Front Psychol. 2016; 7: 1664.

Published online 2016 Oct 27. doi: 10.3389/fpsyg.2016.01664

PMCID: PMC5081393

PMID: 27833578

Quality of Life, Psychological Interventions and Treatment Outcome in

Tuberculosis Patients: The Indian Scenario
Vidyullatha Peddireddy*

Author information ► Article notes ► Copyright and License information ► Disclaimer

Abstract
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Introduction
Psychological distress is a common phenomenon experienced by humans in a variety of
conditions, but is vaguely understood. It is defined as a state of mind where the emotional
suffering is associated with depression and anxiety (Drapeau et al., 2011; Peddireddy, 2016).
Psychological distress due to many living conditions such as work pressure, societal changes,
financial needs and changing life style leads to diseased states and the mortality in these
individuals is on the rise (Kessler et al., 2009). It is projected that individuals who experience
immense psychological distress have less survival rates compared to the general population
(NASMHPD, 2006). On the other hand, people affected with any disease also undergo
psychological distress and the medical outcome in these individuals is dependent on the
psychological interventions (Trangle et al., 2016). The necessity of psychological
interventions during diseased conditions is important due to the fact that individuals with
chronic diseases exhibit altered mental status resulting in risky behaviors such as non-
adherence to treatment, altered life style (tobacco smoking, alcoholism) and indulging in
unsafe sexual practices (Pasco et al., 2008; Huther et al., 2013; Moore and Posada,
2013; Pachi et al., 2013; Behera et al., 2014; Pezzoni and Kouimtsidis, 2015). The risky
behavior stems from the feeling that they will not survive for long and all the pleasures of
life should be experienced as soon as possible. Because of the risky behavior resulting from
psychological distress, these individuals are likely to die 25 years earlier than the normal
population (NASMHPD, 2006). In addition to this, psychological distress induced inability
to take care of their own health affects quality of life (QOF) in terms of physical inability and
the extent of suffering from chronic pain (Veggi et al., 2004).
A variety of diseases such as cancer, diabetes, hypertension, AIDS, malaria and tuberculosis
(TB) affect millions of people around the world. The incidence and the extent to which the
QOF is affected in these diseased conditions depend on the status of the disease,
geographical location, medical interventions and most importantly the psychological
interventions. Though some of the diseases are not common in the developed world, TB
remains a major disease entity causing millions of deaths annually across the world, with
higher rates of mortality in the developing nations (WHO, 2015a). The treatment for TB
depends on the drug resistant nature of the causative agent, i.e., Mycobacterium
tuberculosis (M.tb). Most M.tb strains are sensitive to the first line drugs such as isoniazid
(INH) and rifampin (RIF) causing active TB and the disease is completely treatable in about
6 months. Multi drug resistant tuberculosis (MDR-TB) is caused by the M.tb strains that are
resistant to first line drugs and the treatment period is up to 2 years. Mismanagement of
MDR-TB patients resulted in the emergence of M.tb strains that cause Extreme drug resistant
tuberculosis (XDR-TB) which need treatment with second line of drugs such as amikacin
and kanamycin, or capreomycin. It is very surprising to note that the number of countries that
reported confirmed cases of XDR-TB has increased from 49 to 84 in the years between 2008
and 2013 (WHO, 2013). Treatment of MDR-TB and XDR-TB are very complicated due to
logistic difficulties in acquiring the first and second line drugs, requirement for frequent
administration by intravenous route, requirement of a surgery, side effects of these drugs,
strict adherence of the patient and the long duration of treatment and higher mortality rate
(Iseman, 1993; Ormerod, 2007). Further, social factors such as financial implications, loss of
employment and social stigma are also associated (Booker, 1996). An important aspect
of M.tb is its ability to remain latent in the host for extended period of time which ranges
from months to years. A person with latent TB appears normal, but can exhibit symptoms
when the causative agent gets reactivated due to favorable survival conditions, such as
waning of the immune system. Patients experiencing re-emergence of TB after being latent
are caught unaware and experience a sudden change in life and the associated implications.
Another important feature of TB is its association with HIV-infected patients. Because of the
unique life cycle and survival strategies of M.tb, TB remains a global challenge throughout
the world. Because of its complexity involved in TB and the associated clinical and social
implications, people affected with this disease are subjected to enormous psychological
distress regardless of the type of TB they are affected with.
In the present day world, outstanding research contributions have advanced the strategies to
treat TB targeting the pathogen and the host at the molecular level. I am interested in
studying the contribution of mycobacterial proteins during latency and the immune pathways
that are targeted by M.tb to establish a successful latent phase in the host (Peddireddy et al.,
2016). My studies also include interaction with TB patients to record the disease status.
General conversations with them made me to realize that they undergo immense stress and
have no support system to cope up with the psychological trauma. A thorough revision of
studies conducted throughout the world suggested that, at the patient level, psychological
interventions seems to make a lot of difference in the morbidity and mortality. In the
advanced nations, psychological stress experienced by TB patients and the interventions
made to address them have enhanced the treatment quality, morbidity and mortality in all
types of TB. Nature of psychological distress in Indian TB patients still remains an
unexplored area, though this country is ranked among the high burden countries. Further,
India is one of the fastest growing economies and the quality of medical treatment has
increased leaps and bounds. However, treatment of TB patients in combination with
psychological interventions is not being practiced by the medical professionals. It is a pity to
note that such psychological interventions are not in the reach of Indian TB patients. In light
of the above mentioned reasons, an attempt is made in this review to draw the attention of
health care providers toward the urgent need to include psychological interventions for the
treatment of this disease in the Indian scenario.
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Methods
Direct interaction with TB patients and extensive literature review was conducted. Studies
that relate to the QOF in TB patients and the effect of psychological interventions on the
treatment outcome were identified using PubMed search with the keywords: TB and QOF;
TB and psychological intervention; TB and treatment outcome and psychological aspects.
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Observations

Psychological Distress in Tuberculosis Patients

Psychological evaluation in many clinical conditions including TB has gained importance in
the recent years. Based on a number of studies it is widely believed that psychological
distress is evident in TB patients throughout the world. Depression and anxiety rates that
contribute to psychological stress were found to be high in TB patients compared to the
general population (Shen et al., 2014) and this trend is more evident in the developing and
under developed nations such as Nigeria, Ethiopia, South Africa, and Pakistan (Aamir and
Aisha, 2010; Coker et al., 2011; Peltzer et al., 2012b). It is interesting to note a positive
correlation between adverse life events with increased incidence of TB (Geldenhuys et al.,
2011). Further, the morbidity in TB was found to be associated with psychological distress
(Doherty et al., 2013). Besides clinical manifestations, social and the individual’s behavioral
aspects contribute to the high psychological distress in TB patients. These factors include
social status, poverty, education, perception toward the disease and the anti-TB medications,
gender, support from the family and friends, marital status, smoking and alcohol
consumption (Peltzer et al., 2012a,b; Pachi et al., 2013; Masumoto et al., 2014; Peltzer and
Louw, 2014; Feng and Xu, 2015).

