Dear Editor,
TB is an important cause of maternal morbidity.1 Studies among adults with TB in several countries have consistently demonstrated that a lack of TB-related knowledge and increased stigma can be a barrier to early diagnosis, seeking treatment and treatment adherence.2–6 India has the highest number of pregnant women with TB, raising significant challenges in early diagnosis and access to treatment.7 To our knowledge, no studies have specifically examined TB-related knowledge and stigma among pregnant women, a particularly vulnerable population who tend to seek healthcare frequently.8 Our study addresses this gap by assessing TB prevalence and factors contributing to TB-related knowledge and stigma in pregnant women from urban India.
We conducted a cohort study, ‘Impact of Immune Changes of HIV and Stages of Pregnancy on Tuberculosis (PRACHITi)’, among pregnant women from June 2016 to 2019 at Byramjee Jeejeebhoy Government Medical College (BJGMC) in urban Pune, India, which primarily serves a low-income population. The study participants consisted of HIV-infected and HIV-negative pregnant women, with and without latent TB infection (LTBI). A convenience sample of pregnant women attending the antenatal clinic at BJGMC were eligible for the PRACHITi study if they were between 18 and 40 years old, with a gestational age between 13–34 weeks. Women with active TB were excluded from this study.
While the primary aim of this study was to assess immunological changes during the second and third trimester of pregnancy, a period associated with significant immunological changes, in women with and without LTBI, an additional aim was to understand TB knowledge and stigma by utilizing cross-sectional data drawn from a questionnaire administered at the enrollment visit to all women in PRACHITi. A TB-related knowledge and stigma questionnaire from a WHO guide (on knowledge, attitudes, and practices surveys)9 was adapted and then pre-tested among TB community health workers at BJGMC to ensure the questionnaire’s content and organization (including the flow, timing and reliability of the survey) were appropriate. The pre-testing confirmed the effectiveness of the questionnaire. TB-related knowledge was measured using questions regarding TB transmission, HIV-TB co-infection, and TB diagnosis and treatment. TB-related stigma was measured through two yes/no questions asking if the participant: 1) thought it was shameful to have TB, and 2) would hide their TB disease from others. Additional baseline sociodemographic data included age, household income, education, occupation and marital status. Descriptive statistics were generated for baseline characteristics and compared by HIV status using χ2 tests. In addition, we also compared the mean number of 1) correct responses to knowledge questions and 2) stigma answers consistent with a positive attitude by HIV status using a t-test. For questions on TB knowledge, 1 point was given per correct response with a possible total of 5 points. For questions on stigma, 1 point was given for each answer consistent with a positive attitude towards the disease, with a possible total of 2 points. Using analytical approaches from previous studies,10,11 the two primary outcome variables for this risk factor analysis were binary variables: 1) incomplete TB-related knowledge (scores of <5 were coded as 1) and 2) stigmatizing attitude to TB (scores of <2 were coded as 1). Simple logistic regression models were fit to examine the association between these outcomes and each baseline sociodemographic exposure variables, including HIV status, education, and household income. For the model with stigmatizing attitude as the outcome variable, we also assessed incomplete knowledge as a potential risk factor. This study was approved by the Institutional Review Boards at BJGMC (Pune, India), Johns Hopkins (Baltimore, MD, USA) and Cornell University (Ithaca, NY, USA).
The median age of study participants (n = 202) was 23 years (interquartile range 21–26); 25% (n = 51) of the women were HIV-positive and 76% (n = 153) had a monthly household income below India’s poverty line of ≤INR10,255 (US$136.44). Fifty participants (25%) were educated to primary level or lower (Table). There were no significant differences by HIV status for these characteristics, except for household income, with HIV-positive participants having higher incomes (n = 20, 39% vs. n = 29, 19% [income >INR10,255]; P = 0.007).
Table.
