Abstract
Abstract
Objective
Social support is an important factor for psychosocial well-being and motivation to follow the treatment strictly in people with drug-resistant tuberculosis (DR-TB). Thus, this study aimed to determine the availability of social support and its association factors in people with DR-TB in selected hospitals in Ethiopia.
Design
A cross-sectional study was conducted in Addis Ababa (at Saint Peter and ALERT hospitals) and Bishoftu Hospital in Ethiopia. The study involved 130 people with DR-TB from January to May 2023.
Participants
All adult people on DR-TB treatment for at least 2 months were enrolled consecutively from the registration book. A structured questionnaire was used to collect data. Data were entered to Open Data Kit and analysed with SPSS V.22. Descriptive statistics were used to describe the characteristics of the participants. A linear regression model was used to assess factors associated with social support.
Main outcome
Availability of social support from different sources.
Results
The overall proportion of availability of social support obtained from different sources was 97.7% with 95% CI of (93.1% to 99.5%). Sex (β=0.61, 95% CI (0.28 to 0.94); p<0.001), marital status (β=0.59, 95% CI (0.26 to 0.93); p=0.001) and patient self-stigma score (β=0.60, 95% CI (0.42 to 0.78); p<0.001) were significantly associated with social support score.
Conclusions
A considerable proportion of people with DR-TB were obtaining social support from different sources. Interventions targeted female sex, single marital status and perceived social stigma are required to enhance social support conditions in people with DR-TB.
Keywords: Tuberculosis, Social Support, EPIDEMIOLOGIC STUDIES, Public health, Patient-Centered Care
STRENGTHS AND LIMITATIONS OF THIS STUDY
Enrolment of a large number of people with drug-resistant tuberculosis using a random sampling method to minimise selection bias and increase estimation power.
Use of a previously validated standardised data collection tools and cross-confirmation of some variable values from records to reduce information bias.
Data were collected with an electronic device that used a pattern, which significantly reduced the errors that could occur during data entry.
Including only participants from a part of the country and predominantly urban residents could limit the generalisability of this study.
Background
Tuberculosis (TB) continues to cause illness and death among millions globally each year. Ethiopia is one of the 30 high TB and TB/HIV burden countries with an estimated incidence of 140 cases per 100 000 population in 2024.1 The incidence of drug-resistant TB (DR-TB) in Ethiopia is estimated to be 1.1% in new and 7.5% in previously treated cases based on the recent survey data conducted in 2019.2 A review study reported from Ethiopia is also estimated to have the prevalence of 2.2% for DR-TB in new cases and 21.1% in previously treated cases in 2018.3
TB mainly affects the poorest and the most marginalised members of society and it possesses significant adverse effects on their quality of life (QoL) and socioeconomic status.4 5 The QoL and economic hardship could be aggravated by the sickness, drug side effects, the catastrophic costs incurred during care seeking and treatment follow-up.4 5 Financial burden attributable to long-term treatment follow-up, household expenditure and income loss during sickness is also the main source of socioeconomic and psychological distress among people with DR-TB, which could in turn affect social support expectation.6 The contagious nature of the disease and its relation to HIV/AIDS may also induce social isolation and stigma, which have a negative impact on the available social support and mental health of the participants.7 8
Social support refers to assistance available to individuals and groups from within the communities and organisations, which can provide a buffer against adverse life events and living conditions, and can provide a positive resource to enhance QoL.9 It may include emotional support, information sharing and the provision of material resources and services by taking to treatment centre. It is also important for psychosocial well-being and to increase health-seeking behaviour and motivation for treatment adherence.10 11 Social supports from family, friends, community and healthcare workers have important value in promoting patient treatment adherence through encouraging optimism and self-esteem, buffering stress, reducing depression, improving sick role behaviour and providing practical material assistance.10
Social support for people with TB is also considered an important mechanism to improve QoL, recovery from illness and compensate psychosocial and economic hardship during DR-TB treatment follow-up.12 13 It is also recommended as one of the cross-cutting interventions to ease socioeconomic and psychological hardship during DR-TB treatment follow-up in low-income countries where social network is strong.5
Evidence confirmed that social support has influence on a number of health-related conditions and behaviours including treatment adherence.14,16 However, limited recent evidence exists on the level of received social support among people with DR-TB in low-income countries where the incidence of TB is high. People with DR-TB are receiving some kind of social support from different bodies such as family, friends, neighbour, healthcare workers, charities and TB programme in Ethiopia. However, there is limited evidence on the level of social support received among people with DR-TB in Ethiopia. Although social support is vital for overcoming several social determinants of health such as financial, material and psychological hardship and social stigma in low-income countries, there is limited evidence on the factors associated with social support among people with DR-TB. Moreover, understanding these factors in Ethiopia, where people with DR-TB are significantly affected by social problems, is crucial for designing risk factors targeted and culturally tailored interventions. Therefore, we aimed to determine the level of social support received by people with DR-TB and its associated factors in Addis Ababa city and Bishoftu town in Ethiopia.
