Drivers of Tuberculosis Epidemics: Risk Factors and Social Determinants

The provided content includes several studies and articles related to the social determinants of tuberculosis (TB) in various countries. The studies examine factors such as gender, socioeconomic status, and cultural influences that contribute to TB-related stigma and delay in diagnosis. Specifically, the research explores the role of these determinants in Bangladesh, India, Malawi, and Colombia. The findings suggest that addressing these social factors is crucial for effective TB control and elimination.

Systematic review on
“Prevalence and
Determinants of
Tuberculosis in Bangladesh”

ABSTRACT
Key background literature: Tuberculosis is an infectious air borne disease. Tuberculosis (TB)
has emerged as the next global public health crisis. This is because it is responsible for ill health
among millions of people every year. TB occurs in all parts of the world. Bangladesh is a lower
middle income country. The rate of tuberculosis per 100, 000 population in Bangladesh has
increased in the past years. In the 2011, the rate was 225 incident cases per 100, 000 of
population. This has increased to 227 cases per 100, 000 of population
Rationale: As the number of cases of tuberculosis is increasing in Bangladesh and the problem is
being aggravated by the TB stigma, there is a need to find out the underlying reasons associated.
Aims: The overall aim of this systematic review is to investigate TB and its associated stigma in
Bangladesh.
Methods: In the present study, systematic literature review study design has been employed.
Search strategy comprised of key search terms, boolean operators, electronic databases.
Findings: Tuberculosis is prevalent in Bangladesh in the poorer sections, urban slums and
prisons. There are a number of determinants of the disease such as social contact pattern, lack of
awareness and knowledge, inequitable distribution of health benefits, health system delay and
high prevalence of TB in prisons. TB is highly stigmatized in the country which results into
delay in diagnosis and initiation of treatment thus leading to increased prevalence of the disease.
Conclusion: The results of this review suggest that various determinants are responsible for high
prevalence of TB in Bangladesh. There is a n the prevalence of TB is increasing in Bangladesh
owing to the various determinants.
Implications: There is a need to take steps to raise awareness and increase knowledge about the
disease. Health system delay should be tackled. Provision of treatment services for TB should be
made equitably accessible.
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TABLE OF CONTENTS
ABSTRACT....................................................................................................................................2
CHAPTER 1- INTRODUCTION ...................................................................................................5
1.1 Introduction ...........................................................................................................................5
1.2 Background ...........................................................................................................................5
1.3 Rationale of the study ...........................................................................................................7
1.4 Research Question ................................................................................................................8
1.5 Aims and Objectives of study ...............................................................................................8
1.6 Scope of dissertation..............................................................................................................8
1.7 Conclusion ............................................................................................................................9
Chapter 2- literature review ..........................................................................................................10
2.1 Introduction..........................................................................................................................10
2.2 Prevalence and transmission of pulmonary tuberculosis ....................................................10
2.3 Lack of Knowledge of regarding tuberculosis leads to its increased prevalence ...............14
2.4 Spread of tuberculosis in Bangladesh..................................................................................17
2.4 Multi-drug resistant tuberculosis- nursing practice guidelines............................................18
2.5 Tuberculosis control ............................................................................................................19
CHAPTER 3- METHOD ..............................................................................................................21
3.1 Introduction .........................................................................................................................21
3.2 Research design ..................................................................................................................21
3.3 Inclusion and exclusion criteria ..........................................................................................22
3.4 Searching strategy ...............................................................................................................23
3.5 Screening strategy ..............................................................................................................26
3.6 Data extraction ....................................................................................................................27
3.7 Quality Appraisal ................................................................................................................27
3.8 Ethical issues .......................................................................................................................28
3.9 Analysis ...............................................................................................................................29
3.10 summary ............................................................................................................................30
CHAPTER 4- RESULTS ..............................................................................................................31
4.1 Introduction .........................................................................................................................31
4.2 Summary of the selected studies .........................................................................................33
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4.3 Findings of the study ...........................................................................................................33
4.4 Summary .............................................................................................................................36
CHAPTER 5- DISCUSSION .......................................................................................................37
5.1 Introduction .........................................................................................................................37
5.2 Main results and comparison with existing literature ........................................................37
5.3 Implications of findings and their significance for public health policy ............................41
5.4 Critical evaluation of the present review ............................................................................42
CHAPTER 6- CONCLUSION ....................................................................................................44
6.1 Conclusion ..........................................................................................................................44
6. 2 Future research .................................................................................................................44
references ......................................................................................................................................46
APPENDIX 1.................................................................................................................................54
APPENDIX 3.................................................................................................................................63
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CHAPTER 1- INTRODUCTION
1.1 Introduction
This chapter will discuss the aspects related to tuberculosis in Bangladesh and stigma
associated with it. Key background literature will be provided on TB in Bangladesh and stigma
related to it. The introduction chapter will also provide an explicit and convincing rationale
behind carrying out this systematic review. Aim and objectives of the review will be clearly
stated in this chapter.
1.2 Background
1.2.1 What is tuberculosis and drug-resistant tuberculosis?
According to World Health Organization, Tuberculosis is an infectious disease which
affects the lungs (Tuberculosis (TB), 2016). It is caused by Mycobacterium. Its transmission
from one person to another takes place via droplets from the throat or lungs of people who have
respiratory disease in the active state (Tuberculosis (TB), 2016). In healthy people, the immune
system acts as a barrier and fights the bacteria. Therefore, Mycobacterium tuberculosis shows no
symptoms. Symptoms of active TB of lungs includes coughing, night sweats, fever, chest pains,
weakness, weight loss etc. the bacteria which is responsible for causing TB can develop
resistance to the antimicrobial drugs which are administered for curing the disease (World Health
Organization, 2016). Multi drug resistant TB (MDR TB) is defined as a type of TB infection
which is cause by bacteria that shows resistance to treatment with most powerful first line TB
drugs (What is multidrug-resistant tuberculosis (MDR-TB) and how do we control it? 2015).
1.2.2 Tuberculosis: A global health crisis
Tuberculosis (TB) has emerged as the next global public health crisis. This is because it
is responsible for ill health among millions of people every year (Global tuberculosis report,
2014). The death toll from the disease it unacceptably high and the current efforts prove to be
insufficient to control the disease. Moreover, XDR TB has also emerged as a form of TB which
is resistant to most TB drugs thus increasing the burden of this disease (Global tuberculosis
report, 2014). This highly contagious airborne disease may become difficult to be controlled as
the nations are not prepared to meet the threat posed by this disease (Lienhardt et.al., 2012). In
the year 2014, TB killed 1.5 million people. In the year 2013, nine million people contracted TB.
Of them, half million infections were of drug resistant TB. Moreover, the problem is likely to
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grow more as the funds which are required for prevention, diagnosis and treatment of TB
worldwide are $ 1.7 billion short (Foster, 2015). There is meagre level of investment in research
on vaccines and new treatment. The scale on which people are suffering from the disease and
dying is alarming. However, potential for wide consequences is the matter of concern of public
health advocates. Various surveillance studies and outbreak investigations indicate increasing
prevalence of extensively drug resistant (XDR) form of tuberculosis in the world (Ellner, 2008).
The scale of spread of tuberculosis has become comparable with HIV/ AIDS. The disease
has become a top killer among various infectious diseases all over the world (Global tuberculosis
report, 2014). Though significant advances have been made against TB throughout the mid 20
century. However, by the end of century, the disease followed a rising trend (Sotgiu et.al., 2014).
The alarming stage of TB came when doctors documented new strains of TB which showed
resistance to a number of indicated medicines (Sharma et.al., 2011). Centre for Disease Control
and Prevention states that spread of MDR TB and extensively drug resistant TB has become a
global security health concern (Frieden, 2015). Funding and maintaining the supply of expensive
drugs or treatment of TB has become a struggle (Kimbrough et.al., 2012). According to WHO,
one of the health targets of the newly adopted Sustainable Development goals is to end TB
epidemic by the year 2030 (Tuberculosis, 2016).
1.2.3 Prevalence of TB
TB occurs in all parts of the world (Gupta et.al., 2015). In the United States and Western
Europe, TB is relatively well controlled. However, it is widely spread across Asia, Latin
America, Eastern Europe and Africa. According to WHO, more than 95 per cent of deaths due to
TB take place in low and middle income countries. Most severe burden is carried by Africa with
281 cases per 100, 000 population in the year 2014 (Tuberculosis, 2016). In 2014, 6 countries
that had the largest number of incident cases of TB were India, People's Republic of China,
Pakistan, South Africa, Nigeria and Indonesia.
Bangladesh is a lower middle income country. The rate of tuberculosis per 100, 000
population in Bangladesh has increased in the past years. In the 2011, the rate was 225 incident
cases per 100, 000 of population. This has increased to 227 cases per 100, 000 of population
(Incidence of tuberculosis (per 100,000 people), 2016). Every year, TB causes death of 80, 000
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Bangladeshis. Also, 190, 000 new cases of tuberculosis occur per year in the country. Every
hour, 9 people die due to TB in Bangladesh. The cases of TB occur mostly among poor people
(Post-2015 Development Agenda, 2016). This suggests that TB is a big problem in Bangladesh.
However, there is scope for effectively tackling this problem.
1.2.4 TB stigma- What does it mean?
Stigma is a social determinant of health. This begins when a particular trait of a person or
a group is considered to be undesirable. TB is highly stigmatized which results into considerable
discrimination towards the sufferers (Chang and Cataldo, 2014). There are various factors which
are associated with TB which themselves create stigma. These include poverty, refugee status,
homelessness, HIV, drug and alcohol misuse etc. Fear of infection is one of the most common
cause of stigma. Once TB is identified, the person is set apart and linked to undesirable
stereotypes. These lead to discrimination and unfair treatment. In Bangladesh, stigma is one of
the major socio- cultural barriers in access TB care. This is because people delay obtaining care
and treatment for TB because of the fear of being discriminated and socially excluded. They
avoid going to the doctor for getting tested for TB. This is as detection of the disease is
considered to be undesirable in the society in Bangladesh. Therefore people avoid to go to the
doctors even if they have been experiencing the symptoms of the disease due to the fear of being
excluded from the society. This leads to the growth of the problem in the country (Ahmed et.al.,
2013). The present systematic review aims to investigate tuberculosis in Bangladesh and stigma
associated with it. This is important to be done as spread and transmission of disease within the
country can be tackled to a great extent by eliminating the stigma associated with it.
1.3 Rationale of the study
Tuberculosis is a growing public health problem all over the world. It has been a major
health problem for Bangladesh since long. According to World Health Organization (2016),
Bangladesh ranks 6th on the list of 22 countries which bear the highest burden of TB in the world
(Tuberculosis Control Programme, 2016). For a lower middle income country, it is even more
important to tackle the problem. There has been an increase in the cases of tuberculosis in the
year 2014. It leads to death o several people every year with the emergence of new cases as well.
It is estimated that every day approximately 875 new cases and 180 TB deaths occur in the
nation (National Tuberculosis Control Program (NTP), 2016). Moreover, stigma associated with
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TB makes the infected people delay seeking help. This increases the probability that the will
become seriously ill as well as transmit the infection to others. Stigma acts as a barrier in
accessing TB care thus aggravating the condition.
As the number of cases of tuberculosis is increasing in Bangladesh and the problem is
being aggravated by the TB stigma, there is a need to find out the underlying reasons associated.
There is a requirement of determining factor in Bangladesh and increasing alertness regarding it.
There is a need to explore the concealed gaps of current health strategy in Bangladesh so that it
can be recovered and impact of TB in society can be improved. However, before taking any step
further, it is essential to develop a clear idea of the prevalence and determinants of TB in
Bangladesh. But, very few studies have been conducted till now to find out the causes of TB
stigma in Bangladesh. Therefore, there is a need to gather the available findings and put them
together so that research gaps can be identified. This will help in reforming the current heath
strategy for controlling TB in Bangladesh. This systematic review will therefore investigate the
causes of TB stigma in Bangladesh.
1.4 Research Question
What is the prevalence of TB and its determinants in Bangladesh?
1.5 Aims and Objectives of study
The overall aim of this systematic review is to investigate TB and its associated stigma in
Bangladesh. Therefore, the systematic review was conducted to fulfil the following objectives:
a) To review all systematic works to address current prevalence rate and determinants of
TB in Bangladesh
b) To systematically review literature to find out the determining factor associated with TB
in Bangladesh
c) To systematically review literature to identify the gaps in the current strategy in
Bangladesh
1.6 Scope of dissertation
The dissertation will comprise of the following chapters:
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a) Chapter 1- Introduction: This chapter will introduce the topic of the systematic review. It
will provide background literature to the study. Also, rationale will be provided which
will convey the importance of carrying out the present systematic review.
b) Chapter 2- Literature review: This chapter will review the available literature related to
the topic of the present review. It will provide the context and background for the study.
Primary studies conducted on TB in Bangladesh will be critically appraised and
evaluated. Evidence gaps will be determined.
c) Chapter 3- Method: This chapter will provide details about the methodology adopted for
carrying out the systematic review. This will include research design, inclusion exclusion
criteria, searching strategy, data extraction, ethical issues and analysis.
d) Chapter 4- Results: The results chapter will describe the findings of the review. It will
focus on key results which provide answers for the research question.
e) Chapter 5- Discussion: This section will succinctly summarize the key findings of the
review and will interpret and explain them. This chapter will critically consider the
results in relation to the existing literature. Therefore, comparison will be drawn between
the results and findings of review and the previous research. Strengths and weaknesses of
the present study will be discussed.
f) Chapter 6- Conclusion: This chapter will summarize the dissertation by conveying the
methods used, the key findings and implications of study. It will also propose future
research that needs to be conducted.
1.7 Conclusion
From the introduction chapter, it can be concluded that TB has become a global crises.
However, it is a serious problem to be tackled in low income countries like Bangladesh. The
present systematic review is important as Bangladesh ranks 6th on the list of 22 countries that
bear the highest burden of Tuberculosis. This review is important as it will help in revealing
concealed gaps in the current health strategy in Bangladesh so that impact of TB in the society
can be improved.
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CHAPTER 2- LITERATURE REVIEW
2.1 Introduction
According to Kumar, (2014), literature review is an account of the literature that has been
published on a topic by researchers and accredited scholars (Kumar, 2014). It conveys to the
readers the ideas and knowledge that have been established on a particular topic. Chenail, (2011)
assert that literature review situates a research focus within the context of the wider academic