Factors associated with stigmatising attitude
| Total (n = 202) n (%) |
Simple logistic regression* |
||
|---|---|---|---|
| OR (95%CI) | P value | ||
| HIV status | |||
| HIV-negative | 151 (75) | Reference | |
| HIV-positive | 52 (25) | 0.85 (0.45–1.60) | 0.61 |
| Age, years | |||
| 18–20 | 50 (25) | Reference | |
| 21–25 | 89 (44) | 0.92 (0.46–1.83) | 0.80 |
| 26–30 | 45 (22) | 0.94 (0.42–2.10) | 0.88 |
| >30 | 18 (9) | 0.75 (0.25–2.24) | 0.60 |
| Income, INR | |||
| <10,255 | 153 (76) | Reference | |
| ≥10,255 | 49 (24) | 1.17 (0.61–2.22) | 0.64 |
| Education | |||
| Illiterate to primary education | 50 (25) | Reference | |
| Middle school and above | 152 (75) | 1.12 (0.59–2.13) | 0.74 |
| Total knowledge | |||
| Complete | 85 (42) | Reference | |
| Incomplete | 117 (58) | 14.99 (6.98–32.1) | <0.01 |
Simple logistic regression analysis used to evaluate the association between each variable and stigmatizing attitude (score <2).
OR = odds ratio; CI = confidence interval; INR = Indian rupee.
For questions assessing TB-related knowledge, 94% of participants knew that TB is caused by bacteria, and 99% knew that TB can be transmitted through the air. For TB progression and treatment, 78% knew that TB can be extrapulmonary and 91% knew that TB can be cured. However, only 51% of total participants thought that HIV-positive persons have a higher risk of developing TB (47% HIV-positive and 51% of HIV-negative women). Overall, 42% of participants achieved a perfect score (score = 5/5) on the knowledge portion of the questionnaire with a mean score of 4.11/5 (standard deviation [SD] 0.90). There was no significant difference between the mean scores of HIV-positive and -negative women (4.04, SD 0.93 vs. 4.11, SD 0.89; P = 0.63). For the stigma questions, 40% thought it was shameful to have TB, and 29% stated that they would hide their diagnosis from others if they developed TB. Overall, 56% of study participants answered all TB-related stigma questions consistent with a positive attitude (score = 2/2), with a mean score of 1.32; there were no differences by HIV status (P = 0.51).
Findings from the simple logistic regression suggested that there was no significant association for HIV status, age, income, or education with incomplete knowledge (data not shown) or with stigmatizing attitude (Table). However, incomplete knowledge about TB was significantly associated with stigmatizing attitude (odds ratio 14.99, 95% confidence interval 6.98–32.1; Table).
Some previous studies in non-pregnant populations have shown an association between stigma and knowledge,12 while a community-based study among men and women in India showed no association between TB stigma and TB knowledge.13 In our study, we saw an association with large effect estimates; however, a direct comparison with these studies is challenging because of their non-pregnant study population. Our wide confidence intervals are likely because of the limited sample size. Another limitation is the small number of questions to evaluate stigma.
Our study of pregnant women enrolled in an antenatal clinic in India showed that more than half of the study population had incomplete knowledge of TB and close to half had a stigmatizing attitude towards TB. Moreover, incomplete knowledge was associated with stigmatizing attitudes. If our findings are confirmed in other studies (e.g., using national data in India or in other low-resource settings), policies for care and counseling should be integrated within antenatal health clinics in order to increase TB awareness, decrease TB stigma and ultimately eliminate barriers to care. Because pregnant women can be more susceptible to TB,14,15 improvements to their TB knowledge could help reduce stigmatizing attitudes, prevent delayed diagnosis and treatment, ultimately reducing TB related morbidity and mortality in mothers.
Acknowledgements
The authors thank all the clinical staff at the Byramjee Jeejeebhoy Government Medical College antenatal clinic, Pune, India, and study participants for their time and contributions. Research reported in this publication was supported by Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (NIH; Bethesda, MD, USA) under award number R01HD081929 to AG. RS was supported by R00HD089753 and JM was supported by K23AI129854. SM was supported by the Johns Hopkins University Provost’s Undergraduate Research Grant. Additional support for this work was the NIH-funded Johns Hopkins Baltimore-Washington-India Clinical Trials Unit for National Institute of Allergy and Infectious Diseases Networks (U01AI069465 to AG). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors also acknowledge support from Persistent Systems, Pune, India, in kind.
Footnotes
Conflicts of interest: none declared.
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