Methods
Study setting and design
A cross-sectional study was conducted among people with DR-TB treatment from January to May 2023 in three hospitals (Saint Peter, ALERT and Bishoftu hospitals) in Ethiopia. These hospitals were selected purposively, because they are the largest treatment initiation centres for people with DR-TB in Addis Ababa city and Bishoftu town. There are more than 100 DR-TB treatment initiation centres in Ethiopia. Saint Peter and ALERT hospitals provide treatment for people with DR-TB who are residing in Addis Ababa and those referred from other parts of the country. Bishoftu hospital is found at Bishoftu town, southeast of Addis Ababa at 45 km and provides treatment for people with DR-TB who are living in the town and surrounding districts. Thus, this study was conducted in these three hospitals which cover the majority of DR-TB cases in Addis Ababa city and Bishoftu town.
Sample size calculation and sampling methods
We included all people with DR-TB who were on treatment during the study period in the selected three public hospitals since the number of people with DR-TB in the selected hospitals is small. However, the minimum required sample size for this study was calculated by considering 10 true population SD of availability of social support, 2 margin of error and 95% confidence level. The sample size was further increased by 15% for non-repose rate and registration-related errors. Thus, a total sample size calculated for this study was 112. However, we included a total of 130 people with DR-TB in this study to include all people with DR-TB on treatment during the study period.
Inclusion and exclusion criteria
We included all people with DR-TB who were treated at least for 2 months, mentally capable to provide informed consent, 18 and older. However, people with DR-TB who were severely sick and unable to provide required information and transferred out to other health facilities were excluded.
Data collection tools and methods
A structured questionnaire was used to collect data on sociodemographic variables such as age, sex, marital status, employment status, education level and family size. Economic status was assessed with 10 researcher-made structured questions which ask the ownership of basic assets such as personal house, refrigerator, cupboard, water supply in compound, electricity, satellite dish and having ability to pay monthly electricity and water bill. The responses to these questions were recorded by ‘Yes and No’.
Kessler-10 items (K-10) scale was used to collect data on psychological distress.17 The frequency with which each item of K-10 experienced by a patient was recorded using a five-point Likert’s scale ranging from ‘none of the time’ with lowest score to ‘all of the time’ with highest score of psychological distress. The total score of psychological distress was computed by total sum score method and categorised based on the recommendation of the authors.17 Those who scored less than 19 were considered as well, while those with scores greater than 19 were considered as they had at least mild distress.
The social support rating scale (SSRS) was used to assess social support obtained from different sources. The SSRS was designed by Xiao in 1994.18 It consists of 10 items that measure three constructs of social support. These constructs include subjective support (four items), objective support (three items) and support-seeking behaviour (three items). Subjective support domain refers to the social relationships that the individual believes and relies on and the perceived level of support from surrounding persons including family members, neighbours, friends and other people. Objective support refers to the actual support gained from social surroundings. Support-seeking behaviour reflects the pattern of behaviour shown by an individual when the individual seeks support.
The TB-Related Stigma scale was used to assess the availability of TB-related stigma.19 The scale consists of two dimensions: community perspectives on TB and patient perspectives on TB.19 The community perspective dimension includes 11 items which explore the behaviour of a given community towards people with TB. Patient perspectives towards TB disease dimension consist of 12 items that related to feelings of the individuals which include fear, guilt and sorrow in coping with the disease. The responses of each item were recorded with a five-level Likert’s scale that ranged from ‘strongly agree’ with higher score to ‘strongly disagree’ with lower score. The composite index of economic status, social support and stigma-related items was computed by one-dimensional categorical principal component analysis (CPCA).
Data on clinical characteristics of people with DR-TB: HIV and antiretroviral therapy (ART) status, previous TB treatment history, TB type and adverse drug reactions (ADRs) were collected through interview and confirmed from TB registration book. The questionnaires were translated to local languages (Amharic and Afaan Oromo) before data collection. The standard questionnaires used in this study were validated for the Ethiopian context. However, we conducted a pilot study in one DR-TB treatment initiation centre to assess the reliability of the questionnaires. A Cronbach’s alpha test was used to assess the reliability of the items; almost all questionnaires scored above the acceptable threshold (α≥0.7) (table 1). However, the medication adherence rating scale scored 0.55, which indicated poor reliability (table 1).