Quality of Life in Tuberculosis Patients

For many decades, it is known that TB inflicts physical suffering and the analysis of this
infection on the health related quality of life (HRQOL) has emerged to be an active area of
investigation in the recent years. In general terms, QOL is defined as the physical, emotional
and social well-being status during a disease as perceived by the patient (Roila and Cortesi,
2001). However, these definitions change depending on the type of disease the patient is
experiencing. In the context of TB, because of the complexity displayed by M.tb, an
individual may be infected (latent) or carrying a disease (active). Further, the disease can be
pulmonary or extra pulmonary infecting many organs. Thus a specific parameter that defines
the HRQOL in this diseased condition is not possible. Though QOF assessment was
standardized and practiced in diseases such as cancer, the attention paid to assess the QOF in
TB patients is meager. Until 2004, only 60 studies were retrieved that addressed the QOF in
TB patients (Chang et al., 2004). A number of generic instruments were used to measure
HRQOL in TB, though none of them were specifically designed for this disease (Table
Table11). A major stumbling block to measure HRQOL in TB patients is the nature of
controls to be used. Since TB is generally associated with lower socio-economic groups or
specific ethnic groups, comparing them with the general population does not reflect the
actual status. The best possible control would be the population having latent infection,
though these individuals themselves have impaired HRQOL when compared to healthy
controls (Schwindenhammer et al., 2013).
Table 1
Salient features of instruments used to measure HRQOL in TB patients.

Name of the instrument Number of Remarks

items

Generic

Brief Disability Questionnaire (BDQ) 11 HRQOL inversely proportional to score

Duke Health Profile (DUKE) 63 Higher the score, better is the HRQOL

Dysfunctional Analysis Questionnaire (DAQ) 50 HRQOL inversely proportional to score

Euro-QoL (EQ 5D) 5 Higher the score, better is the HRQOL

General Health Questionnaire 12 (GHQ 12) 60 Higher the score, better is the HRQOL
Name of the instrument Number of Remarks
items

Health Utilities Index (HUI) 8 Score 0 indicates death and 1 indicates

perfect health

Life Satisfaction Index Z 13 Higher the score, better is the HRQOL

Patient Health Questionnaire – 9 (PHQ9) 9 Higher the score, worse is the HRQOL

Severe Respiratory Insufficiency Questionnaire (SRI) 49 Higher the score, better is the HRQOL

Symptoms Check List – 90 (SCL-90) 90 Higher is the score, worse is the HRQOL

Sheehan Disability Scale (SDS) 20 Higher is the score, worse is the HRQOL

SF-6D utility score 11 Higher the score, better is the HRQOL

SF-36 Health Survey (SF-36) 36 Higher the score, better is the HRQOL

Standard Gamble 1 Higher the score, better is the HRQOL

Name of the instrument Number of Remarks
items

Visual Analog Scale (VAS) 10 Score 0 indicates death and 10 indicates

perfect health

World Health Organization’s Quality of Life–BREF 26 Higher the score, better is the HRQOL
(WHOQOL-BREF)

Anxiety – Depression

Beck Depression Inventory (BDI) 21 >13 score indicates depression

Beck Depression Inventory (BDI Short Form) 13 >16 score indicates depression

Centre for Epidemiologic Studies Depression Scale 15 Higher score indicates depression
(CES-D)

Hospital Anxiety and Depression Scale (HAD) 14 Higher scores indicate depression and
anxiety

Kessler 10 10 Higher the score, better is the HRQOL

Name of the instrument Number of Remarks
items

Mood Adjective Check List Short Form (MACL) 38 Evaluates calmness, pleasantness and
activation

Rosenberg Self-Esteem Scale (RSE) 10 Higher the score, better is the HRQOL

Self-Rating Anxiety Scale (SAS) 20 Higher is the score, worse is the HRQOL

State-Trait Anxiety Inventory Short Form (STAI-6) 6 Higher is the score, higher is the anxiety

Disease specific

Schedules for Clinical Assessment in Neuropsychiatry 1872 Higher is the score, worse is the HRQOL

St. George Respiratory Questionnaire Short Form 50 Evaluates symptoms, activity and impact
(SGRQ)

DR-12 12 TB-specific; Higher the score, better is

the HRQOL
Name of the instrument Number of Remarks
items

World Health Organization’s Quality of Life – HIV 100 HIV specific; Higher the score, better is
(WHOQOL-HIV) the HRQOL