community. It also identifies a gap within the literature which the study will address. A critical
review of literature is crucial for a dissertation (Chenail, 2011). This is because it persuades the
reader by setting a context which indicates that the study is relevant and worth carrying out.
Therefore, for critical review of literature, interpretation as well as synthesis of published work is
essential.
Studies have been conducted focusing on the aspects related to TB throughout the world.
In this chapter, accumulation of available data on the research topic will be done. This
information will be presented under different themes thus structuring the review in a logical
manner. This will help in analyzing the previously done primary research. Moreover, an
understanding will be developed on the subject matter. Thus, the researcher will be able to
develop links between the previous research studies and the present research being conducted.
In this respect the main themes coming out of Literature review are
 Prevalence and transmission of pulmonary tuberculosis
 Lack of Knowledge of regarding tuberculosis leads to its increased prevalence
 Spread of tuberculosis in Bangladesh
 Multi-drug resistant tuberculosis- nursing practice guidelines
 Tuberculosis control
2.2 Prevalence and transmission of pulmonary tuberculosis
In the year 2012, there were approximately 8.6 million new cases of tuberculosis. Also,
the disease led to 1.3 million deaths all over the world (Global tuberculosis report, 2013). TB is
considered to be a major cause of mortality and morbidity in prisons. Spread of diseases like TB
is facilitated due to factors such as overcrowding, high turnover of inmates, poor general health
of the prisoners, inadequate ventilation etc. the reported prevalence of TB is much higher in
prisons as compared to the corresponding general population (Chang and Cataldo, 2014). Banu
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and et.al. (2015) carried out research to find out the effect of Active case finding on prevalence
and transmission of pulmonary tuberculosis in Dhaka Central Jail in Bangladesh. The authors
found that there was an association between implementation of active screening for TB and
decline in TB cases in Dhaka Central Jail (Banu and et.al., 2015). Under Banu et.al. (2015) the
findings suggested that national burden of TB in Bangladesh can be substantially reduced by
implementation of active screening in prison settings.
One of the key factors responsible for overall incidence of TB, its prevalence and
mortality rates is the spread of TB from prisons to communities. Banu and et.al. (2015) carried
out the study from October 2005 to February 2010. Under Banu and et.al. (2015) there was
establishment of an active case finding strategy for pulmonary TB at the entry point of the prison
as well as inside the prison. Collection of three sputum specimens was done from all the
suspects. These were then subjected to smear microscopy, culture and drug susceptibility testing.
The methods also included mycobacterial interspersed repetitive units (MIRU). The results of the
study indicated 466 inmates with pulmonary TB out of 60, 585 inmates who were screened
(Banu and et.al., 2015). However, it can be critically analyzed that the authors might have failed
to detect some cases of pulmonary TB. Moreover, it can be said whether the intervention used by
authors are capable of decreasing the burden of TB in the absence of a control group.
Under Hossain and et.al. (2012) the socio- economic position (SEP) of actively detected
cases from the community was assessed and compared. The study also assessed cases which
were being routinely detected under the National Tuberculosis Control Program (NTP) in
Bangladesh. Validated asset item was used for assessing SEP for each of 21, 427 households
which were included in the national prevalence survey 2007- 2009 (Hossain and et.al., 2012).
Household scores were generated with the help of a principal component analysis. These were
then categorized into quartiles. The authors compared the distribution of 33 actively identified
cases with 240 NTP cases. It was found that the population prevalence of tuberculosis was 5
times higher in lower quartiles of population to highest quartile of population. 25 cases out of the
33 detected cases from the survey were from lower two quartiles. The rest cases belonged to
upper two quartiles (Hossain and et.al., 2012).
The findings of the study done by Hossain indicate that despite the free of charge
availability of DOTS, it cannot be accessed equally by the poorer sections of population. Health
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systems in Bangladesh in most instances are in equitable (Hossain and et.al., 2012). These follow
an inverse care law in which more is provided to the rich who are in less need of them. Though
the services provided through the government are universal. However, it can be critically
analysed that upper quintiles of population get a great share of them. The study has a major
strength that it represents the population of the country by using a valid methodology. However,
it can be critically evaluated that the data collection method was not appropriate. This is because
certain household assets have dual ownership such as TV, motorcycles. Therefore, the
assessment of assets on individual households was not valid. This is because ascertainment bias
could have been there which would have affected the data collection methods.
However, different contexts associated with the prevalence of Tuberculosis and drug
resistant tuberculosis were explored by researchers. Under Banu and et.al. (2012) the patterns,
magnitude and molecular characterization of drug resistant Mycobacterium tuberculosis strains
in a tertiary referral hospital in Bangladesh were investigated. The authors randomly interviewed
patients suffering from pulmonary tuberculosis admitted at National Institute of Diseases of the
Chest and Hospital during Feb 2002 to September 2005. Testing of 189 patients was done for
finding out susceptibility to rifampicin (RMP), streptomycin (STM), isoniazid (INH) and
ethambutol (ETM) (Banu and et.al., 2012). The results of the study showed that 88 per cent or
167 patients possessed a history of previous anti -TB treatment. The remaining 12 per cent
denoted new cases of TB. Significantly higher levels of multidrug resistance were found in the
130 patient who had a previous history of anti- tuberculosis treatment. From the findings of the
study, it can be concluded that there is high level of drug resistance among re- treatment patients.
This increases the threat of transmission of resistant strains to those people in the community
who are susceptible to it (Banu and et.al., 2012).
Banu and et.al. (2012) suggested that there is a need for proper counseling of patients.
Also, attention is required to be paid towards the completion of anti- TB treatment. However,
this is in contrast to the findings of Hossain and et.al. (2012). It can be critically analysed that the
health systems in Bangladesh are inequitable and the poorer sections are not able to access the
services (Hossain and et.al., 2012). Hence, proper counseling and completion of anti TB
treatment will not help in controlling the disease. Before this, there is a need to make the
treatment available to the poorer sections of the nation. Banu and et.al. (2012) stressed that less
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data is available about the prevalence of drug resistant TB in Bangladesh. Drug resistance is
found more in the cases that have previous history of tuberculosis. Hence, the overall prevalence
of drug resistance is associated with the number of previously treated cases in Bangladesh.
Strains of the T family are prevalent in Bangladesh. The local TB program faces serious threat
from the emergence of the ‘T’-types as well as drug resistant M. tuberculosis
strains that belong to the ‘Beijing’ (Banu and et.al., 2012) .
The National Tuberculosis Control Programme in Bangladesh adopt the strategy of
directly observed treatment short course (DOTS). However, the services provided in this regard
to the urban slum dwellers still consist of gaps. This leads to decreased TB case detection. TB
prevalence survey (2007- 2009) of Bangladesh reported a high incidence of TB in rural areas as
compared to urban areas. However, there are still some regions in the urban areas which have
high prevalence of TB. These include the urban slums (Gupta et.al., 2015). Banu and et.al.
(2013) carried out a cross sectional study on epidemiology of tuberculosis in an urban slum of
Dhaka city in Bangladesh. The aim of the study was to assess the burden of TB so that insights
can be provided regarding the type of M. tuberculosis species which is circulating in the urban
slums of Bangladesh. The authors screened the household members to assessing the presence of
symptoms and signs associated with TB for less than or equal to 3 weeks. Sputum specimens
were collected to undertake drug susceptibility testing, culture and acid fast bacilli (AFB)
microscopy (Banu and et.al., 2013). Spoligotyping was used for genotyping of M. tuberculosis.
The results obtained from the study were that among 9877 adults screened for pulmonary TB, 25
were found to be positive for AFB on microscopy. The authors estimate the prevalence of new
cases of TB as 253/ 100, 000. among the 5147 children screened, only one TB case was
diagnosed. Of the 26 cases that were found to be infected, 21 had cough for several durations.
From the study, it was found that there is high prevalence of TB in urban slums. Screening for
low BMI (Body Mass Index) can be helpful for assessing TB among high risk population (Banu
and et.al., 2013).
The existing NTP guidelines in Bangladesh suggest that a patient cannot be suspected to
have TB unless he has been coughing or the past three or more weeks (Lienhardt et.al., 2012).
However, Banu and et.al. (2013) argue that because of this criteria, quite a large number of cases
of Tuberculosis may be missed. However, one of the limitation of the study is that it cannot be
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commented whether TB is more common in males or in females. This is because the authors may
have missed the women with TB because of their denial about suspicion of TB, social stigma
related to TB or their ability to produce quality sputum specimen. However, it can be critically
analysed that longer delays are experienced by women in obtaining help for treating TB. Hence,
it is more important to address gender differences in TB diagnosis and treatment. Moreover, it
can be critically evaluated that the authors made purposive selection to use Mirpur slum (Banu
and et.al., 2013). Hence, the prevalence of TB cannot be judged solely on the basis of data
obtained from this slum. Furthermore, the authors also did not take HIV status into
consideration. The prevalence of TB is also required to be found out in HIV infected individuals.
2.3 Lack of Knowledge of regarding tuberculosis leads to its increased prevalence
A number of strategies were adopted by Bangladesh National Tuberculosis (TB) Control
Program for facilitating diagnosis and treatment of tuberculosis. One of these strategies was
‘Advocacy, Communication and Social
Mobilization (ACSM)’. This was recommended by World Health Organization as a framework
to be adopted by all national TB control programs. Assessment of knowledge and attitudes
related to TB is important so that the strategy can be made more effective. Moreover, stigma and
discrimination are among significant factors which prevention early detection of TB and its
further treatment. This leads to spread of disease in the country. Paul and et.al. (2015) carried out
a study to assess knowledge and attitudes of key community members who participated in
ACSM in BRAC TB control areas. Qualitative and quantitative methods were combined by
authors to carry out mixed methods study. In order to assess the ACSM program, the authors
targeted key community members (KCM) in three districts that low rates of TB case detection. It
was found that most of the patients, around 99 per cent had heard about TB. They also knew that
TB was a contagious yet curable disease. BRAC workers were more knowledgeable as compared
to KCM (Paul and et.al., 2015).
From the findings of the study by Paul and et.al. (2015), it can be analysed that there are
varying levels of knowledge about TB. KCMs carry mixed attitudes related to the disease. There
is poor knowledge regarding child TB. The TB program has been successful to a great extent.
However, it can be critically evaluated that stigma is still prevalent in the community. People
feel humiliated when any family member is detected with the disease. They also do not want to
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disclose if any member had TB (Paul and et.al., 2015). This is suggestive of delay in TB
treatment and thus further spread of disease. Strength of the study carried out by Paul and et.al.
(2015) was utilization of mixed method as research method. Moreover, the authors selected
study participants from a diverse background (Paul and et.al., 2015). This indicated
representation of different sectors of a particular area. However, it can be critically evaluated that
the study may have suffered from significant bias. This is because the participants were not
recruited randomly. Hence, this may have affected the results.
As compared to study carried out by Paul and et.al. (2015), a different context was
explored by Hossain and et.al. (2015). Paul and et.al. (2015) examined the knowledge and
attitude of the key community members. The authors did not determine the factors responsible
for lack of knowledge. However, Hossain and et.al. (2015) conducted a nationwide survey to
assess the factors associated with poor knowledge among adults on TB in Bangladesh. The
authors included 240 TB cases which were embedded in TB prevalence survey of 2007- 2009
(Hossain and et.al., 2015). the participants were randomly selected from households. A
structured and pretested questionnaire was used for interviewing the respondents. It was found
that overall, there was presence of fair knowledge regarding TB. However, in the domains of TB
transmission, the participants demonstrated poor knowledge. From the findings it can be
analysed that there was significant variation in knowledge on various aspects of TB and TB
services between TB cases and community controls in Bangladesh. Even after controlling other
factors such as education and occupation, community controls demonstrated poor knowledge as
compared to TB cases. It can be analysed as TB cases are provided information during their
diagnosis and treatment under DOTS, they have more knowledge than community controls
(Hossain and et.al., 2015). Information about TB dos not effectively reaches people with poor
education standards. Moreover, Hossain and et.al. (2015) found that women had poorer TB-
knowledge as compared to men. It can be analysed that this is the reason behind low case
detection in women. However, it can be critically evaluated that high levels of knowledge do not
necessarily lead to improved behavior for seeking care and treatment for TB. However, Hossain
and et.al. (2015) suggest that TB cases can act as a useful source of information about
tuberculosis. They can identify themselves as peer educators which can lead to improvement in
care seeking behavior of TB suspects (Hossain and et.al., 2015).
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Similarly, Islam and et.al. (2015) carried out a cross sectional survey to determine the
extent of knowledge of workers in Bangladesh with respect to prevention and control of
tuberculosis. The authors carried out survey in multiple workplaces such as jute mils, tobacco
factories, steel mills, flour mills and garment factories & for this, a multi stage sampling
procedure was followed. It was found that the workers were quite knowledgeable about symptom
of pulmonary TB (Islam and et.al., 2015). They are also knowledgeable about free of cost
sputum test and drug treatment. However, there is presence of only superficial knowledge bout
modes of transmission and causation. Lesser number of people are aware about preventive
measures such as vaccines and spitting here and there (Islam and et.al., 2015). From the findings
of the study carried out by Islam and et.al. (2015) it can be analysed that there is inadequate
knowledge in the workers regarding causes of TB, its transmission and prevention. This is likely
to cause interference with the treatment seeking for chronic cough including sputum test. The
study was healthful in identifying the current knowledge regarding TB in the workplaces so that
a TB prevention and control program can be designed (Islam and et.al., 2015). However, it can
be critically analysed that the authors have used only quantitative survey or carrying out
research. It can be critically evaluated that use of qualitative approaches could have better
conceptualized the perspectives related to knowledge and attitudes of workers regarding TB.
Rana and et.al., (2015) carried out a cross sectional study to assess the knowledge about
TB among non-medical university students in Bangladesh. 839 students were included in the
cross sectional survey. The authors used Chi square test so as to determine the factors related to
knowledge of students regarding TB. 99.4 per cent of students had information about the term
RTB. 50 per cent of them were informed through social media. Lower than 50 per cent of
students had knowledge that TB was caused due to bacteria (Rana and et.al., 2015). However,
there was poor knowledge about latent TB and DOTS program. From the findings of the study, it
can be analysed that there was lack of general knowledge about TB in the non – medical
students. This suggests that there is a need for health education program. The available
knowledge was a result of the frequent advertisement on Bangladesh television about
communicable disease.
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2.4 Spread of tuberculosis in Bangladesh
As listed by WHO, Bangladesh is among the 27 high burden countries for multi drug
resistant tuberculosis. Some of the diseases like tuberculosis are more influenced by various
social factors (Feenstra and et.al., 2013). Various socio economic determinants also act as major
factors behind the transmission of this disease. An essential role is played by the interaction
among people through social contact in the spread of disease. The number and variety of social
contacts as well as their intensity and duration is influenced by a number of determinants such as
social, economic and cultural factors. Feenstra and et.al. (2013) carried out a qualitative
exploration of social contact patterns which are relevant to airborne infectious di9seases in north
west Bangladesh. Focus group discussions were used by the authors in Nilphamari and Rangpur
districts of Bangladesh. These are predominantly rural areas and are one of the poorest parts of
the country (Feenstra and et.al., 2013).
The authors formed four discussion groups with 10-12 healthy individuals in each of the
selected areas. It was found that in the homes family members and relatives regularly visited one
another. Moreover, the houses were made of bamboo and mud. The same fenced courtyard was
being shared regularly among different households with out without a family connection
(Feenstra and et.al., 2013). A single room was shared among 2 or more people. Both rural as well
as urban people living in nearby villages visited one another regularly. Moreover, working adults
also worked in groups where they share the same roof. Mosque and temples are regular meeting
places of people in Bangladesh. From these contact patterns, it can be analysed that these are
highly relevant for the transmission of airborne diseases like tuberculosis which were prevalent
in these areas. This is a determinant of spread of tuberculosis among different age groups and sex
groups in Bangladesh (Feenstra and et.al., 2013). However, it can be critically analysed that
author chose the poorest areas of the country where people do not have a high living standard
which affects their social contact patterns. Hence, this cannot be considered to be representative
of the whole voluntary which also includes developed urban areas.
Rifat and et,.al. (2015) conducted a study to investigate the health system delay in the teatment
of multidrug resistant tuberculosis in Bangladesh. The authors collected information as a part of
a case control study which was conducted previously. It was found that 207 patient suffering
with multi drug resistant TB faced a delay of median 7.1 weeks in health system (Rifat and
17