Table 1. Name of questionnaire, number of items and reliability test statistics (Cronbach’s alpha).
| Name of questionnaire | Number of items | Cronbach’s alpha |
|---|---|---|
| Economic status | 10 | 0.87 |
| Kessler Psychological Distress Scale | 10 | 0.96 |
| Social support rating scale | 10 | 0.76 |
| Community perspectives towards tuberculosis | 11 | 0.79 |
| Patient perspectives towards tuberculosis | 12 | 0.76 |
| Tuberculosis-related stigma scale | 23 | 0.85 |
The data were collected by health professionals who have experience in DR-TB treatment after obtaining a 2-day training on the objective, data collection tools and procedure of the study and ethical principles. The face-to-face interview was conducted in a separate quiet room in Open Data Kit (ODK) on a smart phone. The interview was conducted for an average of 40 min.
Data management and analysis
The data were collected in ODK at field and exported to Microsoft Excel for cleaning. Data analysis was performed by SPSS V.22. Sociodemographic and clinical characteristics of the participants were summarised by descriptive statistics. Availability of social support was presented by proportion. However, the score of social support received was presented by mean with SD. The economic status measured by 10 questions that indicates the ownership status of certain assets was converted to composite index by CPCA. After CPCA was conducted, the correlation of three questions was lower than 0.4; and these questions were removed from the analysis, and the composite index of economic score was categorised to three categories (low, medium and high) by visual binning with ±1 SD.
Independent sample student t-test and one-way analysis of variance (ANOVA) were used to assess the mean score difference of social support score and independent variables. Scheffé post hoc ANOVA was conducted to identify the place of significant difference between three or more groups compared by one-way ANOVA. Linear regression model was used to determine factors associated with social support. Variables with p-values less than 0.25 during bivariate analysis were included to multiple linear regression models by stepwise model building method while checking model fitness by adjusted R.2 Assumptions of linear regression model were assessed before the main analysis and met. Regression coefficients with 95% CIs were reported to show strength of association. Level of significance was set at p<0.05.
Patient and public involvement
There was no patient and public involvement in this study at any stage.
Results
Sociodemographic characteristics of the participants
Table 2 depicts distribution of sociodemographic characteristics of the participants. A total of 130 people on DR-TB treatment were enrolled to this study. Nearly 50% of the participants were male and the mean age of the participants was 32 (±SD = 11.3) years with age range of 18–66 year. The mean family size of the participants was 3.8 (±SD = 1.7), and the majority (69.2%) of the participants were urban residents. 76 (58.5%) of the participants were unmarried and 91 (70%) were unemployed. The majority (76.2%) of the participants were in low socioeconomic status (table 2).
Table 2. Sociodemographic characteristics distribution of drug-resistant tuberculosis people on treatment in three hospitals (Saint Peter, ALERT and Bishoftu hospital), Ethiopia.
| Variable | Frequency | % | |
|---|---|---|---|
| Sex | Male | 67 | 51.5 |
| Female | 63 | 48.5 | |
| Residency | Rural | 28 | 21.5 |
| Urban | 90 | 69.2 | |
| Semiurban | 12 | 9.2 | |
| Marital status | Unmarried | 76 | 58.5 |
| Married | 54 | 41.5 | |
| Employment status | Employed | 39 | 30.0 |
| Unemployed | 91 | 70.0 | |
| Economic status | Low | 99 | 76.2 |
| Medium | 13 | 10.0 | |
| High | 18 | 13.8 |
Clinical characteristics of the participants
The majority (92.3%) of the participants had pulmonary TB (PTB), and 85 (65.4%) were new for the treatment (table 3), and 13 (10%) of the participants were living with HIV, and all of them were on ART (table 3). Only three (2.3%) participants had other comorbidity, and the comorbidities were diabetes mellitus (n=2) and asthma (n=1). The majority (94.6%) of the participants did not develop an ADR (table 3). Of the participants who developed drug side effects, the majority (n=5) reported dyspepsia, skin rash (n=1) and blurred vision (n=1) (table 3).
Table 3. Clinical characteristics of people on drug-resistant tuberculosis treatment in Saint Peter, ALERT and Bishoftu hospitals, Ethiopia, 2023.
| Variable | Frequency | % | |
|---|---|---|---|
| TB type | Pulmonary | 120 | 92.3 |
| Extrapulmonary | 10 | 7.7 | |
| TB treatment history | New | 85 | 65.4 |
| Previously treated | 45 | 34.6 | |
| HIV sero-status | Non-reactive | 117 | 90.0 |
| Reactive | 13 | 10.0 | |
| ART status | On ART | 13 | 10.0 |
| Not applicable | 117 | 90.0 | |
| Other comorbidity | No | 127 | 97.7 |
| Yes | 3 | 2.3 | |
| Type of other comorbidities (n=3) | Diabetic | 2 | 66.7 |
| Asthma | 1 | 33.3 | |
| Adverse drug reaction | No | 123 | 94.6 |
| Yes | 7 | 5.4 | |
| Type of adverse drug reaction (n=7) | Dyspepsia | 5 | 71.4 |
| Skin rash | 1 | 14.3 | |
| Blurred vision | 1 | 14.3 | |
| Psychological distress symptom | Yes | 83 | 63.8 |
| No | 47 | 36.2 |
ART, antiretroviral therapy; TB, tuberculosis.