MOS-HIV 35 HIV specific

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The QOF in active TB patients was reported by many studies and the objectives were widely
varied. Holistic HRQOL, psychological morbidity and physical well-being were some of the
parameters on which the studies focused. Nevertheless, it is generally observed that lower
levels of QOF and physical pain were the most common outcomes of these studies (Brown et
al., 2015). Some studies that focused on the QOF in active TB patients in comparison with
latent TB revealed a lower health status with a Physical Component Survey score of 44.8 and
Mental Component Survey score of 54.7 in the active TB patients. The corresponding PCS
and MCS scores in the latent TB patients were 54.7 and 50.3 respectively (Guo et al., 2008).
Qualitative research methodologies provided the reasons for reduced QOF in TB patients.
Upon diagnosis, TB patients experience stigmatization and social isolation, loss of
employment and inability to access higher levels of health care. On the other hand,
hospitalization as one for the treatment strategies had profound effect on the QOF in TB
patients. Those receiving supervised care in a hospital setting is always recommended and is
predicted to have better QOF than those compared to those receiving ambulatory care (Diel
et al., 2012). Assessment of QOF post TB treatment is understudied. However, social stigma
and its repercussions affected the QOF in individuals who have been completely treated with
TB (Dias et al., 2013). Further, the St. Georges Respiratory Questionnaire (SGRQ) scores
were found to be increased (worse health status) in subjects who underwent at least 20 weeks
of TB treatment compared to those having latent TB (Pasipanodya et al., 2007). Assessment
of QOF did not receive much attention in patients with extra-pulmonary TB. A decline in
QOF was reported in patients with extra-pulmonary TB (Dhingra and Rajpal, 2005) and on
the contrary no significant differences in were observed in a Chinese study (Chamla, 2004).
The lack of assessment of QOF in patients with extra-pulmonary TB underlines the urgent
need to take up such studies since this form of the disease also affects a large number of
people around the world.
Co-infection of HIV in TB patients is very common (WHO, 2015b) and are subjected to high
level of stigmatization (Hsiung et al., 2011) and very low QOF. Exclusion of TB patients
with HIV co-infection or not declaring the status of HIV infection and the associated
antiretroviral therapy in the study subjects in many studies resulted in poor understanding of
the levels of QOF in this subset of patients. In a large South African study comprising of
4900 participants, significantly lower health status and QOF were observed in HIV infected
TB patients than their TB alone infected counterparts (Louw et al., 2012; Peltzer et al.,
2013). The physical health summary scores were found to be significantly different in TB
patients with or without HIV co-infection (Dowdy et al., 2013). In an Ugandan study, the
visual analog scale (VAS) score was significantly improved in patients receiving TB
treatment over a period of 6 months. But the scores were not significant between the HIV-TB
co-infected and TB along infected groups (Babikako et al., 2010, 2011). The QOF in HIV-
TB co-infected and TB alone infected patients was significantly improved after a 6 months
anti TB therapy (Deribew et al., 2013). However, the HIV alone infected counter parts did
not show much improvement in the QOF since they were recruited from clinics that were
administering antiretroviral therapy for a long time (Deribew et al., 2009). HIV patients
receive antiretroviral therapy immediately upon diagnosis, and thus assessing QOF in HIV-
TB infected patients who are not receiving antiretroviral drugs becomes impossible. Since a
direct comparison of QOF in HIV-TB infected patients with or without antiretroviral therapy,
but receiving only anti-TB therapy cannot be reported, the interference of antiretroviral
therapy has always been a matter of concern in these studies.
Another complexity that is encountered during TB treatment is drug resistance and it is
anticipated that this condition results in severe impairment of QOF since the patient has to be
under medical isolation leading to loss of employment and social activities. The QOF seems
to be higher in MDR-TB compared to XDR-TB patients (Conradie et al., 2014), suggesting
that the severity of the disease has a direct effect on the well being. Because of the use of
highly powerful antibiotics in different combinations for extended periods of time, MDR-
/XDR-TB, neurological disorders, hearing loss and reduced body weight are evident, which
has a profound effect on the QOF (Seddon et al., 2012, 2013; Bassili et al.,
2013; Melchionda et al., 2013). The global distribution of MDR-/XDR-TB varies highly
between geographical regions (WHO, 2015b) and the importance given for assessing QOF
also varies globally. Thus it becomes very challenging to suggest a common level of loss of
QOF in TB patients. Because of high morbidity and mortality in MDR-/XDR-TB patients,
not many studies were conducted to assess the quality of living in these patients. On a severe
note, the survival rate of patients with MDR-/XDR-TB and HIV co-infection reduces
drastically and this makes it very difficult to assess QOF. A Brazilian study on MDR-/XDR-
TB indicated lower Airways Questionnaire 20 (AQ20) scores (improvement in health
symptoms) in terms of lung function tests, chest radiographs and walk tests (Godoy et al.,
2012).
An interesting feature of M.tb infection is its ability to remain latent in the host and cause
asymptomatic TB. It is believed that identifying individuals with latent TB is a significant
measure to reduce the global burden of TB and to evolve better strategies for the treatment.
Labeling an individual as a latent TB patient causes distress and anxiety and thus resulting in
loss of QOF. A significant reduction in HRQOL was observed in individuals with latent TB
than their healthy counterparts (Bauer et al., 2002). Factors that contribute to the decreased
QOF in latent TB patients is anxiety, depression, social stigma, side effects of treatment and
unwillingness to believe that they are having disease despite appearing normal and healthy.
Besides adults, children are also at a high risk for TB (WHO, 2015b). Unfortunately, no
studies have been conducted that included TB patients aged less than 10 years (Bauer et al.,
2013). Other neglected groups that did not receive attention to evaluate the QOF and TB are
individuals working in health care settings, prisoners, pregnant mothers and children born to
them. Thus, till today, the real picture of QOF in TB patients is not clear.
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The Indian Scenario