et,.al., 2015). This included provider delay, diagnostic delay and delay in initiation of treatment.
From the findings it can be analysed that there was presence of some degree of delay in the
initiation treatment after diagnosis of TB. Delay in the initiation of treatment as well as
diagnostic delay, leads to further transmission of MDR- TB.
2.4 Multi-drug resistant tuberculosis- nursing practice guidelines
In Bangladesh, multidrug resistant tuberculosis poses a threat to the prior gains obtained
in TB control. Heysell and et.al. (2015) carried out a study on quantitative drug- susceptibility in
patients who are treated for multi drug resistant tuberculosis in Bangladesh. The authors enrolled
adult patients throughout Bangladesh during the period of 2011- 2013 at the initiation of MDR
TB treatment. It was found that there can be significant impact of quantitative MIC testing on
MDR TB regimen choice in Bangladesh. Clinician actionable data can be obtained through use
of quantitative susceptibility testing by MYCOTB plate (Heysell and et.al., 2015).
In contrast to the study carried out by Heysell and et.al. (2015), Hossain and et.al. (2015) carried
out a retrospective cohort study to determine the pre- diagnosis and pre- treatment attrition
among presumptive and confirmed patients with multi drug resistant TB. The authors also study
factors associated with attrition. Presumptive MDR-TB patients belonging to microscopy centers
were included in the study. These centres serve 60 per cent of the total population of Bangladesh.
There were 836 presumptive MDR TB patients who were referred frm 398 periphery microscopy
centres (Hossain and et.al., 2015). However, of them, only 161 MDR TB patients were
diagnosed. This was significantly less than the country estimates of 2000 cases. Among the
diagnosed patients, pre- treatment and pre- diagnosis attrition was found to be 21 per cent and 17
per cent respectively. From the findings of the study, it can be analysed that pre-diagnosis and
pre-treatment attrition in patients was low under programmatic condition. However, it can be
critically analysed that all the presumptive MDR TB patients were not detected by the recording
and reporting system. This suggests the for the need to improve the system. The study raises
implications for practice and policy with respect to TB (Hossain and et.al., 2015). There should
be development of an improved mechanism for tracking of referrals from presumptive diagnosis
to commencement of treatment.
18