The mean psychological distress score was 24.6 (±SD = 8.0), and 83 (63.8%) of the people with DR-TB had at least mild psychological distress symptom during treatment (table 2).
Social support
Table 4 shows material support obtained from different social supporters. The overall proportion of availability of any type of social support for people with DR-TB was 97.7% with 95% CI (93.1% to 99.5%). Only 50% of people with DR-TB obtained food, and 87 (66.9%) money from different sources during the treatment. Less than 50% of people with DR-TB were obtained information support, and only seven (5.4%) were obtained support in taking to health facility. The majority (96.2%) of people with DR-TB obtained fruit support, while 120 (92.3%) obtained cleaning materials and 107 (82.3%) transportation support (table 4).
Table 4. Material support obtained from different sources among people on drug-resistant tuberculosis treatment in Saint Peter, ALERT and Bishoftu hospitals, Ethiopia, 2023.
| Material | Frequency | % | |
|---|---|---|---|
| Any type of social support | Yes | 127 | 97.7 |
| No | 3 | 2.3 | |
| Food support | Yes | 66 | 50.8 |
| No | 64 | 49.2 | |
| Money support | Yes | 87 | 66.9 |
| No | 43 | 33.1 | |
| Information support | Yes | 56 | 43.1 |
| No | 74 | 56.9 | |
| Taken to health facility | Yes | 7 | 5.4 |
| No | 123 | 94.6 | |
| Advice obtained | Yes | 44 | 33.8 |
| No | 86 | 66.2 | |
| Fruit obtained | Yes | 125 | 96.2 |
| No | 5 | 3.8 | |
| Food materials obtained | Yes | 44 | 33.8 |
| No | 86 | 66.2 | |
| Cleaning material obtained | Yes | 120 | 92.3 |
| No | 10 | 7.7 | |
| Transportation support obtained | Yes | 107 | 82.3 |
| No | 23 | 17.7 |
The mean score of subjective support was 1.4 (±0.92), while the objective support mean score was 1.7 (±1.0) and support seeking mean score 1.8 (±0.96) (figure 1). The mean total SSRS was 1.8 (±0.96) (figure 1).
Figure 1. Mean score of subjective, objective, support seeking and social support rating score among people on drug-resistant TB treatment in Saint Peter, ALERT and Bishoftu hospitals, Ethiopia, 2023 (S-Support, the error bar in the figure is SE). TB, tuberculosis.
Bivariate analysis
Table 5 depicts the mean score differences between groups on social support. An independent two samples Student’s t-test was conducted to assess the mean score differences in social support between two groups, while one-way ANOVA with Scheffé post hoc analysis was used to identify significant mean score differences between three or more groups.
Table 5. Social support mean score difference in sociodemographic and clinical variables among people with DR-TB in Saint Peter, ALERT and Bishotu hospitals in Ethiopia, 2023.