In the Indian scenario, assessing QOF in TB patients has been a neglected area for a long
time (Aggarwal, 2010). It gained momentum in the recent years only due to increased
awareness on the benefits of psychological interventions and measuring of the treatment
outcome in terms of the overall health status of the patient. Indian TB patients experience
stigma and this is dependent on the social, geographical and gender factors. In the capital city
of India, Delhi, immense stigma was experienced by patients and about 60% of the patients
concealed it from family members and friends. The stigma was more prevalent in women
(Dhingra and Khan, 2010). In a study that recruited TB patients from South India, it was
observed that distress and anxiety was observed in about 50% of the study subjects when
disclosed about the diagnosis and about 9% of them contemplated suicide (Rajeswari et al.,
2005). Social stigma was prevalent and it did not vary between men and women. Despite a
significant increase in the health status, only 54% of them perceived “happy mental status”
after TB treatment. In a recent study involving TB patients from rural parts of Gujarat, a
Northern state of India, psychosocial reaction was severe when informed of the diagnosis for
TB and the main worries were mainly about the deadliness of the disease, treatment options,
embarrassment, social stigma and the feeling that fate was not kind to them (Thakker et al.,
2014). Further, in a rural Andhra Pradesh region of India, it was widely believed that TB is
caused by natural and supernatural origins, witchcraft, evil, and imbalance in the quantity of
consumption of hot and cold foods and people with TB are considered as those with ill fate
(Venkatraju and Prasad, 2010). Severe depressive symptoms were evident in MDR-TB
patients, which then improved substantially during the course of treatment (Das et al., 2014).
Similarly, psychological impairment in the regions of the brain is associated with family,
social and personal activities in TB patients of Delhi region (Bhatia et al., 2000).
The HRQOL was found to be severely impaired in pulmonary TB and substantial
improvement was evident after treatment in Indian TB patients (Aggarwal, 2010). The mean
scores for QOF were lower in TB patients and the most affected domains were physical and
psychological followed by social and environmental (Dhuria et al., 2008, 2009). In another
North Indian cohort, it is reported that HRQOL was better in pulmonary TB patients than the
MDR-TB patients (Sharma et al., 2014). In both these conditions, besides social stigma, the
effect on psychological and environmental domains was more profound than in the physical
and social domains.
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Psychological Interventions and their Effect on Tuberculosis Treatment
Outcome
As the saying goes, pain is inevitable; suffering is optional, for every disease, suffering either
in physical or emotional or psychological form is inevitable. How a patient deals with these
depends on the will power and the support extended by family and friends. Despite the
invention of advanced technologies to diagnose diseases and development of powerful drugs
to cure them, the treatment outcomes vary among patients. The pharmacologic profile of the
patient is an important determinant for the treatment outcome. Another crucial aspect that has
gained importance to achieve better treatment outcomes in many diseases is the
psychological intervention. Such non-medical interventions have been practiced in the
developed nations for the treatment of many diseases including TB. The psychological
interventions for TB are more complicated when compared to other diseases because of the
negative perception and stigma toward this disease in the society on one side and the
biological complexities on the other side. Despite the complexities, psychological
interventions have improved the prevention and treatment outcome of TB.
Prevention of TB infection also seemed to be psychologically associated. In a Vietnamese
population, the high incidence of TB was reduced by developing a culturally sensitive
educational and psychological intervention programs (Houston et al., 2002). Stigma
experienced by people due to TB contributes to keeping the disease as a secret, avoiding
visiting the clinics and the reluctance to comply with the prescribed medication. A literature
review of about 170 research articles indicated that stigma toward TB was highly prevalent
and contributes to delayed treatment and non-compliance to medications (Courtwright and
Turner, 2010). It is surprising to note that not many studies have focused on psychological
interventions to reduce stigma and its effect on the treatment outcome. The few studies
conducted indicated mixed results. Interventions included creation of TB clubs, TB
education/support programs and empowering TB infected individuals (Courtwright and
Turner, 2010). Creation of TB clubs had positive effect on reducing TB stigmatization and
the treatment outcomes (Demissie et al., 2003; Macq et al., 2008). Effective questionnaires
that can measure stigma, assessing the effect of reducing stigma on treatment outcome and
psychological interventions to reduce stigma are to be taken up at a large scale throughout
the world especially in those regions where the prevalence of TB is very high (Courtwright
and Turner, 2010).
One of the major obstacles in treating TB patients is their non-adherence to the treatment
regimen and these results in prolonged disease transmission and development of resistance to
the anti-TB drugs. Psychological counseling improved the compliance to treatment and the
successful treatment of the disease in an Ethiopian cohort (Tola et al., 2016). An extensive
review on the effect of psychological interventions on adherence to medication suggested
that improvement in compliance toward medication was observed when psychological
aspects such as depression were better managed in TB patients (Pachi et al., 2013). The
compliance to medication was found to be improved in MDR-TB patients who underwent
psychosocial support program (PSS) (Kaliakbarova et al., 2013). A programmatic
psychological intervention improved the patients’ treatment compliance, outcome and levels
of CD4+T lymphocytes suggesting that besides changing the mental attitude, physiological
responses can also be improved due to such interventions (Wei et al., 2016). Psychotherapy
in TB patients decreased dysfunctional beliefs and increased the hope to get well soon and
lead a happy life with a concomitant compliance to treatment (Safa et al., 2013). Systematic
review and meta-analyses indicated implementation of simple psychological interventions to
scale up MDR-TB programs for a better treatment outcome (Toczek et al., 2013; Thomas et
al., 2016). In the Indian context, direct population based studies, literature survey and meta-
analyses indicate psychological effects in TB patients and comprehensive studies that focus
on the benefits of psychological intervention on the treatment outcome are not available
(Thomas et al., 2016). Compliance to medication was significantly improved in Indian TB
patients who underwent multiple psychological sessions (Janmeja et al., 2005). However, the
implementation of psychological interventions and its application to TB patients needs to
operationalized at different levels (Table Table22) in this country.
Table 2
Operational plan to provide psychological support to tuberculosis patients in the health care
system.

Level Action Targets to be achieved

• •
National Wide publicity in social media on the prevention Awareness among the people to maintain
and management of tuberculosis. hygiene and avoid transmission of
•
Publicize the importance of psychological support tuberculosis.
•
to tuberculosis patients. Reduce stigma toward tuberculosis patients
and also empowering these patients for proper
treatment.

• •
Community Campaigning at household and community levels Awareness on tuberculosis and knowledge on
on the prevention, management and support systems access to treatment.
•
(medical and psychological) available for Support tuberculosis patients and guide them
tuberculosis patients. toward treatment options.

• •
Hospital Implement training programs on psychological Sensitize the medical practitioners on the
interventions and their benefits on treatment psychological needs of tuberculosis patients
regimen. and the beneficial effects of such interventions
Level Action Targets to be achieved

•
Support groups should be created and managed by on recovery.
•
an experienced counselor or social worker. Assessment of emotional and socioeconomic
•
A health worker (nurse) trained in management of issues.
•
TB should be co-opted. Establishment of drug abuse, if any and
•
Creating a support group should be based on a clear initiate treatment accordingly.
•
eligibility criteria. Identification of patients with depression and
•
Review of each support group meeting to be made prescribe antidepressant regimen.
•
by the counselor and steps initiated for the Analyze the drugs being given to the patients
betterment of the next meeting, based on the and the possible psychological side effects.
•
experiences in the current meeting. Involving family members to provide
emotional support.

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Health literacy is one of the most important factors that determine the incidence,
transmission and morbidity of TB. In general, the incidence of many diseases including TB is
more in populations where health literacy levels are lower. Limited literacy on health issues
are associated with lower practices of prevention measures, immunization, use of antibiotics,
seeking proper medical treatment, especially in infectious diseases such as TB and malaria
(Castro-Sanchez et al., 2016; Osborne et al., 2016). Increased morbidity and mortality due to
infectious diseases is observed in adults with limited health literacy (Bostock and Steptoe,
2012). The awareness on TB was found to be very low in a tribal group in central India
(Muniyandi et al., 2015). Though awareness on TB was good in an Indian urban slum
population, information on access to proper medical care was not known (Chinnakali et al.,
2013). It is suggested that TB patients with low health related literacy had higher
psychological distress (Theron et al., 2015). Thus it appears that health literacy, morbidity
due to TB and psychological well-being are interlinked. It is suggested that investments on
critical health literacy are crucial and worthwhile to develop qualitative and quantitative
approaches of evaluating health literacy and their application to enhance QOF (Chinn, 2011).
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Conclusion
Psychological stress is prevalent in TB patients throughout the world. The importance given
to this aspect varied in different geographical locations and it is very surprising to note that
studies relevant to this aspect were not conducted on a large scale basis in countries that
contribute to the highest global burden of TB. Though few studies focused on TB associated
psychological distress and QOF, the benefits of psychological intervention for treatment
outcome are not conducted.
It is high time that all the agencies in India that work for reducing TB burden realize that
improving health literacy and adopting psychological interventions should be practiced to
improve the QOF, treatment outcome and prevention of this disease. Mandatory
psychological counseling to patients and training on psychological interventions to medical
practitioners should be introduced in all health care units. Since, majority of the TB patients
are on long treatment regimen and remaining in hospital is not mandatory, online portals that
will allow interaction between the patient and the health care provider should be launched.
Telephonic access to psychological practitioners should be made available to patients to
express their difficulties and the same should be communicated to the health care providers
to design better treatment strategies.
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Author Contributions
VP conducted literature search and compiled the manuscript.
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Conflict of Interest Statement

