Murray, Emma Jane (2010-12)
Thesis (MPhil (Communicable Diseases)) (Dept of Interdisciplinary Health Sciences. Community Health))--University of Stellenbosch, 2010.
past 50 years. The rising incidence of transmitted (primary) drug resistant TB threatens
the very fabric of conventional TB control efforts, which are already strained by a
rampant human immunodeficiency virus (HIV) epidemic. Ongoing transmission of
Mycobacterium tuberculosis is a key factor that sustains the TB epidemic in endemic
areas such as the socio-economically deprived townships of Cape Town, South Africa.
My research explores the disease context, or social terrain, of TB in this endemic setting.
It is primarily concerned with how the social terrain of endemic TB may contribute to
ongoing transmission and the potential that it holds for enhancing TB control efforts.
Analyses of qualitative data from eight township research sites in and around Cape
Town show that pragmatic and novel approaches are required to pierce through the
enormity of TB as a political and economic problem. Broadening the current biomedical
focus on treating individual patients, to include more holistic community-based
interventions, can and should be developed.
Data were collected as part of qualitative pre-intervention community surveys conducted
in 2005 and 2006 for a public health intervention trial (ZAMSTAR) performed in Zambia
and South Africa. Twenty-four communities were selected as research sites and this
study draws on the survey data collected in the trial’s eight South African sites. Although
the data were collected for the ZAMSTAR trial, the aims and analyses presented in this
study - which seek to improve our understanding of how the social terrain is meaningful
for TB control - remain independent of ZAMSTAR.
Through a retrospective analysis of the South African data, I inductively present three
distinctive ways in which the social terrain is meaningful for TB control. First, the
interaction between social cohesion and social diversity may be an important variable
that predicts community response to public health interventions aimed at reducing the
prevalence of TB in these endemic areas. This is demonstrated by triangulating
ZAMSTAR’S adaptation of a social systems model with further analysis of the research
sites. Second, the study identifies a common discourse running through the sites that
stigmatizes TB as both a dirty and HIV-related disease. It is argued that this may be
significantly contributing to TB diagnostic delay and I call for more holistic approaches to
TB control that can reduce perceived marginalization and TB-HIV stigma. Third,
congregate settings emerge as noteworthy visible features of social terrain that clearly
have the potential to facilitate TB transmission within communities. The pre-intervention
surveys qualitatively described public spaces within each research site and the use
thereof. Basic principles of TB transmission are applied to these descriptions,
developing a novel method of mapping the relative transmission risk possibly posed.
Innovative use of similar approaches could identify likely transmission “hot spots” that
may serve as focal points for targeted interventions, such as adjustments that increase
ventilation or encourage TB suspects to seek urgent medical diagnosis and treatment.
AFRIKAANSE OPSOMMING: Die beheer van tuberkulose (TB) bly steeds een van die grootste gesondheids
uitdagings van die 21ste eeu, ten spyte van die beskikbaarheid van effektiewe
behandeling vir die afgelope 50 jaar. Die stygende insidensie van oorgedraagde
(primêre) middelweerstandige TB bedreig die wese van konvensionele TB kontrole
programme, wat reeds gebuk gaan onder die oorweldigende impak van die menslike
immuungebrek virus (MIV) epidemie. Ononderbroke oordrag van Mycobacterium
tuberculosis is ‘n kardinale faktor wat die epidemie onderhou in areas soos die sosioekonomies
agtergeblewe dele van Kaapstad, Suid-Afrika. My navorsing ondersoek
sosiale terrein (konteks) van TB in hierdie hiperendemiese konteks. Dit is primêr
gemoeid met die moontlike bydrae van die sosiale terrein tot voortgaande TB oordrag en
die potensiaal wat dit mag inhou om TB kontrole te verbeter. Analise van kwalitatiewe
data van agt agtergeblewe gemeenskappe in en om Kaapstad wys dat nuwe en
pragmatiese benaderings benodig word om die volle omvang van TB as ‘n politieke en
ekonomiese problem aan te spreek.
Data is versamel as deel van kwalitatiewe pre-intervensie gemeenskapsopnames wat
gedoen is gedurende 2005 en 2006 vir ‘n publieke gesondheid intervensie studie
(ZAMSTAR) in Zambië en Suid-Afrika. Die studie sou poog om die TB prevalensie
betekenisvol te verlaag in gemeenskappe wat erg geaffekteer word deur MIV. Vir
navorsings doeleindes is vier-en-twintig gemeenskappe geselekteer, waaronder agt
Suid-Afrikaanse gemeenskappe. My studie analiseer kwalitatiewe data wat versamel is
in hierdie agt gemeenskappe, wat verskeie observasie en deelnemende tegnieke
ingespan het. Die studie poog om algemene begrip te verbeter van hoe die sosiale
terrein betekenisvol kan wees in TB kontrole; dit is my eie werk en is totaal onafhanklik
van die groter ZAMSTAR studie.
Induktiewe retrospektiewe analise van data identifiseer drie voorbeelde wat illustreer hoe
die sosiale terrein betekenisvol mag wees vir TB kontrole. Eerstens, die interaksie
tusses sosiale kohesie en sosiale diversiteit mag ‘n belangrike verandelike wees wat
gemeenskapsrespons tot publieke gesondheidsintervensies voorspel. Dit word
geïllustreer deur die toepassing van ‘n sosiale sisteme model (soos aangepas deur
ZAMSTAR) en analise van ander aanvullende data. Tweedens, identifiseer die studie ‘n
gemeenskaplike diskoers in alle navorsings gemeenskappe wat TB stigmatiseer as
beide ‘n vuil en MIV-verwante siekte. Dit word geargumenteer dat hierdie verskynsel
moontlik betekenisvol bydra tot vertraging van TB diagnose en die nodigheid vir meer
holistiese benaderings wat marginalisasie en TB-HIV stigma kan verminder word
uitgewys. Derdens blyk dit dat openbare vergaderplekke ‘n belangrike deel van die
sosiale terrein vorm en duidelik die potensiaal het om TB oordrag binne gemeenskappe
te fasiliteer. Die pre-intervensie opnames het alle openbare vergaderplekke sorgvuldig
beskryf en basiese beginsels van TB oordrag is gebruik om vergaderplekke geografies
te kaart volgens die moontlike transmissie risiko wat dit mag inhou. Innoverende gebruik
van GIS-gebasseerde benaderings, soortgelyk aan die metode wat gebruik is om
potensiële “transmission hot spots” te kaart, mag bydra om intervensies beter te fokus,
deur bv. verbeterde ventilasie te verskaf of mense met simptome van TB aan te moedig
om dringend mediese hulp te soek.
Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/5387
This item appears in the following collections: Masters Degrees (Community Health)9