| Variable | n | SS, mean (SD) | OS, mean (SD) | S-seeking, mean (SD) | SSRS, mean (SD) | |
|---|---|---|---|---|---|---|
| Sex | Male | 67 | 1.7 (1.0) | 1.4 (1.1) | 1.5 (0.98) | 2.0 (1.3) |
| Female | 63 | 1.2 (0.71) | 2.0 (0.87) | 2.1 (0.85) | 2.8 (1.0) | |
| t-test | 3.4 | −3.4 | −3.6 | −3.92 | ||
| P value | 0.001* | 0.001* | <0.001* | <0.001* | ||
| Age | <25 | 37 | 1.4 (0.91) | 1.5 (0,70) | 1.7 (1.7) | 2.2 (1.1) |
| 26–30 | 31 | 1.6 (0.93) | 1.9 (1.1) | 2.0 (1.0) | 2,6 (1.3) | |
| 31–45 | 49 | 1.3 (0.86) | 1.7 (1.2) | 1.8 (1.1) | 2.3 (1.3) | |
| ≥45 | 13 | 1.4 (1.2) | 1.9 (1.0) | 1.8 (0.94) | 2.5 (1.2) | |
| F-test | 0.472 | 0.921 | 0.83 | 0.75 | ||
| P value | 0.702 | 0.433 | 0.481 | 0.527 | ||
| Residency | Rural | 28 | 1.4 (0.95) | 1.8 (1.1) | 1.9 (1.1) | 2.3 (1.2) |
| Urban | 90 | 1.5 (0.90) | 1.5 (0.98) | 1.7 (0.89) | 2.3 (1.3) | |
| Semiurban | 11 | 1.2 (1.0) | 2.4 (1.0) | 2.6 (1.0) | 2.8 (1.1) | |
| F-test | 0.56 | 2.9 | 3.83 | 0.98 | ||
| P value | 0.582 | 0.58 | 0.024* | 0.380 | ||
| Marital status | Unmarried | 76 | 1.6 (0.96) | 1.3 (0.74) | 1.5 (0.77) | 2.0 (1.2) |
| Married | 54 | 1.2 (0.82) | 2.3 (1.1) | 2.3 (1.0) | 2.8 (1.1) | |
| t-test | 2.2 | −5.7 | −4.9 | −4.16 | ||
| P value | 0.033* | <0.001* | <0.001* | <0.001* | ||
| Education status | No formal education | 34 | 1.1 (0.62) | 1.5 (0.94) | 1.7 (0.85) | 2.1 (1.1) |
| Elementary | 39 | 1.3 (0.93) | 1.8 (1.1) | 1.9 (1.0) | 2.5 (1.3) | |
| High school and certificate | 37 | 1.8 (0.98) | 1.7 (1.0) | 1.8 (1.0) | 2.4 (1.4) | |
| Diploma and above | 20 | 1.6 (0.95) | 1.9 (1.0) | 1.9 (0.89) | 2.3 (1.1) | |
| F-test | 5.1 | 0.59 | 0.44 | 0.49 | ||
| P value | 0.002 | 0.62 | 0.726 | 0.691 | ||
| Employment status | Employed | 39 | 1.4 (0.98) | 1.9 (1.3) | 2.0 (1.1) | 2.4 (1.3) |
| Unemployed | 91 | 1.4 (0.90) | 1.6 (0.89) | 1.8 (0.87) | 2.3 (1.2) | |
| t-test | −0.007 | 1.5 | 1.06 | 0.37 | ||
| P value | 0.994 | 0.137 | 0.293 | 0.709 | ||
| Economic status | Low | 99 | 1.5 (0.96) | 1.6 (1.0) | 1.7 (0.98) | 2.2 (1.3) |
| Medium | 13 | 1.3 (0.82) | 1.5 (0.87) | 1.7 (0.75) | 2.3 (1.2) | |
| High | 18 | 1.3 (0.75) | 2.5 (0.88) | 2.4 (0.80) | 3.1 (0.83) | |
| F-test | 0.59 | 7.4 | 4.43 | 4.15 | ||
| P value | 0.555 | 0.001 | 0.014 | 0.018 | ||
| TB type | PTB | 120 | 1.5 (0.91) | 1.7 (1.0) | 1.8 (0.97) | 2.3 (1.2) |
| EPTB | 10 | 1.3 (1.1) | 1.5 (0.76) | 1.6 (0.80) | 2.3 (1.2) | |
| t-test | 0.64 | 0.51 | 0.64 | 0.042 | ||
| P value | 0.526 | 0.611 | 0.525 | 0.966 | ||
| TB treatment history | New | 85 | 1.6 (0.96) | 1.9 (1.1) | 2.1 (1.0) | 2.6 (1.3) |
| Retreatment | 45 | 1.2 (0.79) | 1.3 (0.76) | 1.4 (0.66) | 1.8 (1.0) | |
| t-test | 2.24 | 4.07 | 4.35 | 3.84 | ||
| P value | 0.027 | <0.001 | <0.001 | <0.001 | ||
| HIV sero-status | Reactive | 13 | 1.7 (0.91) | 1.4 (1.1) | 1.5 (1.0) | 1.8 (1.4) |
| Non-reactive | 117 | 1.4 (0.92) | 1.7 (1.0) | 1.9 (0.95) | 2.4 (1.2) | |
| t-test | 1.16 | −1.25 | −1.49 | −1.72 | ||
| P value | 0.249 | 0.214 | 0.139 | 0.088 | ||
| Psychological distress symptoms | Yes | 47 | 1.3 (0.79) | 2.0 (1.0) | 2.1 (0.95) | 2.6 (1.1) |
| No | 83 | 1.5 (0.98) | 1.5 (0.99) | 1.7 (0.94) | 2.2 (1.3) | |
| t-test | −1.39 | 2.52 | 2.26 | 1.74 | ||
| P value | 0.166 | 0.013 | 0.025 | 0.084 |
Presence of significant difference; n-number of participants.