The author declares that the research was conducted in the absence of any commercial or
financial relationships that could be construed as a potential conflict of interest.
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References

1. Aamir S., Aisha. (2010). Co-morbid anxiety and depression among pulmonary
tuberculosis patients.J. Coll. Physicians Surg. Pak. 20 703–704. [PubMed]
2. Aggarwal A. N. (2010). Health-related quality of life: a neglected aspect of
pulmonary tuberculosis.Lung India 27 1–3. 10.4103/0970-2113.59259 [PMC free
article] [PubMed] [Cross Ref]
3. Babikako H. M., Neuhauser D., Katamba A., Mupere E. (2010). Feasibility, reliability
and validity of health-related quality of life questionnaire among adult pulmonary
tuberculosis patients in urban Uganda: cross-sectional study. Health Qual. Life
Outcomes 8:93 10.1186/1477-7525-8-93 [PMC free article] [PubMed] [Cross Ref]
4. Babikako H. M., Neuhauser D., Katamba A., Mupere E. (2011). Patient satisfaction,
feasibility and reliability of satisfaction questionnaire among patients with pulmonary
tuberculosis in urban Uganda: a cross-sectional study. Health Res. Policy
Syst. 9:6 10.1186/1478-4505-9-6 [PMC free article] [PubMed] [Cross Ref]
5. Bassili A., Fitzpatrick C., Qadeer E., Fatima R., Floyd K., Jaramillo E. (2013). A
systematic review of the effectiveness of hospital- and ambulatory-based management
 of multidrug-resistant tuberculosis. Am. J. Trop. Med. Hyg. 89 271–280.
10.4269/ajtmh.13-0004 [PMC free article][PubMed] [Cross Ref]
6. Bauer B. S., Tredget E. E., Marcoux Y., Scott P. G., Ghahary A. (2002). Latent and
active transforming growth factor beta1 released from genetically modified
keratinocytes modulates extracellular matrix expression by dermal fibroblasts in a
coculture system. J. Invest. Dermatol. 119456–463. 10.1046/j.1523-
1747.2002.01837.x [PubMed] [Cross Ref]
7. Bauer M., Leavens A., Schwartzman K. (2013). A systematic review and meta-
analysis of the impact of tuberculosis on health-related quality of life. Qual. Life
Res. 22 2213–2235. 10.1007/s11136-012-0329-x [PMC free article] [PubMed] [Cross
Ref]
8. Behera C., Krishna K., Singh H. R. (2014). Antitubercular drug-induced violent
suicide of a hospitalised patient. BMJ Case Rep. 2014 10.1136/bcr-2013-
201469 [PMC free article] [PubMed][Cross Ref]
9. Bhatia M. S., Bhasin S. K., Dubey K. K. (2000). Psychosocial dysfunction in
tuberculosis patients.Indian J. Med. Sci. 54 171–173. [PubMed]
10. Booker M. J. (1996). Compliance, coercion, and compassion: moral dimensions of the
return of tuberculosis. J. Med. Humanit. 17 91–102.
10.1007/BF02276811 [PubMed] [Cross Ref]
11. Bostock S., Steptoe A. (2012). Association between low functional health literacy and
mortality in older adults: longitudinal cohort
study. BMJ 344:e1602 10.1136/bmj.e1602 [PMC free article][PubMed] [Cross Ref]
12. Brown J., Capocci S., Smith C., Morris S., Abubakar I., Lipman M. (2015). Health
status and quality of life in tuberculosis. Int. J. Infect. Dis. 32 68–75.
10.1016/j.ijid.2014.12.045 [PubMed] [Cross Ref]
13. Castro-Sanchez E., Chang P. W., Vila-Candel R., Escobedo A. A., Holmes A. H.
(2016). Health literacy and infectious diseases: why does it matter? Int. J. Infect.
Dis. 43 103–110. 10.1016/j.ijid.2015.12.019 [PubMed] [Cross Ref]
14. Chamla D. (2004). The assessment of patients’ health-related quality of life during
tuberculosis treatment in Wuhan, China. Int. J. Tuberc. Lung Dis. 8 1100–
1106. [PubMed]
15. Chang B., Wu A. W., Hansel N. N., Diette G. B. (2004). Quality of life in
tuberculosis: a review of the English language literature. Qual. Life Res. 13 1633–
1642. 10.1007/s11136-004-0374-1[PubMed] [Cross Ref]
16. Chinn D. (2011). Critical health literacy: a review and critical analysis. Soc. Sci.
Med. 73 60–67. 10.1016/j.socscimed.2011.04.004 [PubMed] [Cross Ref]
17. Chinnakali P., Ramakrishnan J., Vasudevan K., Gurumurthy J., Upadhyay R. P.,
Panigrahi K. C. (2013). Level of awareness about tuberculosis in urban slums:
implications for advocacy and communication strategy planning in the National
program. Lung India 30 139–142. 10.4103/0970-2113.110422 [PMC free
article] [PubMed] [Cross Ref]
18. Coker A. O., Kuyinu Y. A., Mohammed A. (2011). Psychological distress and
psychiatric symptoms among patients receiving treatment for tuberculosis in a
Teaching Hospital in Lagos, Nigeria. J. Community Med. Prime Health 23 1–2.
19. Conradie F., Mabiletsa T., Sefoka M., Mabaso S., Louw R., Evans D., et al.
(2014). Prevalence and incidence of symmetrical symptomatic peripheral neuropathy
in patients with multidrug-resistant TB. S. Afr. Med. J. 104 24–26.
10.7196/samj.6455 [PubMed] [Cross Ref]
20. Courtwright A., Turner A. N. (2010). Tuberculosis and stigmatization: pathways and
interventions.Public Health Rep. 125(Suppl. 4) 34–42. [PMC free article] [PubMed]
21. Das M., Isaakidis P., Van den Bergh R., Kumar A. M. V., Nagaraja S. B., Valikayath
A., et al. (2014). IV, multidrug-resistant TB and depressive symptoms: when three
conditions collide. Glob. Health Action 7:24912 10.3402/gha.v7.24912 [PMC free
article] [PubMed] [Cross Ref]