2.5 Tuberculosis control
Anowar and et.al. (2013) evaluated the improvement in nurses's practice by using the
newly developed guidelines for nursing practice for prevention o MDR TB. The authors
conducted the study in six wards. These comprised of two non- TB medical wards, two MDR TB
wards and two TB wards in the National Institute of Diseases of the Chest and Hospital in Dhaka
city. Three distinct sets of self-reported questionnaires were developed for measurement of
preventive nursing practice for MDR TB. Improvement in nursing practice was studied by
included 64 nurses from all three wards. It was found that there was improvement in the overall
preventive nursing practices in all three levels of wards (Anowar and et.al. 2013). This suggests
that with the implementation of guidelines, the nurses were supported in the identification of
risks of MDR TB.
Summary
It can be summarized that TB is highly prevalent in slums, rural areas, underprivileged sections
of the society and prisons in Bangladesh. TB cases and their family members possess knowledge
about the disease and other aspects related to it. However, people in Bangladesh lack awareness
and knowledge about the disease which worsens the condition of the disease. Moreover, this also
results into further transmission and spread of disease. Prevalence of drug resistant TB is more in
people who had a previous history of TB. Health services for TB control and treatment are not
equitably accessible by people of the country.
19

CHAPTER 3- METHOD
3.1 Introduction
Systematic reviews are the ones that provide a summary about the results on carefully designed
healthcare studies. This chapter will discuss the methodology used for conducting the present
systematic review on Tuberculosis in Bangladesh. This chapter provides information on
inclusion and exclusion criteria, data extraction, quality appraisal, ethical issues analysis methods
used for carrying out the present systematic review; and finally it provides justification for using
this method.
3.2 Research design
While carrying out a research, one of the most important aspects is deciding research
design. This provides definition for the type of study that the researcher will conduct (Cronin,
Ryan and Coughlan, 2008). The research question for the present systematic review was “What
is the prevalence of TB and its determinants in Bangladesh?”. In the present study, systematic
literature review study design has been employed. More specifically, the research design was a
descriptive type of systematic review as the findings were summarized in a more descriptive
way.
Systematic literature review is a study design which involves identifying, appraising,
selecting and synthesizing all high quality research evidence with reference to a particular
research question (Flick, 2011). Systematic review research design helps in the provision of a
coherent, persuasive and updated synthesis of studies that have been carried out in an particular
area of scientific inquiry (Systematic literature review guidance, 2014). It comprises of critical
consideration of studies which forms an integral part of systematic literature reviews. This
includes critiquing methodological issues associated with the works of other authors. Systematic
literature reviews generate new levels of understanding, conclusions as well as recommendations
in a particular area which has been chosen by the researcher.
For the current study, systematic literature review design was used due to various
reasons. The research aimed to review Tuberculosis in Bangladesh and the stigma associated
with it. This was required to be done so that the current health strategy with respect to control of
TB in Bangladesh could be improved. This is because by reviewing the previously done primary
researches, the researcher was able to determine the gaps in the current health strategy of
20

Bangladesh regarding TB control. Moreover, review of previous literature would help in
determining the factors associated with TB stigma and its prevalence. By gaining knowledge
about these aspects, the current health strategy could be improved by directing the efforts
towards educating the people about TB and also tackling the stigma associated with it. For all
these, there is a need of obtaining wide ranging information which is superior in quality.
Moreover, in order to improve the impact of TB on the society in Bangladesh, information is
needed on the current state of disease in the country, its determinants and prevalence rates.
Although this information can be collected with individual articles, blogs, books, government
reports etc. But, reading the studies gives unclear and confusing results (Franklin, 2012).
Moreover, looking at each of the studies individually would have provided little insight into the
issue of tuberculosis. Hence, systematic review was the most suitable research design for the
present study as it helped in taking the studies together to obtain a clearer picture regarding the
disease. It helped in fulfilling the need of information that was required for addressing the
research aim being Tuberculosis in Bangladesh and the stigma associated with it followed by
attaining the objectives of present research.
3.3 Inclusion and exclusion criteria
Inclusion and exclusion criteria are important concepts which are to considered while
carrying out a research. This helps to select the best studies for current systematic review.
Inclusion criteria are defines as the attributes of subjects which are required for their selection to
participate in a research (Gray, 2013). These are the characteristics that must be present in the
prospective subjects if they are to be included in a particular study. In contrast to this, exclusion
criteria are those attributes due to which subjects are disqualified from being included in the
study. Specifying the inclusion and exclusion criteria is extremely important for the researcher.
This is because, the purpose of the research can only be accomplished if subject population has
the desired attributes (Ihantola and Kihn, 2011). While carrying out the present systematic
review on tuberculosis, studies have to be selected which make it possible to attain the aim of the
review. Inclusion and exclusion criteria helped in specifying which studies should be included or
excluded from the review.
The following criteria were established in the present systematic review on tuberculosis in
Bangladesh:
21