DR-TB, drug-resistant tuberculosis; EPTB, extra-PTB; OS, objective support; PTB, pulmonary TB; SS, subjective support; SSRS, Social Support Rating Scale.
Significant gender differences were observed across all social support dimensions. Male participants reported a significantly higher mean score for subjective social support (M (mean score)=1.7) compared with females (M=1.2, p=0.001). Conversely, female participants scored significantly higher in all other areas, including objective social support (M=2.0 vs 1.4, p=0.001), support-seeking (M=2.1 vs 1.5, p<0.001) and the overall social support rating (M=2.8 vs 2.0, p<0.001).
Significant mean differences in social support scores were observed based on marital status. Unmarried participants reported higher subjective support (M=1.6) compared with married participants (M=1.2, p<0.033), married participants scored significantly higher in all other categories (table 6). Married individuals reported significantly higher objective support (M=2.3 vs 1.3, p<0.001), support-seeking (M=2.8 vs 1.5, p<0.001) and overall social support ratings (MD=2.8 vs 2.0, p<0.001).
Table 6. Social support mean score differences between sociodemographic variables with more than two groups by post hoc analysis among people with DR-TB in Saint Peter, ALERT and Bishotu hospitals in Ethiopia, 2023.
| Support-seeking mean score difference between residency | ||||
|---|---|---|---|---|
| (I) Residency | (J) Residency | MD (I–J) | P value | 95% CI |
| Rural | Urban | 0.14 | 0.486 | −0.26 to 0.55 |
| Semiurban | −0.69 | 0.043* | −1.4 to −0.023 | |
| Urban | Rural | −0.14 | 0.486 | −0.55 to 0.26 |
| Semiurban | −0.83 | 0.007* | −1.4 to −0.23 | |
| Semiurban | Rural | 0.69 | 0.043* | 0.02 to 1.4 |
| Urban | 0.83* | 0.007 | 0.23 to 1.4 | |
| Subjective support mean score difference between education status | ||||
|---|---|---|---|---|
| (I) Education status | (J) Recoded education status | MD (I-J) | P value | 95% CI |
| No formal education | Elementary | −0.25 | 0.230 | −0.66 to 0.16 |
| High school | −0.77 | <0.001* | −1.2 to −0.36 | |
| Diploma and above | −0.054 | 0.030* | −1.0 to −0.05 | |
| Elementary | No formal education | 0.25 | 0.230 | −0.16 to 0.66 |
| High school | −0.52 | 0.010* | −0.92 to −0.13 | |
| Diploma and above | −0.29 | 0.224 | −0.77 to 0.18 | |
| High school | No formal education | 0.77 | <0.001* | 0.36 to 1.2 |
| Elementary | 0.52 | 0.010* | 0.13 to 0.92 | |
| Diploma and above | 0.23 | 0.350 | −0.25 to 0.71 | |
| Diploma and above | No formal education | 0.54 | 0.030* | 0.05 to 1.0 |
| Elementary | 0.29 | 0.224 | −0.18 to 0.77 | |
| High school | −0.23 | 0.350 | −0.71 to 0.25 | |
| Objective support mean score difference between economic status | ||||
|---|---|---|---|---|
| (I) Economic status | (J) Economic status | MD (I–J) | P value | 95% CI |
| Low | Medium | 0.08 | 1.000 | −0.61 to 0.78 |
| High | −0.94 | 0.001* | −1.5 to −0.33 | |
| Medium | Low | −0.08 | 1.000 | −0.78 to 0.61 |
| High | −1.0 | 0.014* | −1.9 to −0.16 | |
| High | Low | 0.94 | 0.001* | 0.33 to 1.5 |
| Medium | 1.0* | 0.014 | 0.16 to 1.9 | |
| Support-seeking mean score difference between economic status | ||||
|---|---|---|---|---|
| (I) Economic status | (J) Economic status | MD (I–J) | P value | 95% CI |
| Low | Medium | −0.01 | 1.000 | −0.68 to 0.66 |
| High | −0.71 | 0.011* | −1.3 to −0.13 | |
| Medium | Low | 0.01 | 1.000 | −0.66 to 0.68 |
| High | −0.70 | 0.127 | −1.5 to 0.13 | |
| High | Low | 0.71 | 0.011* | 0.13 to 1.3 |
| Medium | 0.70 | 0.127 | −0.13 to 1.5 | |
| Social support rating score MD between economic status | ||||
|---|---|---|---|---|
| (I) Economic status | (J) Economic status | MD (I–J) | P value | 95% CI |
| Low | Medium | −0.09 | 1.000 | −0.95 to 0.77 |
| High | −0.89 | 0.014* | −1.6 to −0.14 | |
| Medium | Low | 0.09 | 1.000 | −0.77 to 0.95 |
| High | −0.79 | 0.215 | −1.9 to 0.27 | |
| High | Low | 0.89 | 0.014* | 0.14 to 1.6 |
| Medium | 0.79 | 0.215 | −0.27 to 1.9 | |
*Presence of significant difference.