22. Demissie M., Getahun H., Lindtjorn B. (2003). Community tuberculosis care through
”TB clubs” in rural North Ethiopia. Soc. Sci. Med. 56 2009–2018. 10.1016/S0277-
9536(02)00182-X [PubMed][Cross Ref]
23. Deribew A., Deribe K., Reda A. A., Tesfaye M., Hailmichael Y., Maja T., et al.
(2013). Change in quality of life: a follow up study among patients with HIV
infection with and without TB in Ethiopia. BMC Public Health 13:408 10.1186/1471-
2458-13-408 [PMC free article] [PubMed][Cross Ref]
24. Deribew A., Tesfaye M., Hailmichael Y., Negussu N., Daba S., Wogi A., et al.
(2009). Tuberculosis and HIV co-infection: its impact on quality of life. Health Qual.
Life Outcomes 7:105 10.1186/1477-7525-7-105 [PMC free article] [PubMed] [Cross
Ref]
25. Dhingra V. K., Khan S. (2010). A sociological study on stigma among TB patients in
Delhi. Indian J Tuberc. 57 12–18. [PubMed]
26. Dhingra V. K., Rajpal S. (2005). Health related quality of life (HRQL) scoring (DR-
12 score) in tuberculosis–additional evaluative tool under DOTS. J. Commun.
Dis. 37 261–268. [PubMed]
27. Dhuria M., Sharma N., Ingle G. (2008). Impact of tuberculosis on the quality of
life. Indian J. Community Med. 33 58–59. 10.4103/0970-0218.39249 [PMC free
article] [PubMed] [Cross Ref]
28. Dhuria M., Sharma N., Narender Pal S., Ram Chander J., Saha R., Gopal Krishan I.
(2009). A study of the impact of tuberculosis on the quality of life and the effect after
treatment with DOTS. Asia Pac. J. Public Health 21 312–320.
10.1177/1010539509336242 [PubMed] [Cross Ref]
29. Dias A. A., de Oliveira D. M., Turato E. R., de Figueiredo R. M. (2013). Life
experiences of patients who have completed tuberculosis treatment: a qualitative
investigation in southeast Brazil. BMC Public Health 13:595 10.1186/1471-2458-13-
595 [PMC free article] [PubMed] [Cross Ref]
30. Diel R., Rutz S., Castell S., Schaberg T. (2012). Tuberculosis: cost of illness in
Germany. Eur. Respir. J. 40 143–151. 10.1183/09031936.00204611 [PubMed] [Cross
Ref]
31. Doherty A. M., Kelly J., McDonald C., O’Dywer A. M., Keane J., Cooney J.
(2013). A review of the interplay between tuberculosis and mental health. Gen. Hosp.
Psychiatry 35 398–406. 10.1016/j.genhosppsych.2013.03.018 [PubMed] [Cross Ref]
32. Dowdy D. W., Israel G., Vellozo V., Saraceni V., Cohn S., Cavalcante S., et al.
(2013). Quality of life among people treated for tuberculosis and human
 immunodeficiency virus in Rio de Janeiro, Brazil.Int. J. Tuberc. Lung Dis. 17 345–
347. 10.5588/ijtld.12.0123 [PMC free article] [PubMed][Cross Ref]
33. Drapeau A., Marchand A., Beaulieu-Preávost D. (2011). Epidemiology of
Psychological Distress. Mental Illnesses-Understanding, Predict Control. Available
at: http://www.zums.ac.ir/files/research/site/medical/Mental%20and%20Behavioural
%20Disorders%20and%20Diseases%20of%20the%20Nervous%20System/Mental_Ill
nesses_-_Understanding__Prediction_and_Control.pdf [accessed May 23, 2016].
34. Feng D., Xu L. (2015). The relationship between perceived discrimination and
psychological distress among Chinese pulmonary tuberculosis patients: the
moderating role of self-esteem. Psychol. Health Med. 20 177–185.
10.1080/13548506.2014.958505 [PubMed] [Cross Ref]
35. Geldenhuys H., Sorsdahl K., Kafaar F., Hatherill M., Hanekom W. A., Stein D. J., et
al. (2011). Risky behaviour and psychosocial correlates in adolescents - is there a link
with tuberculosis? Afr. J. Psychiatry (Johannesbg) 14 383–387.
10.4314/ajpsy.v14i5.6 [PubMed] [Cross Ref]
36. Godoy M. D., Mello F. C., Lopes A. J., Costa W., Guimaraes F. S., Pacheco A. G., et
al. (2012). The functional assessment of patients with pulmonary multidrug-resistant
tuberculosis. Respir. Care 571949–1954. 10.4187/respcare.01532 [PubMed] [Cross
Ref]
37. Guo N., Marra C. A., Marra F., Moadebi S., Elwood R. K., Fitzgerald J. M.
(2008). Health state utilities in latent and active tuberculosis. Value Health 11 1154–
1161. 10.1111/j.1524-4733.2008.00355.x [PubMed] [Cross Ref]
38. Houston H. R., Harada N., Makinodan T. (2002). Development of a culturally
sensitive educational intervention program to reduce the high incidence of
tuberculosis among foreign-born Vietnamese.Ethn. Health 7 255–265.
10.1080/1355785022000060718 [PubMed] [Cross Ref]
39. Hsiung P. C., Fang C. T., Wu C. H., Sheng W. H., Chen S. C., Wang J. D., et al.
(2011). Validation of the WHOQOL-HIV BREF among HIV-infected patients in
Taiwan. AIDS Care 23 1035–1042.
10.1080/09540121.2010.543881 [PubMed] [Cross Ref]
40. Huther J., von Wolff A., Stange D., Harter M., Baehr M., Dartsch D. C., et al.
(2013). Incomplete medication adherence of chronically ill patients in German
primary care. Patient Prefer. Adherence 7237–244. 10.2147/PPA.S38373 [PMC free
article] [PubMed] [Cross Ref]
41. Iseman M. D. (1993). Treatment of multidrug-resistant tuberculosis. N. Engl. J.
Med. 329 784–791. 10.1056/NEJM199309093291108 [PubMed] [Cross Ref]
42. Janmeja A. K., Das S. K., Bhargava R., Chavan B. S. (2005). Psychotherapy
improves compliance with tuberculosis treatment. Respiration 72 375–380.
10.1159/000086251 [PubMed] [Cross Ref]
43. Kaliakbarova G., Pak S., Zhaksylykova N., Raimova G., Temerbekova B., van den