Inclusion criteria Exclusion criteria
studies published in English language studies that are reported in languages other
than English
studies carried out within a time frame of
2005- 2016
studies conducted prior to the year 2005
Research studies conducted on tuberculosis
in Bangladesh
Research studies carried out on tuberculosis
in any other country
Including studies which comprise patients
from Bangladesh only
Excluding the studies which have patients
from other countries
Studies conducted on tuberculosis Studies conducted on any other disease
Rationale
Rationale and justification can be provided for each criterion that was used for selecting
studies for the present systematic review. The first criterion was set to include only those studies
that have been conducted in English language. The studies carried out in languages other than
English were excluded from the review. This is because these studies would have posed practical
difficulty of translation (McGrath and O'Toole, 2012). The second criterion was to select the
studies on the basis of time period. Only those studies carried out within the time frame of 2005-
2016 were included in the review. Research that was conducted prior to 2005 was excluded from
the review. This was done so as to obtain latest and up – to – date information about tuberculosis
in Bangladesh and stigma associated with it. Studies prior to 2005 would contain obsolete
information and hence would not have presented the actual condition of the disease and stigma
within the chosen country. The third criterion was on the basis of region according to which only
those studies were included which were doe on tuberculosis in Bangladesh. Studies carried out
on any other country were excluded from the review. This criterion was used because the
purpose of the review would not have been accomplished had the researcher included studies
carried out in any other country. The review aimed to study tuberculosis and its associated
stigma specifically in Bangladesh. Hence, only those studies were included which were carried
out on this country.
22

3.4 Searching strategy
The search strategy can be defined as a structured organization of terms which are used
for searching in a database. It depicts the ways in which search terms have been combined to
retrieve the best result (Bennett, Cumberbatch and Francis, 2015). Development of an
appropriate search strategy is vital because it helps in tailoring the search. The present systematic
review on tuberculosis required the researcher to carry out an online search of research materials.
In this regard, a systematic search strategy was developed by the researcher which comprised of
key search terms, boolean operators, electronic search etc.
Key search terms
Key words are the important words which help in providing description of information in
a search engine. These are important as key words significantly impact the number of relevant
records retrieved. This is because, when a key word search is performed, the system identifies
and locates words and phrases throughout bibliographic record (Shea and et.al., 2007). In the
present systematic review, key search terms were formulated to retrieve relevant and useful
results. The topic of the present review combined two concepts, tuberculosis and its stigma.
Hence, key words proved to be extremely helpful in searching for information pertaining to the
topic. The following key search terms were used:
TERM 1 Tuberculosis, phthisis
TERM 2 Stigma, disgrace, dishonour
TERM 3 Bangladesh
TERM 4 Prevalence, widespread, presence,
TERM 5 Determinant, source, factor, cause
Boolean operators
Boolean operators, also called as logical operators or connectors, are another important
aspect which conducting search using key search terms. Boolean operators were used because
the present systematic review required the researcher to search for relevant articles on
tuberculosis and stigma associated with it. In order to make the search precise as well as to
thoroughly search all the available literature, Boolean operators were used. This is because these
helped in making combinations of the search terms with which apt research articles could be
retrieved thus savi9ng the time of the researcher. These are the words which are used for
23

connecting search terms so that the search within a database can be narrowed or broadened. With
boolean operators, search terms can be combined by using different combinations which helps in
locating relevant information (Manchikanti and et,.al., 2008). There are three types of boolean
operators AND, OR and NOT. Boolean operator OR helps in expanding the research. It is used
for connecting the terms that have same meaning or that are synonyms. OR helps in retrieving
only those records that contain any of the search terms (Smith, 2011). In the present study,
Boolean operator OR was used for connecting synonyms such as stigma, Disgrace, dishonor.
Thus, it helped in retrieving all those records which contained any of the search words from
stigma, disgrace or dishonour.
In contrast to this, Boolean AND is used for connecting terms that have different
meanings. It retrieves all those records which contain all the search terms (Thomas and Harden,
2008). In this way, boolean AND helps in narrowing the search. In the present systematic
review, boolean AND was used for making the search specific. For example, tuberculosis AND
Bangladesh, tuberculosis AND stigma. With the help of this, all those records were retrieved that
contained both the key words, tuberculosis and Bangladesh.
Boolean operators were used in the present systematic review so as to bring precision in
the search strategy. These helped in eliminating unwanted results thus saving the time of the
researcher. Through boolean operators, only that information was displayed with the help of
which the research goal of the present review could be accomplished.
Electronic databases
For collecting data for the present systematic review, the researcher referred
computerized databases. E-database is defined as a collection of information which is
arranged in a systematic manner so that search can be made easy and fast. It includes
journals, book reviews etc.(Manchikanti and et.al., 2008) Electronic databases were used
in the present review because these helped in obtaining information in least time by
providing high searching speed. Moreover, these could be used to retrieve results at any
time from any place all over the world. Therefore, these provided flexibility and
convenience to the researcher (Egger, Smith and Altman, 2008). For the present systematic
review, the following databases were used:
Databases Description
24

selected
BioMed
Central
It is a UK based publisher which provides peer reviewed open access
journals on various subjects. These include science, medicine, technology
etc. On this database, original research articles can be accessed freely
online (BioMed Central, 2015).
The Cochrane
library
The Cochrane library comprises of a collection of six databases. These
make available different types of independent evidence of high quality
which provide information on health care decision making (About the
Cochrane Library, 2016).
PubMed It consists of around 25 million citation for biomedical literature from life
science journals, online books and MEDLINE. This literature is on
subjects such as life science and biomedicine.
BioMed Central, PubMed and The Cochrane Library databases were used for retrieving
literature for the present systematic review. This is because these contained research articles and
primary studies pertaining to the topic of the review. In the present study, the researcher was
required to investigate TB in Bangladesh and stigma associated with it. The chosen databases
contained journal articles pertaining to this topic. Therefore, these were utilized for carrying out
the systematic review.
Some approaches used
Apart from the methods and tools used in the present systematic review on tuberculosis,
there are other search techniques which may have been used. These include reference list
checking, manual or hand searching, emailing authors etc. manual searching of literature could
have been done (Dixon-Woods and et.al., 2007). However, it was avoided as it is time
consuming and limited time was available with the researcher to complete the systematic review.
It is for the same reason that other techniques such as reference list checking and emailing
authors were not adopted for the present study.
25

3.5 Screening strategy
The search results were screened against the inclusion and exclusion criteria by using an
appropriate screening strategy. This comprised of six stages:
a) Stage 1: Inclusion and exclusion criteria were applied to titles and abstracts of the
articles.
b) Stage 2: Studies that clearly met one or two exclusion criteria were eliminated.
c) Stage 3: Full text of the remaining studies was retrieved
d) Stage 4: The remaining studies were evaluated to inclusion and exclusion criteria
e) Stage 5: All those studies were selected which met all the inclusion criteria and no
exclusion criteria were included
f) Stage 6: At this point, the studies were excluded from the systematic review for
appropriate reasons such as inadequate statistics to incomplete results.
3.6 Data extraction
After the relevant studies were selected on the basis of eligibility criteria, data extraction
was the next step. This comprised of extracting information from each of the studies that were
selected to be included in the review. In the present review, full text of each article was read for
its inclusion and data was extracted by using a standardized data extraction or coding form. It
was necessary to use a standardized data extraction form as with it bias could be reduced
(Jonnalagadda, Goyal and Huffman, 2015). It also helped in maximizing reliability and validity
of the study. By using standardized data extraction form, relevant information can be extracted
from the study. This included author's name, study title, publication year, study setting, study
design, time frame, name of the journal, sample size and target population, study outcomes and
data collection procedure. The data extraction form helped in producing a summary table of
study characteristics which were essential for inclusion.
3.7 Quality Appraisal
Assessment of quality of all the identified studies is an important part of systematic
reviews. This is because, the risk of bias and error in the findings can be reduced by excluding
studies with lesser quality (Voss and Rehfuess, 2013). Quality appraisal is the process by which
research is carefully and systematically examined so that judgement can be made regarding its
trustworthiness, value and relevance. Quality appraisal of primary studies is a vital requirement.
26