DR-TB, drug-resistant tuberculosis; MD, mean difference; n, number of participants.
Regarding psychological distress, participants without distress had significantly higher social support ratings (M=2.0) than those with distress (M=1.5, p=0.013). Conversely, support-seeking scores were significantly higher among those experiencing psychological distress (M=2.1) compared with those without (M=1.7, p=0.025).
Significant mean difference in support-seeking score was identified across residence type (rural vs semi-urban p=0.043; urban vs semi-urban p=0.007 and economic status (low vs high, p=0.011) (table 6). Subjective support scores varied significantly by education level, particularly for those with formal education compared with high school levels (p≤0.001). Similarly, significant differences on subjective support scores were found between those with no formal education and diploma holders or above (p=0.030), and elementary versus high school attendees (p=0.010).
Furthermore, economic status played a significant role in social support need scores. Objective support scores differed significantly between low-income and high-income groups (p=0.001), and medium and high-income groups (p=0.014) (table 6). Similarly, significant mean differences were found between low and high economic status for both support-seeking (p=0.011) and social support rating (p=0.014) (table 6). However, all other variables did not show significant mean differences across the four support categories (table 6).
Multivariate analysis
Stepwise multiple linear regression model analysis was conducted to explore the association between social support rate score and sociodemographic and clinical variables among people on DR-TB treatment. Preliminary analyses were conducted to ensure no violation of the assumptions of normality, linearity, multicollinearity and homoscedasticity. The final multiple linear regression model that contains eight independent variables such as sex, residency, marital status, education status, economic status, previous TB treatment history, HIV sero-status, patient self-stigma score and psychological distress explained 47.1% of the variance in total SSRS (F(9, 119) = 13.29, p<0.001). In the final model, sex (β=0.61, 95% CI (0.28 to 0.94); p<0.001), marital status (β=0.59, 95% CI (0.26 to 0.93); p=0.001) and patient self-stigma score (β=0.60, 95% CI (0.42 to 0.78); p<0.001) were significantly associated with total SSRS (table 7). However, residency, education status, previous TB treatment history and HIV sero-status were not significantly associated with total SSRS (table 7).
Table 7. Factors associated with social support rating score among people with drug resistance in Saint Peter, ALERT and Bishotu hospitals after adjusted for the potential confounders in Ethiopia, 2023.
| Variable | B | SE | P value | |
|---|---|---|---|---|
| Constant (α) | −0.13 (−1.0 to 0.76) | 0.452 | 0.770 | |
| Sex | Male | |||
| Female | 0.61 (0.28 to 0.94) | 0.165 | <0.001* | |
| Residency | Rural | |||
| Urban | ||||
| Semiurban | 0.06 (−0.26 to 0.38) | 0.162 | 0.700 | |
| Marital status | Unmarried | |||
| Married | 0.59 (0.26 to 0.93) | 0.171 | 0.001* | |
| Education status | No formal education | |||
| Elementary | ||||
| High school/certificate | ||||
| Diploma and above | 0.02 (−0.15 to 0.19) | 0.086 | 0.776 | |
| Economic status | Low | |||
| Medium | ||||
| High | 0.23 (−0.02 to 0.48) | 0.125 | 0.068 | |
| TB treatment history | New | |||
| Previously treated | −0.25 (−0.62 to 0.11) | 0.183 | 0.172 | |
| HIV sero status | Reactive | |||
| Non-reactive | 0.29 (−0.25 to 0.83) | 0.273 | 0.288 | |
| Patient self-stigma score | 0.60 (0.42 to 0.78) | 0.089 | <0.001* | |
| Psychological distress symptom | Yes | |||
| No | −0.09 (−0.44 to 0.27) | 0.179 | 0.631 |
Presence of significant difference.
B, regression coefficient (β); n, number of participants.
Discussion
Evidence indicates that social support could play an important role in the psychosocial well-being, health-seeking behaviour and treatment adherence.10 11 The results from the present study indicate that 97.7% of people with DR-TB were getting any type of social support from different sources such as family, friends, neighbours, relatives, healthcare workers and TB programme. Moreover, although people with DR-TB were obtaining social support, they were still in need of it to recover from the disease and follow their treatment. In the current study, female sex, married marital status and having a high mean score of patient self-stigma were significantly associated with SSRS.
