“Honestly, this problem has affected me a lot”: a qualitative exploration of the lived experiences of people with chronic respiratory disease in Sudan and Tanzania
Authors: Egere Uzochukwu , Shayo Elizabeth H , Chinouya Martha , Taegtmeyer Miriam , Ardrey Jane , Mpagama Stellah , Ntinginya Nyanda Elias , Ahmed Rana , Hussein El Hafiz , Sony Asma El , Wingfield Tom , Obasi Angela , Tolhurst Rachel ,   The IMPALA Consortium, Addo-Yobo Emmanuel , Allwood Brian , Banda Hastings , Bates Imelda , Binegdie Amsalu , Falade Adegoke , Khan Jahangir , Lesosky Maia , Mbatchou Bertrand , Meme Hellen , Mortimer Kevin , Mutayoba Beatrice , Niessen Louis , Rylance Jamie , Worodria William , Zar Heather , Zulu Eliya , Chakaya Jeremiah , Zurba Lindsay , Squire S Bertel 
Published: March 2023

Abstract
Background
Over 500 million people live with chronic respiratory diseases globally and approximately 4 million of these, mostly from the low- and middle-income countries including sub-Saharan Africa, die prematurely every year. Despite high CRD morbidity and mortality, only very few studies describe CRDs and little is known about the economic, social and psychological dimensions of living with CRDs in sub-Saharan Africa. We aimed to gain an in-depth understanding of the social, livelihood and psychological dimensions of living with CRD to inform management of CRDs in Sudan and Tanzania.

Method
We conducted 12 in-depth interviews in 2019 with people with known or suspected CRD and 14 focus group discussions with community members in Gezira state, Sudan and Dodoma region, Tanzania, to share their understanding and experience with CRD. The data was analysed using thematic framework analysis.

Results
People with CRD in both contexts reported experiences under two broad themes: impact on economic wellbeing and impact on social and psychological wellbeing. Capacity to do hard physical work was significantly diminished, resulting in direct and indirect economic impacts for them and their families. Direct costs were incurred while seeking healthcare, including expenditures on transportation to health facility and procurement of diagnostic tests and treatments, whilst loss of working hours and jobs resulted in substantial indirect costs. Enacted and internalised stigma leading to withdrawal and social exclusion was described by participants and resulted partly from association of chronic cough with tuberculosis and HIV/AIDS. In Sudan, asthma was described as having negative impact on marital prospects for young women and non-disclosure related to stigma was a particular issue for young people. Impaired community participation and restrictions on social activity led to psychological stress for both people with CRD and their families.

Conclusion
Chronic respiratory diseases have substantial social and economic impacts among people with CRD and their families in Sudan and Tanzania. Stigma is particularly strong and appears to be driven partly by association of chronic cough with infectiousness. Context-appropriate measures to address economic impacts and chronic cough stigma are urgently needed as part of interventions for chronic respiratory diseases in these sub-Saharan African contexts.