This is because it enables the researcher to retrieve reliable, up – to – date information about a
particular topic (Furlan and et.al., 2009). There may be variations in the studies with respect to
methodological strength, study design etc. In the present review, quality appraisal of the selected
studies was done because with the help of it, the research was able to determine if the review
would be affected by any aspect of study design. Hence, the strength of the review outcomes
could be determined.
For the purpose of appraising quality of studies included in the review, CASP (Critical
Appraisal Skills Program) tool was used. This helps in assessing internal validity, relevance to
practice and results. CASP tools enable to critically appraise different types of evidence such as
cohort, case control, qualitative research, Randomized Controlled Trails, systematic reviews etc.
(Moher, 2010). there are 10- 12 questions in each of the seven critical appraisal tool of which the
first two are screening questions (Critical appraisal tools to make sense of evidence, 2016). The
quality of the included studies was appraised by using the question specific to the type of study.
(Refer to appendix for table)
3.8 Ethical issues
Since the introduction of ethics in biomedical research, these have assumed a significant
place. A systematic literature review involves synthesis of large amounts of information in a
scientific way. There may be studies that may suffer from ethical insufficiency (Vergnes and
et.al., 2010). Therefore, it is important to consider ethical issues while carrying out systematic
review. Also, ethics are important to be taken into consideration as it may help to improve the
ethical and methodological quality of the study. The following ethical issues were relevant and
pertinent while carrying out the present systematic review to investigate tuberculosis in
Bangladesh and stigma associated with it:
a) Accurate and fair treatment of works of other researchers- It is ethical practice to give
fair and accurate treatment to the works of existing researchers (Moher and et.al., 2007). Issues
would arise if the researcher fails to address the works of other researchers in a fair manner. This
issue was relevant and pertinent to the present study. This is because the present study was a
systematic review and included primary studies conducted by other researchers. Therefore, it was
important to properly treat the works of other researchers. To address this issue, the researcher
ensured to name that author first who did the majority of work while citing a particular study.
27

Along with that, the researcher ensured that the works of other authors have been properly
represented.
b) Ethics questions pertaining to the studies involved- It is an ethical practice to consider the
ethical questions that are raised by the research which is being reviewed (Ganann, Ciliska
and Thomas, 2010). Failure to do so would raise ethical issues for systematic review.
This issue was relevant for the present systematic review on tuberculosis because it
involved primary studies which contained health information about respondents. In order
to address this issue, the researcher ensured that the ethics questions raised by the
selected primary studies have been addressed. The information pertaining to the
participants of these studies was kept confidential and private.
c) Plagiarism- Plagiarism means use of somebody else's work or ideas and claiming them as
your original work without acknowledging the person or obtaining prior permission
(Fink, 2013). This is an ethical issues which was relevant for the present systematic
review. This is because the present study reviewed research carried out by other
researchers. In order to address this issue, the researcher ensured that the content taken
from the selected studies is properly rephrased.
Ethics approval
Before the research is conducted in health sector, it is essential to seek verification from a
Research Ethics Committee. This is required so as to ensure that the research is in accordance
with the commonly accepted ethical and legal principles (Vergnes and et.al., 2010). The present
study was a systematic review. Hence, it did not involve any human subjects. However, ethics
approval was necessary for the present review. Therefore, the researcher sought ethical approval
from Institute for Health Research Ethics Committee (IHREC) of the University of Bedfordshire.
3.9 Analysis
Analysis is another crucial aspect of a systematic literature review. It comprises of
collecting, combining and summarizing the findings of the relevant literature. This is carried out
to provide answer to the research question of the review (Jonnalagadda, Goyal and Huffman,
2015). Generally, there are two types of analyses in systematic review. These are meta- analysis
and narrative synthesis (Cronin, Ryan and Coughlan, 2008). In the present systematic review,
narrative synthesis was used for analysing the data. This is because, narrative synthesis provided
28

a qualitative approach which was more suitable to combine the results of the present review
instead of meta analysis.
The present systematic review was carried out by selecting 13 articles. Four studies
focused on the prevalence of tuberculosis in Bangladesh (Banu et.al. 2013, Banu et.al. 2012,
Hossain et.al. 2012 and Banu et.al. 2015). Three studies determined knowledge as an important
factor which impacts the prevalence of TB in Bangladesh (Paul et.al. 2015, Islam et.al. 2015 and
Rana et.al. 2015). Two studies focused on the spread of tuberculosis in Bangladesh (Rifat and
et,.al. 2015, Feenstra and et.al. 2013). There were two studies on multi- drug resistant
tuberculosis (Hossain and et.al., 2015, Heysell and et.al., 2015). One study was on TB control in
Bangladesh (Anowar and et.al., 2013).
3.10 summary
From this section it can be summarized that all the aspects related to methodology of
systematic literature review have been followed. Electronic search was carried out by utilizing
databases such as PubMed, BioMed Central and The Cochrane Library. An appropriate search
strategy that was used for this systematic review comprised of deciding search terms and
Boolean operators. Ethical issues were considered by the researcher.
29

CHAPTER 4- RESULTS
4.1 Introduction
This chapter provides description of findings in a structured manner without interpreting
them. Key results that answer the research question will be focused upon. Important and relevant
findings of the study have been presented in this chapter.
In the present review, after the initial search was conducted based on the selected search
terms, 1156 abstracts and titles of studies were identified. Of these articles, 840 articles were
excluded due to first and second inclusion criteria. Out of the remaining 316 articles, 267 were
excluded on the basis of the third exclusion criteria. Thus, 49 articles were left out of which 36
studies were further excluded due to inadequate information for the assessment. Finally, 13
studies were selected to be included in the review.

31

For the present systematic review, the researcher considered both qualitative and
quantitative studies. All the studies selected were primary studies. Also, all the studies were
based on Bangladesh. The selected studies were written in English language and published
between 2005 and 2015. in this systematic review, only those studies were included which
provided information on tuberculosis in Bangladesh. The researcher did not imply any restriction
on the basis of age, gender, ethnicity, culture or religious identity of the patients suffering from
TB.
4.2 Summary of the selected studies
All the 13 studies which were selected for the review- Banu et.al. (2013), Banu et.al.
(2012), Hossain et.al. (2012), Feenstra et.al. (2013), Banu et.al. (2015), Heysell et.al. (2015),
Hossain et.al. (2015), Rana et.al. (2015), Rifat et.al. (2015), Islam et.al. (2015), Anowar et.al.
(2013), Hossain et.al. (2015) and Paul et.al. (2015), which were conducted in Bangladesh
provided information related to tuberculosis in the country. The studies conducted by Banu et.al.
(2013), Banu et.al. (2012), Hossain et.al. (2012) and Banu et.al. (2015) focused on prevalence
and transmission of tuberculosis. Paul et.al. (2015), Islam et.al. (2015) and Rana et.al. (2015)
carried out studies on knowledge of health care workers regarding tuberculosis. Studies carried
out by Rifat and et,.al. (2015) and Feenstra and et.al. (2013) focused on spread if tuberculosis in
Bangladesh. Hossain and et.al. (2015) and Heysell and et.al. (2015) conducted studies regarding
multi – drug resistant tuberculosis. Study carried out by and Anowar and et.al. (2013)
emphasized on tuberculosis control in Bangladesh. The table below present a brief summary of
the selected studies. (Refer to table in Appendix 1)
4.3 Findings of the study
By using the method of narrative synthesis, the researcher came up with the main
findings of the systematic review. Themes were formulated with the help of this method so that
results could be presented appropriately and clearly.
4.3.1 Prevalence of TB in Bangladesh
Of the 13 selected studies, 4 studies assessed the prevalence of tuberculosis in
Bangladesh. One study described the prevalence of TB in prisons (Banu and et.al., 2015).
another study assessed the socio-economic position of actively detected cases (Hossain and et.al.,
32

2012). Banu and et.al., (2015) found that TB is the major cause of morbidity and mortality in the
prisons in Bangladesh. The results of the study indicated 466 inmates with pulmonary TB out of
60, 585 inmates who were screened. Moreover, the prevalence of TB in prisons is higher as
compared to that in general population in Bangladesh. The major factor responsible for the
overall incidence of TB, its prevalence and mortality rate is the spread of TB from prisons to
communities (Banu and et.al., 2015). Hossain and et.al., (2012 ) found that though DOTS has
been made available free of cost, it is still not equitably accessible by the poorer sections of the
society. The affluent sections of the society get most of the benefit from the service of the
government in Bangladesh. Hossain and et.al., (2012 ) found that population prevalence of
tuberculosis was 5 times higher in lower quartiles of population to highest quartile of population.
25 cases out of the 33 detected cases from the survey were from lower two quartiles. (Hossain
and et.al., 2012). Banu and et.al., (2012) found that prevalence of drug resistant tuberculosis is
more in the people who have a previous history of anti – tuberculosis treatment (Banu and et.al.,
2012). The prevalence of multi- drug resistant strains of T family is higher.
4.3.2 Stigma associated with TB in Bangladesh
Paul and et.al. (2015) focused upon the assessment of knowledge and attitudes of key
community members who participated in ACSM in BRAC TB control areas. The authors found
that despite successful TB control program, stigma associated with the disease is still prevalent
in Bangladesh (Paul and et.al., 2015). Presence of cough for the past few weeks cannot be taken
as the criteria for suspecting a person for tuberculosis (Banu and et.al., 2013). Stigma associated
with TB makes people deny about TB suspicion. People also do not seek early treatment and
care because of social stigma associated with the disease. This is because the presence of TB is
considered to be undesirable in the society. People infected with the disease are discriminated.
Detection of the disease also leads to social exclusion of the people (Banu and et.al., 2013).
Dishonor and disgrace is experienced by the person who is infected with TB and his family as
well. Banu and et.al. (2013) found that stigma related to TB may prevent women from being
included in the study. This stigma is also responsible for spread of disease in the country
because it leads to delay in treatment initiation as the patients hide their symptoms from the fear
of being stigmatized.
4.3.3 Determinants of TB in Bangladesh
33

