Australia [ 30 ].

It is an archipelago of 82 islands, of which 65 are inhabited, and the country is divided into six administrative provinces Tafea, Shefa, Malampa, Penama, Sanma and Torba Figure 1 [ 30 ]. The population of approximatelypeople are Eighty percent of the population live in rural areas where subsistence agriculture provides the main source of income [ 30 ].

The national language of Vanuatu is Bislama, a pidgin English [ 30 ]. Map of Vanuatu, showing the four study sites circled in green see separate file. Source: Secretariat of the Pacific Community permission granted for reproduction. Health care in Vanuatu is provided by the national government the Ministry of Health with little involvement of the private sector.

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There are two regional referral hospitals, three provincial hospitals, 30 health centres, 97 dispensaries and aid posts located throughout the country, making primary health care accessible to most of the population [ 31 ]. After independence inthe government introduced a fee-based system for inpatient and outpatient care [ 31 ]. Free health care was then introduced in [ 31 ]. However, patients may still have to pay a contribution fee for outpatient services [ 31 ].

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The population of the Vanuatu archipelago includes people with a wide range of social systems and customs. In addition, many traditional elements of life in Vanuatu are influenced by Christianity, introduced by missionaries in the 19th century [ 30 ]. In parts of Vanuatu where people hold traditional beliefs, social taboos associated with the notion of pollution - usually by blood during menstruation and childbirth, food preparation and sexual intercourse - are common.

Such taboos may align with fear of deliberate poisoning or malevolent magic. Traditional healers in Vanuatu are not enumerated, but they are accessible in almost all villages, and there may be as many as 1, located throughout the country [ 38 ]. When unwell, most ni-Vanuatu people will access health care from a traditional healer before seeking health care in the government funded health care system [ 37 ]. After doing so, they will be offered leaf medicine, prayer, water treatments, massage or bone-setting [ 3435 ]. Traditionally, kava was prepared by chewing the roots before adding water to them, and it is still prepared in this way in some areas of Vanuatu [ 39 ].

Vanuatu reports approximately cases of TB each year and is regarded as a medium burden TB country in the Pacific [ 340 ].

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However, in the period to the incidence of TB has not declined [ 3 ]. Vanuatu reports good treatment success rates; an indicator of programmatic success [ 3 ]. Anecdotally, many TB patients access traditional medicine before seeking health care from an aid post or health centre. Participants included the patients who were currently on TB treatment, and patients who had recently completed TB treatment at the time of the study. To enrol patients in the study, the interviewers reviewed the national TB register and identified TB patients from the four study sites who were registered during the study period.

Eligible patients were approached at the TB clinic, hospital or at home to invite participation in the study. If patients were not available upon first visit i. The same approach was used for patients who were currently on or had completed TB treatment. Participants were interviewed between October and February and were recruited until thematic saturation was obtained. No material incentives were provided. All participants provided written informed consent to participate, and all consented to having the interview recorded. We developed a structured questionnaire for our study which contained open and closed questions and interviewers were able to ask additional questions if further clarification was needed.

All participants were interviewed by one of five trained nurse interviewers and the interviews were conducted in either Bislama, or for participants in Tanna, in east-Tannese, one of the local languages. The interviewers were all local nurses who were working for the NTP at the time of the interviews.

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All interviews were recorded, and abbreviated responses were written on the paper data collection forms in either Bislama or English. The recorded interviews were transcribed in Bislama, then translated into English.

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The English translations of the questionnaires were used for the analysis. The participants did not verify the content of their responses after transcription and translation, for logistical reasons. The questionnaire was divided into two sections. Section A contained questions about patient demographics and general knowledge about different illnesses in the community, including TB.

Quantitative data were double entered into EpiData version 3. Descriptive analyses were carried out in EpiData Analysis version 2. Quantitative analysis was based on the responses provided to closed questions. Qualitative analysis was based on the responses provided to open questions.

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