Ho S. (2013). Psychosocial support improves treatment adherence among MDR-TB
patients: experience from East Kazakhstan. Open Infect. Dis. J. 7 60–64.
10.2174/1874279301307010060 [Cross Ref]
44. Kessler R. C., Aguilar-Gaxiola S., Alonso J., Chatterji S., Lee S., Ormel J., et al.
(2009). The global burden of mental disorders: an update from the WHO World
 Mental Health (WMH) surveys.Epidemiol. Psichiatr. Soc. 18 23–33.
10.1017/S1121189X00001421 [PMC free article] [PubMed][Cross Ref]
45. Louw J., Peltzer K., Naidoo P., Matseke G., McHunu G., Tutshana B. (2012). Quality
of life among tuberculosis (TB), TB retreatment and/or TB-HIV co-infected primary
public health care patients in three districts in South Africa. Health Qual. Life
Outcomes 10 77 10.1186/1477-7525-10-77 [PMC free article] [PubMed] [Cross Ref]
46. Macq J., Solis A., Martinez G., Martiny P. (2008). Tackling tuberculosis patients’
internalized social stigma through patient centred care: an intervention study in rural
Nicaragua. BMC Public Health8:154 10.1186/1471-2458-8-154 [PMC free
article] [PubMed] [Cross Ref]
47. Masumoto S., Yamamoto T., Ohkado A., Yoshimatsu S., Querri A. G., Kamiya Y.
(2014). Prevalence and associated factors of depressive state among pulmonary
tuberculosis patients in Manila, The Philippines. Int. J. Tuberc. Lung Dis. 18 174–
179. 10.5588/ijtld.13.0335 [PubMed] [Cross Ref]
48. Melchionda V., Wyatt H., Capocci S., Garcia Medina R., Solamalai A., Katiri S., et
al. (2013). Amikacin treatment for multidrug resistant tuberculosis: how much
monitoring is required? Eur. Respir. J. 42 1148–1150.
10.1183/09031936.00184312 [PubMed] [Cross Ref]
49. Moore D. J., Posada C. (2013). HIV and psychiatric co-morbidities: what do we know
and what can we do? Psychology and AIDS Exchange Newsletter. American
Psychological Association; 1.
50. Muniyandi M., Rao V. G., Bhat J., Yadav R., Sharma R. K., Bhondeley M. K.
(2015). Health literacy on tuberculosis amongst vulnerable segment of population:
special reference to Saharia tribe in central India. Indian J. Med. Res. 141 640–
647. [PMC free article] [PubMed]
51. NASMHPD (2006). National Association of State Mental Health Program Directors
Medical Directors Council-thirteenth in a Series of Technical Reports. Morbidity and
Mortality in People with Serious Mental Illness. Available
at: http://www.nasmhpd.org/sites/default/files/Mortality%20and%20Morbidity%20Fi
nal%20Report%208.18.08.pdf [accessed May 23, 2016].
52. Ormerod L. P. (2007). Role of surgery in pulmonary multidrug-resistant
tuberculosis. Thorax 62:37710.1136/thx.2005.056135 [PMC free
article] [PubMed] [Cross Ref]
53. Osborne R. H., Beauchamp A., Batterham R. (2016). Health literacy: a concept with
potential to greatly impact the infectious diseases field. Int. J. Infect. Dis. 43 101–102.
10.1016/j.ijid.2015.12.012 [PubMed] [Cross Ref]
54. Pachi A., Bratis D., Moussas G., Tselebis A. (2013). Psychiatric morbidity and other
factors affecting treatment adherence in pulmonary tuberculosis patients. Tuberc. Res.
Treat. 2013:48986510.1155/2013/489865 [PMC free article] [PubMed] [Cross Ref]
55. Pasco J. A., Williams L. J., Jacka F. N., Ng F., Henry M. J., Nicholson G. C., et al.
(2008). Tobacco smoking as a risk factor for major depressive disorder: population-
based study. Br. J. Psychiatry 193322–326.
10.1192/bjp.bp.107.046706 [PubMed] [Cross Ref]
56. Pasipanodya J. G., Miller T. L., Vecino M., Munguia G., Bae S., Drewyer G., et al.
(2007). Using the St. George respiratory questionnaire to ascertain health quality in
 persons with treated pulmonary tuberculosis. Chest 132 1591–1598.
10.1378/chest.07-0755 [PubMed] [Cross Ref]
57. Peddireddy V. (2016). Psychological interventions to improve the quality of life in
Indian lung cancer patients: a neglected area. J. Health
Psychol. 10.1177/1359105316650930 [Epub ahead of print]. [PubMed] [Cross Ref]
58. Peddireddy V., Doddam S. N., Qureshi I. A., Yerra P., Ahmed N. (2016). A putative
nitroreductase from the DosR regulon of Mycobacterium tuberculosis induces pro-
inflammatory cytokine expression via TLR2 signaling pathway. Sci.
Rep. 6:24535 10.1038/srep24535 [PMC free article][PubMed] [Cross Ref]
59. Peltzer K., Louw J., McHunu G., Naidoo P., Matseke G., Tutshana B.
(2012a). Hazardous and harmful alcohol use and associated factors in tuberculosis
public primary care patients in South Africa. Int. J. Environ. Res. Public
Health 9 3245–3257. 10.3390/ijerph9093245 [PMC free article][PubMed] [Cross
Ref]
60. Peltzer K., Naidoo P., Matseke G., Louw J., McHunu G., Tutshana B.
(2012b). Prevalence of psychological distress and associated factors in tuberculosis
patients in public primary care clinics in South Africa. BMC
Psychiatry 12:89 10.1186/1471-244X-12-89 [PMC free article] [PubMed][Cross Ref]
61. Peltzer K., Louw J. S. (2014). Prevalence and factors associated with tuberculosis
treatment outcome among hazardous or harmful alcohol users in public primary
health care in South Africa. Afr. Health Sci. 14 157–166. 10.4314/ahs.v14i1.24 [PMC
free article] [PubMed] [Cross Ref]
62. Peltzer K., Naidoo P., Matseke G., Louw J., McHunu G., Tutshana B.