Studies carried out by Rifat and et,.al. (2015), Feenstra and et.al. (2013), Rana et.al.
(2015) and Hossain and et.al., (2015) found out the deteminants of tuberculosis in Bangladesh.
There are various causes which lead to spread of TB in the prisons. These include high turnover
of inmates, overcrowding, inadequate ventilation and poor general health of the prisoners. In the
general population in Bangladesh, prevalence of tuberculosis is high in poorer sections of the
society and rural areas (Hossain and et.al., 2012). Thus socio economic determinants also act as
major factors behind spread of disease. The disease is also more prevalent in urban slums.
People in Bangladesh are aware about tuberculosis and its spread. However, this level of
knowledge about TB differs significantly (Hossain and et.al., 2015). They do not have adequate
knowledge regarding child TB. People who have had a family member suffer from TB or the TB
cases themselves possess more knowledge about the disease (Paul and et.al., 2015). They can
play a significant role in transferring knowledge to other people and encouraging them towards
early treatment. Another reason for high prevalence of TB in Bangladesh is that information
about TB does not effectively reach the people with poor educational standards. Apart from that,
study carried out by Islam and et.al., (2015) found that there is lesser awareness among people in
Bangladesh regarding preventive measures such as vaccines (Islam and et.al., 2015). Superficial
knowledge about the disease and and transmission is also held to be responsible for high burden
of tuberculosis in Bangladesh. Students act as a change agent in the country as they lead to fast
spread of information in the society. However, lack of knowledge about TB in non- medical
students further leads to lack of awareness about the disease in the country and its spread.
Rana et.al. (2015) found that 99.4 per cent of students had information about the term
TB. 50 per cent of them were informed through social media. Lower than 50 per cent of students
had knowledge that TB was caused due to a bacteria (Rana and et.al., 2015). There is problem of
health system delay in Bangladesh which can be regarded as a factor for high prevalence of the
disease. Rifat and et.al. (2015) found that 207 patient suffering with multi drug resistant TB
faced a delay of median 7.1 weeks in health system There is provider delay, diagnostic delay and
delay in initiation of treatment (Rifat and et.al., 2015). These factors are responsible for further
transmission of MDR- TB. The infected patients are not able to get treatment, support and care
on time (Rana and et.al., 2015). This not only aggravates the condition of the disease but also
leads to its transmission to other people. Further, another determinant is the pattern of social
34

contact. People in Bangladesh regularly visit each other which promotes the transmission of
disease. Seller from one city travel to other cities to earn their livelihood. Moreover, within the
neighborhood, there is regular movement of people to each others' house (Feenstra and et.al.,
2013). Moreover, in the underprivileged sections of the society, people live in houses made of
bamboo and mud and the same fenced courtyard is shared among different households. Two or
more people share a single room. Mosques and temples form other meeting places of people. All
these factors lead to transmission of disease and its spread in the country.
The main outcome gained from the present systematic review is that TB is more prevalent in
prisons, poorer sections of society and underprivileged sections. The stigma associated with the
disease acts as a barrier in controlling TB. There are various determinants of disease. These
include social contact patterns, spread of disease from prisons to communities, lack of
knowledge and awareness among people etc.
4.4 Summary
From the results chapter it can be summarized that majority of the studies focused upon
prevalence of TB in Bangladesh and factors associated with it. The results of the review show
that TB is highly prevalent in Bangladesh. Lack of knowledge about the disease increases its
transmission and spread. The studies also highlighted the determinants of TB in the country.
Studies were suggestive of gaps in the current health strategy in Bangladesh.
35

CHAPTER 5- DISCUSSION
5.1 Introduction
After presenting the key findings and results of the study, the next chapter is that of
discussion. This is one of the most important part of dissertation. In this chapter, a succinct
summary of results has been provided. This is followed by interpretation and explanation of the
findings to address the research questions. Results and findings have been compared with the
previous research and critically analysed. This is inclusive of determining the differences and
similarities. Implications of the findings of review have been provided. This chapter also
determines the significance of findings of the review for relevant public health policy and
professionals. Lastly, critical evaluation of the systematic review has been done.
5.2 Main results and comparison with existing literature
The present systematic review aimed to investigate tuberculosis in Bangladesh and
stigma associated with it. The results indicate that there is high prevalence of tuberculosis in
Bangladesh. It is among one of the countries that experience highest burden of tuberculosis in the
world. There are various determinants of TB in Bangladesh. These include health system delay,
poor knowledge, patterns of social contact, inequitable access to DOTS services, lack of
information regarding preventive measures, high prevalence of TB in prisons. In Bangladesh, TB
has stigma associated with it. Infected person and his family feels humiliated on detection of TB.
It brings disgrace and dishonor to the family which is also a reason for denial to TB suspicion
and delay in treatment initiation. These factors lead to transmission of disease.
5.2.1 Prevalence of TB in Bangladesh
It was found that there is high prevalence of TB in prisons in Bangladesh as compared to
general population (Banu and et.al., 2015). High prevalence of TB in prisons of Bangladesh has
many reasons associated with it. The inmates of the prison are kept in overcrowded conditions. It
can be analysed that TB is a highly infectious air borne disease. Overcrowding leads to its
transmission among the healthy prisoners from the infected ones. Moreover, poor general health
of prisoners further makes them vulnerable to the disease. It was found that spread of TB from
prisons to communities is one of the key factors which is responsible for overall incidence of the
disease, its high prevalence and mortality rates (Banu and et.al., 2015). from this it can be
interpreted that in order to control the incidence of TB, it is more important to take measures to

control the disease in prisons. However, it can be critically analysed that the conditions of he
prisons in Bangladesh are worse which promote the transmission of disease. According to
Somma and et.al., (2008), the current health strategy in Bangladesh for control of TB does not
take into account the determinants associated with prisons (Somma and et.al., 2008).
37

It was found that in Bangladesh, treatment for TB is available effectively. DOTS has
been made available free of cost. However, it cannot be accessed by all in an equitable manner
(Hossain and et.al., 2012). from this it can be interpreted that the poorer sections of the society
are not able to obtain the benefit of the services provided by the government for treatment of TB.
This indicates the gaps in the current health strategy of Bangladesh for TB control. As TB is
more prevalent in the underprivileged sections, these people should be provided the services at
priority. However, it can be critically analyzed that poor people may not be able to obtain the
free of cost services provided by Bangladesh government as they may not be knowledgeable and
aware about it. According to Hargreaves and et.al. (2011), lack of awareness can be held
responsible for inaccessibility of health care services by people of poorer sections in the country.
As people are not aware about the services, they are not able to use them (Hargreaves and et.al.
2011). Interpretation of the results also suggests that people also need to be aware about the
disease and its causes.
From the study, it was found that in Bangladesh, drug resistant tuberculosis is prevalent
more in those people who have been previously obtained anti- TB treatment. From this it can be
interpreted that with the increase in the number of TB patients who have obtained treatment,
there will be increase in the incidence of drug resistant TB in Bangladesh. Thus, considering the
control and management of TB, it is important that efforts are made to prevent the disease.
Lönnroth and et.al., (2009) argue that inconsistent or partial treatment of TB leads to resistance.
In adequate therapy prescribed to the patients or discontinuation of drugs by the patients
develops resistance (Lönnroth and et.al., 2009). It can be critically analysed that lack of follow
up and inadequate information about the disease causes patients to stop the treatment or take
partial treatment.
Results of the review show that a person cannot be suspected to have TB on the basis of
the reason that he has been coughing for the past few weeks (Banu and et.al., 2013). From this it
can be analysed that there are other factors which needs to be considered as well while
suspecting a person to be infected from TB. These are different from the previous research. Dye
and et.al., (2009) argue that common diagnostic tests should be performed to lead to suspicion of
TB in a person (Dye and et.al., 2009). According to the views of Gosoniu and et.al. (2008), there
are various features other than coughing which raise suspicion of TB. These include coughing
38

out blood, feeling tired, loss of weight, chest pain, fever and nigh sweats (Gosoniu and et.al.,
2008).
5.2.2 Stigma associated with TB in Bangladesh
According to the present systematic review, there is high level of stigma associated with TB in
Bangladesh. Detection of TB leads to humiliation for the patient and his family (Paul and et.al.,
2015). From this it can be analysed that government efforts to raise awareness about the disease
do not seem to be effective in eradicating the stigma associated with TB.
It can be discussed that there are various points of similarities between the results of the
present systematic review and previous research. Murray, Oxlade and Lin, (2011) assert that
institutional and community norms lead to stigmatization of tuberculosis. These are also
responsible for hindering TB control and management. According to the authors, stigma is a
social determinant of health that must be tackled for controlling TB. It begins when the presence
of disease is considered as undesirable in a person (Murray, Oxlade and Lin, 2011). This sense of
disvalue is internalized by the stigmatized individual. Following this, the infected person adopts
attitude which comprises of shame, guilt and disgust. It is these behaviors which make the person
hide stigmatized trait thus increasing risky behavior. From this it can be analysed the stigma
associated with TB makes a person feel disgusting and guilty about himself. This makes him
hide the disease and its symptoms. These factors lead to delay in TB detection and treatment
initiation.
5.2.3 Determinants of TB in Bangladesh
The review found out that there is presence of superficial knowledge about TB and its
spread. Moreover, people also do not have adequate knowledge regarding child TB (Paul and
et.al., 2015). Moreover, sufficient knowledge about the disease is possessed by TB cases or his
family members (Hossain and et.al., 2015). They can act as source of knowledge for other
people. From this it can be analysed that as people have suffered the disease, the gain
information about its causes, treatment, importance of complete treatment etc. In similar ways,
family members of TB cases would become knowledgeable about the routes of transmission of
diseases, preventive measures etc. as they would be provided information about these aspects
while seeking treatment for the infected patient. However, on comparing the results to the
previous research, various points of differences and similarities arise. Ploubidis and et.al. (2012)
39

