Community perspectives on tuberculosis care in rural South Africa

Patient nonadherence to tuberculosis (TB) treatment is an ongoing challenge, particularly since the advent of drug-resistant TB and complications posed by HIV/AIDS. Some solutions may lie in understanding patient and community perspectives about barriers to TB care and treatment adherence. Using a qualitative framework, we explored community perceptions and beliefs about TB and perceived facilitators and barriers to care in a rural South African community affected by TB. We were particularly interested in capturing cross-cutting themes and the "merged voices" of participants. Interviews were conducted in 2013 and 2014 with 43 participants, including home-based care workers, clinic staff, patients living with TB and community members in and around a primary healthcare clinic. The data were analysed using principles of thematic analysis. The study reveals the complex interplay between contextual factors and community understandings of the disease. Cultural beliefs about causality and treatment-seeking paths were often mentioned in conjunction with biomedical views. There was a strong interface between TB and HIV in this community, and knowledge of TB was often confused with HIV. HIV-related stigma has been extended to those living with TB. The impact of poverty on treatment adherence was a particularly important theme. Other themes related to the role of the clinic in the community. Our study highlights the socioeconomic vulnerability of this community and the fragility of existing care systems. The findings reinforce the need for a community-centred approach to TB care that takes cognisance of lifeworld issues. We discuss some implications of this study for practice and policy.