(2013). Prevalence of post-traumatic stress symptoms and associated factors in
tuberculosis (TB), TB retreatment and/or TB-HIV co-infected primary public health-
care patients in three districts in South Africa. Psychol. Health Med. 18 387–397.
10.1080/13548506.2012.726364 [PubMed] [Cross Ref]
63. Pezzoni V., Kouimtsidis C. (2015). Screening for alcohol misuse within people
attending a psychiatric intellectual disability community service. J. Intellect. Disabil.
Res. 59 353–359. 10.1111/jir.12168 [PubMed] [Cross Ref]
64. Rajeswari R., Muniyandi M., Balasubramanian R., Narayanan P. R.
(2005). Perceptions of tuberculosis patients about their physical, mental and social
well-being: a field report from south India. Soc. Sci. Med. 60 1845–1853.
10.1016/j.socscimed.2004.08.024 [PubMed] [Cross Ref]
65. Roila F., Cortesi E. (2001). Quality of life as a primary end point in oncology. Ann.
Oncol. 12(Suppl. 3) S3–S6. 10.1023/A:1013026527758 [PubMed] [Cross Ref]
66. Safa M., Ebrahimi M., Ghassem Boroujerdi F., Talischi F. (2013). Cognitive group
psychotherapy in patients with tuberculosis. Pract. Clin. Psychol. 1 157–162.
67. Schwindenhammer B., Podleska L. E., Kutritz A., Bauer S., Sheu S. Y., Taeger G., et
al. (2013). The pathologic response of resected synovial sarcomas to hyperthermic
isolated limb perfusion with melphalan and TNF-alpha: a comparison with the whole
group of resected soft tissue sarcomas.World J. Surg. Oncol. 11:185 10.1186/1477-
7819-11-185 [PMC free article] [PubMed] [Cross Ref]
68. Seddon J. A., Godfrey-Faussett P., Jacobs K., Ebrahim A., Hesseling A. C., Schaaf H.
S. (2012). Hearing loss in patients on treatment for drug-resistant tuberculosis. Eur.
Respir. J. 40 1277–1286. 10.1183/09031936.00044812 [PubMed] [Cross Ref]
69. Seddon J. A., Thee S., Jacobs K., Ebrahim A., Hesseling A. C., Schaaf H. S.
(2013). Hearing loss in children treated for multidrug-resistant tuberculosis. J.
Infect. 66 320–329. 10.1016/j.jinf.2012.09.002 [PubMed] [Cross Ref]
70. Sharma R., Yadav R., Sharma M., Saini V., Koushal V. (2014). Quality of life of
multi drug resistant tuberculosis patients: a study of north India. Acta Med.
Iran. 52 448–453. [PubMed]
71. Shen T. C., Wang C. Y., Lin C. L., Liao W. C., Chen C. H., Tu C. Y., et al.
(2014). People with tuberculosis are associated with a subsequent risk of
depression. Eur. J. Intern. Med. 25 936–940.
10.1016/j.ejim.2014.10.006 [PubMed] [Cross Ref]
72. Thakker R. M., Gunjan P., Upadhyay P. (2014). Psychosocial reaction of diagnosing
tuberculosis – An experience of tertiary care center of rural gujarat. Int. J. Med. Sci.
Public Health 3 1498–1500. 10.5455/ijmsph.2014.190920141 [Cross Ref]
73. Theron G., Peter J., Zijenah L., Chanda D., Mangu C., Clowes P., et al.
(2015). Psychological distress and its relationship with non-adherence to TB
treatment: a multicentre study. BMC Infect. Dis. 15:253 10.1186/s12879-015-0964-
2 [PMC free article] [PubMed] [Cross Ref]
74. Thomas B. E., Shanmugam P., Malaisamy M., Ovung S., Suresh C., Subbaraman R.,
et al. (2016). Psycho-socio-economic issues challenging multidrug resistant
tuberculosis patients: a systematic review. PLoS
ONE 11:e0147397 10.1371/journal.pone.0147397 [PMC free article] [PubMed][Cross
Ref]
75. Toczek A., Cox H., du Cros P., Cooke G., Ford N. (2013). Strategies for reducing
treatment default in drug-resistant tuberculosis: systematic review and meta-
analysis. Int. J. Tuberc. Lung Dis. 17 299–307.
10.5588/ijtld.12.0537 [PubMed] [Cross Ref]
76. Tola H. H., Shojaeizadeh D., Tol A., Garmaroudi G., Yekaninejad M. S., Kebede A.,
et al. (2016). Psychological and educational intervention to improve tuberculosis
treatment adherence in ethiopia based on health belief model: a cluster randomized
control trial. PLoS ONE 11:e015514710.1371/journal.pone.0155147 [PMC free
article] [PubMed] [Cross Ref]
77. Trangle M., Gursky J., Haight R., Hardwig J., Hinnenkamp T., Kessler D., et al.
(2016). Institute for Clinical Systems Improvement. Adult Depression in Primary
Care. Available at: https://www.icsi.org/_asset/fnhdm3/Depr-
Interactive0512b.pdf [accessed May 23, 2016].
78. Veggi A. B., Lopes C. S., Faerstein E., Sichieri R. (2004). [Body mass index, body
weight perception and common mental disorders among university employees in Rio
de Janeiro]. Rev. Bras. Psiquiatr.26 242–247. [PubMed]
79. Venkatraju B., Prasad S. (2010). Beliefs of patients about the causes of Tuberculosis
in rural Andhra Pradesh. Int. J. Nurs. Midwifery 2 21–27.
80. Wei W., Wei S., Wenwen S., Qin S. (2016). Impact of programmatic intervention on
the treatment compliance of patients with HIV/TB dual infection. Int. J. Exp. Clin.
Med. 9 4173–4177.
81. WHO (2013). Multidrug-Resistant Tuberculosis (MDR-TB) 2013 Update. Available
at: http://www.who.int/tb/challenges/mdr/MDR_TB_FactSheet.pdf [accessed May 23,
2016].
82. WHO (2015a). WHO Global Tuberculosis Report 2015.
WHO/HTM/TB/2015.22. Available
at: http://who.int/tb/publications/global_report/en/ [accessed October 03, 2016].
83. WHO (2015b). World Health Statistics 2015. Available
at: http://www.who.int/gho/publications/world_health_statistics/2015/en/ [accessed
May 23, 2016].