argue that TB cases would possess knowledge but it would not be helpful in making the people
aware about the prevention of disease. Also, TB cases would not have adequate knowledge about
the importance of nearly initiation of treatment and risks of partial treatment (Ploubidis and
et.al., 2012). Hence, they would not be effective at providing complete information to the general
population regarding all the aspects of TB. However, according to Evans, (2011) TB patients
who have been cured for the disease have suffered through the disease. They have also attended
counseling sessions. Hence, they have basic information about the disease, its causes, treatment,
transmission routes etc. This makes them a good source of information for the general population
(Evans, 2011).
Useful information regarding TB is not able to reach the people with low educational
standards. From this it can be analysed that people with poor education may not know how to
read. This inability may prevent them from becoming aware about the disease, its transmission
and spread. This is similar to the previous research conducted on the topic. Dye and Williams,
(2010) support that lack of education makes the people unable to read and interpret the
information. Bangladesh is a low income country. Along with other basic needs, illiteracy is also
a basic need of people there. As illiterate people are unable to read, information related to TB is
not able to reach them (Dye and Williams, 2010). However, it can be critically analysed that
there can be selection of other media through which people can be made aware of TB such as
plays, shows. TV commercials etc. from the results it can be interpreted as people are not
informed about TB, they are not able to take precautionary measures or early treatment for the
disease. Hence, this can be considered to be a determinant of TB in Bangladesh.
Results also show that people in Bangladesh do not have adequate knowledge about the
preventive measures such as vaccines. From this it can be analysed that people in the nation
would not be able to protect themselves from the disease because they are not aware of the
vaccine. Information about this could significant reduce the prevalence rate. Moreover, as people
are not aware, the spit here and there which leads to transmission of disease and its spread to
other areas of the country. According to Weiss and et.al. (2008), unhygienic human habits like
spitting spread air borne diseases such as TB. This is because bacteria stay alive in the spit of the
patient for a longer time. This leads to spread of the disease (Weiss and et.al. 2008). Hence, lack
of awareness about preventive measures is also a determinant of TB in Bangladesh.
40

There is problem of health system delay in Bangladesh. There is delay in initiation of
treatment. Moreover, the nation also suffers from the problem of diagnostic and provider delay.
From this it can be analysed that health system delay can be regarded as a determinant of TB in
Bangladesh and its high prevalence. As there is delay in treatment, it leads to growth of disease
in the infected person which tall a toll on his life. Furthermore, delay in diagnosis of disease
results in its transmission to other person. It also worsens the condition of the patent as he is not
provided any treatment. This leads to higher mortality rates and increased burden of the disease
in the country due to rise in health expenditure. This is similar to the previous research
conducted on the topic. According to Lönnroth and et.al., (2010), timely diagnosis and initiation
of treatment are extremely important to control TB. Delay in the start of treatment enhances
transmission of infection. This not only increases the risk of death but also becomes a reason for
increase incidence of TB. Moreover, provider delay may also lead to discontinuation of
treatment or partial treatment thus resulting in increased incidence of MDR – TB.
Analysis of the present systematic review shows that pattern of social contact is also a
determinant of TB in Bangladesh. It can be interpreted that this is an important factor which
must be considered while listing the determinants of TB. This is because TB is an infectious air
borne disease and proximity with the infected person increases the possibility of contracting the
disease (Tuberculosis (TB), 2016). According to the review, people in Bangladesh visit each
other regularly. They also come under the same roof while paying homage to temples and
mosques (Feenstra and et.al. 2013). These regular visits coupled with lack of knowledge and
awareness about the disease result in transmission and spread of disease. Hence, it is an
important determinant of tuberculosis in Bangladesh.
5.3 Implications of findings and their significance for public health policy
The findings of the review have several implications. These inform about the
determinants and factors which lead to high prevalence of TB in Bangladesh and increased
burden of the disease in the country. Moreover, the findings of the review are informative about
the gaps in the current health system in Bangladesh. These imply the need to make people more
aware about the disease and other important aspects related to it. These include its causes,
transmission, treatment, importance of complete treatment etc. Moreover, the findings suggest
that there is a need to focus upon prevention of TB in Bangladesh and make people more aware
41

about it. Efforts are required towards the direction of the root causes of spread of TB in
Bangladesh such as spread o disease from prison to the communities.
Further, the findings of the present systematic review are significant for public health
policies as well as professionals regarding control of TB. There is a need to make the services
provided by the government equally accessible by all in the country. It has been reported that
DOTS strategy has been effective in treating tuberculosis (Hossain and et.al., 2012). As TB is
more prevalent in the poorer sections of the society, there is a need to re-design policies for TB
control in a way that these focus on raising awareness of the people in these areas. Moreover, the
problem of health system delay is required to be tackled. Timely diagnosis and treatment is
important to control TB. The health strategy should be made strong and capable of handling the
increased demand for TB treatment and control so that all the patients get treatment on time.
5.4 Critical evaluation of the present review
One of the strengths of the present systematic review is that it extends knowledge about
the tuberculosis in Bangladesh which is one among the 22 countries which bear the highest
burden of this disease. Another strength of the review is its rigorous search methods. A
systematic search strategy was adopted for the review which comprised of searching the relevant
literature across a wide range of databases. Well defined inclusion and exclusion criteria guided
the search and helped in selection of relevant studies as per their eligibility. Further, the third
strengthening part of the systematic review was quality appraisal of the selected studies. This
helped in reducing the bias and error in findings of the review. With this methodological rigor,
the validity and reliability of the review could be enhanced.
However, the review also suffered with certain limitations. Firstly, most of the studies
included in the review were carried out at small scale. This poses challenge to the ability of the
results to be generalized to the entire population of Bangladesh. Secondly, despite searching for
the studies on a wide range of databases, it is possible that some studies may have been missed to
be included in this systematic review. Moreover, as studies carried out in languages other than
English were excluded from the review, the researcher may have missed to include some
potentially related papers in the review. Thirdly, all the studies that were selected focused upon
prevalence of tuberculosis and its determinants in rural areas, slums and prisons of Bangladesh.
42

As a result of this, the review was unable to comment separately on TB in the urban areas of
Bangladesh.
43

CHAPTER 6- CONCLUSION
6.1 Conclusion
The present systematic review was aimed to find out the prevalence of TB in Bangladesh.
It intended to answer the research question of finding out the determinants of TB in Bangladesh.
It was important to be examined so that gaps in the current health strategy can be revealed.
Moreover, it was significant for improving the impact of TB on society. The present study used a
systematic search strategy that comprised of inclusion and exclusion criteria, electronic search,
Boolean operators etc. The methods comprised of using a screening strategy, data extraction,
quality appraisal and analysis.
From the review, it can be concluded that TB is more prevalent in the rural areas,
underprivileged and poorer sections of society. Prevalence of TB is higher in prisons as
compared to the general population in Bangladesh. One of the major factor responsible for high
prevalence of TB in Bangladesh is its spread from prisons to the community. Moreover, people
are less aware about the disease and its preventive measures. Benefits of government services
cannot be equitably accessed by the people especially those in the poorer areas. Hence, there is a
need to fill this gap and make the treatment services such as DOTS accessible by the people
belonging to poorer sections. There are various factors which can be considered as determinants
of high prevalence of TB in Bangladesh. These include social contact patterns, high prevalence
of TB in prisons, lack of awareness and knowledge of people, health system delay and TB
stigma. TB is highly stigmatized in Bangladesh which prevents people from seeking early help
and treatment. Detection of the disease becomes a source of humiliation for the infected person
as well as for his family.
6. 2 Future research
Future research is needed to find out the scope of current TB control programs and
policies in Bangladesh. It has been found that prevalence of TB in prisons is higher as compared
to the general population. Research is needed to determine the ways in which TB can be
controlled in prisons in Bangladesh. It may also be important to carry out research on the ways in
which information about the diseases can be made available to the people with poor education
standards. It is recommended that research should be carried out about the effectiveness of
strategies for making people knowledgeable about TB. This will help in determining which
44

strategies prove successful and effective in making the people of Bangladesh knowledgeable
about TB. This will help government to educate more people about the disease by adopting that
strategy which is found to be the most efficient. Research is also needed about the factors that
lead to stigmatization of TB in Bangladesh and the ways of addressing the stigma. This would
help in devising strategies for tackling this issue. Further this research will provide information
on the ways in which stigma can be reduced.
45

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Appendix 2
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APPENDIX 3
Ethics approval form
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