The present study finding is in line with previous studies14 15 20 in which people with TB are receiving any kind of social support from different sources. According to studies reported from Ethiopia,20 21 people with TB were able to explain the importance of social supports they earned from family, friends, relatives, neighbour, healthcare workers and healthcare facilities during their treatment follow-up period. Although we were not able to find similar studies which reported social support level among people with DR-TB, the study reported by Paz-Soldán et al14 indicated that people on TB treatment are in strong need of social support, which agrees with the present study finding in which the mean score of social support is high.
Although we were not able to find a similar study that compared sex with SSRS in people with DR-TB, the current study finding indicated that females with DR-TB had 0.61 times higher mean SSRS compared with males with DR-TB. This might be due to females being more participants in social activities than males.22 However, males are perceived to have more social support than females.22 23 These findings are similar to our finding in which females had higher social support score ratings than males. In contrast, the study reported from China indicated that there is no significant MD in SSRS between male and female patients with DR-TB.24 This difference could be due to the difference in sociocultural characteristics of the study population and sample size.
The current study showed that married participants had higher mean SSRS than unmarried participants. This finding is consistent with results reported by Fang et al25 in which marital status was significantly correlated with SSRS in people with TB. This is most probably due to married people being under social pressure of different commitment, and the majority of them participating in social groups which might require some payments. Moreover, the study reported by Saqib et al26 showed that being widowed was significantly associated with self-reported SSRS. This finding agrees with the present study in which married marital status was significantly associated with higher social support rating mean score.
People on DR-TB who scored high mean scores of patient self-stigma also scored high mean scores of SSRS. Although we were unable to find similar previous studies (with comparable study participants in terms of demographics and others), one study reported by Chronister et al27 indicated that lower mean score of SSRS was associated with high mean score of social and internalised stigma, which is consistent with the current study findings. Moreover, experienced stigma is fully mediating the association between social support and psychological distress.28 Thus, experienced stigma has an effect on the social support rating mean score, which is similar to the current study finding in which patient self-stigma was significantly associated with high social support rating mean score.
The association between patient self-stigma and social support scores in people with DR-TB could be happening due to the stigma associated with the disease itself and the link TB disease has with HIV. A high patient self-stigma score in people with DR-TB could also be due to negative perception and discrimination from the healthcare workers, community, friends and even family members, which could lead to self-stigmatisation.29 30 Moreover, the association between patient self-stigma and social support might occur due to misconceptions about TB transmission and the community’s perception of TB as a disease of poverty.29 30 Finally, these factors could lead to feelings of shame, guilt and worthlessness among people with DR-TB, which in turn leads to high social support need.
The present study enrolled a sufficient number of people with DR-TB using a random sampling method which could minimise selection bias. We also reduced information bias by providing training for data collectors, validated data collection tools and cross-confirmed some variable values from records. These are the main strengths of the current study because we improved the measurement of social support and its associated factors. This study has also limitations. The data covered only participants from urban areas, which could reduce the generalisability of the current study results to national level. However, the results of the present study are less likely to be influenced by this limitation as the results were found to be corroborating with some previous studies reported from different settings.
Conclusions
A considerable proportion of people on DR-TB treatment was obtaining any type of social support from different social groups. However, people with DR-TB are still required to have social support to recover from the disease and follow their treatment. Female sex, married marital status and having a high patient self-stigma score were significantly associated with social support score. Promoting a social support scheme is vital for psychological and material compensation for people with DR-TB and to overcome social determinants of health. Interventions that targeted in addressing female sex, married marital status and patient self-stigma are vital to enhance social support among people with DR-TB. A large-scale study is also required to understand the link between patient self-stigma and social support among people with TB in general.
Acknowledgements
The authors acknowledge the contribution of Saint Peter, ALERT and Bishoftu hospitals for their cooperation and support during data collection. We also appreciate all study participants and data collectors for their cooperation and tolerance during data collection.
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Prepublication history for this paper is available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-097011).
Patient consent for publication: Consent obtained directly from patient(s).
Ethics approval: This study involves human participants and was approved by Rift-Valley University, Abichu Campus (036/RVU), Oromia Regional State Health Bureau (BF/UBTR/1-16/10865), Saint Peter hospitals (V72/16/06/2023), Armauer Hansen Research Institute (AR/030/2023) research ethics committees. Participants gave informed consent to participate in the study before taking part.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability free text: All data used in this study is presented in the manuscript, however, can be accessed from the corresponding author upon reasonable request.
Data availability statement
Data are available on reasonable request.
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